Making the most of a Morbidity and Mortality meeting

Abstract

BACKGROUND:

Morbidity and Mortality meetings (M&Ms) are a fundamental element of surgical practice. However, there has been little investigation into best practices, to maximise education and improvement outcomes.

OBJECTIVE:

Create a new, evidence-based M&M methodology, that facilitates standardised analysis of errors in a non-judgemental fashion, and highlights areas for improvement.

METHODS:

A Quality Improvement (QI) methodology was used. This project encompassed a literature review and two sequential QI cycles. A literature review and initial survey highlighted best practice and identified areas for improvement. From this information, a new standardised format was created, which centred around a new modified Fishbone framework, incorporating the London Protocol methodology. The project then sequentially tested new formats, with feedback collected for every new format.

RESULTS:

The literature review and surveys guided improvement of the M&M. The need for standardisation was highlighted. The new PowerPoint template and modified Fishbone ensured presentations and analysis were consistent and systematic. Participants reported that M&Ms were more engaging, interactive and structured, ensuring improved discussion of errors. The modified Fishbone framework reinforced a blame-free, system-focused analysis.

CONCLUSION:

M&Ms are a critical aspect of patient safety. This project utilised simple QI tools to encourage collaborative reflection, learning and improvement.

Keywords

M&M quality improvement fishbone healthcare

1. Introduction

Morbidity and Mortality meetings (M&Ms) are common practice in healthcare systems globally. Whilst M&Ms have significant potential to improve patient care and educate professionals, there has been little study, change or development into the practice. Currently, most M&Ms struggle to overcome common obstacles including blame, inadequate error analysis and poor inclusivity. This results in lower quality M&Ms, that fail to deliver high quality education and improvement outcomes.

The aim of this project was to review the available literature on M&Ms to identify the alternative approaches to maximise the benefits of M&Ms. Using this information and the Model for Improvement [1,2], sequential improvement cycles were used to create a new, improved, evidence-based M&M, that would ensure that educational and improvement opportunities available are maximised for all participants.

2. Method

The project took place between 01/10/2020 and 30/01/2021 in a district general hospital’s general surgery M&M meeting. This project started with a systematic evidence review of the literature, which was followed by two improvement cycles. With each cycle of improvement, the format was modified using suggestions from surveys completed by M&M participants. The methodology for this project can be seen in Fig. 1.

Fig. 1.

Project methodology.

To assess the local original M&M format, an online survey (Survey 1) was completed by doctors currently working in the general surgery department. The survey aimed to identified strengths and weaknesses of the current format. Survey 1 was formed of free-text questions which can be seen in Table 1. Surveys were an opportunity to study the impact of M&Ms and to understand areas for improvement. Responses were used directly to plan and refine a new format for the M&M.

Table 1

Survey 1 questions

Free text questions
1	In your department — do you have a regular MDT meeting?
2	Do you feel your M&M meeting is interactive?
3	Do you feel your M&M meeting is engaging?
4	How (if at all) would make your M&M more interactive and engaging?
5	Do you feel that your M&M currently has a blame-free culture?
6	Do other healthcare professionals (e.g. nurses, physios, HCAs etc) regularly attend your M&M?
7	Do you feel your M&M has an MDT approach to the cases it discusses?
8	How (if at all) is the M&M meeting you attend currently attend structured?
9	What elements do you particularly like about your M&M meeting?
10	What elements do you feel are missing from your M&M meeting?

Following this, a literature review was conducted on EMBASE, to collect information about how M&Ms were carried out in a variety of settings across the world using the PRISMA framework [3]. Literature was collected from 2000–2020. The keywords used for the search were (morbidity AND mortality) AND (meeting OR conference) AND (structure OR characteristic^∗). Records were further refined to include literature only containing clear details of M&M structures.

Information from Survey 1 and the literature review were collated and used to plan a new M&M format (Format 1) to be tested in a real M&M.

Format 1 focused on creating a standardised PowerPoint which was hoped would improve both the quality and ease of error analysis. The new format was centred around a modified Fishbone framework, which incorporated the London Protocol [4,5]. The London Protocol was incorporated to tailor the Fishbone to a medical setting.

Both the London protocol and Fishbone framework are established tools for multifactorial error analysis [4,5]. The newly modified Fishbone enabled causative aspects of multifactorial errors to be broken down into their fundamental elements, hence supporting thorough analysis of errors. The modified Fishbone framework is shown in Fig. 2.

Fig. 2.

M&M Fishbone (adapted from Ishikawa’s Fishbone and The London Protocol).

For the first improvement cycle, Format 1 was tested in a real M&M to present cases and the format was surveyed by attendees (Survey 2). This was an opportunity to measure the impact of change and to appreciate how changes were received by participants. Questions for Survey 2 can be found in Table 2. For the second improvement cycle, the results from Survey 2 were used to improve the format further and create Format 2. Details of Format 2 have been included in Fig. 3.

Table 2

Survey 2 questions

Likert scale — Strongly agree to strongly disagree
1	There was enough time to discuss each case adequately
2	The new style of analysis (using the fishbone) gave more structure to discussion
3	I have a clearer idea of what need improving or changing following the new structure
4	The new M&M structure made the M&M more interactive
5	The new M&M structure made the M&M more engaging
Free text questions
6	What did you like best about today’s trial of the new M&M structure?
7	How would you improve the new M&M structure?

Fig. 3.

Final M&M format.

Originally, another test was planned for Format 2, in a similar fashion to that of the first improvement cycle for Format 1. However, this was cancelled due to the COVID-19 pandemic. Instead, individuals were asked to use Format 2 individually, inputting case details into the format and then offer feedback on their experience with Format 2.

This work was carried out within a small general surgical department; this was reflected in survey response numbers and thus significance and error calculations could not be carried out.

3. Results

3.1. Literature review

Sixteen studies were identified from the literature review [6–21]. Whilst there was significant heterogeneity between articles, the importance of structured and standardised meetings was highlighted throughout the literature [12,13,15,21,22].

As part of a standardised structure, there was an emphasis on structured error analysis however, evidence of the most effective analytical tools was limited [12,15,20,21]. Sellier et al noted that only 30% of M&Ms utilised some form of structured analysis of cases [20]. Despite often being overlooked, structured analysis was demonstrated to reduce blame and improved the perceived effectiveness of M&Ms, promoting open, honest and engaging discussion and learning [12,15].

Whilst structured analysis was uncommon, a Fishbone framework was highlighted in the literature as a possible tool for analysis [12,15,20,21]. The literature contained almost no information about how analysis tools were put into practice and the evidence available was unable to suggest which method was most effective [15,21]. As a result, our modified Fishbone framework was created. The London Protocol was incorporated to tailor the Fishbone to a medical setting. In addition to the results of the literature review, the Fishbone framework was known to be easy to use, required little training and is particularly effective at analysing complex multifactorial events [5].

The literature also highlighted common barriers experienced at M&Ms, which included the perception of blame of individuals and failing to gain multi-disciplinary team (MDT) input [6,10,13,15,18,20,21].

3.2. Survey 1

Survey 1, assessing the pre-existing format, was completed by six doctors, all working in the general surgery department. The survey highlighted current strengths and weaknesses of the existing M&M. The respondents believed that meetings were already interactive (83%, 5/6 respondents) and engaging (83%, 5/6 respondents), and 67% (4/6 of respondents) agreed that meetings were blame-free. However, there was also agreement (83%, 5/6 respondents) that M&Ms were not particularly inclusive, especially of the whole multi-disciplinary team including allied health professionals. The survey respondents also confirmed a lack of standardisation during meetings.

3.3. Format 1

The results from Survey 1 and the literature review were used to create a new methodology for M&Ms (Format 1). Whilst functional, the original format lacked a structured approach to identify factors that contributed to errors. As a result, a Fishbone framework was combined with the London Protocol and used to aid a process of root cause analysis. This ensured that errors could be analysed in a more standardised fashion, thus shifting blame from individuals to environmental, system and organisational factors, which can often be overlooked and contributory. The standardised and systematic error analysis using the new methodology meant that errors were more clearly understood, individual blame reduced, and improvements could be made that would prevent recurrence of errors.

3.4. Format testing

During the first cycle of testing, two cases were presented using Format 1. After becoming familiar with Format 1, a second survey was conducted of participants (Survey 2). This was completed by the eleven meeting attendees. Attendees were all doctors working in general surgery, ranging in grade from foundation doctors to consultants.

100% of respondents (11/11 respondents) agreed or strongly agreed that the new structure was more interactive and engaging. All participants also agreed or strongly agreed that the discussion was also more structure with a more open discussion and reduction in blame.

55% (6/11 respondents) participants stated that the modified Fishbone framework was the best aspect of the M&M. Other participants liked other aspects of the meeting, including discussion as a means of identifying areas for improvement (27%, 3/11 respondents) and the clearly identified timeline of each case (9%, 1/11 respondents).

Format 1 utilised a simple standardised format that presenters and participants could use for any error to effectively analyse errors and their causative factors in detail. The Fishbone framework was clearly instrumental to simply errors and guide discussion, and this was reflected in the feedback received. Format 1 dramatically improved staff perception of the M&M, as indicated in Survey 2, improving discussion and engagement, ultimately increasing education for participants. Furthermore, the Fishbone framework successfully broadened error analysis and highlight areas for improvement.

With the feedback from participants in Survey 2, improvements to Format 1 were made to reflect the learning from the first QI cycle. Format 2 was shorter, and elements of repetition found in Format 1 were removed. Unfortunately, M&M meetings were cancelled, and Format 2 was only tested by two participants.

The feedback from the meeting using Format 2 indicated that the modified Fishbone helped structure discussion and identification of issues. In addition, it forced participants to think “outside of the box” and include more system level failures that contributed to poor outcomes.

Format 2 utilised the same elements as Format 1, including the Fishbone framework, to increase educational value and improvement initiative opportunities. It was a simplified version of Format 1 that eliminated any repetition and streamlined the meeting. Overall, Format 2 ensured the M&M was more time efficient and ran smoothly. In the current environment of increasing demand on healthcare staff, it was important for the final M&M to provide as much value as possible in the limited time available.

Following the COVID-19 pandemic and the restarting of regular M&Ms, Format 2 has been adopted as the standard M&M format in the department.

4. Discussion

This project encompassed a literature review and a two stage Quality Improvement (QI) process. The QI methodology was based on the Model for improvement utilising multiple iterations of Deming’s Plan-Do-Study-Act cycle [1,2]. Improvement efforts focused on learning from a literature review and Survey 1 with several cycles of improvement work thereafter. At every testing stage, the improved format was well received and reported improved engagement, better quality of discussion and a more system focused approach. The final iteration of the M&M format is now the standard of practice for the department.

4.1. Error analysis

Medical errors are often a result of many small errors which do not cause harm individually however, when combined, cause harm and poor outcomes [23]. By understanding the factors that have contributed to errors, improvement initiatives can specifically target these areas, thus improving practice and preventing recurrence of errors [24].

To maximise the potential of the Fishbone framework, it was combined with The London Protocol [4]. The London Protocol is specifically designed to comprehensively understand complex, multifactorial errors using a systematic and evidence-based approach. Its structured approach ensures uniformity and consistency when approaching incident analysis. The modified Fishbone successfully enabled individuals to categorising causative factors, thus guiding analysis and future improvement work for M&M participants.

4.2. Structure standardisation

Standardisation of case presentations is both recommended and the norm for most M&Ms, however there is significant variation between meetings [7–9,13,15,19,22]. To ensure that M&Ms can meet their goals of education and improvement, it is critical that a formal process of error analysis occurs. Whilst often being overlooked, structured analysis also reduces blame and improves the perceived effectiveness of M&Ms [12,15].

A template PowerPoint was created to ensure standardisation. Secondly the modified Fishbone framework supported standardisation during error analysis. The Fishbone guided presenters and the audience to analyse errors in a detailed and consistent approach.

4.3. Blame

In addition to changing the basic structure of the M&Ms, it was important to understand the common barriers to effective M&Ms and solve these problems accordingly. Blame is a common issue in M&Ms, resulting in reduced participation and education [15,20,21]. Fundamentally, M&Ms should be non-punitive to facilitate open, honest and engaging discussion. Participants did not comment on levels of blame during the QI process, however Survey 1 indicated that the existing format did not include a significant blame element. In future it would be useful to focus on collecting more detailed information about how the levels of blame were perceived with multiple cycles of improvement.

Much like the literature, results from survey supported the idea that some level of anonymisation (which was already a feature of the M&M), reduced the feeling of blame [6,7,16]. Anonymity aims to create a system-focus, however survey results suggested that there are multiple ways to achieve a system-focused M&M, namely the modified Fishbone framework contributed significantly to participants perception of a system focus. The modified Fishbone framework encouraged depersonalisation of events. Its system-based focus highlighted how individuals had been failed by a system, which had then resulted in patient harm, rather than the specific failings of individuals. Whilst it inevitable that individuals will make mistakes, we should strive to improve systems to protect patients from errors [6,7,10,13,14,18,21].

4.4. Continuous improvement

As with any QI initiative, multiple cycles of improvement helped to refine the new format and ensure educational and improvement goals were met most effectively. Continuous improvement is critical in medicine to meet ever changing goals and challenges faced daily in the healthcare system. Whilst many changes were successful, there are still many areas that require further improvement.

The new M&M was developed using evidence from the literature as well as participant feedback. Common barriers experienced in M&Ms were targeted to ensure that the M&M was inclusive, non-punitive and delivered in its goals of education and improvement.

The Fishbone framework was central to the new M&M format, supporting high quality analysis of errors and helping to overcome many of the barriers and pitfalls that are commonly experienced in M&Ms. Overall, the new M&M efficiently delivered high quality education and highlighted areas for improvement, both of which should improve patient care over time. The changes to the meeting proved valuable to the team, who have maintained the structure to become normal practice.

4.4.1. Limitations

Measuring the outcomes of M&Ms posed challenges. The breadth and variety of learning that occurs during an M&M can be vast, and it was felt that surveys were the best way to collect as much data as possible. Unfortunately, surveys are susceptible to bias, and response rates can be variable, resulting in challenging analysis. Results are often ungeneralizable, particularly if response rates are low and surveys are only collected at one site. Whilst limited by lower response rates, the combination of evidence from a literature review and surveys did strengthen improvements somewhat.

In addition, the COVID-19 pandemic limited our ability to further test and refine our formats. However, following resumption of M&M meetings, Format 2 was accepted as the new standard for M&M presentations.

4.4.2. Key message

This project highlighted that by utilising simple QI tools, with relatively few iterations, there was significant improvement to a practice that has been largely unchanged since its inception. Simple but effective tools have been utilised here to ensure that education and improvement are integrated into the everyday work of participants. Perhaps most valuably, a new standardised M&M was created that gave participants the ability to analyse and categorise errors, facilitating the process of improvement, thus preventing error recurrence, and protecting patients.

5. Conclusion

Errors are an inevitable part of medicine. Unfortunately, patients are often the ones who are most affected by these errors. To prevent these mistakes from recurring, we must consistently and methodically learn and adapt from errors.

This project created a standardised methodology that encouraged critical reflection and constructive cooperation. The modified Fishbone framework ensured that all errors could be analysed in a systematic and consistent manner. Furthermore, it guided participants to easily identify and discuss areas for improvement which could then be implemented to protect patients from errors. Ultimately these simple changes have the power to improve patient care in a long-term and sustainable manner.

5.1. Implications

The features utilised in this M&M are highly transferrable to other M&Ms. Improvements made to this M&M helped to overcome just some of the barriers commonly experienced by M&Ms globally. Therefore, we encourage others who want to improve their M&M or who are facing such issues to trial some of the tools used in this project.

Footnotes

Ethical considerations

This project formed part of an Individual Research Project of a fourth-year medical student, following all guidelines set by Brighton and Sussex Medical School. The project was peer reviewed by the Individual research project committee at BSMS and it was established that no need for a submission to the Ethical committee was required for this quality improvement project. The student had no prior affiliations to the hospital but was supervised by a Consultant General Surgeon (as required by the university). All participants consented to involvement however the project required no formal ethical approval. All personal information from participants has been anonymised.

Conflict of interest

No conflicts of interest are declared.

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