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Best practice for conducting morbidity and mortality reviews: A literature review Print E-mail


Introduction

Patch Adams MD once said of the role of doctors: "Our job is improving the quality of life, not just delaying death." That statement is truer today than ever before. Mankind now has greater means to prolong the life of patients through the use of sophisticated machines and new technologies. Nevertheless, patients do die, and sometimes they die because of avoidable medical errors. Therefore, we are duty bound to review such deaths, so that we learn from these mistakes and prevent them from happening again to another patient. As Publiliu Syrus, the Latin writer born 85 BC said: "From the errors of others, a wise man corrects his own." And the wise medical leader will want to put systems in place to ensure the health service he or she is leading learns from its own errors.

All of us are aware that preventable hospital mortality is a critical public health issue, particularly when mortalities are associated with events that are preventable. As a result, there is a clear need for medical leaders to put in place rigorous, systematic and effective processes to enable the assessment of quality of care in a timely manner. Morbidity and Mortality Reviews (MMR) provide an open, collaborative and transparent review process for clinicians to examine practice and identify areas of improvement such as patient outcomes and adverse events without fear of blame or individual focus [1-3].

Historically, MMRs are commonly conducted in surgical departments as a mode of clinical education and a way of reviewing and improving practice [4-9]. However, this process has been conducted in a variety of settings such as: acute care [10, 11], community medical centres [12], emergency departments [13], general medical divisions [1], intensive care unit [14], and palliative care [15]. In addition to this, there have been a number of investigations exploring the use of MMRs hospital-wide [16-19].

At Monash Health, we decided to examine the literature surrounding best practices for conducting morbidity and mortality reviews. Specifically we asked:
  • What outcomes have been used to evaluate MMRs (Patient centered care)?
  • What are the most common features of MMRs?
  • What are examples of tools used to facilitate MMRs

Methodology

A search of PubMed and the grey literature for documents published in English from 2009 to present was conducted (list provided on request). This time period was selected as there has been a recent comprehensive review conducted on MMRs from inception until 2009 done on behalf of the Victorian Department of Health and Human Services [20]. We have included this review in our report findings. Only documents that covered the mortality review process in a hospital setting were included however, items that included "mortality" and "morbidity" were not excluded.


Results

The search of the databases identified 827 citations of which 27 full text were retrieved. The search of the grey literature identified 256 results. Fifteen documents met the inclusion criteria. A total of 33 documents are included in this review (18 peer reviewed articles and 15 items of grey literature). The included documents are from national and international settings and cover hospital wide disciplines.


Outcomes of Morbidity and Mortality Reviews (Patient centered care)

There is very limited evidence in the literature evaluating outcomes or measurements of patient centered care as a result of MMRs It has been reported that in surgical departments, mandatory MMRs result in a 40% decrease in gross mortality over 4 years [4].

Previous reviews have described other literature on the effectiveness of specific MMR approaches and identified MMRs to be effective in identifying and engaging clinicians in system improvements, reducing deaths from cholera, and creating a safe forum for discussion of errors for junior medical staff, including removing fear of incrimination [20].

Recent research however, has identified improvement in outcomes around decreased mortality rates [10, 21], reduction in medical malpractice claims [11], clinician satisfaction [17, 18, 22], improved safety culture [19, 23], and quality of care [21, 23].


Most common features for conducting Morbidity and Mortality Reviews

The most common features identified from the literature for conducting MMRs have been summarised (Table 1), and categorised under the following headings:
  • Purpose of MMRs
  • Case selection/types of cases
  • Conduct of meetings (when the meetings are held, for how long, who leads, who attends, what type of case is presented, location, frequency of meeting, how the case is presented/analysis)
  • How the process is convened (by who, terms of reference, agendas, minutes)
  • Governance integration
  • Follow up processes of reviews

Table 1. A summary of these features is included below (specific information is available on request from This e-mail address is being protected from spambots. You need JavaScript enabled to view it )

Features Summary
Purpose of the MMR "The purpose of individual MMRs varies however the most commonly reported goals are medical management, teaching and patient safety and quality improvement. An effective MMR should: identify events resulting in adverse patient outcomes; foster discussion of those events; identify and disseminate information and insights about patient care that are drawn from experience; reinforce accountability for providing high-quality care, and create a forum in which physicians acknowledge and address reasons for mistakes." [20]
Case selection Predominantly, all mortality (sentinel events) and morbidity cases. Others cases may include: serious incidents, adverse events, close calls, complications, clinical incidents, and major complaints. In addition to these, medico-legal, cases with the possibility of quality improvement or those with some form of educational variable, including identifying cases with outstanding outcomes for discussion and case learning have also been selected as suitable for MMRs.
Previous review suggests an average of three cases per meeting [20], and recent literature supports this [22].
How the meeting is conducted
When There is no clear consensus and it is variable. Number of reported cases can determine frequency [19]. Options used are: within a week of event, whenever practical within days of the event, within 24 hours of event, weekly [1, 4, 11, 12, 15, 17, 18], monthly [1, 5, 8, 9, 11, 13, 14, 22], bimonthly [11], three-monthly [6]. There has not been empirical evaluation of timing.
How long Evidence regarding meeting duration varies however, 15 min presentation with 5 minutes questions has been implemented [8, 17]. Additionally, 30 minutes per case has also been used [18]. Of note, MMRs have been reported to go from 20 minutes up to 4 hours [1, 20].
Who leads It is suggested that leaders should have high skills and expertise in the area of morbidity and mortality cases. Leaders should be trained or have skills in auditing, ability to understand and interpret the clinical information accurately, ability to access senior medical advice, understanding of environment [2]. Leaders may include; consultants, physicians or senior doctors or nurses however, this role could be performed by any suitably trained staff member with access to senior medical advice as required.
Recent review suggests there is no fixed or determined way of convening MMRs, that is, no clear indicator as to whether they need to be convened by a designated individual or role (e.g. the head of a department), or even a set procedure for what is typically a forum. [20]
Who attends Who attends Most of the literature employs a multidisciplinary team [1, 5, 6, 11, 14-17, 19, 22].
Participants may include any of the providers involved in the care of the patient, selected experts, and others who can contribute to the analysis of the event and to the development of practical recommendations to improve patient safety[24]. These people include: Nominated Clinician (Chair), Executive Director, Medical Services and Chief Medical Officer, Director Medical Services, Program Directors, Surgery, Perioperative and Ambulatory Services, Emergency and Acute Medicine, Women’s and Children’s, Medical Unit Heads, Clinical Service Directors, Manager Operations, Risk Manager, Clinical Risk Coordinator, Pharmacy and Radiology Representatives, Clinical Coders, Obstetricians, Physicians, Neonatologist/Paediatrician, Pathologists, Laboratory technicians, Pharmacists, Nurse-midwives, Anaesthetists, public/community health professionals, hospital administrators, local statisticians, representative of local women’s advocacy group, and representative of the local health authority.
Location Generally not stated. Onsite or in a seminar lecture room have been suggested [1].
How the case is presented/analysis Case presentations vary in structure. SBAR format (Situation, Background, Assessment and Analysis, Recommendation) most structured and best evaluated [8]. Other guidelines include: presenting using a structured format, terms of reference, purpose, reporting structure, scope of activities and membership all outlines at beginning of meeting. The Chairperson is responsible for creating an atmosphere that is conducive to open discussion and should ensure all members have an opportunity to contribute; focus should be placed on identifying the issues related to any processes or systems of care that contributed to the death, and not on the individuals who provided the care. Discussions should consider if any measures may be recommended or implemented to prevent a similar incident or adverse outcome. Not all cases need to result in recommendations. Consider using a fishbone diagram or Vincent's model to assist in identifying causative factors.

Tips: Primary questions to consider for each case are:
  • What happened?
  • If there was a breach of a standard of care or an error, why did it happen?
  • What can be done to prevent a recurrence?
  • What went wrong (or right)?
  • How did it go wrong (or right)?
  • Why did it go wrong (or right)?
  • What could we do differently in future?
  • What are the key lessons for the organisation?
Tips: Important items for M&M:
  • Mandatory resident and Faculty attendance
  • Decreasing defensiveness and blame
  • Improving the efficacy of the case presentations
  • Use of slides
  • Use of radiographic images
  • Focused analysis of error
  • Focussed on facts
  • De-identified
  • Integration of evidence-based literature into the morbidity and mortality discussion
  • Providing educational points related to the complication
  • Audience participation in the process
  • Allowing for a consensus to be met with respect to analysis of the cases presented
  • Facilitation of the conference by a moderator

Tips: An effective MMR should:
  • identify key events resulting in adverse patient outcomes
  • foster open and honest discussion of those events
  • identify and disseminate information and insights about patient care that are drawn from individual and collective experience
  • reinforce system level and individual accountability for providing high quality care
  • create a forum which supports open and honest discussion through the provision of a just, patient centred culture
  • contribute to clinical governance processes
Analysis: Previous review has identified "the analysis process can be ad hoc and dependent on individual experience and “intuition” but conflicting evidence shows that there appears to be an increasing use of a range of analysis tools, including modified root cause analysis, classification processes, educational competencies, and surveys, to review adverse events and recommend follow up strategies." [20]
How the process is convened
Terms of Reference
  • MMRs have the organisational and leadership support (Appendix 3)
  • There is clear and defined terminology when describing MMRs [1]
  • Only factual information in incident/occurrence reports is provided and refrain from statements of blame, speculation, opinion or other commentary as to the reasons for what happened [24]
  • MMRs are a safe and supportive environment (Appendix 3)
  • MMRs are be consistent and reproducible (Appendix 3)
  • MMRs are not about active detection of systemic causes of harm to assist in setting improvement priorities [1]
  • Screening tools used in MMRs (e.g., root cause analysis) are essential to ensure a focus on system level issues [1]
  • MMRs have a structured process, including a framework to investigate underlying contributing factors
  • MMRs have a detailed feedback and follow up program (Appendix 3)
  • MMRs have a clear link to governance processed (Appendix 3)
  • MMR members are to determine whether the institutions' quality improvement committee is properly constituted under the relevant legislation and seek assurances that quality improvement reviews will be conducted in a confidential manner. If not, members should promote the use of properly constituted quality improvement committees [24].
Agenda There is a limited evidence regarding agenda. Some evidence to suggest that an agenda that includes appropriate documentation to inform the MMR Committee and support decision making should be circulated one week before each meeting to ensure that members have time to consider the contents and raise questions they may have before the meeting date (Appendix 3).
Minutes There is limited evidence regarding MMR minutes. There is some evidence that minutes of each meeting should be prepared, circulated and retained as the complete and formal record of each meeting of the MMR Committee (Appendix 3). The minutes of each meeting should be confirmed or amended and confirmed at the next ordinary meeting of the MMR Committee (Appendix 3).
Governance integration and Follow up There is a mixture of evidence for positions responsible for follow-up within an organisation. Generally, leadership/management should be involved in the findings of all MMRs [2, 24, 25]. Additionally, Risk/Quality teams should also be involved in the process as findings may be a result of issues with system processes [1, 2, 24]. Improvement measures determined by the MMRs should also be communicated down to the frontline staff through ward-based specialty governance and clinical management positions/staff. Leadership/management may also have a responsibility to further report the findings and recommendations to an appropriate health or regulatory authority.
A previous review has identified that: "Follow up tends to be limited to either case summary reports and or designating individual to follow up actions,...some studies have reported more comprehensive approaches including documentation of outcomes, evaluations, development of action plans, verbal updates at subsequent MMRs, written reports and tracking of actions" [20]


Examples of tools used to facilitate Morbidity and Mortality Reviews

A vast variety of tools used in the literature and by healthcare partners (e.g. checklists, etc.). Below is a list of some selected examples.


SAFE Anaesthesia Liaison Group - Anaesthesia Morbidity and Mortality Meetings: A Practical Toolkit for Improvement

Emergency Care Institute New South Wales - ED Quality Framework Death Audit

Szostek, J. H., Wieland, M. L., Loertscher, L. L., Nelson, D. R., Wittich, C. M., McDonald, F. S., ... & Reed, D. A. (2010). A systems approach to morbidity and mortality conference. The American journal of medicine, 123(7), 663-668

Bechtold, M. L., Scott, S., Nelson, K., Cox, K. R., Dellsperger, K. C., & Hall, L. W. (2007). Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. Quality and Safety in Health Care, 16(6), 422-427


Conclusion

From the evidence identified, there is no peer reviewed evaluation of the best-practice guidelines of MMRs. Furthermore, there is very limited peer-reviewed literature exploring patient-centered outcomes as a result of the MMR process. It has been reported that in surgical departments, mandatory MMRs result in a 40% decrease in gross mortality over 4 years [4]. There is evidence that indicates that MMRs are effective in identifying and engaging clinicians in system improvements, reducing deaths, and creating safe discussion forums [20].

In saying this however, there is a vast body of grey literature available that has been developed by a range of national and international healthcare partners.

From a synthesis of these evidence sources, the medical leader, be that person a Chief Executive Officer, Chief Medical Officer, Director of Medical Service, Director of Clinical Governance or Head of Quality, can set up an MMR framework based on the following principles derived from the available literature:
  • The actions of individuals should not be the focus during MMRs - rather an educational and/or quality perspective should be the focus.
  • MMRs should have clear terms of reference and these should be presented at the commencement of each meeting.
  • The MMR terms of reference should include (but not be limited to) the following:
    • That an agenda is sent out prior to the MMR.
    • That a structured presentation format is essential (e.g. SBAR).
    • That an analysis of error is conducted
    • That the MMR concludes with actions to be performed and these followed up at beginning of subsequent MMR.
  • MMRs should consist of a multidisciplinary, interprofessional team, including those who had the most contact with the patient.
  • MMR frequency is dependent on the number of cases discussed, but based on the evidence, should be approximately 2 hours per week with about 4 cases per MMR.
  • The length of each MMR case presentation should be approximately 15 minutes, with 5 minutes of questions.
  • Finally, if possible, a single standardised MMR should be implemented health service-wide guided by the key features outlined in this article.

References
  1. Higginson, J., R. Walters, and N. Fulop, Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Quality & Safety, 2012. 21(7): p. 576-85.
  2. Wales, E.C.I.N.S. ED Quality Framework. 29 July 2015]; Available from:
    http://www.ecinsw.com.au/sites/file/Standardised%20Death%20Reviews%20in%20ED%20resources_1.pdf.
  3. Robinson, G., et al., Providing assurance, driving improvement. Learning from mortality and harm reviews in NHS Wales, in Improving Healthcare White Paper Series. 2013.
  4. Antonacci, A.C., et al., A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. The Journal of Surgical Research, 2009. 153(1): p. 95-104.
  5. Berenholtz, S.M., T.L. Hartsell, and P.J. Pronovost, Learning from defects to enhance morbidity and mortality conferences. American College of Medical Quality, 2009. 24(3): p. 192-5.
  6. Marini, H., et al., Surveillance of unplanned return to the operating theatre in neurosurgery combined with a mortality--morbidity conference: results of a pilot survey. BMJ Quality & Safety, 2012. 21(5): p. 432-8.
  7. McVeigh, T.P., et al., Increasing reporting of adverse events to improve the educational value of the morbidity and mortality conference. Journal of the American College of Surgeons, 2013. 216(1): p. 50-6.
  8. Mitchell, E.L., et al., SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations. American Journal of Surgery, 2012. 203(1): p. 26-31.
  9. Pal, K.M.I., et al., Morbidity meetings: what makes it to; what stays out of the forum. The Journal of the Pakistan Medical Association, 2013. 63(2): p. 161-4.
  10. Nimptsch, U. and T. Mansky, Quality measurement combined with peer review improved German in-hospital mortality rates for four diseases. Health Affairs (Project Hope), 2013. 32(9): p. 1616-23.
  11. Chan, L.S., et al., A medical staff peer review system in a public teaching hospital--an internal quality improvement tool. Journal for Healthcare Quality, 2014. 36(1): p. 37-44.
  12. Nolan, S.W., et al., Effect of morbidity and mortality peer review on nurse accountability and ventilator-associated pneumonia rates. The Journal of Nursing Administration, 2010. 40(9): p. 374-83.
  13. Seigel, T.A., et al., Morbidity and mortality conference in emergency medicine. The Journal of Emergency Medicine, 2010. 38(4): p. 507-511.
  14. Ksouri, H., et al., Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice. American Journal of Critical-Care Nurses, 2010. 19(2): p. 135-146.
  15. Pekmezaris, R., et al., Transforming the mortality review conference to assess palliative care in the acute care setting: a feasibility study. Palliative & Supportive Care, 2010. 8(4): p. 421-6.
  16. Gupta, M., et al., Preventable mortality: does the perspective matter when determining preventability? The Journal of Surgical Research, 2013. 184(1): p. 54-60.
  17. Mitchell, E.L., et al., Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Academic Medicine, 2013. 88(6): p. 824-830.
  18. Schwarz, D., et al., Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Quality & Safety, 2011. 20(12): p. 1082-8.
  19. Sellier, E., et al., Morbidity and mortality conferences: their place in quality assessments. International Journal of Health Care Quality Assurance, 2012. 25(3): p. 189-96.
  20. Travaglia, J. and D. Debonoj, Mortality and morbidity reviews: a comprehensive review of the literature. Centre for Clinical Governance Research in Health 2009. Faculty of Medicine(University of New South Wales).
  21. Deis, J., et al., Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement, in Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). K. Henriksen, et al., Editors. 2008, Agency for Healthcare Research and Quality (US): Rockville (MD).
  22. McDonnell, C., R.M. Laxer, and W.L. Roy, Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Joint Commission journal on quality and patient safety / Joint Commission Resources, 2010. 36(3): p. 117-25.
  23. Huddleston, J., et al., Learning From Every Death. Journal of Patient Safety, 2014. 10(1): p. 6-12.
  24. Canadian Medical Protective Association, Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions. 2009.
  25. National Office of Clinical Audit. Irish Audit of Surgical Mortality. 2012 29 July 2015]; Available from: www.noca.ie.

Corey Joseph1
Marie Garrubba1
Angela Melder1
Erwin Loh2

1Centre for Clinical Effectiveness, Monash Health
2Monash Centre for Health Research & Implementation, Monash Health.




The Royal Australasian College of Medical Administrators
C. Joseph, M. Garrubba, A. Melder, E. Loh, , p759
www.racma.edu.au /index.php?option=com_content&view=article&id=775&Itemid=451
Last Updated on Monday, 21 May 2018 11:31