The Morbidity, Mortality and Improvement conference is an adaptation of previous Morbidity and Mortality conference (M&M) where a physician would present a case of theirs in which the patient had an adverse outcome. The physician would then be grilled by an audience of their peers and superiors to defend their decisions. Often they humiliated the speaker and dissuaded others from coming forward with their mistakes.

The Morbidity, Mortality and Improvement conference restructured the traditional M&M conference to emphasize improvement of processes ([^Dies-2008]). Instead of focusing on an individual and their decisions, we look at the system and how it led us to decisions. Then we focus on altering the system to lead us to better decisions. In the end, we end up with a better system and a culture where people aren’t afraid to bring up adverse events.

Checklist for your MM&I Case

• ❏ Get the MRN of a case from Patwari. We want a fairly recent case that is fresh in everyone’s mind.
• ❏ Review the case in the electronic health record. Build the thin timeline. Include your first and second year resident associates.
• ❏ Discuss the case with your faculty and nurse mentors for more insight.
• ❏ Discuss the case with the team who cared for the patient to figure out why they made the choices they did. Build the thick timeline.
• ❏ There are several documents to download, complete and send to Anna Kundis. Use the templates below and most can be filled in fairly generically.
  • Bio & Conflict Of Interest Form at least 2 weeks prior to the presentation
  • MM&I Flier at least 2 weeks prior to the presentation
  • MM&I Agenda Template at least two weeks prior to the presentation
  • MM&I Case Slides and QI Portion Slides a week to a few days prior to the presentation.
• ❏ Review your slides with Patwari at least 2-3 days prior to the presentation.

Team

The MM&I case team comprises several people:

• Third-year resident: the presenter and main driver of the team
• Second and first-year residents: help the R3 gather data and thus exposed to the process
• Faculty Advisor: faculty member who helps the R3 by providing context that may not come across in the written notes.
• Nursing Mentor: provides the nursing perspective by interviewing the involved nurses.
• QI Mentor (Patwari): provides QI perspective, reviews the presentation deck for any legal or professional tripwires.

People from whom you can get information, but aren’t part of the MM&I team.

• Other Services: you may want to consult with other services to get their perspective, protocols and expectations. You may invite them as guests of the presentation to call on as needed.
• Providers who cared for the patient: speaking with these providers is important to understand why decisions were made and what challenges existed. Given they are directly involved in the case, they should never be part of the team.

Medicolegal aspects

This information includes patient data and as such is protected under HIPAA. Do not put it in publicly available platforms such as Google Slides or Zoom. Rush’s OneDrive and Teams (or WebEx) are secure platforms we’re allowed to use. However, to be safe use as little patient identifying information as possible on any documents we create.

The entire quality improvement process should be a safe space to encourage providers to examine their errors. As such, it is protected under the Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), signed into law on July 29, 2005. However, plaintiff’s attorney’s can request these slides during discovery. Our approved slide template includes the appropriate disclaimer, but using this phrase doesn’t always protect your slides from discovery.

This document is privileged and confidential under the Illinois Medical Studies Act and should not be shared or distributed other than through the Quality Assurance Committee structure.

We separate our slides into two sets. The templates for both are available (see link above).

1. The MM&I slides includes the description of the case. Only include what you can already find in the electronic medical record. Don’t include what you discovered in your conversations with providers, your own speculation of what happened or criticisms of what could have been done. This can all be verbally discussed during the presentation, but do not write it down.
2. The QI slides are separate from the MMI slides. These should refer to no specifics from the case. In this set, we will only be referring to generalities. This set is meant to go through the QI methodology.

Recommendations for the Presentation

• We should set up the microphones & WebEx meeting
• MMI Slides
  • Introduction (1 minute): Remind the group that this is about learning and identifying systemic problems, not about blame & shame. We follow Academic Vegas rules, “What is said here, stays here. What is learned here, can leave here.”
  • Present the case (5-10 minutes): Review the case with enough detail to set up the scenario. This is not a CPC where we ask the audience for a differential or their work up. Our goal is not to dissect the case but to use the case to improve our systems. Present the thin timeline (what happened) on slides and the thick timeline (why things happened based on your discussion with providers) verbally
  • Nursing presentation: The nurse assigned to the case can summarize nursing care and provide their perspective.
• QI Slides (now switch to the other slide set).
  • Discuss the case: Review the risk profile, Just Culture algorithm, identify potential causes using a fishbone diagram with the group. 
  • Look for systemic problems and solutions: The goal of the exercise is to identify potential solutions that would prevent a similar mistake from happening again. 

References

1. Dies. Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement. Agency for Healthcare Research and Quality (US); 2008 Aug. https://pubmed.ncbi.nlm.nih.gov/21249895/