Using the Mortality and Using the Mortality and Morbidity Conference to Morbidity Conference to Improve Patient SafetyImprove Patient Safety

Karen Cosby MDKaren Cosby MDCook County Hospital/Rush Medical Cook County Hospital/Rush Medical

CollegeCollegeICEP Academic ForumICEP Academic Forum

What is M&M?What is M&M?

Someone diesSomeone dies

Something bad happensSomething bad happens

Someone does something wrongSomeone does something wrong

Assumption:Assumption:– There was an “error”There was an “error”– It was “preventable”It was “preventable”

Why do we have M&M Why do we have M&M Conference?Conference?

It’s tradition!It’s tradition!

It’s honorableIt’s honorable

It’s good for educationIt’s good for education

It looks good for QAIt looks good for QA

What is the goal of M&M?What is the goal of M&M?

Education: A case conference with: Education: A case conference with: – mystery, intrigue, suspense!mystery, intrigue, suspense!

Learn from our mistakesLearn from our mistakes

Educate new traineesEducate new trainees

Teach accountabilityTeach accountability

Traditional M&M ConferencesTraditional M&M Conferences

Accounts for failuresAccounts for failures

Teach accountabilityTeach accountability

Education: the best Education: the best teaching hour in teaching hour in curriculumcurriculum

Sometimes results in Sometimes results in shameshame

Sometimes, a hazing Sometimes, a hazing ritual. ritual.

Education is only part Education is only part of the potential of of the potential of M&MM&M

Tradition isn’t EverythingTradition isn’t Everything

The Traditional M&M fails to realize it’s full The Traditional M&M fails to realize it’s full potentialpotential

There is more to be gained….There is more to be gained….

The Enlightened Approach to M&MThe Enlightened Approach to M&M“The DISSIS Approach”“The DISSIS Approach”

D = DiscoveryD = Discovery

I = InsightI = Insight

S = StrategiesS = Strategies

S = SolutionsS = Solutions

I = ImprovementI = Improvement

S = Satisfaction S = Satisfaction

The Enlightened M&M ModelThe Enlightened M&M Model

Acknowledges Acknowledges complexitycomplexity

Identifies human and Identifies human and system factors system factors

Encourages open Encourages open discussiondiscussion

Actively seeks Actively seeks solutionssolutions

DiscoveryDiscovery

InvestigateInvestigate

Discuss and ProbeDiscuss and Probe

Allow new facts to Allow new facts to surfacesurface

Appreciate complexity Appreciate complexity of caseof case

Include cognitive and Include cognitive and system factors to be system factors to be discovereddiscovered

The Question of Anonymity: ?The Question of Anonymity: ?BenefitsBenefits

ProtectiveProtective

Preserves Self-EsteemPreserves Self-Esteem

May remove defensive natureMay remove defensive nature

The Problem with AnonymityThe Problem with Anonymity

Limits fact finding and discoveryLimits fact finding and discovery

Limits insightLimits insight

Encourages secrecyEncourages secrecy

Adds to shame, fearAdds to shame, fear

Limits problem-solvingLimits problem-solving

Exposing the Clinician Who ErredExposing the Clinician Who Erred

Allows conversationAllows conversation

Provides a more balanced view of the Provides a more balanced view of the error (for audience and clinician)error (for audience and clinician)

Audience can help moderate tendency Audience can help moderate tendency toward maladaptive behaviortoward maladaptive behavior

There is some opportunity for absolution There is some opportunity for absolution

Insight: The “Aha!” MomentInsight: The “Aha!” Moment

Full discovery of factsFull discovery of facts

Audience discussionAudience discussion

Expand audience to Expand audience to cross disciplines and cross disciplines and rolesroles

May provide the best May provide the best learning opportunitylearning opportunity

Insanity: Doing the same thing Insanity: Doing the same thing over and over again and over and over again and

expecting different results. expecting different results.

Albert Einstein (attributed)Albert Einstein (attributed)

Strategies and SolutionsStrategies and Solutions

How can we do better?How can we do better?

Each case should have:Each case should have:– A lesson for medical decision-makingA lesson for medical decision-making– A system problem to pursueA system problem to pursue– A planA plan

Optimizing M&M Conference to Optimizing M&M Conference to Drive ImprovementDrive Improvement

Use Group Dynamics to solve problemUse Group Dynamics to solve problem– Fresh ideasFresh ideas– Creative solutionsCreative solutions– Forge alliancesForge alliances– Promote teamworkPromote teamwork– Foster collaborative spiritFoster collaborative spirit

An “expert” to offer guidance and adviceAn “expert” to offer guidance and advice

Optimizing the M&M Conference to Optimizing the M&M Conference to Drive ImprovementDrive Improvement

Identify System Identify System Factors in every caseFactors in every case

– Can you design a Can you design a system that could help system that could help another person avoid another person avoid the same error?the same error?

When the problems are really big…When the problems are really big…

M&M can serve as a meeting groundM&M can serve as a meeting ground

Neutral academic settingNeutral academic setting

Fascinating case discussionFascinating case discussion

Allows heroes to emerge: Allows heroes to emerge: – new policynew policy– new agreementsnew agreements

The Multidisciplinary M&MThe Multidisciplinary M&M

Target and assemble the right audience: Target and assemble the right audience: power players who can make changepower players who can make change

Collect the cases:Collect the cases:– 1 case is interesting1 case is interesting– 2 cases seem like bad luck2 cases seem like bad luck– 3 cases make a pattern that can’t be ignored3 cases make a pattern that can’t be ignored

State the problemState the problem

Ask for a solution! Ask for a solution!

Special Cases: Better by DesignSpecial Cases: Better by Design

Multidisciplinary M&MS:Multidisciplinary M&MS:Ectopic Ectopic

RLQ pain in womenRLQ pain in women

Aortic dissectionsAortic dissections

Abdominal pain in the elderlyAbdominal pain in the elderly

Look for the problem in YOUR institutionLook for the problem in YOUR institution

ImprovementImprovement

State what’s been done to address issues.State what’s been done to address issues.

Existing problems that need fresh Existing problems that need fresh solutionssolutions

Recruit your audience to find solutionsRecruit your audience to find solutions

Changes role of the individual from Changes role of the individual from passive, enduring punishment to active passive, enduring punishment to active problem-solver. problem-solver.

SatisfactionSatisfaction

There is nothing more painful than the There is nothing more painful than the shame of failure made publicshame of failure made public

There is nothing more invigorating than There is nothing more invigorating than meeting a challenge and solving a tough meeting a challenge and solving a tough problemproblem

M&M Can Be:M&M Can Be:

A rational approach to solving real A rational approach to solving real problemsproblems

Done well it will :Done well it will :– Provide good medical educationProvide good medical education– Give insightGive insight– Find creative solutions to real problems.Find creative solutions to real problems.– Teach clinicians a healthy approach to Teach clinicians a healthy approach to

managing medical error.managing medical error.

Long Term GainLong Term Gain

Traditional M&M teaches accountability, Traditional M&M teaches accountability, but creates shame.but creates shame.

The Enlightened M&M teaches life-long The Enlightened M&M teaches life-long strategy for dealing with error, a healthy strategy for dealing with error, a healthy constructive approach to real life practice.constructive approach to real life practice.

One approach documents error; the other One approach documents error; the other changes things for the better. changes things for the better.

““Failure is not an option”Failure is not an option”

Gene KranzGene Kranz

Every failure is an opportunity Every failure is an opportunity for improvementfor improvement