Implementing Quality Improvement to Morbidity and Mortality Conferences: Focusing on Action Plans By Closing the Loops with Timely Follow Ups

Introduction

Morbidity and Mortality (M&M) meetings are often part of the medical curriculum for doctors in training where junior doctors present cases for reflection on diagnostic or treatment decision-making, and in return they attain clinicopathological wisdom. Studies have shown that for M&M meetings to facilitate improvement, they need to be structured and systematic in reviewing and discussing sentinel events, directing discussions towards improving system and process variations. Often, the structure of M&M meetings led to a lack of organizational learning and accountability. We sought to restructure the traditional M&M process in our department and utilize this process as a Quality Improvement initiative. Using a structured follow up process as a “closing the loop” mechanism, we wanted to assess what impact this would have on the original emphasis of the meetings and on professional learning.

Setting and Objective

M&M conferences are held at monthly Hematology & Oncology division meeting attended by fellows, senior staff physicians, advanced practice providers, nurses, pharmacists, and administration members. A case is curated and presented to the group by one of the Hematology and Oncology Fellows on a rotational basis. Guests from other divisions are invited depending on the cases being discussed. The hospital's peer review coordinator facilitates the coordination among stakeholders before and after the conference. Typically, these discussions result in fruitful proposals, however there was no formal process in place to implement changes and report follow up back at the M&M conferences. There were incidents where multiple similar issues were brought up in a repeated fashion creating frustration and mistrust in the system among team members.

Subajects and Methods

Consequently, an intervention was planned to streamline proposed action plans, implement them and provide updates at future M&M conferences on cases previously discussed. The process involved creating a tracking spreadsheet, each case culminated with proposed action plans. The outcome was reported three months later at the beginning of the M&M conference. This redesigning of the M&M process was carried out in a PDSA cycle fashion. This quality improvement study design was a prospective cohort study. In July 2022, a pre-intervention survey was sent to all stake holders and the same survey was sent 10 months later after completion of 10 M&M conferences in the redesigned format. The survey covered the following 5 questions:

• Rate the overall educational value of past M&M conferences that you have attended in this department.

• On average, how engaged or involved did you feel during past M&M conferences in this department?

• To what extent have prior M&M conferences in this department contributed to your ability to prevent or handle similar complications to those that were presented?

• How satisfied were you with the action plan being proposed by the end of the meeting?

• How assured were you that the proposed action plan will be followed up on after the meeting is over?

Results and Discussion

Follow-up action plans included improving access to outpatient oncology care, coordinating transition of care between inpatient & outpatient teams, providing education regarding hospital policies, communications with multiple inpatient consult services as well as outpatient affiliated infusion centers, treatment coordination with blood bank and stem cell transplant teams, feedback suggestions to improve on existing departmental policies covering anti-neoplastic chemotherapy administration. Due to anonymity of survey, there was no way to link or know if the same person took the pre survey and then completed the post survey, so we were limited in the types of analyses that we could do with the data. Nonetheless, there was a positive trend in answers to all the questions asked. Statistical significance was reached in the third question of survey as illustrated.

Conclusion

This quality improvement initiative reinforces the importance on follow through on action plans after the conference as well as the need to close the loop with follow up reporting back to the group on previously discussed cases. The hematology and oncology fellowship program at Henry Ford Hospital will implement this action plan in future conferences and will continue to address areas of improvement with regards to peer review and M & M case discussions.