Editor's Note: The online version of this article contains a figure depicting an example internal medicine morbidity and mortality conference case.

Introduction

The morbidity and mortality (M&M) conference has been an integral component of residency education for nearly a century.1–3 Over time, M&M conferences increasingly focused on physicians' reflections on how care was delivered, often in a punitive environment.4–6 More than a decade ago, the Accreditation Council for Graduate Medical Education (ACGME) and Institute of Medicine (IOM) recommended increased focus on systems-based practice (SBP), suggesting that trainees “demonstrate an awareness of and responsiveness to the larger context and systems of health care” and use health care system resources to improve the quality and safety of patient care.7–9 Because the M&M conference provides a forum for discussing adverse events, this conference has been identified as a venue to promote education in SBP.10,11

Despite the ACGME and IOM recommendations, the discussion of adverse events, medical errors, or SBP in M&M conferences has remained infrequent.10,12 In a multicenter analysis of M&M conferences, fewer than 40% of internal medicine M&M conferences included an adverse event.12 Since the ACGME recommendations, several studies report that M&M conferences can be used to identify adverse outcomes and initiate system changes.13–15 However, only 2 articles16,17 have described the steps taken to design and implement a multidisciplinary M&M conference with a focus on SBP (hereafter referred to as a “systems-focused” M&M conference), and these works presented only general guidelines for the process or targeted use in underserved countries. Furthermore, while trainee and faculty perceptions and attitudes toward M&M conferences have been evaluated before the ACGME and IOM recommendations, they have not been evaluated in the context of systems-focused M&M conferences.18,19

In a prior study, we describe the well-integrated systems-focused M&M conference at the Beth Israel Deaconess Medical Center (BIDMC) residency program.10 Using it as a model, we established a new multidisciplinary, systems-focused M&M conference at the University of Pittsburgh Medical Center (UPMC), a large academic medical center without a preexisting M&M conference. In this article, we describe the steps taken to implement the conference. We evaluated the frequency of adverse events, SBP discussion, allocation of blame, multidisciplinary attendance, and the change in interns' perceptions after experiencing 1 year of M&M conferences. Following implementation of the systems-focused M&M conference, we additionally assessed trainee and faculty attitudes and perceptions regarding this conference series.

Methods

UPMC is a large academic, tertiary care center with numerous ACGME-accredited training programs, including an internal medicine residency program with 156 residents. In 2009, deficiencies in resident perceptions of patient safety culture were identified, including communication openness, teamwork, handoffs, and frequency of adverse events reported.20 To advance resident and faculty education in SBP and initiate improvements in the patient safety culture, a planning committee was formed to implement a new M&M conference. The committee, consisting of curriculum committee leaders, residency program directors, a faculty member (G.M.B.) with training in quality improvement, and a medical education fellow (J.D.G.), was charged with the goal of fostering a safer health care system by increasing SBP discussion surrounding adverse events. The specific aims were to develop an M&M conference that (1) included adverse events, medical errors, or near misses; (2) was multidisciplinary; (3) had a strong SBP focus; (4) was free of individual blame; and (5) balanced medical and SBP learning objectives. table 1 and the following sections describe approaches taken to achieve these aims, strategies used to overcome challenges, and metrics used to measure success.

TABLE 1 Resources and Strategies for Preparing a Multidisciplinary Systems-Focused Morbidity and Mortality Conference

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Results

Adverse Events, SBP Discussion, and Allocation of Blame

We analyzed all 9 M&M conferences presented during the 2010–2011 academic year. All 9 cases presented an adverse event and included SBP topics, with 6 of 9 cases resulting in system-wide changes (table 2). The percentage of questions asked by the moderator and audience relating to SBP issues was 58% and 74%, respectively. The percentage of comments stated by the moderator and audience members relating to SBP issues was 87% and 80%, respectively. Interrater reliability among the 2 reviewers for the distinction of SBP from non-SBP content was high (κ  =  0.81). Reviewers determined that explicit blame of an individual occurred in 0 of 9 M&M conferences, while implicit blame occurred in 3 of 9 M&M conferences (33%, κ  =  1.0).

TABLE 2 Internal Medicine Morbidity and Mortality Conference Topics, Systems Issues Discussed, and Hospital Improvements Occurring as a Result of Case Presentations in 2010–2011 at the University of Pittsburgh Medical Center

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Interns' Pre-M&M and Post-M&M Conference Assessment

Sixty-four percent (43 of 67) completed the preacademic year assessment survey and 56 (84%) completed the postacademic year assessment survey (table 3). Compared to the preacademic year assessment, on the postacademic year survey, interns felt more strongly that the purpose of an M&M conference was to improve hospital systems (4.35 versus 4.71, P  =  .02); complications and deaths were discussed objectively without blame (3.81 versus 4.34, P  =  .01); they were more able to identify systems failures (3.70 versus 4.04, P  =  .01); and faculty discussants provided good role models for dealing with medical errors (3.91 versus 4.43, P  =  .001). Additionally, significantly fewer interns felt that identifying systems failures is solely the task of quality improvement/patient safety personnel (4.02 versus 3.64, P  =  .05).

TABLE 3 Interns' Perceptions Before and After 1 Year of Systems-Focused Internal Medicine Morbidity and Mortality (M&M) Conferences in 2010–2011 at the University of Pittsburgh Medical Center^a,b

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Faculty and Trainee Perceptions of Systems-Focused M&M Conferences

The end-of-year survey produced 166 responses from 226 invitations (73% response rate; 46 of 66 faculty and 120 of 160 residents/fellows; table 4). Most respondents “somewhat” or “strongly” agreed that the purpose of the M&M conference is to improve hospital systems (95%), discussion of complications or adverse events at M&M conferences are without “blame” (93%), the M&M conference is important for their education (97%) and leads to a better understanding of SBP (88%), and the M&M conference is effective at improving patient safety and reducing errors (87%). Eighty-six percent of respondents “somewhat” or “strongly” agreed they would refer a case involving an adverse event to be discussed at the M&M conference.

TABLE 4 Trainee and Faculty Characteristics and Perceptions of 2010–2011 Medicine Morbidity and Mortality (M&M) Conferences at the University of Pittsburgh Medical Center^a

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Discussion

Using a well-established M&M conference as a model, we implemented a multidisciplinary, systems-focused M&M conference at a large academic medical center with a focus on adverse events and improving the health care system rather than assigning individual blame. This M&M conference model is among the first published since the ACGME and IOM recommendations for educational reform in SBP. To our knowledge, this is the first assessment of trainee and faculty perceptions regarding systems-focused M&M conferences. Our successful implementation highlights strategies in adapting such conferences more widely.

Several elements of the implementation process were crucial in achieving our objectives. First, we systematically identified and documented our program's deficiencies and need for a change in systems-focused education.20 Secondly, we relied on an M&M conference model that had already demonstrated significant inclusion of SBP principles and adapted it to our environment.10 Additionally, at the outset of our planning process, we identified goals that informed our educational strategies, anticipated challenges, and strategies to overcome those challenges. While these elements contributed to successful implementation, the full impact of a systems-focused M&M conference on the patient safety culture would have been limited without multidisciplinary involvement. The literature includes many descriptions of how departmentalized work silos prevent communication in shared systems and impact the quality of care delivered.21–26 By inviting discussants from multiple specialties, providing CME credit, and assuring a blame-free environment, we facilitated and achieved multidisciplinary participation in our M&M conference. Ultimately, a multidisciplinary approach promotes a positive safety climate that results in improved hospital performance.27

Faculty members were active participants in our M&M conferences, contributing significantly to the educational value of the conferences for both faculty and trainees. Although trainees' knowledge and skill development in SBP rely largely on teachers' skills sets, many academic faculty physicians were not trained in an educational system that highlighted SBP, which has limited the ability to propagate these important principles to trainees.22,28–30 Targeting an audience of not just trainees but also faculty allowed us to address documented difficulties in teaching SBP for CME.31,32 The discussion-based approach of M&M conferences is also consistent with recommendations that CME on SBP topics be delivered in an interactive format.33

Our approach builds on other M&M conference models that include SBP principles, including one that incorporated the ACGME competencies, another that focused on quality improvement in a developing nation, and another that incorporated root cause analyses into the M&M conferences.15–17 All resulted in an increased emphasis on systems failures and interventions. However, these models were not designed to explicitly address a culture of individual blame that can arise when adverse events are scrutinized. We directly measured SBP content in our conferences and evaluated our ability to focus on systems improvement rather than individual blame by assessing the participants' perceptions of the tone of these conferences. To our knowledge, this study is the first to describe a model for implementing a systems-focused M&M conference and verify the prevalence of SBP content and absence of explicit individual blame.

The implementation of a new M&M conference depends on numerous factors. As with any initiative, buy-in from key leadership was crucial in promoting active participation by faculty and specialty discussants. We increased attendance by providing CME credit. We recognized that although financial costs were minimal, preparation time was significant and had to be considered in the moderator's job description. We did not record moderator preparation time but estimate this to be at least 10 hours per conference, with special attention paid to the crafting language to ensure subsequent discussion of patient events was free of blame. Also, finding appropriate cases that contain systems failures is integral to conference success, as is expertise in identifying and implementing possible system-based solutions. The challenges we encountered in fulfilling our main objectives and strategies used to overcome these barriers are highlighted in table 1.

Our study has several limitations. First, the single-center implementation calls into question how well this can be replicated in other settings, and modifications may be necessary when implementing such a conference elsewhere. Although the surveys were pilot tested for content validity, the construct validity was not rigorously assessed. Lastly, we assessed trainee and faculty perceptions of the M&M conferences and did not measure more objective educational outcomes or changes in their behavior.

Conclusion

We implemented a new systems-focused M&M conference and achieved success in promoting multidisciplinary participation, presenting cases that included adverse events, and highlighting and discussing systems issues in a nonpunitive manner.