Interdisciplinary Quality Improvement Conference: Using a Revised Morbidity and Mortality Format to Focus on Systems-Based Patient Safety Issues in a VA Hospital: Design and Outcomes.

The Veterans Healthcare Administration (VA) has embraced patient safety and quality improvement in the quest to improve care for veterans. The New Mexico VA Health Care System introduced a new morbidity and mortality conference, called the Interdisciplinary Quality Improvement Conference (IQIC), using patient case presentations to focus on underlying systems in the clinical care environment. The revised conference design also effectively teaches the 6 Accreditation Council for Graduate Medical Education (ACGME) core requirements for resident education. A formal process was established for case selection, presentation, systems issue identification, tracking, and follow-up. The IQIC has enabled the identification of more than 20 system issues at the study institution. Outcome data show lasting improvement in system issues that were addressed by this mechanism. The VA IQIC is an effective method to both identify and correct systems issues that affect patient care and is an effective method for teaching residents the 6 ACGME requirements for residency education.