Pierre Antoine Brown1,2,3, Swapnil Hiremath4,5,6, Edward G Clark4,5,6, Edmund S H Kwok7, Christopher McCudden8, Ayub Akbari4,5,6. 1. Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. pibrown@toh.ca. 2. Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada. pibrown@toh.ca. 3. Division of Nephrology, The Ottawa Hospital, 1967 Riverside Dr., Ottawa, ON, K1H 7W9, Canada. pibrown@toh.ca. 4. Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. 5. Kidney Research Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada. 6. Division of Nephrology, The Ottawa Hospital, 1967 Riverside Dr., Ottawa, ON, K1H 7W9, Canada. 7. Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada. 8. Division of Biochemistry, The Ottawa Hospital, Ottawa, ON, Canada.
Abstract
BACKGROUND: Morbidity and Mortality Conferences (M&MCs) have for generations been part of the education of physicians, yet their effectiveness remains questionable. The Ottawa M&M Model (OM3) was developed to provide a structured approach to M&MCs in order to maximize the quality improvement impact of such rounds. STUDY DESIGN: We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3. SETTING AND PARTICIPANTS: All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate. QUALITY IMPROVEMENT PLAN: Structured M&MCs were implemented to identify preventable errors and generate actions to improve quality of care and patient safety. OUTCOMES: Number and nature of cases reviewed, number and nature of recommendations generated through identification of preventable health system and/or cognitive factors. MEASUREMENTS: Morbidity and/or mortality in each case were identified. A determination of the underlying factors and preventability of these events was made. A qualitative review of resulting recommendations was performed. RESULTS: Over the course of sixteen 1-h long conferences, 52 cases were presented. For all cases presented, discussion, action items and information dissemination followed the OM3. As a result of the M&MCs, 29 recommendations (emanating from 27 cases) lead to improve care delivery. LIMITATIONS: Limitations of this study include its retrospective nature and single-center design. CONCLUSIONS: The implementation of regularly scheduled M&MCs at an academic nephrology program, using a structured model, identified preventable health-systems issues and cognitive errors. Approximately one-half of the cases reviewed generated actions for health care delivery improvement.
BACKGROUND: Morbidity and Mortality Conferences (M&MCs) have for generations been part of the education of physicians, yet their effectiveness remains questionable. The Ottawa M&M Model (OM3) was developed to provide a structured approach to M&MCs in order to maximize the quality improvement impact of such rounds. STUDY DESIGN: We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3. SETTING AND PARTICIPANTS: All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate. QUALITY IMPROVEMENT PLAN: Structured M&MCs were implemented to identify preventable errors and generate actions to improve quality of care and patient safety. OUTCOMES: Number and nature of cases reviewed, number and nature of recommendations generated through identification of preventable health system and/or cognitive factors. MEASUREMENTS: Morbidity and/or mortality in each case were identified. A determination of the underlying factors and preventability of these events was made. A qualitative review of resulting recommendations was performed. RESULTS: Over the course of sixteen 1-h long conferences, 52 cases were presented. For all cases presented, discussion, action items and information dissemination followed the OM3. As a result of the M&MCs, 29 recommendations (emanating from 27 cases) lead to improve care delivery. LIMITATIONS: Limitations of this study include its retrospective nature and single-center design. CONCLUSIONS: The implementation of regularly scheduled M&MCs at an academic nephrology program, using a structured model, identified preventable health-systems issues and cognitive errors. Approximately one-half of the cases reviewed generated actions for health care delivery improvement.
Entities:
Keywords:
Healthcare quality improvement; Medical education; Morbidity and mortality rounds; Patient safety