Implementation and evaluation of structured nephrology morbidity and mortality conferences: a quality education report

Pierre Antoine Brown, Swapnil Hiremath, Edward G. Clark, Edmund S. H. Kwok, Christopher McCudden, Ayub Akbari

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. We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3. All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate. Structured M&MCs were implemented to identify preventable errors and generate actions to improve quality of care and patient safety. Number and nature of cases reviewed, number and nature of recommendations generated through identification of preventable health system and/or cognitive factors. 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. 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 of this study include its retrospective nature and single-center design. 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.