# Presentation: 656924

## Patient Safety Case Conference/Modified M&M – Faculty Development

**John Gosbee**
**Ed Dunn**
**Craig Renner**
**Linda Williams**
- _[John.Gosbee@med.](mailto:John.Gosbee@med.va.gov)__[va](mailto:John.Gosbee@med.va.gov)__[.gov](mailto:John.Gosbee@med.va.gov)_**     **_[www.patientsafety.gov](http://www.patientsafety.gov/)_

## Location in our VA NCPS Curriculum Toolkit

_**Content**_
-  Patient Safety Introduction
-  Human Factors Engineering
-  Etc...

_**Alternative Education Formats**_
-   Pt Safety on Rounds (Modulettes)
-  Doc-U-Drama
**Patient Safety Case Conference (M&M)**
-  Etc...

_**Instructor Preparation**_
- Swift and Long Term Trust
-  “Selling the Curriculum”
-  Etc...

## Objectives – Modified Case Conferences

- Overview of formats that have promise
- Introduction to tools (poster and handouts)
- Key instructor skills
- Case selection
- Preparation
- “Recovery” and “redirection”

## Where is this being done?

- University of Michigan (many times/year)
- Senior Resident Morning report Sessions
- Facilitators: chief med residents and a faculty member
- Root causes and countermeasures determined
- Cleveland VA (many times/year)
- Similar to Univ of Michigan
- Modified M&M for internal medicine
- Pittsburgh VA and University of Pittsburgh
- Similar to Cleveland, but for Critical Care Medicine
- Often times with more than one case “aggregated”

## Key Preparation

- “Swift Trust”
- Tell your stories first
- Avoid saying “bad luck” or “the only time I made and error”
- Ask “what happened?”, not “who did it?”
- “Long-term Trust”
- Understand how to protect resident
- Make sure you know your VA or university “rules”
- Make a change, no matter how small, after each case

## Change M&M Conferences?

- Similar to changing/enhancing case conferences
- Differences between medical and surgical M&Ms
- Aggregation of more than one type of case
- Focus on type of vulnerability, not persons
- “Forces” teacher and learner to sharpen their point

## Key Reading and Preparation

- RCA Triage Booklet and Trainer CD
- “Tool” to lower hindsight bias, etc
- Proven to work
- More involved, but a great resource
- Dekker S. *The Field Guide to Human Error Investigation*.  Burlington, VT: Ashgate. 2002.

## Key Web Sites

- To gather ideas for flow and direction
- Web M&M (sponsored by AHRQ)
-     www.webmm.ahrq.gov

**Notes:**
See next slide for more....

## Key Web Sites

- www.mistakeproofing.com

**Notes:**
General examples of hazards and fixes
Several medical/clinical examples with pictures

## Key Web Sites

- Some medical examples with pictures

## Case Selection

- Presenter
- They need to Knows a lot about “system” detail (communication, room layout, etc)
- You need to brief them ahead of time (even if 5 min)
- Discussant/Facilitator
- Knows something about the systems issues..
- Or, works/preps with a patient safety colleague

## Balance with “Professionalism”

## Slide 13

## Morbidity & Mortality ConferenceA Forum for Improving Patient Safety?

## M & M Conference – Historical Roots

- Ernest Codman – “End Results Idea,” early 20th cent.
- End Result Card – annual update (Sx, Dx, Rx plan, complications)
- ACS Standards Committee 1916
- Intense opposition from physicians
- Anesthesia Mortality Committee 1935 – Philadelphia
- Multi-institutional review group
- Precursor to M & M: “share knowledge about fatalities from anesthesia and other interesting anesthetic situations.”
- Anesthesia Study Commission – 1940
- Expanded to include non-fatal complications
- Included “all physicians, residents, and interns”

**Notes:**
From	 Orlander, J. et al. The Morbidity and Mortality Conference: The Delicate Nature of Learning from Error. Acad. Med. 2002; 77:1001-1006.

## Historical tensions inherent in the roots of the M & M conference remain relevant today: Need for Learningv.Fear of Incrimination

## Codman’s concept: Improve medical practice by the examination of experience

**Notes:**
This concept remains true today and is the foundation for M & M conferences and Quality Improvement initiatives. This was the original intent behind the Peer Review laws in 49/50 states. 

## Cross-sectional Study of M&M conferences in 4 hospitals

- Prospective survey of 332 M&M conferences in 4 hospitals (UCSF MC, SF VAMC, SF Gen. Hospital, Stanford Univ. MC) – 7/2000 to 4/2001
- Internal Medicine – 100
- Surgery - 232
- Outcome measure: frequency of presentation of adverse events, discussion/analysis of patient safety issues
- Study conducted by trained physician observors

- *Pierluissi, R et al. Discussion of Medical Errors in Morbidity and Mortality Conferences. JAMA 2003; 290: 2838-42.

**Notes:**
Adverse Event defined as an unintentional, definable injury that was a result of medical management and not a disease process.
Error defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

## Results of M&M Survey*

| Finding | Medicine | Surgery | P Value |
| --- | --- | --- | --- |
| Case presentation & discussion | 34 min. | 12 min. | 0.001 |
| Invited speakers | 43% | 0% | <0.001 |
| Audience discussion | 15% | 37% | <0.001 |
| Adverse events presented | 37% | 72% | <0.001 |
| Errors caused adverse event | 48% | 77% | 0.02 |
| Errors attributed to specific cause | 38% | 88% | <0.001 |
| Individual or team attribution of errors | 75% - 6/8 | 85%- 63/74 | - |

- *Pierluissi et al

## M&M Study Conclusions*

- Key cultural differences: Medicine v. Surgery
- Surgery: present and discuss adverse events but overemphasize role of individual and underemphasize role of systems in posing solutions
- Medicine: infreq present adverse events; M&M more an academic/didactic exercise; overemphasize role of individual
- Similarities between Medicine & Surgery
- conference leaders fail to model error acknowledgment and link discussion to patient safety education and local improvement work
- Both missed opportunities for learning to improve patient safety

- *Pierluissi et al

**Notes:**
For Surgery M & M conferences, ACGME requires presentation of “all deaths and complications” on a weekly basis. 
For Medicine M & M conferences, there is no such ACGME requirement.0

## Orlander reported that 80% of 295 responding Internal Medicine program directors believe that M & M “cases were most often selected because of adverse events or suspected error.”(37% in Pierluissi’s data)

- *Orlander, J. et al. The Morbidity and Mortality Conference: The Delicate Nature
- of Learning from Error, Acad. Med. 2002;77:1001-1006.

**Notes:**
Are Internal Medicine Program Directors out of touch with reality re: their M & M conferences? Responders from 295 program directors in this study were in stark contrast with what was observed in Pierluissi’s observational study of 4 San Francisco Bay area academic medical centers. Perhaps Orlander’s findings reflect a difference between what is desired rather than actual performance – not uncommon with administrative leadership in health systems. There is often a disconnect between the blunt and sharp end of health care re: what is really happening in hospitals.

## Slide 22

## M&M Conference – Forum for Educational Change

**Only time of the week** staff and residents assemble in formal interactive session
- Dept clinical knowledge on display – **“debunk folklore”**
- Develops **organization and presentation skills**
**Venue for testing ideas** and educational techniques
- Opportunity for integrating **“systems thinking”** to PC
- Vehicle to implement “**small team approach**” to PC – same skills for hand-offs, cross coverage, sign-outs
- No need for high level **funding**
- Medical **student recruitment** tool
- Year-long **curriculum** for entire department
- Enhanced **educational value** counters restricted work hours

## M & M Matrix*

- Report events to create a “story” of what occurred
- Report events in a manner that seeks the meaning of the story**
- Develop recommendations for improvement
- Implement lessons learned
- Track the changes and gauge their effect

- *Gordon, LA “Can Cedars-Sinai’s M & M Matrix save surgical education?” Bulletin of ACS, Vol. 89, No. 6, June 2004
- ** Need RCA to bridge #2 and #3

## Next

- Walkthrough a guide book and a documentation card for learners (20 min)
- Linda Williams
- Small group exercise (30 min)

## Patient Safety Case Conference

**Step #1 – **

**From: *****Who done it?***

**To: *****What caused it?***

**Notes:**
Stepping through the Patient Safety CC Card Guide
A Change from linear thinking to systems thinking
What keeps us from systems thinking? – see pictures

## 65 y.o.  - mild chest pain
R/o MI – tests – inconclusive  
Transferred via ambulance  - increased distress          unstable angina, possible MI,         bypass 

- 65 y.o.  - mild chest pain
- R/o MI – tests – inconclusive
- Transferred via ambulance  - increased distress          unstable angina, possible MI,         bypass

- Patient Safety Case Conference

**Step #2 – **

**Noisy environment**

**Monitor malfunction?**

**New equipment – **

**Travel distance**

**Training required?**

**Notes:**
ROS

## Patient Safety Case Conference

**Step #3 – **

**Notes:**
Reminders about teaching points and evaluation of the relative strengths of action types.

## Patient Safety Case Conference

**Assignment:  Conduct a Patient Safety Case Conference **

**Comments and questions will take the discussion in a direction that will reveal systems issues.**

**Goal:**

**Notes:**
Simulation and Pre-testing
And
Real World Testing
If JG doesn’t say something about having the authoritative presence open the conference...do that first

The rules:  (a) is a resident presenting the case – reads the case, but reveals supplementary details only if asked
		(b) is the conference moderator/facilitator [Attending, Chief or Chief Resident]
		Everyone else – PS CC attendees

## References

- Gosbee JW, Anderson T.  Human factors engineering design demonstrations can enlighten your RCA team.  *Quality & Safety in Health Care*.  2003; 12: 119-121. _[http://qhc.](http://qhc.bmjjournals.com/cgi/content/abstract/12/2/119?etoc)__[bmjjournals](http://qhc.bmjjournals.com/cgi/content/abstract/12/2/119?etoc)__[.com/](http://qhc.bmjjournals.com/cgi/content/abstract/12/2/119?etoc)__[cgi](http://qhc.bmjjournals.com/cgi/content/abstract/12/2/119?etoc)__[/content/abstract/12/2/119?](http://qhc.bmjjournals.com/cgi/content/abstract/12/2/119?etoc)__[etoc](http://qhc.bmjjournals.com/cgi/content/abstract/12/2/119?etoc)_
- Beauregard MR, Mikulak RJ, McDermott RE. The Basics of  Mistake-proofing.** **1997. New York: Quality Resources.
- Dekker S. *The Field Guide to Human Error Investigation*.  Burlington, VT: Ashgate. 2002.