Evaluation of the Implementation of a Quality Improvement Program Through Morbidity and Mortality Reviews

Study Overview
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Brief Summary
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Morbidity and mortality reviews represent an opportunity to discuss adverse events and healthcare issues. Aim is to report the first experience of implementing a standardized procedure of morbidity and mortality reviews, and assess its impact on quality improvement.

Detailed Description
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From July 2019 to December 2019, members of the surgical and intensive care unit departments designed and implemented a regular procedure of morbidity and mortality reviews. Cases of severe postoperative complications after curative resection for digestive cancer were selected to be presented by a surgical resident and discussed in an interdisciplinary conference following a standardized presentation based on an analysis tool adapted from the ALARM framework. Process was assessed by the number of morbidity and mortality reviews held, number and type of recommendations issued and implemented. Among 13 serious complications during the study period, 10 were discussed. The Tasks category was activated in 90% of the cases where lack or misuse of protocols was identified in 90% of the events discussed. Test results availability or accuracy were incarnated in 30% of cases. Poor communication was a contributing factor in 60% of the cases. Written medical records were defective in 40% of the cases. From 16 recommendations for improvement emitted, 87.5% (14/16) were translated into projects and successfully implemented. Thus, a standardized and regular procedure of morbidity and mortality reviews in a tertiary care facility in a developing country allowed a significant improvement in patient care through quality initiatives implementation. Morbidity and mortality reviews might be a strong tool for the improvement of surgical care particularly for low-mid income countries

Official Title
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Evaluation of the Implementation of a Quality Improvement Program Through Morbidity and Mortality Reviews in a Developing Country

Conditions
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Quality Improvement

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: severe adverse events defined as postoperative morbidity > 3a according to the Clavien Dindo grading system within the first 90 postoperative days of surgery Cases discussed in a morbidity and mortality review Exclusion Criteria: Cases not discussed in a morbidity mortality review
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Process assessment | evaluation of the number of MMRs, numbers and categories of identified contributing factors, number and types of recommendations and number and types of implemented recommendations. | one year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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morbidity and mortality reviews, implementation, quality improvement, patient safety