Assessment of the contribution of morbidity and mortality conferences to quality and safety improvement: a survey of participants’ perceptions

Morbidity and mortality conferences (MMCs) were established in the United States at the beginning of the 20th century and have become a relevant part of physician education [1]. They were initially set up by surgeons and anaesthesiologists and became a way to fulfill the mandatory requirement for assessment of physicians’ practices. With the emergence of the management of patient safety in the healthcare system in the 1990s, several authors suggested that MMCs could be conducted to improve the quality and safety of healthcare [2]. In this context, MMCs were adopted in France. In 2010, the French health authorities decided to make MMCs mandatory in high-risk specialties such as surgery, anaesthesia, intensive care and oncology. Fulfilling this commitment was a key factor in the accreditation of hospitals.

Therefore, MMCs are now widely implemented in hospitals, but evidence of their effectiveness in improving patient safety is lacking. Numerous authors have found that the characteristics of MMCs varied greatly [3‐5] with variations in their goals, their structures, and their processes.

The best evidence of the effectiveness of MMCs would be to demonstrate an effect on a patient-related outcome. However, this approach presents methodological issues and very few studies have concluded in a significant effect of MMCs on a clinical outcome [6‐8]. Considering the wide variety of situations, choosing and using a patient-related outcome is difficult. Where this is possible, the low incidence of specific events would lead to a lack of statistical power [9]. In this context, several authors estimated the effectiveness of MMCs indirectly through the perception of the participants in these meetings [4, 10, 11]. They assessed their functioning and their impact in terms of knowledge or improvement of practices. Some authors emphasized the wide variety of leadership structures and the perceived effectiveness [4]. They suggested that a formalized framework should lead to a better perception of effectiveness and more satisfying MMCs [4, 10, 11].

The present survey focused on the functioning of MMCs, the perception of their benefits by the participants, especially concerning healthcare quality and safety improvement, the personal motivations of participants, and suggestions for improvement. The main objective was to assess the participants' opinion concerning the effectiveness of MMCs as a tool to improve patient safety. Within a secondary objective, we identified the characteristics of MMC functioning associated with the perception that the MMC produced benefits.

Most of the respondents agreed totally or partially that the meeting was managed satisfactorily (89.9 %, n = 617) and was non-blaming (86.1 %, n = 589). More than 80 % of the respondents agreed totally or partially for each benefit proposed, except improvement of the relationship between medical and paramedical teams (60.6 %, n = 421).

Considering only respondents who totally agreed, the perceived benefits were mainly quality of care improvement and patient safety improvement (Table 1). Personal motivations to participate in MMCs were also most often related to improvement of individual and team practices. Only a minority of participants totally agreed with the suggested areas for improvement. The highest proportion of agreement concerned the increase of paramedical professionals’ participation. There were significant differences in opinion of the various occupational groups, especially for the perceived benefits. Senior physicians and paramedical professionals had a better opinion of the benefits than did residents. Personal motivations also differed with senior physicians more often motivated by improvements in practices than residents. Senior physicians more frequently agreed that MMCs were associated with an educational aspect for initial and continuing education. They more often suggested improving the case analysis method. Paramedical staff more often acknowledged the benefits in terms of practices and improvements of organizational and relational aspects. Paramedical personnel also more often agreed with increasing the participation of the paramedical staff.

There were also differences in the perceived benefits of MMCs, depending on the specialty of the department. MMCs in medical specialties had a greater perceived impact on the relationship between medical and paramedical teams (29.5 % versus 20.9 %, p = 0.03). Surgical MMCs had a greater perceived impact on initial education (45.8 % versus 33.3 %, p < 0.01). Participants in MMCs in anaesthesia/intensive care units were less likely to consider their MMC as non-blaming (27.7 % versus 38.2 %, p = 0.03).

The characteristics of MMCs significantly associated with a better opinion were the prior dissemination of the meeting agenda, the existence of a written charter, the use of a standardized case presentation, the examination of failures during the discussion, and fewer cases presented (Table 2). In addition, a better opinion was significantly associated with a higher effectiveness index based on planning, implementation, and assessment of improvement initiatives.

A greater perception of benefits in terms of continuous training was associated with the use of standardized case presentations (48.4 % versus 34.3 %, p < 0.01), a higher effectiveness index (48.2 % versus 36.8 % %, p < 0.01), and more decisions on initiatives (47.2 % versus 35.2 %, p < 0.01).

Participants from MMCs with a greater effectiveness index more frequently perceived benefits in terms of continuing education (48.2 % versus 36.8 %, p < 0.01), standardization of practices (51.3 % versus 39.4 %, p < 0.01), and application of guidelines (41.6 % versus 33.3 %, p < 0.01).

In multivariable analysis, a thorough analysis of the causes of failures was independently associated with a greater perception of improvement of patient safety (Table 3).

A total of 110 respondents (15.8 %) wrote a comment after having answered the structured questionnaire. Fourteen highlighted the value of MMCs and three others underscored the high rate of physician attendance. Most of them (31) emphasized a low participation rate for several professional categories, especially anaesthetists in surgical wards and paramedical professionals. Another topic related to improvement of case selection with 14 comments. In particular, ten participants suggested reviewing more relevant cases. Concerning the organization of MMCs, 12 comments highlighted the lack of time available for healthcare professionals. Four professionals described an open and friendly environment, whereas eight described a blameful environment with conflicts and subjects that could not be debated.

Finally, a lack of a structured analysis of cases was reported. According to the respondents, the follow-up of initiatives should be improved as well as information provided outside the committee. A lack of involvement from the hospital administration was also pointed out.

Participants mostly agreed that MMCs were beneficial in terms of healthcare quality and safety improvement. MMCs were perceived as beneficial for teamwork and the functioning of the unit. The improvement of practices and organization seemed to be the main objective perceived by the participants. Moreover, an educational role, for initial and continuing education, was perceived by most participants, particularly by the senior physicians. Most of participants were satisfied with MMCs and experienced a friendly and non-blaming environment.

The search for failures and the discussion of errors are well-documented opportunities for improvement of safety and education [2, 14]. The present results suggest that the analysis of these failures was perceived as determinant in improving patient safety. However, without a thorough analysis, this discussion seems to result in a blaming environment that is incompatible with constructive discussion [6, 15‐18]. Indeed, personal failures are often spontaneously discussed first. To overcome personal accusation and to develop a system-wide approach, a thorough analysis should be carried out using a systematic analysis method such as the protocol of the Association of Litigation and Risk Management (ALARM) [19]. However, due to the low number of MMCs that used a systematic method of analysis, it was not possible to study its impact. These methods are known and described, but it must be recognized that they are not commonly used [20]. The time constraints described by several professionals could be a reason for the underuse of a time-consuming method of analysis.

Moreover, the number and the type of cases discussed varied and affected the accuracy of analyses. Some authors suggest reviewing all deaths and complications to avoid missing opportunities to identify failures [21‐23]. Others suggest performing a more thorough analysis based on a prior selection of relevant cases [4, 11, 14]. As the opportunity to spend more time on cases was positively perceived in this study, we would favor this method. According to numerous authors, the choice of cases should be based on errors or system safety issues [2, 16, 24].

The characteristics related to a formalized framework were associated with the perception of MMCs being more effective. This result is consistent with the literature and particularly with the impact of standardized presentations on participant satisfaction and on the production of improvement initiatives [10, 11]. This type of formalized framework could be valuable in providing more time for a system-oriented discussion [16].

The participants suggested including other professionals such as paramedical staff in the MMCs. Considering that incidents could involve all the healthcare professionals in a medical unit, this would allow a more accurate and system-oriented analysis [4, 6, 17, 25, 26] and increase the acceptance of improvement initiatives [16, 26]. Furthermore, paramedical professionals take an interest in safety management [27]. Such a team-based improvement meeting is also a way to establish a culture of safety within the department [16, 26].

We note that residents perceived fewer benefits than the other professionals. Our results do not suggest that they perceived MMCs as more blaming. Given that they change units every 6 months, they cannot perceive long-term improvement. Moreover, they are undoubtedly more focused on their personal training and therefore less motivated by team improvement.

A higher effectiveness index was associated with a greater perception of the effectiveness of MMCs in terms of patient safety. This suggests that an index based on the implementation of improvement initiatives could be a valuable way to assess the effectiveness of MMCs, although this hypothesis deserves further investigation based on clinical outcomes. The type of improvement initiatives and their follow-up are also relevant [28]. Moreover, the results of this study are consistent with those obtained previously concerning the characteristics associated with more effective MMCs.(P François, et al., submitted manuscript).

This study had several limitations. First, we assessed MMCs using the participants’ subjective perceptions. However, these perceptions are associated with the effectiveness index, a more objective measure of effectiveness. Second, we cannot exclude a selection bias and respondents could be particularly motivated or, on the other hand, more critical. Finally, this study was conducted in only three French hospitals. The development of MMCs is rather recent in France and they sometimes take place within specific settings. Consequently, the conclusions should be considered with regard to these specificities.

In conclusion, this study showed the participants’ interest in MMCs. A thorough analysis of failures stands out as the main beneficial characteristic. The suggestions for improving MMCs concern a more structured framework and the attendance by a greater variety of professional categories in order to guide MMCs toward a system-wide approach. Furthermore, the improvement initiatives were associated with MMCs perceived as being more effective.