Introduction
Materials and methods
Research setting & improvement strategy
PLAN | DO | CHECK | ACT | |||||
---|---|---|---|---|---|---|---|---|
Nr | Outcome of M&MM | Professional with assigned task (name/ function) | Desired result (goal setting) | Steps to achieve goal setting |
Start date improvement activity
|
Desired date to finish improvement activity
| Check whether task is completed (date /how) | Additional measures and/ or actions |
Research design
Participatory Action Research (PAR) & participants
Data collection
Interviews
Observations
Data analysis
Ethical considerations
Results
Actions and successful examples
# | Adverse event (AE) | Outcome of the morbidity and mortality meeting (M&MM) | PLAN: Desired result (goal setting) | DO: Steps to achieve goal setting | CHECK/ ACT: Check whether goal is achieved and whether additional steps are needed |
---|---|---|---|---|---|
1. | 2020, January Haemorrhage (blood loss > 500ml) after deep excision | Insufficient knowledge about hemostasis material in colposcopy room. | Inventory of (available) options for haemostatic material (websearch) after a leep excision. | Liquid silver nitrate and Surgicel© as standard absorbable hemostats in the colposcopy room. All team members are aware of which materials are present and where its stored in the colposcopy room. | Lecture held on absorbable hemostats. Liquid silver nitrate is no longer available. |
2. | 2020, February Recurrent urinary tract infection due to urinary retentions after removing the bladder catheter too soon following a Wertheim-Meigs procedure. | Make bladder scans required after Wertheim-Meigs procedure when catheter is removed as urine retention occurs more often. If necessary, long term catheter à demeure, self-catherization are options. | Standard of care protocol used at the ward which bladder retentions are acceptable after a specific procedure | Healthcare professional assigned to the action will check and modify the protocol if necessary. | There is a standard protocol at the inpatient department after surgical procedures of urology, surgery and gynaecology. Protocol does not need to be modified. Additional action: Everyone is aware of this hospital wide protocol. |
3. | 2020a, June Wound dehiscence (“space belly”). | The suture used for closing the fascia was too short. Two sutures were tied together, leading to a weak spot. | Based on new advice - long polydioxanone suture (PDS) barrel (300 cm) is ordered. | Order long PDS barrel. | The PDS barrel is ordered and since July 2020 both short PDS barrel (120 cm) and long barrel (300 cm) are available. |
4. | 2020, July Excessive CO2 accumulation during a laparoscopic procedure. | Clear communication during surgery about peri-operative issues between anesthesiology team and operative team. In patients with higher BMI, the use of longer trocars is necessary to prevent CO2 leakage subperitoneal. | If necessary, introduce additional time-out during OR in case of impending complications. Order longer trocars. | Repeat the outcome at the following M&M meeting. Order longer trocars. Create awareness of the risk of CO2 accumulation during surgery. | Actions are accomplished, and discussed again at the following meeting. |
5. | 2020, August Overbalanced liquid intake postoperatively. | The liquid balance was not documented. | During each bedside rounds the liquid balance is documented (input and output within a 24-hour period in millimeters). | Organize education on liquid balance for registrars and nurses and at the inpatient ward. State liquid balance in the electronic patient file at every bedside round. | Additional education for registrars and nurses on the overbalanced liquid intake policy postoperatively took place. |
6. | 2020, September Wound infection. | High risk of infection after inguinal wound. Particularly in patients with obesity. Research of other products that may aid in wound repair. | Start flushing the wound postoperatively with povidone iodine solution. Communicate with infection prevention/ hospital hygienist to determine how to reduce the risk of wound infection with these procedures. -> Evaluate the outcome of the use of povidone iodine solution at the end of surgery in relation to wound infections | Each staff member will record in the OR report whether the wound was flushed postoperatively for 6 months. Schedule appointment with hospital hygienist. | Each staff member is aware that whether or not the wound was flushed with povidone iodine solution needs to be stated in the patient’s operating report. Contact has been made with hospital hygienist at a later stage (Due to COVID-19 this was postponed). After 6 months the use of povidone iodine solution was evaluated (data from operating reports). |
Relevant factors for successful implementation of areas for improvement
Organizational culture
‘For me it is no problem to say hey guys maybe I did not do this in the right way. … Because when you discuss this with people [colleagues] they will support you and look into it to see what it is you did.’ (#8, registrar gynaecological oncology).
Motivation
‘Look, everything that can improve the quality of care, that is something we should do. And that should be disseminated as well. Because there are also people who say ‘I did not hear about it afterwards and what is the situation right now’. Then you can say what we agreed upon is here on the drive and this was sent around.’ (#6, consultant gynaecological oncology).
Motivational driver | Resistance found during research | General advise |
---|---|---|
A sense of ownership | • Professionals who were not present during the M&MM and received a task afterwards • Professional who were made responsible for a task without giving consent | • Explain the assigned task via phone call or an explanatory email • Explain clearly when a task is part of someone’s roles and responsibilities |
Clear task description with deadline and an environment that promotes independency | • Unclear task/ not feasible • Professionals who lacked the skill to be creative and autonomous in finishing tasks • The person who described the tasks on the action list lacked the skill to do this consistently and clearly | Describe the task SMART (Specific, Measurable, Achievable, Realistic, Time-related) |
A sense of urgency and relevancy of the task | Professionals who received too many emails; emails may be overseen | Repeat tasks in other (weekly) meetings |
Visibility of the status of the tasks | Professionals who did not see or find the status of the task, and/or the task is unclearly written | • Make the action list available on a shared location • Provide regular (short) updates by e-mail with the status of the tasks |
Multidisciplinary M&MM with new perspectives and inter-departmental support to execute tasks | Professionals from other departments did not feel motivated to finalize the task | • Organize regular M&MMs with other departments • Create extra contact moments with professionals from other departments about their tasks • Make someone from your own department responsible for the finalization of a task by another department |
Visibility of practice change when tasks are executed | It was unclear whether the task influenced or changed daily clinical practice | Share task with colleagues and invite colleagues to support in completing the task |
Improvement of the quality of care (described as a feeling) | Professionals who received a task that was unrelated to their daily responsibilities or work-role | The tasks should fit and align with the daily work-role of the person with a task assignment |
Communication to mobilize employees
‘So I think you should assign tasks to people who are part of the group of attendees. And then the task will be to mail person x [person who did not attend the meeting], and the one who receives the task is person y [person who attended the meeting]’. (#10, registrar obstetrics)
‘Yes, well I have seen your name more often so I know what you do related to your research and so on. So I did not think it was weird that this questions came from you. No, definitely not.’ (#12, nurse gynaecological oncology).
Commitment
‘Yes, but either way, even when there is no problem, I feel ownership… So even when the task would have been assigned to someone else and it does not make sense. Even then, it could be possible that this person thinks I am responsible.’ (#11, consultant gynaecological oncology).
Skills
‘Most of the time my colleagues in gynaecology respond well to my feedback. Ofcourse, with a degree of exceptions.’ (#13, senior registrar gynaecological oncology).
‘With these types of protocols, each nurse in our department has a specific focus such as pain, palliative care, or wound care. So first we need to meet with them to see what the protocol entails, whether everything is clear to them, how they ensure people use the protocol and whether they need to do something with the protocol related to the M&MM, or whether it was just an incident.’ (#6, consultant gynaecological oncology).