Neurology Morbidity and Mortality Conferences and Quality Improvement: Single-Center Experience and National Survey

Abstract

Background

Morbidity and Mortality (M&M) conferences are widespread but vary in goals and methodology. Some focus on clinical enigmas while an increasing number utilize quality improvement (QI) tools to effect systems change. Little is known about the current state of US Neurology M&Ms.

Methods

We surveyed 56 US academic neurology departments regarding their M&Ms to understand the use of QI tools and assess variability. Additionally, we reviewed the evolution of M&Ms in our department.

Results

The survey was completed by 44 (80%) departments; 68% reported quarterly frequency with 61% discussing 1–2 safety events per conference. The number of written guidelines or protocols resulting from M&Ms in 2 years varied from 0 (14% of departments), 1–2 (45%), to >5 (5%). Institutional culture regarding quality and safety and conference timing were cited by 71% as important in improving participation. In our own department, the M&M format changed in 2014 based on a sentinel patient event combined with improving safety culture across the hospital: neurology M&Ms transformed into thematic quarterly conferences utilizing QI tools. Attendance increased 3-fold, and in 7 years, we have generated 26 guidelines or pathways with corresponding decision-support tools, among other improvement efforts, resulting in specific systems changes. Based on survey results and our experience, suggested M&M “best practices” include the use of just culture, peer review protection, safety event analysis with QI methodology, trainee involvement, and logistical optimization.

Conclusion

Structured M&Ms incorporating suggested QI-informed “best practices” can be highly effective in driving system change within neurology.

Keywords

morbidity and mortality outcomes safety education quality

Introduction

Morbidity and mortality conferences (M&Ms) have been widely adopted across the United States (US) since their inception in the mid-1900s.^1,2 Despite their ubiquity, there has been considerable variability in terms of structure, content, and aims over time and across specialties. Some M&Ms have focused on clinical education, some on critiquing medical management, while others have increasingly had a quality improvement (QI) focus.³ There has also more recently been a recognition of the conferences as a potential tool for QI education.^4-6 In 2012, Josephson and Engstrom suggested M&Ms could be one of several tools harnessed within neurology for clinical and QI education for residents.⁷ Given the shift in medicine over the last 2 decades toward safety culture and more rigorous implementation of improvement science, M&M conferences, with their roots in error analysis, represent a natural vehicle for identifying systems vulnerabilities and driving systems change.

National surveys in surgery^8,9 and internal medicine¹ have detailed the frequency and characteristics of M&M conferences within those fields. Such surveys have also identified gaps in the traditional M&M format with Orlander and Fincke showing that internal medicine departments tended to have limited follow-up on action items after M&Ms such that change would be difficult to achieve.¹ Similarly, in reviewing the M&Ms across 12 departments at a large academic medical center, Aboumater et al found little adherence to medical incident analysis, with only 8% utilizing modern tools such as root cause analysis to investigate system factors.³ Pieurluissi et al, in a prospective review of internal medicine and surgical M&Ms at 4 academic medical centers, found that discussion of error, even when the error directly led to an adverse event, was often lacking in M&Ms, more so in internal medicine than surgery departments.¹⁰ Despite this growing literature in other specialties, little is known about the current state of neurology M&Ms in the US.

Here we present results of a national survey, the objectives of which were to evaluate use of QI tools, their impact on system changes, and to assess variability across academic neurology M&Ms. We also describe the evolution of the neurology M&M conference at our institution, including more recent changes incorporating QI tools. Based on the above, we propose a list of concrete and practical Neurology M&M best practices rooted in the literature and quality improvement methodology.

Methods

National Survey

We conducted an online, self-report survey of academic neurology departments in the US (Supplemental Appendix 1). In collaboration with a survey design expert, we developed an 18-question instrument through which we sought to understand the frequency, structure, content, aims and outcomes of neurology M&Ms, as well as the extent of incorporation of QI methodology^5,11 (e.g., use of the just culture algorithm). Prior surveys done within other specialties, as well as the literature served as a guide.^1,3,5,8-12 Prior to distribution, the survey was beta tested for clarity and face validity by individuals who were not otherwise involved in its development. A total of 56 medical centers were surveyed based on membership of their departmental leaders in the Association of University Professors of Neurology (AUPN; www.aupn.org). The AUPN members were emailed the survey, requesting completion within 8 weeks by the department chair or delegate most familiar with the departmental M&M conference (quality and safety chair, vice chair, residency training program director or other identified individual). Two reminders were sent prior to the deadline.

The survey was developed through Google Forms, designed to take 5–7 minutes to complete and, in addition to structured questions, offered an option to provide additional free-text comments. Survey respondents were requested to provide their names, e-mail addresses and hospital affiliations in the event follow-up clarification was needed. Respondents were informed that their names would not be revealed; however, if permission was granted, hospital names would be acknowledged in the event of publication. Survey results are presented as means (continuous variables) or frequencies and percentages (categorical variables).

Evolution of M&Ms in Our Department

A descriptive history of M&Ms in our department along with the evolution in the last decade was compiled through informal query of faculty present at our institution for several decades as well as the records kept by current quality chair (AS) who led recent revisions to the conference.

Standard Protocol Approvals, Registrations, and Patient Consents

The manuscript conforms to SQUIRE 2.0 guidelines. The survey was undertaken as a QI initiative at the Massachusetts General Hospital to understand the format of M&M conferences in the US and inform our own practices, and as such was not formally supervised by our Institutional Review Board per their policies.

Results

National Survey Results

Of the 56 neurology departments surveyed, 44 (80%) returned responses within the timeframe. There were no duplicate responses from the same hospital. For departments spread across multiple network hospitals, responses were based on the main (primary) hospital. Department chairs completed 23%, quality leaders 48%, and other departmental leaders 29%. Table 1 provides a summary of demographic information of surveyed departments, as well as basic characteristics of neurology M&Ms being conducted across the US. Only 2 departments did not have regularly scheduled M&Ms (one did not have M&Ms, the other held ad-hoc conferences). Three departments reported initiation of M&Ms within the last 1–3 years. One respondent commented that there was significant resistance to starting the conference initially. Seven departments held stroke-focused M&Ms due to regulatory requirements for comprehensive stroke center certification, as well as the availability of stroke performance metrics that guide quality measurement.

Table 1.

Neurology M&M survey results: demographics of responding departments and basic M&M characteristics.


Neurology department features (N = 44)
Number of faculty (median (IQR), range)	40 (22, 67), 8–220
Number of residents (median (IQR), range)	8 (6, 11), 0–20
Annual patient volume (median (IQR), range)
Inpatient	1550 (1127, 2275), 700–5400
Outpatient	20,000 (10,000, 38,888), 500–80,000
Hospital location
East coast	34%
Mid-west	32%
West coast	14%
South	20%
Electronic safety reporting system	95%
Named quality/safety leader	65%
Frequency of M&Ms
None	2%
Ad hoc	2%
Weekly	4.5%
Monthly	23%
Quarterly	68%
M&M conference features (N = 42)^a
All recent safety events presented	19%
Only selected safety events presented	81%
No. of safety events discussed per M&M
1–2	61%
3–4	25%
5 or more	14%
Moderator
Department chair	7%
Quality/Safety leader	45%
Resident or fellow	29%
Other^b	19%
Attendees
MDs only	31%
Multidisciplinary	69%
Attendance (relative to other conferences)	High/moderate/low
Trainees	12%/50%/38%
Faculty	12%/59%/29%
Duration
≤1 hour	63%
1–2 hours	34%
>2 hours	2%

^aData available from 42 departments with quarterly or more frequent M&Ms for all questions except “Duration” where n= 41 because one department did not provide data.

^bOther moderators included NICU Medical Director, one of the clinical faculty, stroke fellow, resident (with staff supervision), division head for the hospital, attending on service, clinical vice chair, and not specified.

Institutional culture regarding quality and safety and conference timing were cited as important factors in improving M&M participation by 71% of departments. Another 57% identified regular attendance by departmental leaders as an important factor. Approximately 40% (15–20/42) of the departments identified the following factors as important for conference participation: mandatory attendance at a minimum number of annual conferences, just culture algorithm, time for discussion, location and provision of food/beverages. While only 28% of departments provided risk-management continuing medical education (CME) credits for faculty, the majority (72%) reported using M&Ms to meet the QI requirements for trainees established by the Accreditation Council for Graduate Medical Education (ACGME).

The majority of departments reported incorporation of some quality improvement tools (Figure 1). Many departments reported written guidelines or protocols resulting from M&M discussions over the last 2 years; however, the numbers varied widely (45% reported 1–2 guidelines or protocols; 19% reported 3–5; 5% reported >5; 14% reported none; 17% were uncertain). Only 38% of respondents consistently reviewed departmental or hospital performance on specific quality-safety metrics. The free-text comments highlighted challenges with safety culture, for example, skepticism about peer review protection and just culture. For example, one department reported that their conferences only permitted residents (with select faculty attendance by invitation) to preserve a “safe” environment for discussion.

Figure 1.

Percentage of Surveyed US Academic Neurology Departments Reporting the Inclusion of Certain Quality Improvement Practices into their M&M. Abbreviations: RCA—root cause analysis; Q&S—quality and safety; ACGME—Accreditation Council for Graduate Medical Education; CME—Continuing Medical Education.

M&M Conferences in Our Department

History of the Conference

The Neurology Service at Massachusetts General Hospital (MGH) was established in 1872. Departmental M&Ms, which have always included both vascular and general neurology, have been held for over 4 decades and have gone through several iterations. Until 2003, conferences typically began in the early evening and ran for several hours with extensive literature reviews more often focused on interesting or challenging diagnoses than safety events. From 2004 to 2012, they were subsumed into senior residents’ noon conference reviews of their inpatient rotations with a primary focus on diagnostically challenging cases and only a brief review of major adverse events and mortalities. Additionally, our neurointensive care unit began its own M&M conferences run by fellows on a monthly basis. Outpatient and Consult service safety events were neither tracked nor reviewed, unless considered egregious. Faculty participation was voluntary; nurses and multidisciplinary team members participated rarely, and only if specifically invited. No formal incident analysis tools were utilized and there was little follow-up on safety events.

In concert with shifting national priorities, the MGH established its Lawrence Center for Quality and Safety in 2007, resulting in greater emphasis on safety culture and process improvement over the ensuing years. In that context, our department encountered a sentinel safety event concerning a missed opportunity for decompressive hemicraniectomy in large middle cerebral artery infarction. This case was analyzed using modern quality/safety methodology in 2011, resulting in a new guideline and implementation with evidence-based patient selection criteria for preventive neurosurgery.^13,14 The goal of the guideline was to facilitate collaborative decision-making between neurologists and neurosurgeons; subsequent analysis showed a significant positive impact on patient outcomes and length of stay, and improved consensus between providers.¹⁵ Motivated by this experience, we re-examined and later changed our M&M framework in 2014 to maximize safety culture and improvements in our systems of care.

New Format

The new M&M framework formally emphasizes just culture¹⁶ and peer review protection.¹⁷ Influenced by Lucian Leape’s teachings,¹⁸ the conferences focus not on “who did it?” but rather “why did it happen?” Conferences are held quarterly. Faculty are expected to attend at least 2 of the 4 conferences annually. Departmental leadership is typically in attendance. To promote attendance, 1.0-hour risk-management CME credit is awarded, lunch is provided, and attention to the physical location, timing and duration (12:00–1:00 pm) have made it convenient for busy inpatient and outpatient care team members to attend. Attendance is multidisciplinary including faculty, trainees, nurses, therapists, case managers, and others. Key stakeholders and subject-matter experts related to the cases/themes are invited to attend and allocated specific time for commentary. By increasing the breadth and number of attendees, we are better able to achieve impactful analysis, discussions, and ideas for system changes.

One or 2 similarly themed cases encountered over the prior 3 months warranting “systems change” are selected in advance by our multidisciplinary Neurology Quality and Safety Committee; most cases are selected from a review of consecutive safety events submitted via our secure electronic safety reporting system. Cases are formally analyzed using QI tools such as process maps and root cause analysis. The Mass General Brigham Joint Neurology Residency Program has developed a voluntary “QI certificate program” for residents interested in quality/safety. Participating residents are trained on QI methods and present the selected cases using aforementioned tools in a formal incident analysis during the M&M. Key questions are formulated in advance to frame the discussion, moderated by the departmental quality chair. The M&Ms end with consensus for a tangible action item with timeframes for systems improvement, delineation of responsibility, and clear accountability. Progress on prior projects is announced at each M&M providing a strong feedback loop and increasing engagement. Adherence is monitored, and feedback provided if warranted. This learning culture, together with explicit focus on just culture and a robust safety event reporting system, promote a strong safety culture related to our new M&M format.¹⁹

Of note, these quarterly “themed” M&Ms supplement rather than replace the historic resident-run conferences and neurointensive care unit conferences where all mortalities, interesting cases and challenging diagnoses continue to be discussed.

These new-format M&Ms, conducted quarterly since June 2014, have generated 26 evidence-based management guidelines and pathways (examples in Table 2) that advance one or more of the 6 domains of quality care laid out by the Institute of Medicine.²⁰ Generated guidelines are available 24/7 via the electronic health record (EHR) with corresponding “smartphrases” and decision-support tools, and have led to restructuring of care delivery and standardization of processes. Furthermore, they have resulted in research studies aimed at quality improvement.²¹

Table 2.

Selected examples: Massachusetts General Hospital M&Ms since 2014.

Conference Topic	Result	Institute of Medicine Domain (s)
Early decompressive hemicraniectomy (DHC) for large middle cerebral artery infarction	Developed management guideline and criteria to rapidly identify, triage patients for DHC. Comparison of pre- and post-intervention data showed a significant reduction in time from admission to DHC.¹⁵	Effective
		Timely
Subdural hematoma (SDH) management	Completed large retrospective study identifying outcome predictors in SDH and a novel score to guide surgical decision-making²¹; guideline under development	Effective
Subdural hematoma (SDH) management		Efficient
Neurology consultations in the emergency department (ED)	Restructured ED neurology consult service to include expanded real-time supervision of junior residents by senior residents and faculty	Safe
Managing conflicts between care teams	Formal policy to escalate decision-making to attending faculty, nursing leaders, or inpatient or outpatient medical directors for specific conflicts concerning patient care	Safe
Terminal illness	Developed: a “prognostication checklist”; guidelines for family meetings; smartphrases for documenting family meetings and brain death evaluation; tip sheets for requesting autopsy and completing death certificates	Patient-centered
Lumbar Puncture (LP)	Developed LP safety checklist and smartphrase to document procedure and guide appropriate cerebrospinal fluid testing	Safe
Lumbar Puncture (LP)		Efficient
Delirium management	Developed novel delirium screening tool; management guideline; electronic order set; educated all caregivers	Patient-centered
Delirium management		Effective
Cervical artery dissection	Developed evidence-based management guideline	Effective
Functional neurologic disorders (FND)	Developed criteria to diagnose and distinguish FND from organic conditions; developed a multidisciplinary management guideline	Effective
		Patient-centered
		Timely
Dizziness in the ED	Created a step-wise algorithm for ED physicians, neurologists and physical therapists to diagnose etiology; guideline with educational videos concerning bedside procedures to treat peripheral dizziness	Effective
Dizziness in the ED		Efficient
Outpatient Prescription errors and EPIC inbasket management	Produced training video for electronic prescribing; compliance reports for electronic health record inbasket management under development	Safe
		Patient-centered
		Timely
Opioid management	Developed adult and pediatric guidelines for proper opioid prescribing in the inpatient and outpatient settings	Safe
Transfer from neurointensive care unit to inpatient floors	Developed process to optimize hand-offs and transfer notes, with clear accountability between units	Safe
Patient hand-offs	Trained all residents on I-PASS framework for hand-offs; appointed resident champion to monitor compliance	Safe
Evaluation of transient ischemic attack (TIA) and minor stroke in the ED	Developed guideline with criteria for neuroimaging and assessing safety for discharge; pathway for rapid outpatient testing and follow-up	Effective
		Efficient
Management of headache in the ED	Developed step-wise treatment algorithm; guidelines for diagnosis and neuroimaging in the ED; pathway for rapid outpatient testing and follow-up if warranted	Timely
Management of headache in the ED		Efficient

While data concerning M&M attendance and guideline creation prior to 2014 was not systematically recorded, the new-format M&Ms showed greater participation (on average, 40–60 faculty and trainees as compared to 15–20 previously), new guideline creation (26 in 5 years (Table 1), vs 4-6 over the prior several decades) and other systems changes. Our departmental QI projects complement the substantial hospital-wide QI initiatives developed by our hospital’s Center for Quality and Safety. At least one M&M related QI project led to reduced length of stay for neurology patients in the emergency department, among other systems outcomes. Feedback from faculty, residents, fellows, advance practice providers, nurses, other caregivers, and invited guests about our process has been overwhelmingly positive and recognized by hospital leadership. These conferences have become a key component of our resident QI certificate program, and QI education for our faculty and staff.

Discussion

We aimed to understand the status of M&Ms across the US and, combined with our own experience, propose best practices with attention to contemporary QI methodology. Our study builds upon a single-center report describing the evolution of M&Ms after implementation of a novel quality improvement curriculum.²² Our national survey results suggest that many other Neurology departments are beginning to use quality-improvement in M&Ms Our data shows that many neurology departments conduct M&Ms; however, there is variability in their structure, frequency, attendance, and adoption of quality/safety methodology. Between 50% and 70% of departments reported implementation of selected quality and safety “best practices” including peer review protection, just culture algorithm, root cause analysis, multidisciplinary participation and guideline creation. However, the total number of new guidelines created in each case was relatively limited. Nonetheless, the majority of departments’ focus on formal quality/safety analysis and systems change is encouraging. Identified opportunities for improvement include the provision of risk-management CME to encourage faculty participation, increased trainee engagement and review of performance on hospital quality and safety metrics.

In the years since the Institute of Medicine report To Err is Human,²³ there has been a trend toward a more rigorous focus on safety and improvement including utilization of QI methodology to improve the utility of M&M conferences in driving systems change.^6,24,25 The value of the conferences in achieving this end has been demonstrated in various reports throughout the evolving M&M literature. For example, Calder et al created the Ottowa Model for the Departments of Emergency Medicine and Trauma Services that emphasized structured case analysis, interprofessional and multidisciplinary involvement and included a pathway for systems issues to be brought to the respective quality and safety committee for action.²⁴ In the post-intervention period, they found that 100% of the M&Ms identified systems issues as compared to only 56.5% in the pre-intervention period and correspondingly, concrete systems solutions were proposed in 64.3% of post-intervention compared with 21.7% of pre-intervention M&Ms. Similarly, Bechtold et al implemented an Internal Medicine Patient Safety M&M which resulted in increase in attendance, some change in attitudes and although they were not able to do a before/after comparison of systems changes implemented, they did demonstrate a large number of systems improvement implemented over the course of the study period. Tad-Y et al implemented a similar systems-based M&M in their Department of Medicine and also showed increased attendance and adverse event reporting, along with a large number of systems improvements.⁶

Compared with the large surveys conducted in surgery (2017)⁹ and internal medicine (2003),¹ it appears that neurology departments are ahead of other specialties in incorporating QI methodology. However, other specialties may have changed their practices since the publication of these large surveys, as with the departments described above.

Proposed Neurology M&M Best Practices

Two recent reviews, including a structured narrative review by Giesbrecht et al¹¹and an integrative review by Churchill et al⁵ identified similar themes common to QI-centered M&Ms including defining their role, involving stakeholders, careful case selection, structured goal-directed discussion and forming recommendations with assigned follow-up. Based on such guidelines/themes present in the literature,^5,11 our own experience with transformation of the M&M at our institution, and a survey of neurology departments across the country we propose a practical set of Neurology M&M best practices (Table 3). This list is not designed to supplant the more rigorously evaluated and proposed recommendations in the literature but rather to serve as a guide to implementing those recommendations. For example, our list not only includes importance of case selection and use of QI methodology but also the practical recommendations to consider venue, time, and nourishment for hungry trainee attendees, modifications that we found critical in encouraging attendance. We envision these proposed practices can be utilized in further evolution of our and other institutions’ M&Ms so that these conferences can serve to more efficiently drive systems change and safety culture while also providing much-needed education in quality-safety methodology.

Table 3.

Suggested M&M Best Practices.

Just culture (not “who did it?” but rather “why did it happen?”)

Peer review protection

Select a theme and goal based on recurrent or seminal safety events

Select 1–2 cases for review

Outline clear objectives at the start

Moderated, goal-directed discussion

Safety event analysis using quality improvement tools and methods (e.g., root cause analysis, fishbone diagram, driver diagram)

Outcome: Well-defined action items with timeframe, accountability

Feedback loop: discuss progress on previous action items

Convenient venue, time, duration, amenities (e.g.,, food, audio-visual equipment)

Trainee involvement in full scope of the improvement effort

Intentional use for trainee and faculty QI education

Attendance: Multidisciplinary; key stakeholders; subject-matter experts

Leadership participation and support

Provide risk-management continuing medical education (CME) credit

M&M as Tool for QI Education

While traditional M&Ms focus on clinical education they typically do not educate attendees on the tools necessary to implement evidence-based practices into routine workflow, nor do they specifically provide teaching about quality improvement or experiential learning across the full spectrum of the improvement process. In their 2018 Review, the Clinical Learning Environment Review (CLER) noted that while M&Ms were frequently used nationally for QI education and could be useful in providing foundational knowledge about safety issues, they often lacked critical components including a systems-based focus, timely response to safety events and interprofessional involvement.²⁶ At our own institution, we attempted to address these shortcomings by using a systems lens, involving a multidisciplinary group and involving residents in the “full scope of the improvement effort” from reviewing the event to implementing action items when possible via our QI certificate program.

The educational potential of M&Ms extends beyond trainees. The CLER report also noted that institutions “may lack a critical mass of faculty who are competent in performing and instructing QI activities, [such that] it is essential…to invest in faculty development in QI.”²⁶ Interestingly, most respondents to our survey utilized the conferences to meet ACGME requirements around quality and safety, but not for continuing medical education (CME) credits. This may be a reflection of the under-recognition of the need for faculty education on QI methodology.

Factors to Promote M&M Attendance and Engagement

Our experience provides insights into factors that can promote conference attendance and provider engagement, which are critical for the robust case reviews and discussions that help to drive meaningful quality improvement. Our rate of systems changes clearly accelerated after 2014 and is significantly higher than other centers. Further, feedback from our M&M participants suggest that changes such as guidelines with EHR reinforcement, care pathways and restructured inpatient services resulting from M&Ms are viewed as tangible ‘products’ and markers of progress, generating enthusiasm among front-line caregivers to report safety events and contribute to safety and QI initiatives. Also contributing to the success of our M&Ms are factors such as leadership support, involvement of subject-matter experts, convenient location, timing, limited duration, and provision of amenities. While attendance at M&Ms among the majority of survey respondents was reported as being low to moderate relative to other departmental conferences among both trainees and faculty (88% of departments), our M&Ms consistently generate high attendance compared to other educational conferences, presumably secondary to the above factors. Another likely contributor is the inclusion of nursing leadership and the entire multidisciplinary care team as well as medical students. Restricting individual case presentations to 1–2 events, and emphasizing just culture and peer review protection, additionally allow robust participation without concerns about blame or punitive action.

Complementary Formats: Theme-Based and Consecutive Safety Reviews

The new-format theme-based departmental M&Ms at our institution address the full spectrum of neurologic care: emergency department, ICU, inpatient and consult services, transitions of care and the outpatient setting. They complement the traditional inpatient service M&Ms that continue to be trainee-run and focused on reviewing mortalities, major safety events, and diagnostically challenging cases. Our experience suggests that resident engagement, “themed” conferences restricted to 1–2 events emblematic of a theme, with subsequent interventions informed by improvement science (e.g., accompanying decision-support and documentation tools),²⁷ results in prompt and sustained change. Efforts are ongoing to quantify impact on patient safety.

Despite the advantages in selecting a “theme,” we emphasize that it is equally important to review consecutive mortalities and safety events. Indeed, preventable events identified through service-based conferences often became the “theme” for our quarterly conferences. In addition, the key role of systematic case reviews required by regulatory bodies (e.g., stroke quality measure performance as required by the Joint Commission–approved Comprehensive Stroke Centers) cannot be over-stated. Ultimately, we believe a combination of processes is required to optimize patient safety and drive system change.

Limitations

As with other survey-based investigations, we acknowledge several limitations and biases that may influence our results and proposed “best practices.” Departments with an existing quality/safety leader, or those with existing financial or other commitments to quality and safety, may be more likely to respond to such surveys. Answers to the survey questions were based on self-report, and largely descriptive. Recall bias may have impacted answers. Large departments, or those with more frequent M&Ms or robust QI programs may heavily influence the overall result; we were unable to perform sensitivity analysis based on such factors due to the relatively low number of total respondents. Similarly, responses based on M&Ms conducted for regulatory reasons may have confounded our results. Since the survey was restricted to US academic neurology departments, our results and proposed “best practices” are not generalizable to community hospitals, or non-US hospitals. However, the overarching theme of utilizing a structured M&M format to drive systems change and QI education for all types of care providers may be generalizable.

In reviewing our own prior M&M topics as they linked to one or more of the 6 domains of quality care laid out by the Institute of Medicine²⁰ (Table 2) we noted that an M&M specifically advancing equity was lacking; indeed equity is the “theme” for our September 2021 M&M conference. In 2017 the IHI published a white paper entitled: Achieving Health Equity: A Guide for Healthcare Organizations.²⁸ The authors note great progress on all of the aims laid out in “Crossing the Quality Chasm” but admit that equity became the forgotten aim. There have been well-supported proposals that suggest that the key to transformational change around health equity, along with culture change, is to apply quality improvement tools to mitigating health disparities that occur based on identities.²⁹ The M&M conference represents a prime opportunity to put this suggestion into practice. Root cause analyses should consider whether patient or provider identities (race, class, sex, gender, sexual orientation, class, ability, language, and more) contributed to an error and propose actionable systems improvement. The very incorporation of these categories into error analysis will also effect culture change among resident and faculty, although may need to be supplemented with additional sessions directed specifically at culture change.

Conclusions

In summary, we believe that our experience is illustrative of the direction of academic neurology M&Ms across the country. Our proposed best practices provide practical and concrete steps for implementing QI methodology into M&Ms thereby harnessing these conferences to advance patient safety, QI education and systems change.

Supplemental Material

sj-pdf-1-nho-10.1177_19418744211067043 – Supplemental Material for Neurology Morbidity and Mortality Conferences and Quality Improvement: Single-Center Experience and National Survey

Supplemental Material, sj-pdf-1-nho-10.1177_19418744211067043 for Neurology Morbidity and Mortality Conferences and Quality Improvement: Single-Center Experience and National Survey by Sophia L. Ryan, Kathleen E. McKee, Lizbeth Londono-Sanche, Sarah Dougherty and Aneesh B. Singhal in The Neurohospitalist

Footnotes

Acknowledgments

We gratefully acknowledge Karen Lavoie for her expert guidance in survey creation, Professor Karen C. Johnston, MD, MSc, our Chief Merit Cudkowicz, MD, and the Association of University Professors of Neurology for assistance with survey distribution, all survey respondents, Ms Aayushee Jain for assistance with data analysis, the Massachusetts General Hospital Department of Neurology’s leadership, faculty, fellows, and residents (particularly those enrolled in our QI certificate program) for assistance via M&M participation, and Guideline creation and implementation.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data Availability

All data used for analysis are presented in the tables and figures in this article. Anonymized data will be shared if requested by other investigators for purposes of replicating the results.

ORCID iD

Sophia L. Ryan

Supplemental Material

Supplemental material for this article is available online.

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