PHM Focus

Schedule at a Glance

Enough About Death: Redesigning Your Mortality and Morbidity Conference to Focus on System Improvement

Primary Leader:
Diana Stewart

Erin Fisher
Joyee Vachani
Cara Lye

Objective 1:
Participants will identify characteristics of appropriate teaching cases that can be used to for an interactive, patient safety and quality improvement focused morbidity and mortality conference.

Objective 2:
Participants will practice incorporating a system-based approach to address medical errors into morbidity and mortality conferences by using common quality improvement tools and strategies.

Objective 3:
Participants will practice a framework to restructure the mortality and morbidity conference at their institution by discussing key concepts, such as case selection criteria, defining rules, identifying key teaching points including barriers to implementa

Multiple educational objectives can be achieved through participation in Mortality and Morbidity (M and M) conferences. Currently, most M and M conferences focus solely on the clinical aspects of a given case, with minimal planned discussion on system factors that contributed to the errors in the case or solutions for system failures. Errors leading to patient harm are rarely the result of a single individual error, but are instead due to a series of errors resulting from breakdowns in the system. In this workshop, we will demonstrate a framework that can be used to redesign the traditional M and M conference to promote patient safety and quality improvement within your institution. Through small group table work and large group report outs, participants will review innovative models of M and M in use, identify QI tools used in these models, and practice a framework for systematically changing their current conference structure. Participants will be provided a toolkit of resources that can be used to restructure the M and M conference at their institution.