Reflection on everyday work to improve the quality of surgical care

Abstract

This dissertation describes a shift from a focus on adverse outcomes, to learning from everyday work in (surgical) healthcare. The dissertation provides an overview of the development of the Morbidity & mortality conferences (M&M), while illustrating the limitations and challenges that are inherent to traditional M&M practice. Based on this theoretical foundation, the dissertation explores the potential of transforming M&M into a weekly reflective team meeting. This team meeting not only focuses on reflecting on and learning from unsuccessful outcomes, but also considers successful cases. As a result, more attention is given to everyday working conditions and supporting the resilience of healthcare professionals. This can contribute to improving patient safety by fostering a broader understanding of the dynamics in daily practice.

The Safety-II perspective formed a basis for designing and implementing the new type of team meeting. This perspective, with a focus creating ‘success’ on a daily basis, advocates for an approach that not only aims to prevent errors but also enhances the adaptive capacities of healthcare teams, to continue providing safe care under unpredictable circumstances.