Morbidity and mortality (M&M) conferences are an acclaimed method for achieving case-based learning and improving surgical care1. Their educational value is acknowledged, but whether these... Show moreMorbidity and mortality (M&M) conferences are an acclaimed method for achieving case-based learning and improving surgical care1. Their educational value is acknowledged, but whether these conferences contribute to systemic improvement is unclear2. M&M formats vary widely3,4, and are mostly focused on severe adverse events and individual performance, thus lacking consideration of system-level issues or similar cases where successful outcomes were achieved3,5,6. To overcome these shortcomings, an adapted weekly M&M meeting was developed at the authors unit7. In the adapted meeting, the surgical team collectively reflects both on all recently discharged but also on planned procedures, which is consistent with existing frameworks8. Discussing all cases also directs attention to successful outcomes, rather than only the complicated ones. This allows the team to understand how to ensure safety for their patients continuously9,10.The aim of this qualitative study was to investigate how the novel weekly reflective team meeting affects the dynamics of a surgical team and improves the quality of care. Show less
Objective: To discuss practical strategies to consider for morbidity and mortality conferences (M & M). Materials and Methods: This article reflects on (i) insights that can be drawn from the M... Show moreObjective: To discuss practical strategies to consider for morbidity and mortality conferences (M & M). Materials and Methods: This article reflects on (i) insights that can be drawn from the M & M literature, (ii) practical aspects to consider when organizing M & M, and (iii) possible future directions for development for this long-standing practice for routine reflection. Results: M & M offers the opportunity to learn from past cases in order to improve the care delivered to future patients, thereby serving both educational and quality improvement purposes. For departments seeking to implement or improve local M & M practice, it is difficult that a golden standard or best practice for M & M is nonexistent. This is partly because comparative research on different formats is hampered by the lack of objective outcome measures to evaluate the effectiveness of M & M. Common practical suggestions include the use of (i) a skillful and active moderator; (ii) structured formats for case presentation and discussion; and (iii) a dedicated committee to guide improvement plans that ensue from the meeting. M & M practice is affected by various sociological factors, for which qualitative research methods seem most suitable, but in the M & M literature these are sparsely used. Moreover, aspects influencing an open and blame-free atmosphere underline how local teams should tailor the format to best fit the local context and culture. Conclusion: This article presents practice guidance on how to organize and carry out M & M This practice for routine reflection needs to be tailored to the local setting, with attention for various sociological factors that are at play. Show less
Verhagen, M.J.; Vos, M.S. de; Smaggus, A.; Hamming, J.F. 2022
Objective Efforts to study morbidity and mortality conferences (M&MC) are hampered by the lack of rigorous instruments to assess the effectiveness of the conferences for the purpose of quality... Show moreObjective Efforts to study morbidity and mortality conferences (M&MC) are hampered by the lack of rigorous instruments to assess the effectiveness of the conferences for the purpose of quality improvement and medical education. This might limit further advancement of the practice. The aim of this scoping review was to determine commonly used effectiveness measures of M&MC in the literature. Method A scoping review was performed of quantitative, qualitative, and mixed methods studies of M&MC, using databases from PubMed, Emcare, Embase, Web of Science, and the Cochrane library. Studies were included if an outcome was described after a general evaluation or an intervention to M&MC. Study quality was assessed with the Quality Assessment Tool for Studies with Diverse Designs. Results A total of 43 articles were included in the review. The majority used a quantitative (n = 23) or mixed (n = 17) design, with surveys as the most frequent method used for data collection (n = 29). The overall Quality Assessment Tool for Studies with Diverse Designs scores were modest (64%). Outcome measures used to evaluate the effectiveness of M&MC were clustered in the following categories: "participant experiences," "characteristics of the meeting," "medical knowledge," "actions for improvement," and "clinical outcomes." Conclusions This review found a wide variety of effectiveness measures for M&MC. Rather than using isolated measures, approaches that combine multiple effectiveness measures could offer a more comprehensive assessment of M&MC. Although there was a preference for quantitative metrics, this fails to seize the opportunity of qualitative methods to yield insights into sociological purposes of M&MC, such as building professional identities and safety culture. Show less
Verhagen, M.J.; Vos, M.S. de; Sujan, M.; Hamming, J.F. 2022
ObjectivesPreoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to... Show moreObjectivesPreoperative anticoagulation management (PAM) is a complex, multidisciplinary process important to patient safety. The Functional Resonance Analysis Method (FRAM) is a novel method to study how complex processes usually go right at the frontline (labeled Safety-II) and how this relates to predefined procedures. This study aimed to assess PAM in everyday practice and explore the usability and utility of FRAM. MethodsThe study was conducted at an Australian and European Cardiothoracic Surgery Department. A FRAM model of work-as-imagined was developed using (inter)national guidelines. Semistructured interviews with 18 involved professionals were used to develop models reflecting work-as-done at both sites, which were presented to staff for validation. Workload in hours was estimated per process step. ResultsIn both centers, work-as-done differed from work-as-imagined, such as in the division of tasks among disciplines (e.g., nurses/registrars rather than medical specialists), but control mechanisms had been developed locally to ensure safe care (e.g., crosschecking with other clinicians). Centers had organized the process differently, revealing opportunities for improvement regarding patient information and clustering of clinic visits. Presenting FRAM models to staff initiated discussion on improvement of functions in the model that are vital for success. Overall workload was estimated at 47 hours per site. ConclusionsThis FRAM analysis provided insight into PAM from the perspective of frontline clinicians, revealing essential functions, interdependencies and variability, and the relation with guidelines. Future studies are warranted to study the potential of FRAM, such as for guiding improvements in complex systems. Show less
Vos, M.S. de; Hamming, J.F.; Marang-van de Mheen, P.J. 2021
ObjectiveIt remains unclear to what extent the morbidity and mortality conference (M&M) meets the objective of improving quality and safety of patient care. It has been suggested that M&M... Show moreObjectiveIt remains unclear to what extent the morbidity and mortality conference (M&M) meets the objective of improving quality and safety of patient care. It has been suggested that M&M may be too focused on individual performance, hampering system-level improvement. The aim of this study was to assess focus and sustainability of lessons for patient care that were derived from M&M. MethodsThis is an observational study of routinely collected data on evaluated complications and identified lessons at surgical M&M for 8 years, assessing type and recurrence of lessons and cases from which these were drawn. Semistructured interviews with clinicians were qualitatively analyzed to explore factors contributing to lesson focus and recurrence. ResultsThree hundred eighteen lessons were drawn from 10,883 evaluated complications, primarily for those that were more severe, related to surgical or other treatment, and occurring in nonemergent, lower risk cases (all P < 0.001). Most lessons targeted intraoperative (43%) rather than preoperative or postoperative care as well as specifically technical (87%) and individual-level issues (74%). There were 43 recurring lessons (14%), mostly about postoperative care (47%) and medication management (50%). Interviewed clinicians attributed the intraoperative, technical focus primarily to greater appeal and control but identified an array of factors contributing to lesson recurrence, such as typical staff turnover in teaching hospitals. ConclusionsThis study provided empirical evidence that learning at M&M has a tendency to focus on intraoperative, technical performance, with challenges to sustain lessons for more system-level issues. Morbidity and mortality conference formats need to anticipate these tendencies to ensure a wide focus for learning with lasting and wide impact. Show less
Vos, M.S. de; Hamming, J.F.; Boosman, H.; Marang-van de Mheen, P.J. 2021
ObjectivesLinkage of safety data to patient experience data may provide information to improve surgical care. This retrospective observational study aimed to assess associations between... Show moreObjectivesLinkage of safety data to patient experience data may provide information to improve surgical care. This retrospective observational study aimed to assess associations between complications, incidents, patient-reported problems, and overall patient experience. MethodsRoutinely collected data from safety reporting on complications and incidents, as well as patient-reported problems and experience on the Picker Patient Experience Questionnaire 15, covering seven experience dimensions, were linked for 4236 surgical inpatients from an academic center (April 2014-December 2015, 41% response). Associations between complication and/or incident occurrence and patient-reported problems, regarding risk of nonpositive experience (i.e., grade of 1-5 of 10), were studied using multivariable logistic regression. ResultsPatient-reported problems were associated with occurrence of complications/incidents among patients with nonpositive experiences (odds ratio [OR] = 2.8, 95% confidence interval [CI] = 1.6-4.9), but not among patients with positive experiences (OR = 1.0, 95% CI = 0.6-1.5). For each experience dimension, presence of patient-reported problems increased risk of nonpositive experience (OR range = 2.7-4.4). Patients with complications or incidents without patient-reported problems were at lower risk of a nonpositive experience than patients with neither complications/incidents nor reported problems (OR = 0.5; 95% CI = 0.3-0.9). Occurrence of complications/incidents only increased risk of nonpositive experience when patients also had problems on "continuity and transition" or "respect for patient preferences" dimensions. ConclusionsLinking safety data to patient experience data can reveal ways to optimize care. Staff seem able to ensure positive patient experiences despite complications or incidents. Increased attention should be paid to respecting patient preferences, continuity, and transition, particularly when complications or incidents occur. Show less
Cammel, S.A.; Vos, M.S. de; Soest, D. van; Hettne, K.M.; Boer, F.; Steyerberg, E.W.; Boosman, H. 2020
Background Patient experience surveys often include free-text responses. Analysis of these responses is time-consuming and often underutilized. This study examined whether Natural Language... Show moreBackground Patient experience surveys often include free-text responses. Analysis of these responses is time-consuming and often underutilized. This study examined whether Natural Language Processing (NLP) techniques could provide a data-driven, hospital-independent solution to indicate points for quality improvement. Methods This retrospective study used routinely collected patient experience data from two hospitals. A data-driven NLP approach was used. Free-text responses were categorized into topics, subtopics (i.e. n-grams) and labelled with a sentiment score. The indicator 'impact', combining sentiment and frequency, was calculated to reveal topics to improve, monitor or celebrate. The topic modelling architecture was tested on data from a second hospital to examine whether the architecture is transferable to another hospital. Results A total of 38,664 survey responses from the first hospital resulted in 127 topics and 294 n-grams. The indicator 'impact' revealed n-grams to celebrate (15.3%), improve (8.8%), and monitor (16.7%). For hospital 2, a similar percentage of free-text responses could be labelled with a topic and n-grams. Between-hospitals, most topics (69.7%) were similar, but 32.2% of topics for hospital 1 and 29.0% of topics for hospital 2 were unique. Conclusions In both hospitals, NLP techniques could be used to categorize patient experience free-text responses into topics, sentiment labels and to define priorities for improvement. The model's architecture was shown to be hospital-specific as it was able to discover new topics for the second hospital. These methods should be considered for future patient experience analyses to make better use of this valuable source of information. Show less
Objective: To explore possibilities to improve morbidity and mortalityconferences using advancing insights in safety science.Summary background data: Mortality and Morbidity conferences (M&M)are... Show moreObjective: To explore possibilities to improve morbidity and mortalityconferences using advancing insights in safety science.Summary background data: Mortality and Morbidity conferences (M&M)are the golden practice for case-based learning. While learning from complicationsis useful, M&M does not meet expectations for system-wideimprovement. Resilience engineering principles may be used to improveM&M.Methods: After a review of the shortcomings of traditional M&M, resilienceengineering principles are explored as a new way to evaluate performance.This led to the development of a new M&M format that also reviewssuccessful outcomes, rather than only complications. This ‘‘quality assessmentmeeting’’ (QAM) is presented and the first experiences are evaluatedusing local observations and a survey.Results: During the QAM teams evaluate all discharged patients, addressingteam resilience in terms of surgeons’ ability to respond to irregularities and tomonitor and learn from experiences. The meeting was feasible to implementand well received by the surgical team. Observations reveal that reflection onboth complicated and uncomplicated cases strengthened team morale but alsotriggered reflection on the entire clinical course. The QAM serves as a tool toidentify how adapting behavior led to success despite challenging conditions,so that this resilient performance can be supported.Conclusions: The resilience engineering concept can be used to adjustM&M, in which learning is focused not only on complications but also onhow successful outcomes were achieved despite ever-present challenges. Thisreveals the actual ratio between successful and unsuccessful outcomes,allowing to learn from both to reinforce safety-enhancing behavior. Show less
Vos, M.S. de; Hamming, J.F.; Chua-Hendriks, J.J.C.; Marang-van de Mheen, P.J. 2019
Background and objective Incident, adverse event (AE) and complaint data are typically used separately, but may be related at the patient level with one event triggering a cascade of events,... Show moreBackground and objective Incident, adverse event (AE) and complaint data are typically used separately, but may be related at the patient level with one event triggering a cascade of events, ultimately resulting in a complaint. This study examined relations between incidents, AEs and complaints that co-occurred in admissions.Methods Independently and routinely collected incident, AE and complaint data were retrospectively linked for surgical admissions in an academic centre (2008-2014). Two investigators reviewed whether incidents/AEs in admissions were clinically related and in what sequence (incident preceding vs following AE). Likelihood of occurrence of AEs and AE cascades (ie, >= 3 AEs) was studied using logistic regression analyses.Results Complaints were filed for 33 (0.1%) of 26 383 admissions. Complaints filed by patients with incidents and/or AEs (n=13) mostly addressed quality/safety problems, whereas other complaints mostly addressed relationship problems. Incidents and AEs co-occurred in 730 (2.8%) admissions, which seemed clinically related in 34% of these cases. Incidents with related AEs preceded as well as followed AEs (56.6%/44.4%). Patients with incidents were at greater risk of AEs than patients without incidents, even for seemingly unrelated AEs (OR 1.4; 95% CI 1.3 to 1.6). Risk of AE cascades was greater when patients with AEs also had incidents, regardless of whether these seemed related (unrelated: OR 2.0; 95% CI 1.6 to 2.5; related: OR 5.7; 95% CI 4.3 to 7.4) or whether incidents preceded or followed AEs in these admissions (53% vs 52%, P> 0.05).Conclusions Patient-level linkage of incident, AE and complaint data can reveal relations between events that otherwise remain obscured, such as incidents that trigger as well as follow AEs, introducing event cascades, regardless of whether clinical relations seem present. Show less
Quality and safety improvement is a relatively novel discipline in healthcare practice and research that solidified in the early 21st century. Since then, various systems have been installed to... Show moreQuality and safety improvement is a relatively novel discipline in healthcare practice and research that solidified in the early 21st century. Since then, various systems have been installed to collect information on various types of adverse outcomes, such as adverse events, incidents and patient complaints. Data from these systems can be used to evaluate care delivered to individual cases as well as to study aggregated data for patterns, trends and other insights. More research is warranted to assess whether these systems actually meet the objective of continuous, systemwide learning and improvement. It was expected that existing practices could benefit from individual optimization as well as better integration, because most of this intelligence is currently stored and used in isolation. The research in this PhD thesis focused on how we can learn most effectively from various types of adverse outcomes in healthcare, in order to continuously improve the care delivered to patients. Specific research questions included how we can learn from: i) case discussions at morbidity and mortality conferences ; ii) integrating available information sources (e.g., incidents, patient experiences); iii) the context of everyday practice that produces both adverse and desired outcomes. Show less
OBJECTIVES: To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement. DESIGN: This is a qualitative study with... Show moreOBJECTIVES: To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement. DESIGN: This is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare. SETTING: Dutch academic surgical department with a long tradition of M&M. PARTICIPANTS: An interview sample of surgeons, residents and physician assistants (n=12). RESULTS: A total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from 'case type' to 'leadership', were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, 'hierarchy' and 'team spirit'). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes. CONCLUSIONS: This study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M. Show less
After a serious incident, all involved expect it will provide an opportunity to learn and that improvements will follow. However, 'safe' learning is often threatened due to a primary focus on... Show moreAfter a serious incident, all involved expect it will provide an opportunity to learn and that improvements will follow. However, 'safe' learning is often threatened due to a primary focus on accountability. Focus should, instead, be on the needs of both patients and care providers, with the goal of repairing damage and restoring trust in the wider sense - a culture of justice ('Just Culture'). Common daily practice is a more realistic focus for further investigation, with active involvement of healthcare professionals ('Safety-II'). This means that an event is no longer reduced to 'human failure' but that complex work processes and interdependencies are thoroughly investigated, as to understand how things mostly go well but sometimes also go wrong. Deeper insight into the context of a serious incident and its relation to daily practice could ensure that plans for improvement are more closely aligned with this daily practice. Primary focus on the needs of those involved, and appreciation of the complex context, can allow for a safe and realistic approach to learning from undesirable events, such as serious incidents. Show less
