A new approach to M&M means learning from errors

Morbidity and mortality conferences are familiar to every risk manager and physician, but not everyone looks upon them fondly. Though they are intended as an open analysis of complications and an opportunity to improve care, too many physicians see them as humiliating, stressful ordeals that seldom lead to meaningful changes in care.

But a new approach to the morbidity and mortality conference, known as the M&M at most hospitals, could change all that. At Cedars-Sinai Medical Center in Los Angeles, the surgery department has transformed its weekly M&M into an innovative educational study curriculum it calls the M&M Matrix. This progressive approach for reviewing surgical errors provides a forum where complications are discussed, analyzed, summarized into teaching points, and disseminated via e-mail to residents and participating attending staff, who are subsequently tested on the material.

According to Cedars-Sinai’s associate director of surgical education Leo A. Gordon, MD, FACS, Cedars-Sinai’s M&M Matrix is a significant departure from the old conferences that were characterized by heated oral discourse.

"In hospitals across the country, morbidity and mortality conferences often result in tempers flaring and fingers pointing — and the lessons are often left at the door," he says. "In Cedars-Sinai’s conferences, we take a systematic look at three different surgical complications, summarize the points, set them in print, and distribute them to residents and participating attending staff as study guides on which they will be tested."

The typical M&M works much better in theory than in practice, Gordon says, and that’s why Cedars-Sinai developed a different style. In the traditional M&M, the meeting is supposed to be entirely democratic, with the lowliest intern empowered to challenge the chief of surgery. And the participants are supposed to discuss errors openly to promote improvements in patient care.

"It can be a very sobering experience," Gordon says. "You can get some tremendous debate and exchange, but at the end of this conference, what happens to all this passion, debate, and educational juice that has been extracted? Nothing. There is an untapped mine of surgical education regarding error prevention that is developed in these meetings, and then nothing happens to it."

And this, Gordon says, was the impetus for implementing the M&M Matrix educational model about a year ago. The program also dovetails nicely with the goals of the Institute of Medicine’s To Err Is Human: Building a Safer Health System report from 1999.

Matrix ensures information is put to use

The Cedars-Sinai program is focused on taking the M&M information beyond the highly restricted meeting to the hospital’s continuing education program. Gordon acts as the moderator of the weekly M&M conference, and then compiles the information gleaned from the discussion into educational points. Not all of the specific tips, suggestions, and concerns are outlined in the matrix, but the memo is intended to summarize the major concepts discussed and to keep the topics fresh in everyone’s mind after the meeting.

Gordon first distributes the information by e-mail to all residents and attending physicians. The M&M meetings are on Thursdays. He offers a hypothetical example of a 19-year-old male who develops a pulmonary embolism after undergoing surgery for multiple gunshot wounds to his pelvis.

"The M&M Matrix on this case would be called Pulmonary Embolism Following Surgical Procedures for Trauma,’" he says. "At the conference, the moderator would lead a methodical discussion on how and why this complication occurred. The subsequent study matrix would include a summary of the discussion along with current medical references specific to the complication."

Then on Monday, Gordon sends out another M&M memo to the staff — nurses and other clinicians. This memo also outlines the salient points of the M&M discussion, but it sometimes takes a different tack than the memo sent to physicians, addressing the topic in terms of more interest to staff. The memos refer to specific patients and physicians only in a blinded manner, with no identifiers, to preserve the legal safeguards built into the M&M conference. 

E-mail important tool for promoting change

The two e-mails keep the discussion alive after the M&M meeting is history. Gordon emphasizes that e-mail is a tremendously useful way to make sure the M&M conference results are actually put into practice. The two M&M Matrix memos often spark more debate or discussion among recipients, leading to further refinements in the standard of care.

"I have found that people will send an e-mail [who] otherwise will say nothing at the conference," he says. "Some of the most insightful, and sometimes the most vitriolic e-mails come from people who never speak at the conference. It’s a marvelous outlet for extending the educational benefits of the conference."

Physicians and staff have reacted enthusiastically to the Matrix, Gordon says. Achilles A. Demetriou, MD, PhD, chairman of Cedars-Sinai’s department of surgery, says the M&M Matrix is "the perfect mechanism for transforming the valuable lessons of the morbidity and mortality conference into an active and ongoing program of medical education."

The emphasis on clinical improvements and changes in policy or standards or care helps reassure physicians that the M&M is more than just a day to put them in the hot seat and challenge their decisions, Demetriou says. Gordon’s memos always focus on the findings of the conference, he says, never referring to any physician’s error or mistake in judgment.

The memos make sure the ideas survive beyond the meeting, but the Cedars-Sinai Matrix doesn’t stop there. Every four months, a written examination is given to the residents and staff, solely based on the points made at the surgical M&M conference. The examination is voluntary for attending physicians, but mandatory for residents. Then at the end of the year, everyone in the surgery department receives an in-depth analysis of the past year’s complications, along with current references from the medical literature on how to avoid them.

According to Gordon, the complication-focused curriculum is a much more effective way to teach than the older normal-recovery model.

"The M&M Matrix is an evolving concept in resident education, in which the first exposure to a surgical procedure is a complication, rather than a normal recovery," he says. "This tracing backward from a surgical complication to normal physiology and surgical recovery makes a profound impression on young surgeons. It has been shown that surgeons who are exposed to errors early in their careers are less likely to make them later."

Gordon suggests that the M&M Matrix could be applied far beyond the surgical M&M, to any clinical department’s review of complications and even to administration.

"The interest in this is amazing, and the reason is that it’s so simple," he says. "It doesn’t take a focus group or a task force. It doesn’t take a revamping of a hospital system."