Morbidity and Mortality Conferences (MMCs) are held ubiquitously throughout medical services worldwide [
The Accreditation Council for Graduate Medical Education (ACGME) has incorporated mandatory MMC in each training program since 1983 [
Despite efforts to unify MMC format, their contents remain heterogeneous [
The goal of this paper is twofold. First goal is to determine, through a narrative systematic review of the literature, the process and content of MMC in medical and surgical departments. Second goal is to provide a schematic guideline to improve the organization of these conferences based on the available literature.
We performed a computerized medical literature search from January 1, 1950, to October 2, 2012, using OVID MEDLINE, EMBASE, CENTRAL, Scopus, and ISI Web of knowledge 5.6. We selected articles using a search strategy with a combination of MeSH headings and text keywords related to (1) mortality or morbidity and (2) medical education, teaching rounds, conferences, or presentation. We carried out recursive search and cross-referencing using a “similar articles” function. We also identified articles through hand searches after the initial search. We included all original studies on adult population focused on the discussion of the MMC, in French or English. Studies with original data regarding multiple aspects of MMC were assessed. We excluded articles with only abstract publication or conference presentations because these do not provide sufficient information for the purpose of this review. We reviewed national surveys, but we did not collect their data for analysis in this systematic review. Duplicates were excluded. Two investigators (Xin Xiong and Teela Johnson/Alan N. Barkun of the authors) assessed all articles according to the selection criteria independently; disagreements were discussed until a consensus was reached.
In the current literature, there exists a variety of organized terminologies to describe different aspects of MMC. In our study, we adjudicated each article’s main focus into one of the following categories: goals, structure, or process [
Proposed characteristics of MMC, modified with permission from Aboumatar et al. [
Comparative qualitative analyses were performed across studies to assess the clinical homogeneity of study populations (cases, patients, or health care professionals), interventions, and outcomes. Statistical heterogeneity was not evaluated as most outcomes were qualitative in nature.
From a total of 405 citations identified, 358 were excluded because they did not pertain to discussion of aspects of MMC, 8 were excluded given they were either national surveys or review articles, 3 were excluded because they did not address adult populations, and 3 were excluded due to insufficient information. Cross-referencing yielded 5 additional articles. Therefore, 38 studies were included (see Figure
QUOROM diagram.
Tables
(a) Articles for medicine and subspecialties, primary care, and ICU (10 articles). (b) Articles for surgery and its subspecialties, obstetrics, and anesthesia (25 articles). (c) Articles for both medicine and surgery (3 articles).
Study/setting | Stated objective | Category | Type of study | Main results and conclusion |
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Kirschenbaum et al., 2010 [ |
Determining if audit of patients plus a focused MMC improved patient care in ICU | Goal | Interventional: before and after survey | MMCs result in improved rapid response and hospital outcomes (number of cardiac arrests decreased from 3.1/1000 to 0.6/1000, |
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Ksouri et al., 2010 [ |
Evaluating MMC in ICU for improving quality of care and patient safety | Goal, structure, process | Retrospective | MMCs provide educational value and can be used to assess quality of care, patient safety, and interpersonal and team communication. |
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Kuper et al., 2010 [ |
Exploring the role of MMC in medical education | Goal, structure | Prospective/ethnographic: interviews, evaluation of notes, and audiotape of MMC | MMCs are effective vehicles to address competencies in patient safety and quality improvement. A disjunction between teaching valued by staffs and learning valued by students were noted. |
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Szostek et al., 2010 [ |
Determining educational value of system audit | Goal, structure, process | Interventional: before and after survey | MMCs with system audit have higher educational values, 95% (versus 61% preimplementation) and stimulating increased interest in education as well as ensuring improved quality of care. |
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Bechtold et al., 2008 [ |
Describing new MMC experience | Goal, structure, process | Interventional: before and after survey | New MMC format allows good educational forum with increased participation. Educational intervention and recommendations were more likely to be carried out. |
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Hasan and Brown, 2008 [ |
Proposing a format as a model for MMC in academic center for gastroenterology | Structure, process | Prospective: chart review | Overall complication rate of 0.76%, within that reported in the literature. Monthly MMCs are a means of monitoring patient care and enhancing trainee education. |
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Goldszer et al., 2006 [ |
Describing MMC in primary care center | Goal, structure, process | Prospective | The MMC format is a useful tool to improve patient care. |
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Kravet et al., 2006 [ |
Evaluating the role in teaching 6 competencies of ACGME with MMC implemented in Grand Round | Goal, structure | Cross-sectional: survey | MMCs in Grand Rounds are effective (well attended) and add diversity in topic and teaching methods. |
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Denis et al., 2003 [ |
MMC format assessed as a quality improvement tool in gastroenterology | Goal, process | Prospective: chart review | Systematic prospective recording of complications and careful exhaustive retrospective analysis during MMC are efficient and complementary tools for continuous quality improvement. |
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Esselman and Dillman-Long, 2002 [ |
Refocusing MMC onto system issues and avoiding placing blame on individuals | Goal, structure, process | Retrospective | MMCs are important in quality improvement when focusing on system issues. |
Study | Setting |
Stated objective | Category | Type of study | Main results and conclusion |
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Falcone and Watson, 2012 [ |
Academic |
Assessing participation and cost benefit of teleconference in MMC | Goal, structure | Retrospective |
Teleconferencing allows for increased faculty attendance at MMC (5 per conference, |
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Falcone et al., 2012 [ |
Academic |
Describing reporting patterns of general surgery residents. Describing adverse events rates compared to published data | Process | Retrospective cohort | Underreporting of nonfatal adverse events: 2.5% versus 4.3% reported in literature; majority of adverse events were from death (24.1%), hematologic or vascular complications (16.7%), and gastrointestinal complications (16.1%). |
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Thomas et al., 2012 [ |
Academic |
Integrating minor complication reporting in MMC for its educational value | Goal, |
Interventional: before and after survey | Postimplementation of reporting of minor adverse outcomes in MMC; 95% of surveyed population ( |
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Bevis et al., 2011 [ |
Academic |
Characterizing the MMC as a cost-effective and efficient approach for addressing the ACGME competencies | Goal, structure | Retrospective | MMCs address 100% practice-based learning and medical knowledge, 19% systems-based practice, 10% communication, and 6% professionalism or ethics. |
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Kauffmann et al., 2011 [ |
Academic |
Multidisciplinary MMC presents a unique opportunity to incorporate all 6 ACGME competencies effectively and efficiently | Goal, structure, process | Retrospective | Multidisciplinary MMCs are useful in rapidly achieving quality improvement while creating opportunities for system health care delivery initiatives. |
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Kim et al., 2010 [ |
Academic |
Examining the content and process of MMCs and testing the hypothesis that a structured format can improve teaching and learning | Goal, structure | Interventional: before and after survey | A structured MMC format improves the identification of the cause for complication (3.11 to 4.56, |
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Steiger et al., 2010 [ |
Academic |
Describing methods to identify critical cases, the system of analysis, classification of MMC, and resulted impact | Goal, process | Retrospective | A reliable system is employed by MMC to identify cases, providing good instruments for quality control and problem oriented teaching. Impact on quality improvement remains questionable. |
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Antonacci et al., 2009 [ |
Academic and community |
Describing comprehensive surgeon report card system based on MMC, in a nonpunitive error analysis fashion | Goal, structure, process | Prospective | MMCs result in a 40% reduction of gross mortality ( |
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Berenholtz et al., 2009 [ |
Academic |
Describing learning from a defect tool as a strategy to meet ACGME requirements and enhance traditional MMCs | Goal, structure, process | Prospective | MMCs present a helpful strategy to learn from medical incident and improve patient safety and quality of care. Adverse events are usually failures in the system. |
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Bender et al., 2009 [ |
Academic |
Determining heterogeneity of assessment in peer-reviewed MMC and evaluating biases | Process | Prospective: survey | Significant disagreement noted amongst assessors leading authors to conclude that the reliability of peer review is questionable. |
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Dissanaike et al., 2009 [ |
Academic |
Comparing the perceptions of preventability of mortalities and severity of complications of MMC attendees | Structure, process | Prospective | Surgical residents assign higher severity to trauma-related complications than other groups. More objective grading tools are necessary to improve the adequacy of MMC. |
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Greco et al., 2009 [ |
Academic |
Describing the authors’ experience with incorporating a clinical librarian into the process of MMCs | Goal, structure | Prospective | The clinical librarian program has improved the quality of MMC presentations. |
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Folcik et al., 2007 [ |
Academic |
Describing a two-tiered process MMC with dedicated subcommittee for quality improvement for ACGME competencies | Goal, structure, process | Prospective: reviewed MMC note, survey | MMCs with a dedicated quality improvement subcommittee decrease time to implementation of changes (3-4 months compared to 10–12 months). |
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Prince et al., 2007 [ |
Academic |
Analyzing which features of MMC associated with greater educational value and increasing confidence in the future | Goal, structure | Prospective: survey | Audience interaction improves educational value and increased confidence in managing complex problems presented in MMC ( |
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Goldfarb and Baker, 2006 [ |
Community |
Sharing a reproducible process for presenting, analyzing, and reducing surgical morbidity and mortality | Goal, structure, process | Retrospective: chart review | MMCs help in directing changes to resident training, hospital systems, and surgical practice. |
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Hutter et al., 2006 [ |
Academic |
Comparing data as reported in a traditional MMC versus National Surgical Quality Improvement Program (NSQIP) | Goal | Retrospective: MMC data reviewed | MMCs underreport adverse events when compared to NSQIP: 1/2 deaths and 3/4 complications were not presented, especially in patients with incurable disease, transferred care, and “medical” problems. |
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Miller et al., 2006 [ |
Academic |
Comparing complications reported at the MMC versus NSQIP | Goal, |
Retrospective: chart review | MMCs have low sensitivity for detection of complications (25%). NSQIP may be better for urologic quality improvement endeavors. |
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Rosenfeld et al., 2005 [ |
Community |
Evaluating new MMC for ACGME competencies | Goal, structure, process | Retrospective: chart review | The restructuring of MMC so that a case is analyzed according to ACGME general competencies improved general interest and educational value. MMCs provide opportunities to teach ACGME general competencies. |
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Murayama et al., 2002 [ |
Academic |
Evaluating impact of changes made to our MMC (5–10 min case summary, literature review, and faculty discussion with moderator) | Goal, structure | Interventional: before and after survey | Surgical residents perceive significant improvements after changes to the MMC process. This is not the case for surgical staff. |
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Risucci et al., 2003 [ |
Academic |
Assessing interrater agreement before and after initiation of a modified MMC (presentation of 3 cases of 30 minutes with literature review) | Structure, process | Interventional: before and after survey | After modification of MMC, the majority of surveyed population perceives that consensus has been reached more often (96% of cases versus 70% cases |
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Veldenz et al., 2001 [ |
Academic |
Determining educational value of MMC in surgical residency program | Goal, structure, process | Retrospective | A weekly peer-reviewed MMC provides educational value with ongoing examination of common problems encountered in the delivery of surgical care. |
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Hamby et al., 2000 [ |
Academic |
Determining the effectiveness of routine incorporation of local practice data in MMC | Goal, structure, process | Prospective: chart review | Incorporating prospective outcome data into the MMC provides increased educational values and opportunities for quality improvement. |
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Feldman et al., 1997 [ |
Academic |
Comparing the incidence of adverse outcomes recorded in a prospective general surgery database with that of MMC | Structure, process | Prospective: chart review | Although most severe complications (87.5%) are recorded at MMC, a large proportion of complications remain unreported. Rigorous monitoring of outcomes may contribute further to improvements in quality of care. |
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Thompson and Prior, 1992 [ |
Academic |
Determining the role and efficacy of surgical MMC in a current quality assurance program | Goal | Retrospective: chart review | Although many adverse events are not identified by MMC, these conferences remain an important component of quality assurance program. |
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Baele et al., 1991 [ |
Academic |
Describing the format of MMC in detail | Goal, |
Prospective: chart review | MMCs offer a good educational role for residents through sharing of experiences, using a “no-blame” attitude. MMCs improve prevention of complications. |
Study | Setting | Stated objective | Category | Type of study | Main results and conclusion |
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Szekendi et al., 2010 [ |
Academic | Sharing the authors’ experience with a patient safety oriented MMC over 7 years | Goal, structure, process | Interventional: before and after survey | Shift in staff perceptions of culture: increased voluntary reporting (by 66%), improved patient safety, and amelioration of quality of care. |
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Aboumatar et al., 2007 [ |
Academic | Describing MMC formats across multiple clinical departments; comparing MMC processes with previously published medical incident analysis models; and exploring how MMCs could be modified to advance medical education and improve patient care | Goal, structure, process | Cross-sectional: survey | MMCs vary in structure and process and fail to use known analytic framework. Well conducted MMCs provide valuable educational and quality assurance benefits. MMC should elicit input from all caregivers involved, follow a structured approach to identify system defects, and ensure adequate follow-ups on recommendations. |
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Pierluissi et al., 2003 [ |
Academic | Determining the frequency at which MMCs include adverse events and errors; determining whether errors are discussed and attributed to a particular case | Structure, process | Cross-sectional and prospective | Cultural difference between internal medicine and surgery noted. In internal medicine, fewer cases are presented (1.5 versus 2.7 cases, |
Overall, the focus (goal, structure, and process) that these 38 articles have covered (numbers not mutually exclusive) is as follows: 30/38 articles (79%) discussed the goal of the MMC, 30/38 (79%) the structure, and 26/38 (68%) the process. 10/38 articles (26%) discussed goal and structure, 2/38 (5%) goal and process, and 6/38 (16%) structure and process. 14/38 articles (37%) encompassed all 3 categories.
Figure
Characteristics of MMC in medicine (
Figure
Characteristics of MMC in surgery (
As can be noted from Figures
Upon review of the available literature on MMC, it is apparent that there is considerable heterogeneity in the content and goals of MMC across both medical and surgical services. This heterogeneity has been shown to limit the effectiveness of MMC [
To begin with, we note that medical and surgical departments have different approaches to the process of MMC, which has been confirmed by previous reviews [
There exists no direct evidence for a need for differing practices between surgical and medical departments. For example, no empiric data favors presenting more versus less cases; certain studies [
Although MMCs do not include assessment of all adverse outcomes and errors, their benefit in improving patient care has nevertheless been demonstrated quantitatively in some controlled studies: Antonacci et al. [
Traditionally, MMCs have consisted of case presentation by a senior resident, followed by staff discussion of itemized problem lists, in order to systematically identify each underlying issue with the goal of preventing future error [
Based on the heterogeneous nature of the available literature, although it is difficult to synthesize evidence-based recommendations, some suggestions for the conduct of MMC can certainly be proposed.
The goals should be both quality improvement and education. The MMC should be organized such that an optimal balance is maintained at each MMC within a given department. It should also be noted that these goals are not always mutually exclusive and are often complimentary.
As there is no strong evidence for the frequency of MMC, the traditional frequency of monthly MMC in medical departments and weekly MMC in surgical specialties may be appropriate. Instead of commenting on a recommended frequency, we propose that each department evaluates whether monthly or weekly conferences are adequate for meeting the services’ desired goals, while balancing the other priorities of the department (such as time management, resident education, and patient safety). Similar recommendations can be made with regard to the number of cases discussed or the duration of the MMCs. Arguably, the participants ought to be multidisciplinary, particularly as solutions to systematic problems, usually necessitate a multipronged approach. The presence of a formally recognized facilitator, who moderates the participation of the various members, would enhance MMC outcomes.
Cases should be selected with predefined criteria or using other existing complication database registries. The cases selected should include both preventable and nonpreventable adverse outcomes, cases with opportunity for quality improvement, cases with educational values, or rare events. For each event presented, we suggest an analysis based on a framework such as the root cause analysis model, to improve effectiveness in identifying both individual and systemic factors. We also suggest appropriate incorporation of evidence-based medicine as well as initiation of quality improvement recommendations during these conferences.
Patient safety is of vital importance in the practice of medicine. Both medical and surgical services aim to improve patient safety through Morbidity and Mortality Conferences. Although there is a paucity of evidence with regard to their effect on hard outcomes, they are arguably a fundamental tool for achieving important goals in education and quality improvement. Using a unifying conceptual framework for the content and process of MMC, we attempt to summarize the existing literature in a simple, consistent, and reproducible fashion. It is clear that further research is needed to assess the use of different available frameworks to improve the effectiveness of MMC for both medical education and patient safety purposes.
The authors declare that there are no competing interests regarding the publication of this paper.