Question:  What is the proper role of the Morbidity & Mortality Conference in Clinical Peer Review?

Short Answer:  It has potential to make a valuable contribution in support of peer review and quality improvement, but requires appropriate design.

Detail:

In our national study of peer review practices, we found that 58% of 339 facilities responding include Morbidity & Mortality (M&M) conferences within the scope of peer review. (1) This ranged from 54% among non-teaching facilities to 75% among academic medical centers (previously unpublished data).

The M&M conference serves a dual role as a platform for revealing the learning opportunities in adverse events and as a vehicle for graduate medical education. In hospitals with post-graduate training programs, residents and fellows predominate as both the presenters and the primary audience. At academic medical centers, surgical M&M conferences are held weekly and average 60-90 minutes. (2) Surgical training programs tend to have shorter case presentations (12 minutes) and a greater focus on adverse events than do internal medicine programs (34 minutes). (3)

Several investigators have found that traditional M&M conference methods significantly under-report surgical deaths and complications compared to occurrence screening and National Surgical Quality Improvement Program (NSQUIP) methods (4, 5, 6) At the patient level, the sensitivity may be as low as 25%. The M&M conference may also under-report issues with procedure appropriateness, pathology discrepancies and diagnostic errors. (5) Other potential limitations of the M&M model have been noted including lack of participation by the involved clinicians, avoidance of the “tough issues”, and the difficulty of creating a non-punitive environment for learning. (7)

Some have developed effective mechanisms for identifying and tracking surgical adverse events, such as mandatory resident reporting, which have been integrated with the M&M process and other peer review activity. (8-10) These models may include a reconciliation of the root cause when the identified adverse event is a symptom (e.g., hypotension as a sign of sepsis, hemorrhage, etc.), classification of preventability, and attribution of causality to a care-giver, the patient, and/or the system of care. Moreover, there are several reports in which the M&M conference was believed to have made a contribution to improved clinical performance. (11, 12) The time requirement may, however, be substantial. One group reported an average of 2 hours per week, and noted that conferences could go as long as 4 hours. (12) Thus, the M&M conference has potential to make a valuable contribution in support of peer review and quality improvement, but requires appropriate design. The QI Model and the Peer Review Program Self-Evaluation Tool give additional guidance as to key parameters that should influence M&M program design if it is to effectively contribute to peer review and improved clinical performance.

I’d recommend that physician leaders who are redesigning their M&M process ask the following questions:

  • How will the M&M conference fit with the rest of our peer review program?
  • How will we identify, track and monitor adverse events?
  • How will we select cases for presentation and discussion at M&M?
  • How will we create a non-punitive environment that supports self-reporting and the identification of opportunities for improved clinical performance, while maintaining personal accountability?
  • If we can’t accommodate review of at least 1% of our service volume through M&M, what will be the process to manage review of these additional cases?
  • What information will be recorded regarding the findings and conclusions?
  • How will we handle the situation in which an involved clinician is not present?
  • How will we recognize excellent performance?
  • How will we assure that opportunities for improvement are acted upon, whether individual, group or system of care?
  1. Edwards MT, Benjamin EM. The process of peer review in US hospitals. J Clin Outcomes Manage. 2009(Oct);16(10):461-467.
  2. Gore DC. National survey of surgical morbidity and mortality conferences. Am J Surg 2006;191:708-714.
  3. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA 2003;290(21):2838-2842.
  4. Hutter MM, Rowell KS, Devaney LA, Sokal SM, Warshaw AL, Abbott WM, Hodin RA. Identification of surgical complications and deaths: an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program. J Am Coll Surg. 2006;203(5):618-624.
  5. Thompson JS, Prior MA. Quality assurance and morbidity and mortality conference. J Surg Research. 1992;52(2):97-100.
  6. Orlander JD, Barber TW, Fincke G. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med. 2002;77(10):1001-1006.
  7. Miller DC, Filson CP, Wallner LP, Montie JE, Campbell DA, Wei JT. Comparing performance of morbidity and mortality conference and National Surgical Quality Improvement Program for dection of complications after urologic surgery. Urology. 2006;68(5):931-937.
  8. Antonacci AC, Lam A, Lavarias V, Homel P, Eavey RA. A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis, part I. J Surg Res. 2008:147(2):172-177.
  9. Healey MA, Shackford SR, Osler TM, Rogers FB, Burns E. Complications in surgical patients. Arch Surg. 2002;137(May):611-618.
  10. Hamby LS, Birkmeyer JD, Birkmeyer C, Alksnitis JA, Ryder L, Dow R. Using prospective outcomes data to improve morbidity and mortality conferences. Curr Surg. 2000;57(4):384-388.
  11. Stanford JR, Swaney-Berhoff L, Recht KE, Orsagh-Yentis DK. Improved cardiac surgical outcomes with use of total quality management. J Clin Outcomes Manage. 2009;16(9):405-409.
  12. Antonacci AC, Lam A, Lavarias V, Homel P, Eavey RA. A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. J Surg Res. 2009;153(1):95-104.