Implementation and evaluation of structured nephrology morbidity and mortality conferences: a quality education report.

Background: Morbidity and Mortality Conferences (M&MCs) have for generations been part of the education of physicians, yet their effectiveness remains questionable. The Ottawa M&M Model (OM3) was developed to provide a structured approach to M&MCs in order to maximize the quality improvement impact of such rounds.

Study Design: We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3.

Setting And Participants: All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate.

Quality Improvement Plan: Structured M&MCs were implemented to identify preventable errors and generate actions to improve quality of care and patient safety.

Outcomes: Number and nature of cases reviewed, number and nature of recommendations generated through identification of preventable health system and/or cognitive factors.

Measurements: Morbidity and/or mortality in each case were identified. A determination of the underlying factors and preventability of these events was made. A qualitative review of resulting recommendations was performed.

Results: Over the course of sixteen 1-h long conferences, 52 cases were presented. For all cases presented, discussion, action items and information dissemination followed the OM3. As a result of the M&MCs, 29 recommendations (emanating from 27 cases) lead to improve care delivery.

Limitations: Limitations of this study include its retrospective nature and single-center design.

Conclusions: The implementation of regularly scheduled M&MCs at an academic nephrology program, using a structured model, identified preventable health-systems issues and cognitive errors. Approximately one-half of the cases reviewed generated actions for health care delivery improvement.