title: Interdisciplinary Quality Improvement Conference: Using a Revised Morbidity and Mortality Format to Focus on Systems-Based Patient Safety Issues in a VA Hospital: Design and Outcomes.
abstract: The Veterans Healthcare Administration (VA) has embraced patient safety and quality improvement in the quest to improve care for veterans. The New Mexico VA Health Care System introduced a new morbidity and mortality conference, called the Interdisciplinary Quality Improvement Conference (IQIC), using patient case presentations to focus on underlying systems in the clinical care environment. The revised conference design also effectively teaches the 6 Accreditation Council for Graduate Medical Education (ACGME) core requirements for resident education. A formal process was established for case selection, presentation, systems issue identification, tracking, and follow-up. The IQIC has enabled the identification of more than 20 system issues at the study institution. Outcome data show lasting improvement in system issues that were addressed by this mechanism. The VA IQIC is an effective method to both identify and correct systems issues that affect patient care and is an effective method for teaching residents the 6 ACGME requirements for residency education.
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM Wendy.gerstein@va.gov.
authors.forename: Wendy H
authors.initials: WH
authors.lastname: Gerstein
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: Judith
authors.initials: J
authors.lastname: Ledford
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Cooper
authors.affiliation: VA Loma Linda, Loma Linda, CA.
authors.forename: Melissa G
authors.initials: MG
authors.lastname: Lloyd
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: Timothy
authors.initials: T
authors.lastname: Moore
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: Farzana
authors.initials: F
authors.lastname: Harji
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: Vivian
authors.initials: V
authors.lastname: Twitty
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: Annette
authors.initials: A
authors.lastname: Brooks
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: Rosalinda C
authors.initials: RC
authors.lastname: Oliver
authors.affiliation: Raymond G. Murphy VA Medical Center, Albuquerque, NM.
authors.forename: James M
authors.initials: JM
authors.lastname: Goff
mesh_terms: D003142:Communication; D003299:Cooperative Behavior; D004503:Education, Medical, Graduate / Q000458:organization & administration; D006739:Hospital Administration; D006801:Humans; D007858:Learning; D009516:New Mexico; D061214:Patient Safety; D024382:Professional Role; D058996:Quality Improvement / Q000458:organization & administration*; D014481:United States; D014493:United States Department of Veterans Affairs
keywords: case analysis; medical education; morbidity mortality conference; patient safety; quality improvement