title: Leveraging a Redesigned Morbidity and Mortality Conference That Incorporates the Clinical and Educational Missions of Improving Quality and Patient Safety.
abstract: The morbidity and mortality (M&M) conference is a vital event that can affect medical education, quality improvement, and peer review in academic departments. Historically, M&M conferences have emphasized cases that highlight diagnostic uncertainty or complex management conundrums. In this report, the authors describe the development, pilot, and refinement of a systems-based M&M conference model that combines the educational and clinical missions of improving quality and patient safety in the University of Colorado Department of Medicine.
  
  
  
  In 2011, a focused taskforce completed a literature review that informed the development of a framework for the redesigned systems-based M&M conference. The new model included a restructured monthly conference, longitudinal curriculum for residents, and formal channels for interaction with clinical effectiveness departments. Each conference features an in-depth discussion of an adverse event using specific quality improvement tools. Areas for improvement and suggested action items are identified during the conference and delegated to the relevant clinical departments.
  
  
  
  The new process has enabled the review of 27 adverse events over two years. Sixty-three action items were identified, and 33 were pursued. An average of 50 to 60 individuals participate in each conference, including interprofessional and interdisciplinary colleagues. Resident and faculty feedback regarding the new format has been positive, and other departments are starting to adopt this model.
  
  
  
  A more robust process for identifying and selecting cases to discuss is needed, as is a stable, sufficient mechanism to manage the improvement initiatives that come out of each conference.
authors.affiliation: D.B. Tad-y is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. R.G. Pierce is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. J.M. Pell is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. L. Stephan is clinical data analyst, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. P.P. Kneeland is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. H.L. Wald is associate professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
authors.forename: Darlene B
authors.initials: DB
authors.lastname: Tad-Y
authors.forename: Read G
authors.initials: RG
authors.lastname: Pierce
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Pell
authors.forename: Lindsie
authors.initials: L
authors.lastname: Stephan
authors.forename: Patrick P
authors.initials: PP
authors.lastname: Kneeland
authors.forename: Heidi L
authors.initials: HL
authors.lastname: Wald
mesh_terms: D000328:Adult; D002983:Clinical Competence; D003120:Colorado; D003226:Congresses as Topic / Q000458:organization & administration*; D004501:Education, Medical / Q000458:organization & administration*; D004502:Education, Medical, Continuing / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D009017:Morbidity; D009026:Mortality; D061214:Patient Safety; D058996:Quality Improvement / Q000458:organization & administration*; D011787:Quality of Health Care / Q000458:organization & administration*; D017751:Safety Management / Q000379:methods