conducting-morbidity-mortality-reviews

# Conducting Morbidity and Mortality Reviews

Structures surgical M&M conference presentations with case analysis and system improvement recommendations.

## Why This Skill Exists

Morbidity and Mortality (M&M) conferences are the cornerstone of surgical quality improvement and have been a requirement of ACGME-accredited surgical training programs since 1983. The ACS Committee on Perioperative Care and the Joint Commission both endorse structured M&M review as a mechanism for identifying system failures, reducing preventable harm, and fostering a culture of safety. Many state peer review statutes provide legal privilege for M&M proceedings, protecting candid analysis from discovery in malpractice litigation — but only when conducted within the statute's requirements.

Effective M&M conferences analyze adverse events through a systems lens rather than assigning individual blame. Research demonstrates that institutions with structured M&M programs that include root cause analysis and track implementation of corrective actions achieve measurable reductions in complication rates. Poorly conducted M&M conferences — those that focus on blame, lack follow-up, or fail to examine system factors — provide no quality benefit and may expose proceedings to legal discovery. This skill structures the case selection, presentation, analysis, and action-tracking process.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the adverse event or complication to be reviewed? **Default: [VERIFY — obtain from quality/surgical chair]**
2. What was the index operation, date, and surgeon? **Default: [VERIFY]**
3. What was the patient outcome (Clavien-Dindo grade, death, readmission)? **Default: [VERIFY]**
4. Was this event flagged by ACS NSQIP, institutional quality reporting, or surgeon self-report? **Default: [VERIFY]**
5. Is the case being reviewed for educational purposes, quality improvement, or both? **Default: both**
6. Has the patient or family been informed of the adverse event? **Default: [VERIFY]**
7. Is the case subject to peer review privilege under state statute? **Default: yes — confirm with risk management**
8. Who will present the case? **Default: chief resident or fellow**

### Documents to Request

- Complete medical record for the index admission
- Operative report(s)
- Progress notes from the day the complication was identified
- Nursing assessments and vital sign flowsheets
- Laboratory and imaging results relevant to the event
- Anesthesia record
- Code/rapid response records (if applicable)
- ACS NSQIP observed-to-expected ratio for the case type
- Any similar cases from the past 12 months (pattern identification)

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## Step 1: Case Selection and Classification

### Selection Criteria for M&M Review

Cases should be selected based on clinical significance and learning potential:

| Category | Selection Criteria | Priority |
|---|---|---|
| Death | All surgical deaths within 30 days of operation | Mandatory |
| Major morbidity | Clavien-Dindo Grade ≥ IIIb | High |
| Unexpected ICU admission | Unplanned ICU transfer | High |
| Unplanned reoperation | Return to OR for complication of index procedure | High |
| Readmission | Unplanned readmission within 30 days | Moderate |
| Never events | Wrong site, retained foreign body, wrong procedure | Mandatory |
| NSQIP outliers | Observed complications significantly exceeding expected rate | High |
| Near miss | Event that could have resulted in harm but was caught | Moderate (educational) |

### Classification Framework

For each case, assign:
- **Clavien-Dindo grade**: I through V
- **Preventability assessment**: Definitely preventable / Possibly preventable / Not preventable
- **Error type**: Technical error / Judgment error / System error / Communication failure / No error (expected complication despite appropriate care)

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## Step 2: Structured Case Presentation

Present the case in the following standardized format (15-20 minutes):

### A. Case Summary (3-5 minutes)
- Patient demographics (age, sex, relevant comorbidities)
- ASA class and ACS NSQIP predicted risk
- Presenting complaint and preoperative workup
- Surgical indication and decision-making rationale
- Procedure performed (briefly)

### B. Postoperative Course and Complication (5-7 minutes)
- Postoperative course with daily clinical status
- When and how the complication presented
- Diagnostic workup performed and results
- Timeline of recognition, escalation, and intervention
- Final outcome (disposition, Clavien-Dindo grade)

### C. Key Decision Points (2-3 minutes)
Identify 3-5 critical junctures where decisions were made or could have been made differently:
- Was there a delay in recognition?
- Was the diagnostic workup appropriate and timely?
- Was the intervention appropriate and timely?
- Were there communication failures between team members or services?
- Were there system factors (staffing, equipment, protocols) that contributed?

### D. Literature Reference (2-3 minutes)
- Brief review of evidence-based management for this complication
- Published incidence rates for this complication in similar procedures
- Relevant guidelines or quality benchmarks (ACS, ERAS, specialty society)

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## Step 3: Root Cause Analysis

Apply a structured root cause analysis framework. The Swiss Cheese Model (Reason's model) identifies how multiple defense layers failed simultaneously:

### Contributing Factor Categories

| Category | Questions to Ask | Examples |
|---|---|---|
| **Patient factors** | Were there unmodifiable patient factors that increased risk? | ASA IV, morbid obesity, immunosuppression |
| **Provider factors** | Was there a knowledge, skill, or judgment issue? | Unfamiliarity with anatomy, fatigue, cognitive bias |
| **Task factors** | Was the procedure itself unusually difficult? | Re-operative field, distorted anatomy, rare variant |
| **Team factors** | Were there communication breakdowns? | Handoff failures, unclear role assignment, hierarchy gradient |
| **System factors** | Did organizational issues contribute? | Staffing shortages, equipment unavailability, protocol gaps |
| **Institutional factors** | Are there cultural or resource issues? | Safety culture, training support, quality infrastructure |

### The 5 Whys Technique

For each contributing factor, ask "why" iteratively to reach the root cause:

1. Why did the anastomotic leak occur? → Inadequate blood supply to the bowel ends.
2. Why was blood supply inadequate? → The marginal artery was divided too close to the anastomosis.
3. Why was it divided there? → The surgeon was unfamiliar with the vascular anatomy variant.
4. Why was the surgeon unfamiliar? → Preoperative CT angiography was not reviewed.
5. Why was it not reviewed? → There is no institutional protocol requiring vascular imaging review before left colectomy.

**Root cause identified**: Absence of a preoperative imaging review protocol for colonic vascular anatomy.

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## Step 4: Discussion and Recommendations

### Facilitated Discussion Format (10-15 minutes)

The M&M chair should facilitate discussion, not assign blame. Use these prompts:

1. "Given the information available at the time, was the decision-making reasonable?"
2. "What system changes could prevent this from occurring again?"
3. "Is there a protocol gap that contributed to this event?"
4. "Would additional training, equipment, or staffing have changed the outcome?"
5. "Has this type of event occurred before, and if so, what was done?"

### Action Item Generation

For each identified root cause, generate a specific, measurable, assignable, realistic, and time-bound (SMART) action item:

| Root Cause | Action Item | Responsible Person | Deadline | Metric |
|---|---|---|---|---|
| No vascular imaging review protocol | Create preoperative imaging checklist for colorectal surgery | Dr. Chen, colorectal section chief | 60 days | Checklist completion rate |
| Handoff failure at shift change | Implement structured handoff tool (I-PASS) for surgical services | Chief resident | 30 days | Handoff compliance audit |
| Delayed recognition of sepsis | Add q-SOFA scoring to nursing vital sign assessment | Nurse manager | 45 days | q-SOFA documentation rate |

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## Step 5: Documentation and Follow-Up

### M&M Conference Minutes

Document in a format consistent with peer review privilege:

```
M&M CONFERENCE MINUTES — [Date]
[PRIVILEGED AND CONFIDENTIAL — PEER REVIEW PROTECTED]

Case #: [sequential number]
Presenter: [name]
Clavien-Dindo Grade: [grade]
Preventability: [definitely/possibly/not preventable]
Root Cause Category: [system/technical/judgment/communication/none]

Key Discussion Points:
1. [summary]
2. [summary]
3. [summary]

Action Items:
1. [action, responsible, deadline]
2. [action, responsible, deadline]

Follow-up on Prior Action Items:
1. [prior action, status: completed/in progress/overdue]
```

### Action Item Tracking

Maintain a running log of all M&M action items with status:
- Review pending action items at the beginning of each M&M conference
- Report completion rates quarterly to the department quality committee
- Escalate overdue items to department leadership

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Was the case presented using a structured format with timeline, decision points, and literature reference?
2. Was root cause analysis performed using a validated framework (Swiss Cheese, 5 Whys, or equivalent)?
3. Were the discussion and recommendations systems-focused rather than blame-focused?
4. Were SMART action items generated with responsible parties and deadlines?
5. Are M&M minutes documented under peer review privilege protections?

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## Quality Audit

- [ ] Case selected based on defined selection criteria (death, major morbidity, NSQIP outlier, near miss)
- [ ] Clavien-Dindo grade assigned and documented
- [ ] Preventability assessment made (definitely/possibly/not preventable)
- [ ] Case presented with structured format and timeline
- [ ] Decision points identified and analyzed
- [ ] Root cause analysis performed with a validated methodology
- [ ] Contributing factors categorized (patient, provider, task, team, system, institutional)
- [ ] Literature review included with published complication rates and guidelines
- [ ] Discussion facilitated without blame attribution
- [ ] SMART action items generated from identified root causes
- [ ] Action items assigned to specific individuals with deadlines
- [ ] Prior action items reviewed for completion status
- [ ] Minutes documented under peer review privilege protection
- [ ] Patient/family disclosure documented separately from M&M proceedings
- [ ] Conference attendance tracked for ACGME compliance

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## Guidelines

1. M&M conferences are quality improvement and education activities — they must never become forums for public blame or humiliation. The chair is responsible for maintaining a constructive, systems-focused tone.
2. Peer review privilege requires compliance with state statute requirements. Consult risk management before conducting review on cases with active or anticipated litigation. M&M minutes should never be stored in the patient's medical record.
3. All surgical deaths within 30 days of operation should be reviewed at M&M, regardless of whether the death was related to the surgery. This is an ACGME and ACS verification requirement.
4. The most valuable cases for M&M are those where system changes can be implemented — cases where no error occurred (unavoidable complication despite best care) should be acknowledged but do not require extensive root cause analysis.
5. Track action item completion rates. An M&M conference that generates action items but does not follow up provides no quality benefit. Target >80% completion within stated deadlines.
6. Near-miss cases are high-value M&M presentations because they allow learning without patient harm. Actively solicit near-miss reporting.
7. Distinguish between individual performance issues and system issues. Individual performance concerns should be addressed through private, direct feedback and professional development — not through M&M conference discussion.