Promoting a culture of safety

Morbidity and mortality conferences (MMK) have been taking place since the beginning of the 20th century. The number of MMKs in general hospitals has increased significantly in the last eight years.¹ This is partly due to the fact that the “Quality Management Guideline for Contractual Medical Care” (QM-RL) of the Joint Federal Committee lists MMKs, in Part B § 1 Sentence 6 QM-RL, as an example of a clinical risk management tool that inpatient facilities are obliged to implement. The medical associations and the German Coalition for Patient Safety also recommend conducting MMKs. On the other hand, evidence of MMKs is required to obtain selected certificates such as OnkoZert.

The significance of morbidity and mortality conferences lies in their contribution to improving patient safety and treatment quality. In an MMK, treatment processes are reflected upon so that possible deviations from established routines come to light. These are discussed across disciplines with the aim of deriving specific measures to improve the quality and safety of patient care. Thus, the MMK becomes a reflection of the safety culture in practice and an instrument of individual and organizational learning.

MMK guidelines and their penetration into practice

In German-speaking countries, various guidelines on the methodology of MMKs are available, for example from the German Medical Association in Germany or the Patient Safety Foundation in Switzerland. However, with regard to the implementation of MMKs, it is striking that almost a quarter of MMKs are carried out without structure, some healthcare organizations do not have a uniform concept and a cross-professional approach is only chosen in about two thirds of cases. This raises the question of quality. If MMCs only serve to fulfill formal requirements, they are not an expression of a self-critical and beneficial patient safety culture. Their effect in this regard is negligible. This makes the role of managers in the design and implementation of morbidity and mortality conferences all the more important.

The role of the manager

Managers can actively influence the structure of a MMK and, in addition, the safety culture of their department, developing it in the desired direction. The following questions help to structure a MMK in such a way that it fulfills its goal of improving individual and organizational learning and thus also promoting patient safety.

But what if an open dialog arises among those present during an MMK or if participation is low and a controversial exchange does not arise?

In the second case, the participants could be afraid of restrictions. Here it is the manager's job to create an atmosphere of open dialog so that as many employees as possible are willing to share their thoughts with their colleagues. This is the only way to reflect on different perspectives, which can ultimately help optimize treatment.

Are those present willing to see and discuss possible causes for the patient's outcome in the organization of the treatment process or will it be limited to medical care alone?

This makes it possible to see what the employees' understanding of how errors arise in medicine is. The majority of errors in patient care are not based on professional deficiencies, but rather lie in the communication and organization of the treatment. The manager should also repeatedly ask questions to this effect, especially since the organization of the department lies in their area of responsibility.

Conflicts between professional groups or individual actors may become apparent. Can the conflicting parties work together constructively or does the conflict block further cooperation and can thus become a cause of patient harm?

Here, the manager can identify a possible need for action. The manager can resolve professional controversies in a MMK by explaining the best course of action from their point of view. In doing so, they give employees room for interpretation as to how to proceed in such cases. Conflicts at the relationship level cannot be resolved in an MMK. If they arise, the manager should check whether there is a need for action, which is then implemented in other ways.

Does it emerge that guidelines or defined treatment processes are not being followed?

The manager can see from the medical treatment process described whether the guidelines they have set are being implemented by their employees. This provides information about their compliance and the degree of penetration in practice. If guidelines are not adhered to, it should be determined whether this is a one-off deviation or an unfulfillable requirement and whether adjustments are necessary. These can also be evaluated as part of the MMK.

Does the manager participate actively and with full concentration in the MMK or do they allow themselves to be distracted by non-urgent phone calls, arrive late or leave before the end?

The employees can see from the behavior of the manager what significance the MMK has for their manager and in their department. The manager is a role model. The employees imitate their behavior. Employees also arrive late and/or tend to leave early, make phone calls or similar. These disruptions make a constructive dialog impossible. As a result, MMKs may take place as a formality, but cannot contribute to an improvement in the quality of treatment.

How should mistakes by employees be handled?

When evaluating medical procedures and the organization of treatment, mistakes made by individuals can be recognized. How the manager handles these mistakes is closely observed by the employees. Here, the manager can actively influence the safety culture in the department through their behavior. Employees experience whether a mistake results in exposure or harsh verbal comments and draw their own conclusions. In the worst case, the participants learn to keep quiet about mistakes when they happen. Learning from mistakes is thus significantly limited. The opposite reaction of the manager is also not useful for a safety culture in terms of patient safety. If the mistake seems insignificant to the manager, the participants take away the message that their own actions have no consequences. The manager shapes the way mistakes are dealt with in their organizational unit, and the participants learn from this.

Is there an interdisciplinary exchange?

Smooth interdisciplinary cooperation is of great and often crucial importance for patient safety. For this reason, morbidity and mortality conferences should always be conducted in an interdisciplinary manner. Within a department, it makes sense to include the medical and nursing professional groups. In selected cases, the professional groups involved in the treatment should also be included. A morbidity and mortality conference is an instrument of individual and organizational learning. A unit can learn when all the professional groups involved in it are represented. The employees recognize from the interaction of the managers how communication and the degree of cooperation between the departments is structured. In the best case, this is so constructive that a low-threshold consultation takes place without conflict.

Tips for organizing morbidity and mortality conferences in everyday clinical practice

In times of staff and professional shortages, hospital reform plans and the dire economic situation of many hospitals, conducting morbidity and mortality conferences seems to be a secondary concern. In addition, although the existing guidelines describe the process and methodology very well, their transfer into practice sounds visionary and not very realistic in view of the lack of human, temporal and economic resources. However, to refrain from implementing them would be tantamount to foregoing individual and organizational learning, promoting patient safety and, ultimately, employee management. If a department is forced to implement MMIs as quickly and cost-effectively as possible due to a lack of resources, a practical and systematic approach is needed. This could be designed as follows:

Preparation

The department determines which cases are eligible for MMC. The question of whether a case meets the criteria can be discussed in the morning meetings. Case numbers are collected in the secretary's office within a defined period of time, for example three months. The head physician and/or the senior physician select three cases in preparation for an MMC. These are prepared by different employees. To simplify matters, a set of slides is provided in which the course of treatment is inserted. This is based on one of the available guidelines. The participants are invited, with the time and place stated.

Procedure

A list of participants is kept. This also includes a note on the confidentiality of the MMK. It is imperative that a moderator be appointed who has not been involved in the treatment process and is not the manager himself. The focus of MMK is constructive discussion – in the sense of a search for causes. The different professional perspectives on the events should be explained.

Follow-up

If measures are derived, these must be recorded in a results log. This can be done on a PC during the MMK using a template. After the MMK has been completed, the results log is sent to the head of department for approval. The quality and risk management department receives a copy for publication on the intranet and for tracking the measures.

Literature

• Quality Management Guideline. Guideline on the fundamental requirements for internal quality management for contract doctors and contract psychotherapists, medical care centers, contract dentists and licensed hospitals – QM-RL. www.g-ba .de/downloads/62-492-2309/QMRL_2020-09-17_iK-2020-12-09.pdf, last viewed on 06/16/2023.
• KHaSiMiR 21 – Hospital Study on Safety through Management of In-hospital Risks 2021-22, Download Report
   
• 1: Results of the survey on the implementation of clinical risk management, Download Report
• 2: Comparison of the survey results between 2010, 2015 and 2022. www.aps-ev.de/wp-content/uploads/2023/01/KHa-SiMiR_ Abschlussbericht_Teil-II.pdf, last viewed on 06/16/2023.
   
• Schrappe, M. (2018). APS White Paper on Patient Safety. Safety in healthcare: rethinking, targeted improvement. Published by the German Coalition for Patient Safety (APS). Sponsored by the German Association of Health Insurers (vdek). With forewords by Jens Spahn, Donald M. Berwick and Mike Durkin (1st ed.). Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft.
   
• St. Pierre, M. & Hofinger, G. (2014). Human Factors und Patientensicherheit in der Akutmedizin (3rd edition). Springer: Berlin/Heidelberg.
   

¹ Current results from the “KHaSiMiR 21 - Hospital Study on Safety through Management of Internal Clinical Risks 2021-22” show that the proportion of morbidity and mortality conferences in general hospitals increased from 2015 to 2022, from about 85 percent to about 93 percent.