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  The goal of the M&M conference is to provide an opportunity for peers to review and discuss adverse outcomes and surgical complications in a non-punitive, collegial forum

  
  
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  The modern M&M conference has shifted from the traditional, selectively case-based and surgeon-specific review modality to a transparent and objective quality improvement initiative

  
  
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  The long term goal of M&M conferences is to create a global culture of patient safety and surgeon accountability

The morbidity and mortality (M&M) conference has a long tradition in surgery. Its roots can be traced to Dr. Ernest Armory Codman, a surgeon at the Massachusetts General Hospital (MGH) from 1902 to 1914 who championed the “end result” idea, arguing that surgeons should follow patients to discover the ultimate outcome and learn from their mistakes and successes.^1,2 Dr. Codman kept detailed data on his patients for at least a year, including a summary of types of errors committed.³ At the time, this concept was heretical, and he was forced off the MGH staff in 1914. To continue his work, Dr. Codman established his own hospital and published a book, A Study in Hospital Efficiency, documenting outcomes of 337 patients in his first 5 years, including 123 errors.⁴

Despite Dr. Codman’s initial unpopularity, his leadership advocating for the end result idea was fundamental to the creation of the American College of Surgeons in 1913. Under Dr. Codman’s leadership, the ACS created the Hospital Standardization Program in 1918, with the mission that “All hospitals are accountable to the public for the degree of success… If the initiative is not taken by the medical profession, it will be taken by the lay public.” In 1951, the ACS Hospital Standardization Program merged with several other programs to create the Joint Commission on Accreditation of Hospitals, which was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1981, now simply called The Joint Commission.⁵ As an independent, not-for-profit organization, The Joint Commission accredits and certifies healthcare organizations in the United States, with the goal of providing high-quality, high-value health care.

Perhaps the first reported M&M conference was from the Philadelphia County Medical Society’s Anesthesia Mortality Committee, created in 1935.⁶ The committee included surgeons, internists, and anesthetists. At the time, there was some surprise that there would be enough fatalities from anesthesia to discuss; yet the commission soon found that 67% of cases were preventable.

The goal of a conference dedicated to reviewing deaths and complications is to provide a way for peers to review in an objective fashion the adverse outcomes of medical care, and suggest ways in which care could be improved. This requires several largely unstated tenets:

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  All complications and adverse outcomes should be presented. A selective presentation injects a bias of reporting, and prevents any analysis as to the frequency at which any particular surgeon (physician) has errors, or any particular complication occurs.

  
  
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  The group of peer reviewers must comprise true peers who are unbiased for any reason (jealously, financial competition, resentment, etc.).

  
  
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  Those involved in the adverse event must see the review as helpful, and not merely accusatory.

The absence of one or all of the above requirements is likely what plagued Ernest Codman at MGH when he first presented his “end result” concept, and certainly is difficult to accomplish among medical staff environments in which competition for patients (and financial gain) is the norm. Hence, while the incorporation of M&M conferences has been a standard in surgical residency training programs in the United States for many decades, it has not had similar acceptance in the many hospitals and practice environments that provide the majority of surgical care in this country.

The paradox of error analysis in medicine is that there is a societal (and legal) precedent that errors only occur if someone is to blame; yet infallibility is simply not humanly possible. Hence, if errors by physicians are unacceptable, yet unavoidable, this creates a challenging paradox. Through the tradition of admitting that an error or adverse outcome has occurred, discussing the event among colleagues, and identifying ways to improve (either individually or through collaborative, systematic approaches), the M&M conference provides a setting by which physicians can reconcile this paradox. If unbiased peers can review the adverse events, provide helpful advice and counsel, yet continue to allow the surgeon to continue to practice as a peer among them, this is a form of reconciliation, and in some ways, forgiveness. Indeed, the M&M process is one of confession of sins, asking for forgiveness, and having some penance (presenting the case). However, if the M&M process is viewed as punitive, or a way to cast aspersions on a colleague (or potential competitor), then the reluctance to admit to complications is paralyzing to the process of identifying errors and finding ways to prevent their occurrence.

The idealized M&M process seeks to improve patient outcomes and provide an internal method of forgiveness for physicians, even if only among the medical community. In the book, Forgive and Remember, Dr. Charles L. Bosk calls this process, “blame, forgive, and remember.” As Dr. Bosk highlights in his sociological study, recognizing the impact of the culture of medicine on patient safety is essential to understanding ways in which the profession can improve.⁷

From “Blame and Shame” to System Safety

In the last few decades, the discourse around medical errors has shifted from blaming individuals (and expecting them to remember and never repeat the error) to focusing on systems-based improvements to prevent error occurrence. As an example, consider Dr. Codman’s views on retained surgical sponges, which he considered “… a glaring error, obviously preventable, obviously a proof of wretched carelessness.”⁴ A more contemporary approach to the problem of retained foreign bodies involves system approaches such as mandatory sponge counts, x-rays prior to case completion, and sponges impregnated with radio-frequency technology that can be detected with a wand.⁸ These system approaches accept that on occasion, a sponge (or other foreign body) may be inadvertently left behind, even for the best and most careful of surgical teams, and devise ways to help mitigate that expected and (yet still unacceptable) event.

One of the sentinel studies estimating the incidence of adverse events in hospitalized patients was the Harvard Medical Practice Study, published in two parts in the New England Journal of Medicine in 1991.^9,10 This study is generally credited with shifting the conversation from individual blame to understanding how healthcare delivery can improve outcomes. One of the study’s authors, Dr. Lucian Leape, a pediatric surgeon from Harvard Medical School and Tufts University, went on to coauthor the Institute of Medicine’s reports “To Error is Human” in 1999¹¹ and “Crossing the Quality Chasm” in 2001.¹²

Meanwhile, in response to a 1986 congressional mandate, the Veterans Health Administration conducted the National VA Surgical Risk Study, beginning in 1991, which resulted in the formation of the National VA Surgical Quality Improvement Program in January 1994.¹³ In 1999, a private version of the program was piloted at three academic medical centers: University of Michigan, University of Kentucky, and Emory University.¹⁴ The American College of Surgeons (ACS) collaborated with the VA to perform the Patient Safety in Surgery study, funded by the Agency for Healthcare Research and Quality, from 2001 to 2004.¹⁵ The study’s positive results led the ACS to establish the National Surgical Quality Improvement Program (ACS-NSQIP) in 2004. As of April 2016, 742 hospitals in the United States were participating in ACS-NSQIP.¹⁶

By tracking patient outcomes, ACS-NSQIP provides feedback to individual surgeons and hospitals, while also creating a multi-institutional database that allows for an astonishing amount of surgical outcomes research. A study published by ACS-NSQIP showed that hospital participation in its risk-adjusted, outcomes-based program can prevent 300 complications and 14 deaths each year.¹⁷ However, participation in ACS-NSQIP comes at a considerable cost—in addition to paying an annual fee ranging between $10,000 and $29,000, hospitals must hire at least one full-time, dedicated surgical clinical reviewer.¹⁶ As part of the shift toward collaborative responsibility for patient outcomes, several other quality improvement programs in addition to NSQIP have emerged, including the Quality and Accountability Study from University HealthSystem Consortium¹⁸ and the Hospital Safety Score from The Leapfrog Group,¹⁹ among others.

Given this changing paradigm, some have questioned the need for continuing the M&M conference tradition. Our contention is that this tradition has great merit in allowing for discussion with peers of perhaps the most challenging of tasks in medicine—learning to accept and deal with errors. This unique process provides a method to impart reconciliation, while striving to make all in attendance better physicians who are more aware of both error-prevention strategies and harm-mitigation techniques and tools. All involved in the delivery of health care to the sick must be aware of their contribution to error prevention, and in some cases, error acceptance. The modern M&M conference should merge the traditional, case-based, surgeon-specific, and patient-focused M&M conference with its emphasis on personal responsibility, with larger quality improvement efforts to create a culture of safety and responsibility of the system of care.

There are many innovative ways by which M&M conferences can integrate traditional, case-based discussions with systematic quality improvement initiatives. The first is to ensure M&M conferences are organized, methodical, and identify both adverse events and errors.

Identifying a framework for the M&M conference is the first step. Dr. Tad-y et al recommend the following guiding principles to developing a best-practices framework for the M&M conference:²⁰

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   Use standardized methodology for case findings and analysis.

   
   
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   Present adverse events, including morbidity, mortalities, and near misses.

   
   
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   Emphasize routine interprofessional and interdisciplinary participation.

   
   
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   Identify areas for systems improvement as part of the conference discussion.

   
   
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   Link identified opportunities for improvement to performance improvement activities led by faculty, learners, and the hospital.

   
   
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   Develop formal channels of interaction with the hospital’s risk management and clinical effectiveness departments and the medical school’s office of graduate medical education.