The Morbidity, Mortality, and Improvement Conference: An Innovative, Action-Oriented Learning Space.

Abstract

Background: While providing learning from adverse events, traditional morbidity and mortality conferences may not consistently discuss systems, action items, and execution plans, or engage interprofessional audiences to address adverse events. The aim of this study was to design a space to learn from adverse events and, through engaging diverse staff, develop systems-oriented action items, establish mechanisms to follow through on these items, and close the loop with staff on system improvements.

Methods: A planning group designed a quarterly conference in which involved staff review an adverse event with an interdisciplinary, interdepartmental audience. Through interactive discussion, attendees identify root causes and potential system-level solutions. Actionable solutions are implemented and communicated at the next conference. Attendee surveys were conducted to gauge the perceived impact of the conference series on safety culture. The monthly average of submitted safety reports was evaluated as a surrogate safety culture marker.

Results: Conference attendance grew by 157.5%. Participants reported increased comfort in raising concerns (from 84.0% to 100.0%), improved interprofessional teamwork (from 84.0% to 100.0%), unit-based shifts to a learning culture (from 64.0% to 93.4%), positive clinical area changes (from 52.0% to 90.0%), and positive health system changes (from 84.0% to 96.7%). The average number of monthly safety reports increased by 17.0%.

Conclusion: The morbidity, mortality, and improvement conference demonstrated improvements in reported safety attitudes, interdisciplinary collaboration, system design, learning culture, psychological safety, and safety reporting. This interdisciplinary, interdepartmental, system-focused, interactive conference with closed-loop communication is an effective tool for cultivating trust in safety culture and transforming staff into safety ambassadors and change agents.