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The evolution of morbidity and mortality conferences

Morbidity and mortality conferences (MMCs) have become a vital element of patient care, sitting at the intersection of medical education, quality improvement and risk management. MMCs may have increased in importance as a staple of safety education since the Accreditation Council for Graduate Medical Education has identified that the discussion and analysis of adverse events in a structured fashion promotes the learning of key quality and safety concepts.1–3 Groups across specialties and disciplines have implemented innovative models of MMCs as a vehicle to engage clinicians in discussions to learn from adverse events and to identify opportunities to improve care. In studying these new models, it has become clear that deliberate attention to the structure, processes and content of the conference yields the greatest opportunity for improving the quality of patient care beyond just learning the concepts of quality and safety.4 ,5 We now face the next iteration of the MMC and are tasked with describing the facets that will best allow MMCs to drive learning and improved outcomes.

In this issue, Kwok and colleagues highlight the impact of implementing a structured MMC, the Ottawa M&M Model (‘OM3 model’), at their acute care tertiary centre across multiple specialties.6 The model consists of five key elements, including appropriate case selection, structured case analysis, the creation of and dissemination of bottom-line summaries, the development of effective pathways for action items and interprofessional and multidisciplinary participation. The authors conducted a yearlong study of 16 clinical groups implementing the OM3 model. The investigators provided an OM3 toolkit that included relevant educational materials, dedicated coaching to the teams, encouraged the groups to establish a quality committee for subsequent action …