An operating room’s quality-improvement project increased communication and transparency.
Promoting a culture of safety is a high priority for nursing, and The Joint Commission’s focus on zero harm has made it a goal for healthcare organizations, including operating rooms (ORs), which are high risk and intense. Communication and transparency, which are critical to preventing errors and improving nursing care, can be facilitated by nursing morbidity and mortality conferences (MMCs), where open discussion of patient complications, high-risk situations, and deaths can occur. They also provide a venue for exploring current practices and systems and measuring them against evidence-based practice. Nursing MMCs provide an opportunity for frontline leaders to educate their peers about the details of an event, what was learned, and what process changes have been made as a result.
Problem
A lack of communication with frontline staff about patient safety issues and adverse events was an opportunity for improvement within surgical services at the Baylor Scott & White Medical Center, a facility in Temple, Texas, currently on its journey to achieve Magnet® designation. After OR nurses were invited to a physician-led MMC, nurse leaders explored using MMCs as a communication tool.
Planning
Before piloting nursing MMCs for perioperative staff as a quality-improvement project, the nurse management team conducted a literature review. (See About MMCs.) After reviewing best practices, the team developed a nonpunitive format that included presentations by OR staff, RNs, and surgical technologists. Surgeons, anesthesiologists, and ancillary staff also were invited to participate. The team determined that management would provide support during presentation preparation and delivery and that the audience would be reminded at the beginning of the conference that it was a blame-free learning environment. The intent of the nonpunitive format was to help staff incorporate a reliable accountability structure to promote organization-assigned interventions.
The team decided that conference content would be selected by management based on root cause analyses or errors and focused on process breakdowns or system issues. Several topics were chosen, including instrument sterility, trauma, and specimen handling. MMCs would be held every 1 to 3 months in a conference room with projector capabilities. All RNs and surgical technologists would be encouraged to attend. Nurse managers disseminated information about the upcoming conference via the virtual schedule available to all staff.
The management team planned to assess the change in nursing staff’s perception of the MMCs by using pre- and post-intervention surveys.
About MMCs
According to Zovotsky and colleagues, morbidity and mortality conferences (MMCs) began around 1912 and were used as a forum for physicians to review cases that had had unintended results. Other MMC studies (both physician and nurse focused) highlight their benefits.
• Ropp noted that 90% of nurses stated MMCs could help improve their competence, performance, and patient outcomes.
• Gonzalo and colleagues found that multidisciplinary, nonpunitive MMCs receive favorable ratings.
• Cromeens and colleagues reported that using a quality-improvement format allowed staff to categorize complications and identify system solutions.
Intervention
To ensure maximum attendance, the initial MMCs were held on a designated Thursday morning during a staff meeting. Staff involved in the event had at least 3 weeks to prepare their presentations, which were reviewed by the management team. Presenters followed presentation guidelines, including a brief patient history, event details, review of applicable policies, evidence-based practices, lessons learned, process improvements, and expectations or takeaway messages. The case presentation was followed by a question-and-answer period. Managers collected improvement recommendations for possible implementation.
After several MMCs were conducted, staff were invited to complete a survey to determine the perceived effect of the conferences. Out of 67 RNs and surgical technologists asked to participate, 61 (91%) completed the survey. Survey questions included asking staff if the conferences changed their practice, improved patient care, or increased their confidence in caring for patients in situations similar to those presented in the MMCs. Narrative feedback on the conference format was prompted through open-ended questions asking for improvement suggestions, how MMCs affected practice, and future conference topics.
Survey responses revealed that staff believed MMCs improved their patient care or practice by making them more aware of events and the efforts taken to prevent them in the future. Staff also enjoyed gaining knowledge about procedure and patient care best practices. An overwhelming theme from survey responses was an appreciation for increased communication among team members.
Outcomes
Format modifications were made based on the staff feedback. The nature of MMCs is to review adverse events, but presentations on positive topics are used to showcase good events that occur in the OR. Several survey respondents asked for more leadership involvement, indicating a desire for management support when undesired events occur. The management team is now more available to discuss best practices, policies, and procedures. The staff showed interest in additional topics (such as protocol for patient death, personal protective equipment, and health workforce initiatives) for future presentations, indicating engagement. To improve communication and teamwork, surgical and anesthesia colleagues continue to be invited to participate in the conferences.
Providing a safe environment
Lack of communication is a leading cause of healthcare errors. Nursing MMCs are an effective tool for facilitating transparency and communication so that nursing staff is aware of preventable harm events and how to avoid them in the future. These conferences make staff a part of the solution by encouraging feedback in a safe environment and providing education that can improve patient care. Providing developmental growth for nursing staff has been an added benefit.
The MMC format can be adjusted to fit any nursing department. Increased awareness of recurring high-risk events in the OR and elsewhere benefits staff and patients as healthcare organizations strive for zero harm.
The authors work at Baylor Scott & White Health in Temple, Texas. Amy Brunson is an operating room nurse manager. Phyllis Hooten is a nurse scientist. Cari Furst is a neurology coordinator. Wencong Chen is a biostatistician II at the Baylor Scott & White Research Institute – Temple.
Selected references
Cromeens B, Brilli R, Kurtovic K, Kenney B, Nwomeh B, Besner GE. Implementation of a pediatric surgical quality improvement (QI)-driven M&M Conference. J Pediatr Surg. 2016;51(1):137-42.
Gonzalo JD, Bump GM, Huang GC, Herzig SJ. Implementation and evaluation of a multidisciplinary systems-focused internal medicine morbidity and mortality conference. J Grad Med Educ. 2014;6(1):139-46.
Ropp PW. Establishing a nursing morbidity and mortality conference. Nursing. 2011;41(4):18-9.
Zavotsky KE, Ciccarelli M, Pontieri-Lewis V, Royal S, Russer E. Nursing morbidity and mortality: The clinical nurse specialist role in improving patient outcomes. Clin Nurse Spec. 2016;30(3):167-71.
