1. Stop the Blame Game: Restructuring M&M to Focus on QI and Teach Patient Safety Molly Horstman, MD Diana Stewart, MD, MBA Barbara Trautner, MD, PhD Michael E. DeBakey VA Medical Center April 30, 2014

2. Background Shift from old model – Focus on individual fault – Only one discipline present – No actionable take home points Goals – Align with ACGME competencies – Engage residents in patient safety and quality improvement Potential applications of M&M – Teach systems approach to medical errors – Improve patient safety culture – Identify areas for improvement Jt Comm J Qual Patient Saf. 2010;36(1):3-9. J Surg Educ. 2011 Jul-Aug;68(4):303-8. Qual Saf Health Care 2007;16:422–427. BackgroundEvaluationAction ItemsLessonsConclusions

3. Development of a New Model for Internal Medicine M&M at the MEDVAMC Physicians Case Managers Patient Safety Managers Other Services Monthly Resident presenter CRQS Facilitator Information confidential Do not assign blame Case selection based on system error Based on IHI modules Incorporate teaching point into each case Didactics on QI and Patient Safety System- Focused Multiple Disciplines Logistics

4. Outline of Typical M&M conference What happened? Patient Safety Teaching Point Why it happened? What can we do to prevent it from happening again?

5. Conference Evaluation Baseline survey – AHRQ hospital survey on patient safety and culture – Confidence with systems-based approach Post-conference surveys – Confidence with systems-based approach – Likelihood of submitting incident reports – Concern regarding punishment for reporting Post-conference action items BackgroundEvaluationAction ItemsLessonsConclusions

6. Improved Confidence with Systems-Based Approach for Medical Errors Baseline Survey (n=71) Post-Conference Survey (n=37) Ability to use a systems-based approach to analyze medical errors and adverse events 56%95% Ability to identify systems factors that contribute to medical errors and adverse events 77%92% Ability to identify error reduction strategies to improve patient safety 65%84% Ability to identify the likely effectiveness of different error reduction strategies 55%76% Percent of residents reporting somewhat confident or very confident BackgroundEvaluationAction ItemsLessonsConclusions

7. Impact of Conference Attendance on Resident Likelihood to File Incident Reports N=37

8. Attitudes Post Attendance: Residents Unlikely to Worry about Reporting Errors N=37 BackgroundEvaluationAction ItemsLessonsConclusions

9. Action Items from Morbidity and Mortality Conferences Healthcare failure mode and effect analysis (HFMEA) on order entry Resident QI project to improve inpatient procedures Changes to inpatient consult orders Identification of areas for resident education – Timeout for bedside procedures BackgroundEvaluationAction ItemsLessonsConclusions

10. Lessons Learned Leadership support is key Non-MD participation is important – Different perspectives – Important to develop a working action plan Different specialties face common problems – Combined Medicine-General Surgery M&M – Plan for future combined M&M with Psychiatry BackgroundEvaluationAction ItemsLessonsConclusions

11. Interdisciplinary M&M can be incorporated into current resident didactics Effective teaching tool – Systems-based approach to medical errors – Identifying error reduction strategies Positive impact on resident incident reporting and culture of safety Means to identify patient safety initiatives BackgroundEvaluationAction ItemsLessonsConclusions