Journal of Pediatric Surgery 51 (2016) 137142

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Implementation of a pediatric surgical quality improvement (QI)-driven

M&M conference,
Barrett Cromeens a, Richard Brilli b, Kelli Kurtovic b, Brian Kenney a, Benedict Nwomeh a, Gail E. Besner a,
a
b

Department of Pediatric Surgery, Nationwide Childrens Hospital, Columbus, OH, USA

Department of Quality Improvement Services, Nationwide Childrens Hospital, Columbus, OH, USA

a r t i c l e

i n f o

Article history:
Received 1 October 2015
Accepted 9 October 2015
Key words:
Morbidity
Mortality
Quality improvement

a b s t r a c t
Background/Purpose: The M&M conference at Nationwide Childrens Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up
rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed
actions to improve quality of care.
Methods: A classication was developed to enhance analysis of complications. Each complication was analyzed
for identication of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/201310/2014 were reviewed to evaluate the distribution
of failure modes and action items.
Results: Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had
complications attributed to patient disease with no individual or system failure identied, whereas 107 patients
had identiable failures. Eighty-ve patients had one failure identied, and 22 patients had multiple failures
identied. Of the 142 failures identied in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%)
were system failures. One-hundred forty-seven action items were implemented including education initiatives,
establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk
medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training.
Conclusions: Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure
to ensure implementation of assigned interventions intended to address failures. This may lead to improvement
in the processes of patient care.
2016 Elsevier Inc. All rights reserved.

The morbidity and mortality (M&M) conference is the traditional

mechanism by which surgeons conduct peer-review assessment of
patient outcomes with the goal to improve care. One of the earliest
documented examples of M&M was The Anesthesia Study Commission
of the Philadelphia County Medical Society, established in 1940 [1,2].
The commission comprised of anesthesiologists, surgeons, and internists
brought providers together to analyze and thus avoid complications.
Reports of similar conferences soon appeared in the elds of obstetrics

Role of Authors: Gail Besner and Richard Brilli conceived of the development of the
new format of the M&M conference. Gail Besner and Kelli Kurtovic implemented the
new format. Barrett Cromeens and Kelli Kurtovic developed the attendee survey. All
authors assisted with analyzing and interpreting the data, as well as writing and editing
the manuscript. Barrett Cromeens wrote the manuscript and contributed to all of the
domains listed above.
Level of Evidence: IV.
Corresponding author at: Department of Pediatric Surgery, Nationwide Childrens
Hospital, 700 Childrens Drive, Columbus, OH 43205, USA. Tel.: +1 614 722 3914;
fax: +1 614 722 3903.
E-mail address: Gail.Besner@nationwidechildrens.org (G.E. Besner).
http://dx.doi.org/10.1016/j.jpedsurg.2015.10.032
0022-3468/ 2016 Elsevier Inc. All rights reserved.

and gynecology, neonatology, and surgery [1,35]. M&M thereafter

became commonplace in surgical departments nationwide.
Over the decades, the focus of many surgical conferences appears to
have shifted. Some reports describe M&M as a tool to identify avoidable
errors in order to improve patient outcomes through auditing, collaboration, and interdisciplinary discussion [1,5]. However, some have suggested that M&M has become primarily for resident education and
training, shifting away from being a reliable tool for improvement of
patient care [610]. With recent national emphasis on using improvement science to improve patient outcomes, there has been a resurgence
of research directed at reclaiming M&M as a tool for the improvement of
patient care [2,1119].
Similarly, the M&M conference at Nationwide Childrens Hospital
has evolved and began to serve a dual purpose for education and QI.
However, until recently the lessons learned in the conference were
not documented in a manner by which they could be tracked or
analyzed. Also, there was no dened process to ensure that needed
systemic changes were implemented. Therefore a structured QI-driven
M&M conference was implemented to discover true root causes for
untoward outcomes with a focus on both individual and systematic

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B. Cromeens et al. / Journal of Pediatric Surgery 51 (2016) 137142

Table 1
M&M determination template.

Name

MRN

Attending/Fellow

Primary Diagnosis

Procedure

Adverse Event (s)

Outcome

Fellow
Determination
PD-Patient Disease
TETechnical Error

Summary of Case:

Level of Preventability

Individual Failure

Level 1 (expected mortality or recognized morbidity

appropriately dealt with). Even though a
complication occurred, actions were taken to
prevent the complication, it was recognized in a
timely fashion, and it was managed correctly.
Level 2 (unexpected mortality or morbidity, but no
identifiable opportunity for improvement).
Determination

Level 3 (unexpected mortality or morbidity,

potentially avoidable with possibility to improve
care).
Level 4 (unexpected mortality or morbidity with
high likelihood to improve care). Also, a morbidity
that would have been Level 1, but actions not taken
to prevent complication, event not recognized in a
timely fashion, event managed incorrectly.

Description of Failure

System Failure
Structure

Competency

See below

Collaboration mechanisms
Culture

Inadequate knowledge
Consciousness

Non-collaboration

Inattention

Normalized deviance
Process

Distraction
Communication

Inadequate interface

Incorrect assumption

Inadequate checks
Policy & Protocol

Misinterpretation
Critical Thinking

Lacking or informal

Failure to validate/verify

Usability

Tunnel vision
Compliance

Understandability
Technology & Environment

Shortcut
Overconfident

Arrangement

Reckless

Environment

Action Item

None required

Resource allocation

Unformed skills/habits

Follow-up/
Corrective Action

Responsible Party

Due Date

Status

Discussion at M&M:

CONFIDENTIAL QUALITY ASSURANCE COMMITTEE INFORMATION PROTACTED BY LAW (ORC) 2305.25, 2305.251, 2305.252

failures, group those failures into quality improvement related categories, reliably implement improvement interventions, and develop an
accountability structure in which the interventions are placed
(i.e., loop closure). In doing so, the M&M conference would serve as a
tool to improve the processes of patient care by focusing on system
solutions and problem resolution.

happened, whether it could have been avoided, and what improvements

in management could have been made. The moderator guides the discussion utilizing a novel determination template (described below) in
order to ensure that all salient points are covered for each case.

1. Methods

Healthcare Performance Improvement (HPI) LLC has assisted

Nationwide Childrens Hospital (NCH) in building and sustaining a
culture of safety and high reliability [20]. Clinical outcomes associated
with NCHs high reliability journey have been previously published [21].
NCH has used a taxonomy of failure modes, provided with permission
by HPI, to adjudicate all harm events. A template for use in the M&M conference (Table 1) was derived based on HPI taxonomy. Included in the
template are patient identiers, the summary of events, preventability
and failure mode categories, discussion points, and action items with implementation timelines. Based on the discussion, a level of preventability
is determined as described in Table 1 and discussion is utilized to determine what individual or system failures have occurred (Table 1 and
dened in Table 2). Through moderator led discussion, consensus is
reached regarding event preventability and relevant failure modes. Action
items to avoid these failures are assigned to a responsible party and a
timeline of completion delineated. The departmental QI representative
compiles this information in the template, provides the nalized copy to
the attendees and stores it in a digital repository for future auditing.

To convert the M&M conference into a reliable tool for QI, three goals
were addressed: (1) establishing a consistent format, inclusive of all
providers, with a standardized reporting structure and presentation
content; (2) establishing a documentation system that could be
accessed for future data acquisition; and (3) auditing the new conference to determine if the change in format was useful. This new approach
was established in November of 2013.
1.1. M&M format
Weekly M&M conferences include representatives from radiology,
pathology, neonatology, quality improvement, and pediatric surgery.
The moderator begins with a reminder of condentiality, stating that
the purpose of the conference is an open discussion of patient care without judgment in order to improve the care of patients in the future.
Attendees are also reminded that the information discussed is exempted
from legal action and nondiscoverable in a court of law, and is not to be
discussed outside of the M&M conference. Complications on the pediatric surgery service are compiled by the pediatric surgery fellows who
present the issues and provide a written patient summary. After the presentation, an open discussion attempts to clarify what happened, how it

1.2. Determination template

1.3. Attendee survey

A 16 question survey was developed to evaluate conference goals.
After utilizing the new M&M system for more than one year, the survey

B. Cromeens et al. / Journal of Pediatric Surgery 51 (2016) 137142

Table 2
Denition of failure modes.
Individual Failures

System Failures

Competency
Unformed skills/habits inability to
do something well or while
possessing the knowledge, lacks
performance reliability gained
through experience.
Inadequate knowledge lacks
fundamental knowledge of
procedures, principles, or protocols
Consciousness
Inattention preoccupied, rushing,
or not paying attention.

Structure
Resource allocation insufcient
infrastructure, people, budget,
equipment, or other resources.

Distraction divided or diverted

attention.

Communication
Incorrect assumption assuming a
thing to be correct that was in fact
wrong.
Misinterpretation forming an
understanding that is not correct
from something said or done.
Critical Thinking
Failure to validate/verify failure to
nd or test the truth of something or
failure in the cognitive process of
establishing a valid proof.
Tunnel vision the tendency to
focus exclusively on a single or
limited objective or view.
Compliance
Shortcut deliberate act to take a
quicker or more direct route and
deviates from the optimal path.
Overcondent excessively
condent resulting in proceeding in
the face of uncertainty.
Reckless acting without thought or
care for the consequences of ones acts.

Collaboration mechanisms wrong

or inadequate collaboration
mechanisms.
Culture
Noncollaboration disruptive
competition, defensiveness, poor
teamwork, low morale.
Normalized deviance conforming
to a standard, type, or custom where
behavior is sharply different from the
generally accepted standard.
Process
Inadequate interface lack of or
poorly designed handoffs of
information or resources
Inadequate checks lack of or
poorly designed checks, inspections,
or reviews.
Policy and Protocol
Lacking or informal no policy or
protocol.
Usability poor presentation or
information depiction, or poor access.
Understandability difcult to
comprehend because guidance detail
is lacking or inadequate for the
knowledge and skill level of the user.
Technology and Environment
Arrangement physical
arrangement of work space,
department, facility, or campus is
negatively impacting performance.
Environment lighting, noise,
climate, motion, etc. negatively
impacting performance.

was distributed to attendees in December 2014 utilizing an online delivery system that allowed anonymous responses. Surveys were distributed to only those who had experienced both the old and new formats.
The majority of questions utilized a 1 to 5 Likert response scale with
1 = strongly disagree and 5 = strongly agree with additional space
for general comments.
1.4. M&M audit
M&M determinations from November 2013 through October 2014,
including twelve full months of the new QI-directed M&M format,
were reviewed to determine distribution of failure modes and numbers
and types of action items implemented.
2. Results
2.1. M&M conference audit
Forty M&M conferences were held and 237 patients were presented
during the review period. The distribution of preventability and failure
modes was tallied from the determination templates (Table 3). One
hundred and thirty of the patients presented had no identiable failure
in management, with the complication attributed to patient disease. Of
the remaining 107 patients, 85 patients had one failure and 22 patients

139

had multiple failures. There were 142 total failures identied, of which
112 (78.9%) were identied as individual failures and 30 (21.1%) as
system failures.
A total of 147 action items were initiated. One hundred and ve items
were resolved by educational intervention, with the complication typically involving an individual error of unformed skills/habits (i.e., a technical error). Discussion ranged from summarizing key learning points
in conference to assigning individuals to review the literature for presentation at a future conference. The remaining 42 action items were system
based and included optimizing communications, establishing criteria for
interdisciplinary consultation, resolving equipment inadequacies,
removing high risk medications from procedure protocols, modifying
order sets, and restructuring physician handoffs. Representative cases
where action items resulted in a system change are as follows.
(Case 1) An 8 year old male with perforated appendicitis underwent
laparoscopic appendectomy. Postoperative difculties with the nasogastric tube required its replacement in interventional radiology. Shortly after returning to the oor, he went into respiratory failure requiring
intubation. He was found to have methemoglobinemia. Later investigation uncovered the use of cetacaine spray in interventional radiology
but its use or dosage was not documented. This was a system failure
owing to a lack of protocol for the use of cetacaine spray. Action was initiated to correct this failure and cetacaine spray was ultimately deemed
unnecessary and removed from the hospital formulary.
(Case 2) A 2 year old male trauma patient with a spinal cord injury
required tracheostomy and gastrostomy tube placement. On POD 1
there was a persistent air leak and ventilator settings could not be
weaned. Upon evaluation, it was recognized that an adult tracheostomy
tube had been inadvertently placed. The tracheostomy tube was
exchanged to an appropriate tube which led to resolution of the ventilator difculties. Discussion in conference determined that the OR staff
obtained the incorrect tube owing to confusion with tracheostomy
storage in OR supply (a system failure of inadequate interface, i.e., a
process failure manifested by lack of, or poorly designed handoffs of
information or resources) and the operating surgeon failed to recognize
the inappropriate tube (an individual failure owing to unformed skills
and habits, i.e., a technical error). Actions were initiated and an illustrated chart was developed that demonstrates tracheostomy styles and lists
appropriate tube sizes by patient age/size, with the charts located in the
OR and on the supply cart. The supply carts have been organized so that
labeling and division of supplies is clear and user friendly.
2.2. Surveying attendees
There were a total of 23 complete responses. The majority of respondents were pediatric surgery attendings (56%), with additional
responses from pediatric surgery fellows, research fellows, nurses, and
quality improvement representatives. Responses are presented in
Fig. 1. In all cases, the majority of attendees either agreed or strongly
agreed to questions regarding the goals of the format change. The
most common comment from attendees was that the classication
system of failure modes needed renement to decrease confusion and
optimize utilization.
3. Discussion
The reformatting of M&M conferences to increase usefulness for the
improvement of patient care has become increasingly common in recent
years [22,23]. In both the elds of medicine and surgery, numerous approaches have been taken to achieve this goal [11,12,14,1618,2432].
Some approach this problem by simply dening and reinforcing goals
of quality improvement to the moderators and participants [24,2932].
In doing so, a paradigm shift may occur where the traditional methods
of punitive blame are abandoned and increased focus on systems based
discussion occurs. By addressing systems based problems, not only will
patient care improve but the conference will maintain its educational

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B. Cromeens et al. / Journal of Pediatric Surgery 51 (2016) 137142

Table 3
Distribution of levels of preventability and failure modes.
Level of Preventability

(n, %)

Distribution of Failure Modes (n, %)

Level 1 expected M or M appropriately dealt with. Even though a

complication occurred, actions were taken to prevent the complication,
it was recognized in a timely fashion, and it was managed correctly.
Level 2 unexpected M or M, but no identiable opportunity for
improvement.

175 (73.8)

Level 3 unexpected M or M, potentially avoidable with possibility

to improve care.

36 (15.2)

Level 4 unexpected M or M with high likelihood to improve care.

Also, a morbidity that would have been Level 1, but actions not taken
to prevent complication, event not recognized in a timely fashion, event
managed incorrectly.

2 (0.8)

24 (10.1)

Individual Failure (112, 78.9)

Competency
Unformed Skills
Inadequate Knowledge
Consciousness
Inattention
Distraction
Communication
Incorrect assumption
Misinterpretation
Critical thinking
Failure to validate/verify
Tunnel vision

(94, 66.2)
(75, 52.8)
(19, 13.4)
(4, 2.8)
(4, 2.8)
(0, 0)
(7, 4.9)
(6, 4.2)
(1, 0.7)
(7, 4.9)
(5, 3.5)
(2, 1.4)

Compliance
Shortcut
Overcondent
Reckless

(0, 0)
(0, 0)
(0, 0)
(0, 0)

objectives of systems based learning required for resident training by the

American College of Graduate Medical Education (ACGME). Others have
approached this problem with the implementation of more structured
changes, utilizing modalities such as cause-and-effect diagraming, systems auditing, provider specic report cards, Plan-Do-Check-Act
(PDCA) cycles, and Root Cause Analysis (RCA) [11,12,14,1618,2528].
This paper presents a more structured approach to the reformatting of
M&M conference.
Berenholtz et al. [28], suggest that in order improve patient care
through learning from medical incidents, three domains must be
achieved. First, all personnel involved with the incident should be
involved with the analysis of error. Second, there should be a structured
framework to guide the analysis in order to clarify all contributing
factors to the error. Third, any action implemented to obviate future
errors should be assigned to an individual or team. Keeping in line
with these domains, implementation a multidisciplinary M&M conference where involved providers are invited to participate was achieved.
Error is reproducibly analyzed using a comprehensive, structured
taxonomy. Accountability is obtained by assigning action initiatives to
individuals regarding specic errors, and thus loop closure is achieved.
To these authors knowledge, no such M&M conference has been
documented in the eld of pediatric surgery.
During the audit of the new conference, it was apparent that the
specic format offered additional benets. As M&M conference has
evolved to focus on systems based discussion, one concern is that the
individual providers accountability regarding treatment decisions is
lost [10,33]. This format aims to improve analysis of systems based
errors, yet does not ignore the importance of individual failure. This is

System Failure (30, 21.1)

Structure
Resource allocation
Collaboration mechanisms
Culture
Noncollaboration
Normalized deviance
Process
Inadequate interface
Inadequate checks
Policy and Protocol
Lacking or informal
Usability
Understandability
Technology and Environment
Arrangement
Environment
Human capability

evident by the majority of failures identied being individual failures.

Current ndings in QI research reveal that system errors typically
exceed individual errors. Although the majority of errors identied during
the review period were individual errors, prior to the implementation of
this system nearly all errors identied were individual errors. One
would expect that as the new format matures and the process is rened,
the identication of system errors will continue to increase. Another concern is that by steering the focus toward systems based problems, the
benet of the conference as an education tool could be lost. Although
this was a concern with the new format, review of the results showed
that the great majority of action initiatives were educational in nature.
With the implementation of this new format, complications can be
quantied, and errors can be classied by type and to what extent
they are preventable. Additionally, it is known what actions have been
implemented, and most importantly, a system is in place to conrm
loop closure. Prior to the new format, little to no information existed
regarding these domains. With the old format, the burden of QI was
held by each attendee, with each individual being responsible for taking
what was learned and putting it to practice. With the new format, it is
still the responsibility of the individual to apply what was learned, however, mechanisms now exist to work with individuals to carry out action
items. Over time it is expected that these action items will prevent
future complications and will therefore improve the care of patients at
NCH. Overall, changes have been well received and it is the view of
the attendees that the conference is meeting the goal of improving quality of care at NCH. Moving forward, there is continued renement of the
conference format per the recommendations from attendees obtained
from the survey. Thus, a system has been developed so that hypotheses

0%

10%

20%

30%

40%

50%

60%

70%

80%

Compared to the old format, the new format has a clear goal of quality
improvement.
Compared to the old format, the new format determines the type of undesired
outcome.
Compared to the old format, the new format more clearly identifies the
etiology leading to the undesired outcome.
Compared to the old format, the new format allows for more directed action in
order to improve patient care.
Compared to the old format, the new format has better loop closure with the
actions assigned to undesired outcomes.
Compared to the old format, the new format allows for more opportunities to
improve patient care.
The new format has resulted in change in how I practice.
The new format improves patient care at this hospital.
Strongly Disagree (1)

Disagree (2)

(5, 3.5)
(0, 0)
(5, 3.5)
(5, 3.5)
(5, 3.5)
(0, 0)
(5, 3.5)
(3, 2.1)
(2, 1.4)
(13, 9.1)
(13, 9.1)
(0, 0)
(0, 0)
(2, 1.4)
(0, 0)
(1, 0.7)
(1, 0.7)

Neither Disagree Nor Agree (3)

Fig. 1. Survey responses.

Agree (4)

Strongly Agree (5)

90% 100%

B. Cromeens et al. / Journal of Pediatric Surgery 51 (2016) 137142

may be tested through the analysis of newly captured data moving

forward. Future analysis will test whether utilization of a QI-directed
M&M conference will decrease complications and thereby improve
patient care.
A limitation to the present format is that although there is comprehensive analysis and documentation of the cases presented, there is
not a system in place to ensure that all cases necessitating presentation
during M&M conference are being captured. Arca et al. [34], present a
robust QI initiative that tracks patients in all phases of care and includes
documentation from their M&M conferences. The current manuscript
focuses more specically on a comprehensive analysis to be applied
during the M&M conference itself. Their system could benet from the
integration of a more comprehensive M&M analysis such as that
presented here. Likewise, the system presented here would benet
from the integration of more consistent and dened selection process
such as that described by Arca et al. [34]
In this system, the pediatric surgery fellows are responsible for identifying the majority of the complications presented. However, the faculty frequently identify complications and request that they be added to
the presentation list as well. The fellows are instructed to identify all
complications that occur on the service. Although fellow driven identication is robust there may be inherent variability in a fellow-driven
system, representing a potential limitation to this format. Programs
without fellows should adapt a system that best ts their culture. Any
individual who is intimately involved with the surgical service should
be capable of compiling the list of complications. Most important is to
have a QI representative committed to the process that can track action
items and assure loop closure.
Because M&M conferences are already in place at most institutions,
the cost to the institution for implementing changes such as the ones
detailed here is negligible. However, if the interventions implemented
by the conference result in reduction in complications as would be
expected, the savings in healthcare costs may be substantial.
Appendix A. Discussions

141

implement more of the policy and protocol we will see if

that starts to shift and maybe it becomes miscommunication
or something like that and we need to start directing our
focus on correcting those issues.
Joseph Tepas (Jacksonville FL): Barry, I also want to congratulate you
on what youve accomplished, which is essentially to integrate the issue of modication of process to improve outcomes. My question is basically engagement, because the
problem that were having at the NSQIP level nationally and
as our surgeons now suddenly realize that they are going to
be more accountable for quality and outcome is getting
them engaged. Can your system analyze more common individual participation who are participants in some of these
events and begin to drive them into more of an engagement
in the whole process of quality? Conversely, is this one of
the situations where they come for an hour once a week,
they hear this, it stimulates these process changes, but then
they go back to work and theyre not going to think quality
again until the next meeting starts the next week?
Barrett Cromeens: Astute observations. I think that is the beauty of this
conference on multiple levels. An M&M conference is somewhere where everyone comes together on in our case a weekly
and I think that is common in many places and there is a wealth
of knowledge in the room. However, just as you said, this robust discussion occurs and nothing is getting captured and people walk out of the room and it just goes into the ether. The
onus is on the individual to then take that information and
apply it to their practice, but whether someone does or does
not is we are unable to tell. But, with this focusing on systems
initiatives, we are able to then identify these and actually implement action items that are on paper. Individuals are
assigned to actually complete these action items and present
them back to us, so I think the individuals that are directly involved in the care of the patients are hearing the discussion,
hearing the action items and then seeing the results of the action items that we implement.

Presented by Barrett Cromeens, Columbus OH

Mary Brandt (Houston TX): Ill start with a question. Very well
presented and really wonderful idea that I think is going to
be rapidly implemented.
Did you see a difference in the number of cases you could discuss or a change in the time of your conference? Does this
take substantially more time or did it affect that at all?
Barrett Cromeens: So we did not actually look at that entirely but we
did change our conference from being a monthly conference
to a weekly conference just because we were actually picking
up more cases but we didnt look at the actual numbers. Over
time we would be interested to see if there is a we would
expect kind of a spike in the number of cases that were
presenting just owing to implementing the system and then
I would suspect this would level off but we have not looked
at that yet.
Christopher Moir (Rochester MN): Great idea. Great presentation.
Next steps. How do you see your system integrating with
your overall institutional system for quality improvement
such as sentinel event systems, that sort of thing? Do you
see that as an add-on? A threat? Complementary?
Barrett Cromeens: So I think this is complementary and somewhat of
an add-on. We have had errors that end up getting bumped
up to root cause analysis. We still analyze them within this
system and then at the larger system it still gets presented
as well, so there is some crossover there. As far as where we
see this going in the future, I think that really it is tracking
this over time. As we said, for instance, the majority of our
system failures were lacking policy and protocol but as we

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