1. PICU M&M Conference 7/14/17 Erika Wong
DIVISION OF PEDIATRIC CRITICAL CARE MEDICINE
7/14/17
Erika Wong

2. “We believe it is the duty of every hospital to establish a follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians.”
Ernest Amory Codman, an early 20th century surgeon and outspoken reformer  developed end result system
End result card  documented each patient’s symptoms, clinical diagnosis, treatment plan, complications, final diagnosis, and annually updated outcome
This was reviewed and if ”perfection” was not achieved, an analysis was done and open to the physicians and the public
Opposition, but ultimately American College of Surgeons in 1916 developed M&M, then anesthesiologists followed
Codman, 1914.

3. Practice-Based Learning
1983: instituted by all ACGME training programs
1999: “The ACGME Outcome Project”
Patient
Care
Medical
Knowledge
Practice-Based Learning
And Improvement
Interpersonal and
Communication Skills
Professionalism
Systems-based
Practice
Traditionally M&M is to provide a forum for faculty and trainees to explore the management details of particular cases wherein morbidity and mortality occurred; can revisit these errors to gain insight without blame or derision
1983  ACGME required all training programs to institute regular M&M conferences
1999  outcome project developed with the intention of helping to train residents to develop into competent physicians and professionals
Integrated these 6 competencies into M&M
Patient Care: high quality, safe patient are
Medical knowledge: imparting medical knowledge to those in attendance
PBL: investigate and evaluate our own patient care practices, assimilate scientific evidence, and reflect upon ways to improve our performance
I&CS: Lessons that relate to interpersonal and communication skills
Professionalism: Teaching by example or role modeling
SBP: We are often practice within a larger context and system of health care, so there may be issues here
Kravet, 2006.

4. This information is confidential and protected under California Evidence Codes 1156 & 1157
In-hospital medical committees of a licensed hospital may engage in research and medical study for the purpose of reducing morbidity or mortality, and may make findings and recommendations relating to such purpose. The written records of interviews, reports, statements, or memoranda of such in-hospital medical staff committees relating to such medical studies shall not be admitted as evidence in any action or before any administrative body, agency, or person  
Exceptions:
Unprivileged patient information may still be discovered, however the disclosure of information concerning a patient to a hospital medical staff committee does not make unprivileged any information that would otherwise be privileged
Evidence of the original medical records of any patient is still admissible
This section does not exclude evidence which is relevant evidence in a criminal action
These are abbreviated versions of the 1156 and 1157 codes.

5. This information is confidential and protected under California Evidence Codes 1156 & 1157
Neither the proceedings nor the records of organized committees of medical body, having the responsibility of evaluation and improvement of the quality of care rendered in the hospital shall be subject to discovery
Exceptions:
If that person is a party to an action or proceeding the subject matter of which was reviewed at that meeting 
To a person requesting hospital staff privileges
In an action against an insurance carrier alleging bad faith by the carrier in refusing to accept a settlement offer within the policy limits
In medical society committees that exceed 10 percent of membership of the society, nor to any of those committees if a person serves upon the committee when his or her own conduct or practice is being reviewed

6. Logistics Last Wednesday of each month, 7-9 AM
Review any morbidities and mortalities from the preceding month
So, your first M&M will be July 26th reviewing cases that occurred from May 1 to May 31
3rd/4th year fellow coordinates
Subspecialists as well as our department participates

7. Presenter’s role
When you are the on-service fellow, identify cases that should be presented
All mortalities and code whites are reviewed
RRTs and other adverse events may be reviewed (still identify these cases and then discuss with the M&M fellow and Peter)
Notify M&M fellow
Find M&M fellow for appropriate month on the Wiki
should include:
Name, MRN, DOB
Event type, event date
On-service attending, other involved attendings (ex on-call attending), consultants to invite
A few lines about the patient and what happened
Educational or systems issues to be discussed

8. Presenter’s role Continued
Review the case with the attending(s) on service
Can consider reviewing with Peter and/or subspecialists (M&M fellow can help with this)
Develop topics for discussion for improvement in care
This should include the rubric (next slide) and may also include a relevant literature review

9. Patient *** - Assessment of Care
IOM Aims
ACGME
competencies
Safe
Timely
Effective
Efficient
Equitable
Patient-centered
Patient Care
(Overall)
Medical Knowledge
Communication Skills
Professionalism
System-based practice
Think about each box and whether there were any issues for this case. Check boxes (example above) and formulate issues for discussion based on this. For example – care of patient X wasn’t optimally safe, effective, efficient or equitable. The deficits in care were due to lack of knowledge, communication, professionalism or systems-based practice as indicated by the checks below.

10. Presenter’s role Continued
slides to M&M fellow ASAP
Ideally at least 2 weeks ahead of time, but can be determined individually with M&M fellow
Fellow on service at the time the morbidity / mortality occurred presents case

11. Moderator’s role
Invite all the pertinent subspecialists (as identified by presenter), outside hospitals, guest speakers (example: pathology)
Review the presenter’s presentation in advance
Coordinate the timeline and order of cases to be discussed
Ensure M&M stays on the timeline for the day
PowerPoint to Astrid Prackatzsch following M&M

12. Questions? References Ask now or anytime!
Codman, E.A. “Report of Committee on the Standardization of Hospitals.” Boston Medical and Surgical Journal, 1914.
Kravet et al. “Morbidity and Mortality Conference, Grand Rounds, and the ACGME’s Core Competencies.” J Gen Intern Med 2006; 21: