1. Structuring M & M Conferences for Educational Effectiveness
M.J. Kim, F.J. Fleming, J.H. Peters, R.S. Salloum, J.R.T. Monson,
M. Eghbali
Department of Surgery
University of Rochester, Rochester, NY
April 22, 2010
University of Rochester Medical Center

2. Background - Morbidity & Mortality Conferences:
Required by ACGME for surgical residents
“Practice Based Learning and Improvement”
Analyzing patient complications
Identifying causes
Proposing potential solutions
University of Rochester Medical Center

3. Background - Content/format discrepancies - Mixed lessons learned
Aboumatar et al, American Journal of Medical Quality 2007
- Mixed lessons learned
Bender et al, American Journal of Surgery 2009
- Structuring M&M presentations can improve
Understanding of complications
Learner satisfaction
Risucci et al, Current Surgery 2003
Muryama et al, American Journal of Surgery 2002
University of Rochester Medical Center

4. Objectives 1) Evaluate effectiveness of existing M&M conferences
Content/Delivery
Resident learning
Perceptions of effectiveness
2) Develop a standardized presentation format
Missing content
Streamline discussion
3) Determine effectiveness of intervention
University of Rochester Medical Center

5. Definitions Educational Effectiveness
Specificity of the cause of the complication
“OR staff not notified that potentially unstable patient in ED” vs. “Patient had delay to OR”
Specificity of the potential solution/change
“Designate contact person in OR for potential emergency cases” vs. “Need better communication”
University of Rochester Medical Center

6. Methods Study Design Pre/Post intervention evaluation Study Sample
Conferences in five divisions
All presentations by residents
Audience of faculty, residents, students, and staff
University of Rochester Medical Center

7. Methods - Conference Observation (TEACHING)
Two independent observers
Consensus regarding conference practices
- Resident Questionnaires (LEARNING)
2 Questions + any comments
- Surveys of Learners (PERCEPTIONS)
Online, anonymous
Last M&M conference attended
University of Rochester Medical Center

8. Results: Observation %Yes (n = 40) Observation Item
1) Is the complication clearly stated?
80%
2) If so, is it stated by the resident presenter?
55%
3) Is a potential cause clearly established?
65%
4) Is the cause proposed by the presenter?
18%
5) Are strategies for practice change discussed during each case?
85%
6) Are the changes proposed by the presenter? 8%

9. Results: Questionnaires
Specificity of cause of complication (n=26)
Mean rating (±SD) = 3.11 (±1.48)
1 = Vague
5 = Specific
Specificity of a practice change (n=26)
Mean rating = 3.42 (±1.50)
1 = No practice change stated
3 = Vague practice change
5 = Specific practice change based on current discussion
University of Rochester Medical Center

10. Results: Survey Question %Yes (n = 19)
1) Is the current format of M&M presentations effective for analyzing complications?
63%
2) Is the current format effective for learning?
53%
3) Are specific complications clearly stated?
47%
4) Are specific causes clearly stated?
21%
5) After presentation, is it clear how to avoid this complication in the future?
32%

11. Presentation Format Case Presentation (< 5 minutes)
Introduction
Clinical Information
Analysis
Supporting Information (< 5 mins)
Literature/Background Review
Take Home Points (Maximum 2!)
Discussion (< 5 mins)
= Total Time < 15 minutes per case
University of Rochester Medical Center

12. Presentation Format Format based on Introduced to residents
Suggestions from surveys
Previous publications
Introduced to residents
Sample presentation demonstrated
Template slides with instructions
Introduced to faculty
Format/process discussed at faculty meeting
Template, sample, instructions sent to all residents, fellows, and faculty
University of Rochester Medical Center

13. Results: Observation Observation Item Pre-Format %Yes (n = 40)
Post-Format, %Yes (n = 35)
1) Is the complication clearly stated?
80%
100%*
2) If so, is it stated by the resident presenter?
55%
3) Is a potential cause clearly established?
65%
91%*
4) Is the cause proposed by the presenter?
18%
57%*
5) Are strategies for practice change discussed during each case?
85%
89%
6) Are the changes proposed by the presenter? 8%
54%*
* p<0.01
University of Rochester Medical Center

14. Results: Questionnaires
Pre-Format
Mean (±SD)
Post-Format
Specificity of the cause of complication
3.11 (±1.48)
4.56 (±1.03)*
Specificity of a future practice change
3.42 (±1.50)
4.31 (±1.40)*
*p<0.05
University of Rochester Medical Center

15. Results: Survey Question Pre-Format, %Yes (n = 19)
Post-Format, %Yes (n = 18)
1) Is the current format of M&M presentations effective for analyzing complications?
63%
89%
2) Is the current format effective for learning?
53%
3) Are specific complications clearly stated?
47%
4) Are specific causes clearly stated?
21%
72%
5) After presentation, is it clear how to avoid this complication in the future?
32%
78%
University of Rochester Medical Center

16. Conclusions
1) Structuring presentations leads to more specific lessons taught during M&M
2) More specific lessons from resident presenters leads to better learning by peers
3) Structuring presentations is a practical intervention to improve M&M conferences
University of Rochester Medical Center

17. University of Rochester Medical Center

18. University of Rochester Medical Center

19. University of Rochester Medical Center

20. Results: Survey Suggested areas for changes:
Focused discussion period - 79%
Established presentation format - 63%
Time-limited presentations - 53%
Resident-led discussion - 21%
Other (specify improvements, streamline) - 21%
University of Rochester Medical Center

21. Results: Observation Observation Item Pre-Format, %Yes (n = 40)
Post-Format, %Yes (n = 35)
1) Is the complication clearly stated?
80%
100%*
1b) Within 5 minutes?
20%
2) If so, is it stated by the resident presenter?
55%
3) Is a potential cause clearly established?
65%
91%*
3b) Within 10 minutes?
10%
71%*
4) Is the cause proposed by the presenter?
18%
57%*
5) Are strategies for practice change discussed during each case?
85%
89%
6) Are the changes proposed by the presenter? 8%
54%*
* p<0.01
University of Rochester Medical Center

22. Results: Extent of use Did residents use the new format?
Mean = 3.57 ±1.40 (1 = No organization,
5 = Followed each step)
Was there literature review?
Mean = 2.71 ±1.71 (1 = No attempt at supporting info,
5 = clearly applicable studies cited)
Did faculty wait to ask questions?
Yes = 17%
Was each case <15 minutes?
Yes = 51%
University of Rochester Medical Center

23. Future Directions
1) Evaluate long-term (6-8 months) adherence to format changes
2) Study when/why format is not used
3) Compare with other assessments to evaluate extent of benefit
University of Rochester Medical Center