Quality Corner: M&M Conferences as an EMS Learning Tool

You’ve seen it on television’s ER (during Season 8, Episode 1, to be exact) when Dr. Mark Greene faces interrogation at an M&M conference over a patient who died as a result of a medical error—his error. Morbidity and mortality conferences have been a part of physician training since the early twentieth century. They are peer-review meetings where cases in which mistakes or errors were made are presented by the responsible physician as a teaching tool, both for the presenter as well as for their colleagues, in hopes that the error will not be repeated.

Long before industry had its quality-control gurus W. Edwards Deming or Joseph Juran, medicine had Dr. Ernest Codman. Dr. Codman was a surgeon at Boston General Hospital in the early 1900s and was the first physician to be concerned with and start tracking patient outcomes, which pretty much makes him the father of quality improvement in medicine. Dr. Codman was a founding member of the American College of Surgeons (ACS) and headed its Hospital Standardization Program, which eventually evolved into the Joint Commission on Accreditation of Healthcare Organization (JACHO).

In 1914, Dr. Codman implemented the first morbidity and mortality conference at Boston General, where fellow surgeons presented cases of medical error and bad outcomes to their peers as a training tool to standardize and improve patient care. However, the unprecedented concept of questioning the judgment or competence of a physician—even by fellow physicians—was a bit ahead of its time, and as a result Dr. Codman was unceremoniously forced off the staff at Boston General. The American College of Surgeons supported Dr. Codman’s concept of case review, and as their influence as an institution grew, his method of case review slowly became an accepted practice.

M&M conferences are non-punitive as well as legally confidential. They have proven to be so valuable as both a medical education tool and as a quality improvement process that the Accreditation Council for Graduate Medical Education (ACGME) has mandated that they be part of any residency program.

M&M conferences are effective for several reasons. The first is that all the facts of the case are laid out without the distraction of other cases. If the case involves a fatality, autopsy results are typically available to connect the dots between cause and effect. The presenter, after being advised of the error or outcome, has time to focus on what may have gone wrong. In reviewing the case prior to presentation, the ramifications of how a seemingly minor error or oversight could result in serious and possibly even catastrophic consequences becomes clear, demonstrating the importance of attention to detail in the unforgiving profession of medicine. Lastly, the extreme discomfort of having to stand up in front of your peers and your mentors to explain why you did what you did, and admit your error, is almost always a guarantee that you will never make that same mistake again.

So as it is in the rest of medicine, maybe the time has come to start treating paramedics like the grown-up health care providers we want them to be, with emphasis on the importance of responsibility for their actions. Obviously paramedics cannot be expected to have the same knowledge base as physicians. However, a model similar to an M&M conference for EMS could be based fairly on our established scope of practice and reasonable expectations. In cases of serious error or oversight, or where similar errors have been repeated with feedback going unheeded, it may be an imaginative way to see if behavior can be changed by other means.

We recently trialed the M&M conference method at one of the EMS agencies where I participate in the quality improvement process. Because it’s so much more difficult to prove that a teaching method is successful in preventing something from happening than to prove that it's failing by an incidence reoccurring, the jury is still out, but so far so good. Having said that, implementing a teaching method which has historically proven to work so well for so long for the rest of medicine at the very least makes the M&M conference model a viable if imaginative new tool to add to the EMS quality improvement toolbox.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.