Taking Morbidity and Mortality Conferences to a Next Level: The Resilience Engineering Concept

Objective: To explore possibilities to improve morbidity and mortalityconferences using advancing insights in safety science.Summary background data: Mortality and Morbidity conferences (M&M)are the golden practice for case-based learning. While learning from complicationsis useful, M&M does not meet expectations for system-wideimprovement. Resilience engineering principles may be used to improveM&M.Methods: After a review of the shortcomings of traditional M&M, resilienceengineering principles are explored as a new way to evaluate performance.This led to the development of a new M&M format that also reviewssuccessful outcomes, rather than only complications. This ‘‘quality assessmentmeeting’’ (QAM) is presented and the first experiences are evaluatedusing local observations and a survey.Results: During the QAM teams evaluate all discharged patients, addressingteam resilience in terms of surgeons’ ability to respond to irregularities and tomonitor and learn from experiences. The meeting was feasible to implementand well received by the surgical team. Observations reveal that reflection onboth complicated and uncomplicated cases strengthened team morale but alsotriggered reflection on the entire clinical course. The QAM serves as a tool toidentify how adapting behavior led to success despite challenging conditions,so that this resilient performance can be supported.Conclusions: The resilience engineering concept can be used to adjustM&M, in which learning is focused not only on complications but also onhow successful outcomes were achieved despite ever-present challenges. Thisreveals the actual ratio between successful and unsuccessful outcomes,allowing to learn from both to reinforce safety-enhancing behavior.Gynecolog