Chapter 5: The Surgery Morbidity and Mortality Conference: New Approaches to an Old Tradition

INTRODUCTION

• The goal of the M&M conference is to provide an opportunity for peers to review and discuss adverse outcomes and surgical complications in a non-punitive, collegial forum

• The modern M&M conference has shifted from the traditional, selectively case-based and surgeon-specific review modality to a transparent and objective quality improvement initiative

• The long term goal of M&M conferences is to create a global culture of patient safety and surgeon accountability

THE HISTORY OF M&M CONFERENCES

The morbidity and mortality (M&M) conference has a long tradition in surgery. Its roots can be traced to Dr. Ernest Armory Codman, a surgeon at the Massachusetts General Hospital (MGH) from 1902 to 1914 who championed the “end result” idea, arguing that surgeons should follow patients to discover the ultimate outcome and learn from their mistakes and successes.^1,2 Dr. Codman kept detailed data on his patients for at least a year, including a summary of types of errors committed.³ At the time, this concept was heretical, and he was forced off the MGH staff in 1914. To continue his work, Dr. Codman established his own hospital and published a book, A Study in Hospital Efficiency, documenting outcomes of 337 patients in his first 5 years, including 123 errors.⁴

Despite Dr. Codman’s initial unpopularity, his leadership advocating for the end result idea was fundamental to the creation of the American College of Surgeons in 1913. Under Dr. Codman’s leadership, the ACS created the Hospital Standardization Program in 1918, with the mission that “All hospitals are accountable to the public for the degree of success… If the initiative is not taken by the medical profession, it will be taken by the lay public.” In 1951, the ACS Hospital Standardization Program merged with several other programs to create the Joint Commission on Accreditation of Hospitals, which was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 1981, now simply called The Joint Commission.⁵ As an independent, not-for-profit organization, The Joint Commission accredits and certifies healthcare organizations in the United States, with the goal of providing high-quality, high-value health care.

Perhaps the first reported M&M conference was from the Philadelphia County Medical Society’s Anesthesia Mortality Committee, created in 1935.⁶ The committee included surgeons, internists, and anesthetists. At the time, there was some surprise that there would be enough fatalities from anesthesia to discuss; yet the commission soon found that 67% of cases were preventable.

The goal of a conference dedicated to reviewing deaths and complications is to provide a way for peers to review in an objective fashion the adverse outcomes of medical care, and suggest ways in which care could be improved. This requires several largely unstated tenets:

• All complications and adverse outcomes should be presented. A selective presentation injects a bias of reporting, and prevents any analysis as to the ...