Surgical M&M: Can We Do Better?

certainly something our trainees can dread, have to get up at the podium and talk about things that went wrong. Where in reality, I would like to see where people look forward to M& M conference cause it's an opportunity to improve and and do things better. So that's how this started. So that's what I hope to get out of this. No pressure on you guys, but I'm looking for you guys to reinvigorate everybody's love of M& M conference. So we'll start with Dr. Little No. How'd we get here? Yeah you're from Mass General. There's a long storied history of looking at data and quality improvements. How, what can you tell us about the roots of the M& M conference? I think most people attribute the whole concept of outcomes to Dr. Codman, who was at the MGH early in his career and really is the father of outcome reporting. He was not celebrated for that. However, he was really criticized by, Colleagues and the leaders of the Mass General and actually forced to resign because he was passionate about looking

at outcomes, reporting outcomes and making outcomes available for everyone to judge where patients should have the safest surgery. There's a great caricature of the MGH should be proud of ostrich with his head. Buried in the sand with buckets of gold sitting around it and the fear that the board of trustees had related to reporting outcomes. So, common is well respected for what he did, but certainly at his time. He wasn't respected for bringing outcomes to the forefront but certainly now as they become so important and hospitals and departments worry about the rankings all the time I think it's come a long ways. I don't believe Codman should get credit for originating the mortality and morbidity conference. And, and I'm not enough of a historian to know where that comes from, but I can tell you, it has, as you pointed out, been a. a very important part of surgery for as long as any of us, and I'm far older than any of you have been involved with the

field. It has gone from being a conference which would be known for bringing residents to tears, and that was back when most of the residents were male. The tougher the M& M, the tougher the The tougher the chief of surgery was, the, the greater the reputation of M& M became. And I'm not going to name names from the past, but there are legendary stories of institutions where M& M was, was a fairly brutal. I think now as we've evolved towards modern medicine and perhaps maybe a kinder, gentler state, I think there are three components to M& M that we have to value. One, of course, is, is quality improvement. I hate to use the term learning from our mistakes, but maybe learning from our bad outcomes, what we could have done better technically, what we could have, you know, done better Sown in better judgment, either in and out of the O. R. Or you know how we could have communicated better transfer of care, things like that. Things that could have been better. There's certainly education, and at least in our grand rounds,

every case that's discussed has to have a paper related to the topic that reviews expected outcomes for. Pancreatic leak or post operative complications of any kind and then something that maybe I'm showing my old school surgeon background, but there is accountability and the accountability of a surgeon standing up and and taking responsibility for his or her. Decisions not passing them off and taking accountability and whether it be a resident who takes accountability or probably more importantly, the captain of the ship or the attending taking accountability. I think that sets an example of what all surgeons want to see is that. We are responsible for our patients. We're responsible for their outcomes, whether it be complications that occur in the OR or out of the OR or you know, we're, we're directly responsible by acts of omission or commission. We do have to take responsibility. And I think when you see

surgeons who don't do that well, they perhaps lose respect of their group and those who do it well, I think gain respect. So that, that's sort of, My fast forward of 100 years of M& M discussions, and I'm sure Dr. Pernar can add her perception. That's great. I think that I like the way you frame that. And I like starting from that. And that's where I wanted to start was the basic principles, you know, what should be the basic principles. And then we can drill down into kind of some details of how to get at those principles. But, but Dr. Pernar, what do you think? Do you agree? Anything to add? What should a, As far as thousand yard view, basic principles of an effective M& M conference encompass. Yeah, I really just have to add, I certainly don't disagree at all. I think that the M& M is a wonderful opportunity for education and for quality improvement. And I think also I completely agree with the accountability piece and there is really something to, you know, standing up and saying this is where the shortcomings were and

taking responsibility for. However, I think what has really changed or perhaps hasn't changed everywhere, but what I think needs to be kept in mind for M& M to be really effective is probably to make it non punitive and looking at the system in which people work. And seeing what the system can do overall to prevent errors. Very few times is an error, really an individual's mistake. I mean, obviously that happens particularly if you, for a technical complication, that might be the case, but so many of the things that we do occur in systems. And so, making sure that the M& M leaves space for that, looking at the system overall. And then also I think it is easier for people to come forward and take accountability if the punitive piece is taken away. So hopefully nowadays people don't cry anymore at Eminem, but that certainly used to be the culture, at least from, from what I hear

and going sort of the kind of gentler world as Dr. Little was said, I think is actually probably good. You know, what's interesting to me is That residents present cases, that is certainly the way that it is in our institution. It was like that when I was a resident, but when I was a medical student, actually faculty presented cases. And so I guess the, that is really where the educational piece comes in, I think, because the resident does so much under the supervision of the attending that they, I think, preparing the M& M, thinking through the case very carefully. It's really the important educational component. So, you know, as I've dug into this at our institution and learned a little bit more about how quality improvement happens in a departmental and a hospital level, I was really surprised to see that there's a lot of stuff that residents don't necessarily even know is happening kind of constantly at baseline in our departments to kind of monitor complications or

bad outcomes and keep track of them. Can you all just give kind of a brief overview of like, what's the bare minimum that a department does? Because I think a lot of this M& M flexibility for lack of a better term the opportunity that exists within M& M is really because it's kind of superfluous to a lot of other efforts to maintain quality and evaluate outcomes and constantly be tracking these kinds of things. So what's kind of the baseline that happens and how can M& M build on top of what already happens in these, in surgical departments? There are a lot of things that are desired and expected. I think we all are familiar with NISQIP. Most of our academic institutions participate in NISQIP. Of course, this is risk adjusted reporting, which I think is been used as a standard and strongly supported by our American College of Surgeons. Organizations such as UNOS for transplant. Very important. The Society of Thoracic Surgery has set up their way of judging cardiac and thoracic surgery outcomes. And some

of these then have gone forward into aspects of verification. Trauma centers need to be verified because of their outcomes. So, the same with bariatric surgery, they have certain requirements. So Purnar can talk more about that. But there's far more than that as well. The big player in this. Outcomes reporting is now vizient and vizient is not perfect by any means. There are experts in outcome reporting that thinks it has some flaws within it, but it is, it's become sort of the standard which most major hospitals compete. And I do mean compete because that's how your ratings are. And we get presented to us every few months where we are. And we're a long ways from being in the top Invisian reporting. And it's kind of conflicting because many consecutive years we've been exemplary on this whip and we've had multiple stars in, in SDS. And so they're not all the same, but. It turns out that certain organizations such

as U. S. News and World Report and others have focused on Vizient, and so, you know, every, every game has a different set of rules, and if you want to win on the game, you got to follow the rules, and Vizient seems to be setting them right now. So, I think there is a lot going on and the board or the RRC requires quality improvement training for all residents. And so, it shouldn't be a black box. The other thing that most institutions do now is mortality reporting and understanding and review all mortalities to understand. What happened and we're asked to determine, is this an expected outcome due to whether the patient presents is an unexpected outcome and is an unexpected outcome, perhaps due to errors and communication or things along that line. So I think. Quality improvement is very important for our patients, and it's very important for our training and the quality that the products that we want to produce in our residency and so, efforts such as behind the knife of getting this message out there is

another important method to bring this to people's attention. Well, thank you. I do have some more questions about that. Like, I think, you know, what we struggle with a lot of times is there's all, as Nina said, there's like kind of all the, we have a lot of quality metrics. I mean, yeah, like all those things you mentioned, we have NISQIP, we have MBSQIP, we have TQIP, we have leapfrog metrics. And then, you know, that's, then we have our, of course, our hospitals, you know, risk management committee and that line of things. But giving our. Our M and M operationalizing that to connect it with all those things. Sometimes it feels like all those initiatives are kind of, you know, happening in silos. So how to connect our M and M conference, how to truly make it multidisciplinary, you know, how to connect it with those quality improvement pieces so that something actionable comes out of it, I think is a challenge. It's certainly a challenge for us. And, you know, Ways I'm definitely looking at doing it better. So, I think once we get in a little, I wanted to dive into the kind of the nuts and bolts of how you structure M and M conference and how we should be structuring it. But before we get to that, I just want to

reiterate that I definitely so those broad principles of an educational and focus and professional developments and then the Q I and the improvements in air prevention piece as well. But then, Dr Purnar, as you said that, you know, That, that, the importance of that non punitive environment, that's a little bit harder. That's, that's, that, because now we're talking about culture. Anytime we talk about culture in a, in an organization, culture change is almost impossible. So what, do you guys have any tips and tricks? Dr. Lillemo you said it, not me. You've been around for a little while. Maybe remember those more malignant days as a head of a department. How do you steer that culture into that and foster that non punitive environment for M& M? I guess it starts with the leadership. Making sure to set the tone, you know, if there's somebody who's a headhunter in the faculty who is unfairly picking on residents or junior faculty doesn't take much to pull someone aside and

say, you know, maybe that's not quite the attitude that we'd like to have. That's probably best done by the chair of surgery or the program director. So I do think you change the tone and that has had to change over time. I mean, surgery has changed so dramatically from. When I started and to where, where you guys are now, but I do think that in the old days, there was pride of being a tough program and you know, whether malignant is the term we should use to describe a department. And I've certainly been at a number of departments in the past that have been considered malignant or tough. And I would like to think that. At least our program now and many of the programs that I've been involved with have evolved with time, but it takes an effort to sort of take the edge out of this and make sure that if there is some accountability that it's done in a fair way. Dr. Purnar, have you had to deal with this culture, the shift or change and any tips for dealing with, you know, difficult, where surgeons

are famous for having difficult, you know, personalities how do you deal with difficult personality in a group? Right. So I must say that I've been fortunate that neither of the institutions that I've been at, the culture was particularly confrontational around M& M. Where I'm now, it certainly is not. And I think that Dr. Lillen was absolutely correct. The tone is set from the top. And I guess I've just I've not experienced it differently, so I think a sort of more collegial and supportive approach to M& M is kind of what I've seen. I mean, I certainly think that, I think sometimes it's kind of like, for the grace of God, go I, right? So that these complicate, complications happen to all of us, and all of us will find ourselves there, and nobody comes to work with the intention of having a complication. Like you had said, people usually don't look forward to M& M. And certainly it's not your goal to have a case, but what I think is really helpful about it sometimes is that when the case is sort of

discussed, other eyes look at it, it helps you get sort of another perspective of maybe how it could have been managed differently. or what the real issue was, and it's just an opportunity to help evaluate your own thinking. And if that is done in an environment where you really feel like your colleagues are there to give constructive feedback on what has happened, I think the more receptive to learning, and I think that the conversation goes better. So again, I haven't had to deal with the culture change, but certainly it needs to come from the top. The goal should be for it to be educational. And I think that's really the best way to get there. Something that's come up as we've talked about M& M conferences is that, is really to your point, Dr. Purnar, is that these are really rich, kind of concentrated instances of education, right? Those conversations are so high level, and they're what I'm thinking, and they're how I interpret what you did and this

is, you know, I think we've all acknowledged that this is a really educational moment in time. But do programs kind of track that in any way? Are they using that, you know, for lack of a better word, data that they get from those rich conversations that happen in M& M conference? Is there any way that programs have kind of translated that into the world outside of the M& M conference room when it's happening? You know, we all benefit from it in the moment but how do we kind of broaden the educational benefit beyond the walls of where we're doing M& M on a weekly basis? I guess I would say this comes down to the individual program, and at least in our program, it comes down to the individual case. I mean, if there is something that we see that requires further investigation, you know, we will, we'll follow up on where the breakdown took place. We certainly don't necessarily have a next step on every case that's presented. And I, but I do think that if

there's a system error. Or a practice error or something that we see that we're consistently doing wrong that is leading to an outcome. I think we need to take it beyond The auditorium where the discussion takes place into action groups that that will focus on taking the next steps. So, but it's certainly not every case is maybe not every week and it may not just involve. Our department, it may be. Necessary to have a discussion with anesthesia. It may be necessary to have a discussion with the blood bank. It may be discussion to have a time to have a discussion in the emergency room about, you know, how referrals are made or the timing. So, and again, that oftentimes if it leaves the surgical group to go to other groups, we have to do it in a non confrontational fashion. Doesn't do me any good to walk into the department of anesthesia and slam my and say, you know, you guys are.

Causing bad outcomes by doing this or doing that, but you know, maybe we should talk about how we're managing our regional anesthesia or how we're managing induction or things along those lines. You know, I'd like to kind of get into some nuts and bolts about best practices for M& M. I'd like to hear a little bit about how you guys do it at your institutions, and what, ideally, in a perfect world, how it should be done in institutions. So, let's start with, you know, case identification. How do you identify cases? For, for M& M conference, is it self reported? Is it identified by some QI metric? Is it patient safety and reporting? So how do you do it? And again, ideally, what's the best way? How would you recommend people choose cases? To be presented at conference. So at our institution, the cases are submitted by residents. There is a document that outlines what should be submitted. And just from knowing what's

sort of generally going on, not necessarily everything is submitted that possibly could be. But if we are aware, we can also ask that cases be submitted, and then a document is compiled for each submission period that's then sent to the faculty moderator for the conference, the time frame applies to, so we have a rotating set of faculty moderators. And then, if you're up to be the next one to moderate M& M, you get this document and then you pick three cases from it. And because faculty or residents who were involved with the cases may not be available on the specific day you're moderating, you have some backups and so forth. But in the end, it comes from this list of cases and there's No explicit criteria for how to select the cases. It's really whatever the faculty moderator thinks is appropriate. We do encourage our residents to also submit cultural complications, so those can be picked from the list as well.

Yeah, and then this resident is notified that they, the resident and faculty are notified that the case has been selected and then will be presented at a subsequent M& M. We will probably talk about this some more later about the M& M. But the residents are then asked to prepare the presentation and send it to the faculty moderator ahead of time to review. And Dr. Little had talked about this before about the educational component. There should be an education piece attached to this. Typically, it's a review of the paper or. You know, review of relevant anatomy or what have you, whatever is the most applicable. I had a question about that. So the culture, can you expand on that cultural complications? Like some people might not be familiar with what that is. Right. So for instance, if perhaps a complication was due to a language barrier or to mistrust in the medical system or to some kind of bias or something like that, You can, that can be submitted

and sort of flagged, like, so the outcome might just have been a complication, but perhaps the underlying issue was some kind of cultural component, then you can include that when you submit the case. Yeah I would maybe expand on that. I think it's not so much cultural, but it's social determinants of health. So if somebody got readmitted, let's say they were they had a pancreatectomy and they were, had need for insulin after their pancreatic resection, and they got sent home and they didn't get their insulin filled because they didn't understand because they did not speak English or the instructions weren't proper. And the patient got admitted with. You know, hyperglycemia and diabetic ketoacidosis. Maybe there are some social determinants of health. That led to this problem. Maybe it was just instructions given in English as opposed to written instructions in Banish or the proper. So I think those are important things that we need to focus on in terms of

social slash cultural aspects as well. Our overall system is comparable. Every complication is supposed to be reported in some way, shape, or form and then we have evolved from trying to present as many as we possibly could to submitting them and then having a central group of people to choose the cases that have most value in terms of both education and quality improvement. I mean, it probably doesn't do anybody any good to have discussed. Five different cases of delayed gastric emptying following pancreatic resection or, you know, every urinary tract infection unless there was some violation. So we try to mix and match so that their highest educational value and also to make a cover the broad spectrum of complications. And if you have a big group, as we do, you want to share the opportunity for all services to be

represented and not just be heavily, again, on the pancreas service or the colorectal service or the ACS acute care surgery service, but we try to have some diversity of topics and that's what the panel picks. All the residents submit. In general, the residents have a high level of reportability and then the decisions are made to pick two or three cases for every, every week that we have highest educational value. One thing we've added and we don't do it every week, but we try to do it periodically is actually use M& M to celebrate a good outcome and talk about a great job by somebody in an early pickup of some complication that averts even a bigger disaster. And these aren't necessarily meant to be near misses, but they're examples of someone doing their job or even going above and beyond. And we, I think you can't just make it all the negative side of thing, but the periodically celebrate a good outcome. And

that's something that I think is good for morale, and it encourages people to you know, celebrate good outcomes rather than just be critical of bad outcomes. I wonder if that's part of a greater cultural change, right? Talk about kind of making this a less scary conference for trainees. You know, the thought that you could eventually get highlighted for something good that you did is a really nice concept, I think. I heard your group did that, the unexpected good outcome. And I like that. I think that's something I'm going to try and incorporate into, into our practice as well. That's a really great. But I also wanted to add, you know, I think that's, this is an opportunity for where we were talking before about how do we include the quality improvement side of the house? So like, we're the same way. It's like, okay, there's a UTI that that doesn't necessarily need to be presented. But, I think if you go and then look at your data, and if you're an outlier for, well, you should probably be discussing your at your M and M conference until those numbers improve. So I think it just highlights that interplay between, you know, there's

educational component, but then there's also the quality improvement component that we need to have an eye on. How about the the structure of your M& M conference? So you mentioned, I think everybody, for the most part, residents present, is that still the case? Is it a PowerPoint? Is it a book report that the resident has to do? What is it? What does that look like? Just in a practical sense? Bullet point PowerPoint with history key past medical history physical findings some x rays, you know, now you can show the CT scans. You can show things along the way. If there was 1 universal message, I say they need to be a lot briefer. You know, I mean, when we get into complication number 7 on day 37, you know, I think that perhaps better choice of what they present would make everybody happier. And you can tell the, the skilled presenters is they know how to get to where the high points are. So every now and then we have to remind them by saying, maybe you could speed things up a little bit because we have two other cases to come, but

it's a presentation with x rays. And and then at the end of the presentation, we usually give the microphone to the attending to make appropriate comments and then open it to the floor. This is going to make one comment about the whole education side of things, because I think Dr. Purnar said that sometimes the conversations are way high level, and it's very common at our institution for one of the senior surgeons to say, well, for the residents, you need to understand this, this and that. Nine times out of ten, the person saying that really wants to make sure the faculty know that as well. But it is important sometimes that you do remember that there are learners and that don't quite have the knowledge and complexity of knowledge of the complexity of some of the discussions. And it's important for everyone to benefit that. People have to make sure that it's understandable at the, you know, at the PGY 1 level or the senior medical student level. I

think that's important. And then again, as we said, after enough discussion, then they close with a, excuse me, a paper that is recently been published that, that addresses the complication or something about the case. So that's hopefully we can all learn something from it. Yeah, so ours is very similar. So the residents present with PowerPoint, the case or the events around the admission, any relevant imaging findings, what was done, and then ultimately what the complication was and how it was managed. They are asked to provide a summary of what ultimately the problem was. Was it a technical issue? Was it communication? Whatever it was it patient related, related to the provider or the system, and then preventable, likely not preventable, or definitely not preventable. Anticipated or unanticipated. So kind of make those kinds of judgments. And then what could have perhaps been done differently. And then the, you know, people in the audience are certainly able and

encouraged to ask questions during the presentation. The faculty moderator may ask questions during the presentation. And then as it sounds like at the MGH, there's a pause where the attending off record can chime in with their thinking and then it goes into the teaching, which again is most often papers, but it can also be review of policies or a review of anatomy or training. technical aspects. And yes, there's often the shout out to the back row. Oftentimes that shout out is for the benefit of everyone. And we do try to get through three cases. So I definitely echo what Dr. Lillamo said. If people just really focused on the Key things rather than getting lost in the weeds. It would be extremely helpful to really leave room for the discussion Which I think the richness really comes from and I think it's hilarious because i've seen that You know, i've been a part of multiple m& m conferences and that's almost universal when the attending is Asking a resident why on earth would you have done that? I think it's important for the residents to understand The junior residents, a lot of times that's not directed at you. That's

like, I want to say that to this person, but I can't say it to this person directly. So I have to say it through you. It's whether that's good or bad, or I think it's an interesting anthropologic analysis of what's going on. I think somebody should study it because I think it's very fascinating. Sorry, Nina. No, to that point, you know, what PGY level do people start? presenting conferences because I remember we started PGY3 level and I was terrified the first time I was going to have to defend, you know, decisions that in reality were made by my attending most of the time. And so I do wonder, you know, what's, do you all feel is kind of the optimal level at which you start participating in these conversations is more than just an observer from the back row. But our institution, it's the operative surgeon who presents. So, for example, the breast rotation is a PGY2 service, and so if there's a take back for bleeding on a breast procedure, the PGY2 will present it. I don't think I've ever seen an intern present, although, you know, interns do get to do, you know, some lap colies and hernias, things like that.

But it is always heavily rated. Weighted to the P. G. Y. four and five residents, I think, for most of the presentation and fellows will present again. We have a minimally invasive fellow. We'll have a surgeon fellow coat that who will present where I trained. It was P. G. Y. three and opposite. Here, occasionally PGY 2 residents will present. I don't think the interns generally present. I think if a case is picked where an intern was the operating surgeon, it's usually the senior resident on the service that ends up presenting. And yeah, certainly the fellows would present their own cases as well. It's probably kind to the interns out there, so. I'd like to just bring up one other topic, which you might call etiquette of M& M. So when I first got here, we had the Churchill service or the Ward service, and then we had the Baker service, which was the private service. And you could almost have the Mason Dixon line through the middle of the auditorium between, you know, one service and the other. And, you know, there'd be undercurrents of

discussion on one side versus the other and criticisms and people speaking under their voices, but everybody could hear what they were saying. And so one of the things we did is we said, all right, we're going to start mixing people up so that it wasn't distorted. sort of the polar services. And then we started mixing up the hierarchy. So it was always, you know, they had an unwritten rule at the MJHS. You couldn't sit in the front row unless you were a full professor at Harvard. And there's less, there'd be a lot of times I'd be lonely in the front row. And so now some of the more senior surgeons sit back in the sixth or seventh row. So it's not, we can't get the interns out of the back. They've never moved up, but we have changed the seating such that it isn't always, yeah, and it's a terrible auditorium. It's a steep auditorium. I hate being in the front row because I get a stiff neck just looking at the projector. So I'm happy to move up to the fourth or fifth row now. I think that was important to sort of change the culture that, that we're not one versus another in terms of the etiquette.

And then one thing that came to me, a group of our women surgeons came to us and said they had noticed something and then they went to document it. And what they noticed was the number of times that female surgeons, whether it be attendings or residents, got cut off or talked over by senior male surgeons. And it was pretty clear that. There were certain dominant voices, mostly older men, that were used to having the final say on things. And as the department became, you know, broader and more gender representative of where we want to be, there was less diversity who was speaking. And so, just some subtle changes we made to make sure that everybody has an equal voice and they get a chance to speak. To give their opinions and not be shouted out by someone who just happens to be older or senior, and in general have had more complications and more experience, but still, I think there is some etiquette to how you run your M& M, and if you don't

do it right, it may not be the hostile environment. That existed in the 60s and 70s, but it can still come across in a situation where people will come away saying, you know, this isn't a very good environment. And so I think it's a chance for you as a departmental leader, whether it's your division M& M or your departmental M& M to make sure that everybody knows that we're on equal footing and treated fairly. That's a great point. And I think many female residents across the country will probably resonate with that point. It's not uncommon to get cut off. And I think we all expect it. But it's interesting that you've really leveraged even your physical space to try to combat some of that. You know, natural tendency for, you know, junior people to sit in the back and not raise their voice. And I think that's a really interesting thought of just like physically put people together and mix people in and put people on level playing field, as you say. So, Dr. Perna, I want to go back to something you said about your M& M and specifically

this idea of, it sounds like you make your, your trainees kind of put their nickel down as to what they think happened. whether they think an error occurred, how much that error contributed to the ultimate patient outcome. We do something similar at our institution, which I think as a trainee, I've really benefited from because when I've had to do that, sometimes I'm over, overruled by the eventual, you know, kind of consensus conference discussion after we've had our, our discussion. And we actually put numbers on ours and kind of say at the beginning and then say after, after we've discussed the case as a group, what we think happened and how much, you know, physician or surgeon error contributed to the outcome. So I'm curious how that plays out in your conference where you do have trainees kind of stating what they think. Right. Yeah, as I was saying, usually on that slide, that's the transition to the teaching points. That's where there's a pause. And that's typically where the discussion happened, the attending gifts of their thoughts. And then usually other people from the

audience either ask questions or make comments. And that's sort of at the end, no one sort of makes a summary statement as in. I now believe this, the contributing factor was this, and this was in fact unavoidable or whatever, like, it doesn't explicitly get restated, but I think sort of the discussion makes clear whether or not there's a general consensus. Or not. And I agree with you that sometimes when a case is presented that at the end, you know, tending to get, like, say that there was nothing else we could have done, or like, what, what a save in the end this was, or what have you, right? So again, I think speaking more to the culture of having it be supportive and non punitive, or sometimes like, well, what a terrible thing happened, and we're sorry it also, it also happened to you, right? There are a few more things. I think we're getting to the end. I know you guys are very busy, but there's a couple more things I wanted to discuss if we could. One is, what do we do with this information, right? So, you know, we've designed this great

conference where we have the educational component, we're learning, we're having good dialogue, it's a very non punitive environment, and we have a determination at the end of something, you know, something needs to be changed. How do you guys? Tie that into the rest of that quality improvement program. What actions, how do you turn that into actionable, an actionable item? I'll go back to something that was said earlier about having a mix of cases. I think that that certainly is important. But as a faculty moderator, I sometimes notice that the same thing gets, comes up over and over again. And those I think, are opportunities for QI and, and Dr. Bing, you had sort of alluded to that as well, as well as had talked to limo. So our conference is attended by our director of clinical quality and patient safety for the department. And so when there are those things that seem to raise their head at periodically at M& M, we ask her to look into it. And then she might convene a working group

or do some work on investigation with all the Other information that she has, as also was said before, there are all these other mechanisms that are not specifically related, at least our institution, to how M& Ms get submitted that you can look at to see if there truly is a pattern and then try to work on it. And so out of, so out of our M& M has come, have come several changes to host surgical protocols like for care of patients on the floor and things like that. And they are periodically announced at M and M's like, this is like what the group has worked on and like, this is what's now happening. And I think that's incredibly helpful for the trainees and also attending surgeons to hear. And it's also again, an opportunity for education. So I think I commented earlier that, when we see something that is as an actual item we put someone on top of it to make sure that there's followup and we do try to close the loop. So two weeks, four weeks later, someone will come back and say, remember this case

we presented and this is how we've resolved that. I mean, you can't believe how many discussions we've had about various types of staplers. And post operative leads from staplers you know, now everybody's decided what color it is and what stapler to use, et cetera. So, I mean, those are somewhat informal actionable items, but if there's really a systems breakdown or something that we're just doing wrong we do try to close that loop. Dr. Parnar, you brought us with an interesting there that I wanted to I wanted to circle back around on is you have other stakeholders in the room. So when it comes to trying to communicate this up and out of the hospital, you said you have the hospital's safety officer or equivalent there. What other stakeholders do you guys have in the room for M& M? Is it primarily just surgeons and residents or are there? Are there others? So, so it's our the director of clinical quality and patient safety for the department and we invite if there is a

multidisciplinary case, like interventional radiology was involved or anesthesia or urology they're definitely invited. Usually the like, oftentimes. It seems the person who runs the trauma quality improvement project attends for trauma M& Ms. I do not believe that someone from the hospital overall attends to M& M. I think the director for our department communicates it out. What about so one other thing I want to ask about was legal issues. Do you ever encounter this or people concerned about determinations from morbidity, mortality conference making its way into the courtroom to say for like a malpractice suit or into a credentialing meeting, is there any risk of that? Maybe you guys ever come across that. There are plenty of times when a complication has taken place and a discussion of medical legal liability and what someone needs to do or should have done already to let the legal office know that this has the potential to be a

lawsuit, you know, a bowel duct injury or a delayed diagnosis, something along those lines. So we generally don't make a big issue out of it, but we subtly. We'll say, you know, have you contacted legal about this? And if not, you should make sure that they're aware of the case. According to I don't know whose laws these are, but M and M is considered peer review, unobtainable in a legal setting. So if you have a case and you discussed. a case that goes to court. If someone asks you, was this case discussed at your hospital morbidity mortality conference? The answer is that information is privileged and not obtainable. So any good defense lawyer will protect any information from M& M ever surfacing to the To the outside world, it is a peer protected discussion, so it should not be a case. And in terms of people being in the auditorium, when we have M& M, we do not generally invite the public.

We do occasionally, as they do at BU, invite leaders from our quality and safety organization, or we'll bring in people from other specialties that had contributed to the care, but we generally don't turn it out to anybody to want to show up. We went to Zoom during COVID and that was the first thing that came completely off Zoom when we could again get together in a group. And I think it was not necessarily for concerns about legality, but just to bring everybody together in one room. But I think actually interesting because whether or not Eminem being held over Zoom I'm, I know nothing about the value of that or if somebody taping it, what can happen to that information? But I think that is an interesting question. I actually just this week recorded a another episode with some of our risk management folks. And it sounds like there's a pretty clear definition that QI is protected and that those would be under the auspices of QI. And so wouldn't be discoverable, so to

speak. Although I don't, yeah, I mean, there's always right security risks with anything recorded. So, so how much of this Could get leaked or something like that, you know, I don't know. But yeah, supposedly according to the folks I've talked to about it, this typically is protected you know, specifically because they don't want it to be, you know, in the chart punitive or potentially punitive kind of thing. So, that's my understanding. Might as well. I know it comes up. People are concerned about it, but to my knowledge and somebody, if anybody's listening out there, they're no different. They're, I don't think there's been precedent for any of this stuff being discoverable, but I know it certainly sometimes creates a little bit of anxiety. It's always interesting. I think this is such a standard part of surgical education and surgical departmental, you know, protocol, but it's so different across the country. You know, everyone has little tweaks and ways of doing things in their own divisions that I think it's really interesting just to even hear, you know, the difference between how y'all do it. And, you know, there's a lot of talk out there about how we should standardize M and M. And I think a lot of it comes down to what you both have mentioned repeatedly is.

The culture and how we can make this, you know, both an educational and a valuable tool for quality improvement kind of longterm in our departments. So thank you. I know I've certainly learned things that I'm going to, for me, all that I'm going to bring back from all three, all three of you, actually, that I like that the number, the number in the can't wait for that or don't come out, but then I'm going to try and bring back to our department. So I know you're both, everybody's very busy. So, I would just want to thank you on behalf of Nina, myself, and behind the knife for taking the time to talk to us and until next time, Nina.