In recent years, there has been an increasing international interest in using mortality rates to monitor the quality of hospital care.1
Concern about patient safety and scrutiny of mortality rates intensified in the UK with the extensive coverage of investigations into National Health Service (NHS) hospital failures and the Dr Foster report with its patient safety rating for NHS trusts.3
As a consequence, boards of healthcare organisations now require assurance that the care they provide is safe and that patients are not dying through failure of their services. Many trusts include mortality rates in their performance scorecards or dashboards and actively engage with national patient safety improvement initiatives, such as Patient Safety First and Safer Patient Initiative, to reduce mortality rates.5
A forum that has traditionally reviewed in-hospital deaths is the long-standing Mortality and Morbidity (M&M) meeting established by surgeons to further professional education. In regularly reviewing deaths and complications, these meetings have the potential to provide accountability and the necessary improvement measures required for patient safety as well as professional learning. How effective they are in fulfilling these additional roles remains unexplored.
In many countries, M&M meetings are embedded within the medical curriculum for doctors in training.7
Junior doctors present cases to other doctors for reflection on diagnostic or treatment decision-making, and in return they receive clinicopathological wisdom and learn presentation skills. In the past, the brief discussions between the clinicians about the causes of death were thought to be effective peer review and an adequate means of changing practice.8
Little attention was paid to analysing the causes of deaths for quality improvement.10
Studies have shown that for M&M meetings to facilitate improvement and be more than a forum for peer review, they need to be structured and systematic in reviewing and discussing deaths, directing discussions towards improving system and process variations.12–14
Studies recommended that to support this, junior doctors' training should include more focus on systematic process change and less on medical error in M&M meetings.15–17
Historically, M&M meetings have been led and attended only by the medical profession and have remained autonomous, with knowledge not being available or shared with other professions or across the wider hospital governance framework. This ‘silo’ working has led to a lack of organisational learning and accountability.18
Increasingly hospitals are beginning to integrate M&M meetings into their governance processes, by making them mandatory and more accountable for reviewing deaths and taking corrective action should adverse events arise.19–21
To support this, the US Agency for Healthcare Research and Quality has produced web-based guidance for case analysis.22
Traditionally, adverse outcomes discussed at M&M meetings have been attributed to individual competence in treating patients rather than the system or process failures involved with the care.11
Although both contribute to errors, the focus on individuals has led clinicians to fear embarrassment and loss of reputation, making them reluctant to speak openly about errors at meetings.24
This defensive behaviour is thought to be counterproductive to eliminating adverse events and assuring safe care.26
In light of this evidence we wanted to see whether and how M&M meetings in an English teaching hospital could facilitate quality improvement, be accountable and provide assurance within the organisation's governance processes. Using a structured mortality review process as a facilitating mechanism, we wanted to assess what impact this would have on the original focus of the meetings and on professional learning; to explore how hospital staff viewed the changes; and evaluate the potential that a different format of M&M meeting could offer the organisation.