SHM Converge Scientific Abstract ePoster Gallery-Transforming Morbidity and Mortality: Creation of a Case Selection Tool

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This Mayo Clinic project addressed the challenge that morbidity and mortality (M&M) conferences often lack a clear standard for choosing effective cases. The team noted that the educational and patient safety value of M&M depends heavily on selecting the right cases, yet the features of a “good” M&M case had not been well defined.<br /><br />To solve this, they created a case selection tool based on two goals:  <br />1) maximizing educational value for residents, and  <br />2) identifying cases likely to lead to successful quality improvement (QI) efforts within the health system.<br /><br />The tool was developed using Kane’s validity framework, which helped the authors build a validity argument for how the scores would be used. They separated the tool into two sections: one focused on the qualities of a good M&M case, and another on the qualities of a good QI project. Each month, their residency’s QI/patient safety council uses the tool to score cases and then discuss both strengths and weaknesses relevant to resident learning and patient safety.<br /><br />Early findings suggest the tool improves the case selection process by facilitating more productive discussion. Preliminary data also indicate that the patient safety cases chosen through this process are more engaging for residents and have led to practice-changing QI projects. The authors also observed that not all scoring items have equal importance.<br /><br />Next steps include revising the items for clarity, adjusting the scoring rubric to better reflect item importance, testing inter-rater and intra-rater reliability, and gathering more data to determine whether the scores predict real-world educational and QI outcomes.<br /><br />Overall, the project aims to make M&M conferences more effective for both education and patient care.

Asset Subtitle

Neela Nataraj

Meta Tag

Author List John Ratelle, Neela Nataraj

Category Innovations

Concept Morbidity and Mortality Case Selection Tool

Concept Kanes Validity Framework

Concept Morbidity and mortality conference

Concept Educational Value

Concept Quality Improvement

Distinguished Non-Finalist

Presenter Organization Mayo Clinic Rochester

Presenting Author Neela Nataraj

Track Quality Improvement

Keywords

Morbidity and Mortality conference

case selection tool

patient safety

quality improvement

resident education

Kane validity framework

health system

QI project

educational value

inter-rater reliability

Morbidity and Mortality Case Selection Tool

Kanes Validity Framework

Morbidity and mortality conference

Educational Value

Quality Improvement