Morbidity & Mortality Meetings - Why they don't work?

One of the oldest methods of Quality Improvement in health care delivery, is the 'M&M' or 'Morbidity and Mortality Meeting' usually held weekly or monthly in every department of a given hospital. Throughout my medical training, and later on, I noticed these classic 'M&M' meetings taking place in almost every hospital here. However, there is serious doubt that hospital care quality of most hospitals in the area has improved, if at all. I don't have a study to support this statement scientifically, but this is a ubiquitous opinion amongst physicians old and new, patients, administrators and general public.

M&M meetings here typically involve a discussion of how many and what kind of admission were done in the past week/month, what procedures were done, what adverse events occurred, which patients died, and then each and every mortality and mistake is discussed at length. Literature suggests that this review of mistakes was historically meant to act as a corrective force, and a learning opportunity for physicians and care givers. I submit here that this corrective action has not happened at least in my observation. The question is, if this beautiful mechanism is already incorporated in hospital practice, why has it not worked?

There are indeed many reasons, including environmental factors. I wish to point out three of them here:

1. Who attends M&M meeting?

In my 12 months of clinical clerkship as a House Officer, I was never asked nor allowed to attend a single M&M meeting! It was supposed to be for senior trainees and consultants. Now consider this...what percent of a patient's time is spent in contact with a house officer? Perhaps the greatest in the clinical team, sparing the nurses. Oh and that reminds me, nurses also do not attend these meetings. With such a large portion of patient contact left out of a learning opportunity, how can one expect it to work?

2. What is the meeting culture?

I recently interviewed a senior resident in a reputed public hospital of Peshawar, regarding M&M meetings. I asked this person, what do you typically discuss regarding any mistakes? The answer was, "Every TMO [trainee medical officer] who has made a mistake is insulted". While this may not be typical of every unit, in my opinion it should never happen in this way. With such a negative attitude, how can one expect the trainee to learn and maintain a friendly attitude with colleagues? How can one expect the physicians to try not to hide their mistakes, if they know hell is coming?

3. What is the final outcome of M&M meetings?

In the same interview, I asked another question, "What is the final outcome of these meetings?". The answer was a classic phrase I will never forget, "Every mistake is promptly repeated next week!". The problem I believe, is that these meetings usually end at the error identification stage. There isn't an actual decision at the end such as 'We are not going to do X procedure without precautions A, B and C'. While the west is talking about pay for performance, health organizations here don't even touch the basics. How can one expect an improvement in behavior if the loop is left open after identifying the error?

Until our physicians are ready for a quality culture, this tool seems to be of limited use.