M&M meetings discuss the outcomes of patients and mortality rates, with the view to improving clinical care, quality control and professional education. Their purpose is to learn from past issues rather than assign blame. In this article, we help you understand how to prepare cases & what the discussion involves.
Contents
The Format
Regular meetings that include the entire medical team (including all the consultants from the specialty) but other healthcare professions are usually invited to contribute their expertise. They begin with an overview of the previous period’s mortality rates and will then discuss preselected cases in detail.
The cases include either all mortalities or those selected by the consultant. These may include patients with
- Delayed discharges due to complications
- Intraoperative complications or cases where the patient returned to theatre
- Cases where a ‘never event’ occurred or moderate harm occurred due to a critical incident
- Unplanned patient readmissions
- Cases with a CESDI score of ≥1 (see below)
- Cases where excellent care was provided (to impart knowledge)
Preparing a case
Junior doctors are often anxious when preparing cases – they may feel like it’s an inquisition into their team’s errors or may be worried about presenting to the entire consultant body. However, this is a blameless presentation of the facts and even if an error did occur, almost always multiple systems are at fault.
Your consultant or seniors will provide guidance on how the local process works & what specifically to include as this varies by hospital & specialty. However. do ensure the case is presented anonymously without identifying any of the doctors or other healthcare professionals involved. Do not cast aspersions over any particular decision or team member, but instead present the facts in time order as documented.
Patient
To begin, include the demographics & a brief medical background of the patient including any input prior to their admission from the multidisciplinary team (clinic reviews, specialist nurses etc.). Explain the reason the patient was admitted & what the adverse outcome or event was to prove context.
Events
Present the investigations, procedures and treatment they received including any involvement of specialists. For surgical patients, include the operation note & pay attention to pre-operative and post-operative care.
If the patient deteriorated, include detailed events in time order to highlight how the patient was escalated, the seniority of the person reviewing them and the management plan. Do include if any ceilings of care were set.
Finally, if the patient passed away, do discuss what happened in detail. This would include whether end of life care was provided (and if not, why e.g. unexpected deterioration). This includes:
- Restrictions in interventions
- Anticipatory medications for end of life symptoms
- Communication with the patient & family & any issues encountered
- Adherence to patients’ wishes including place of death
- Ceilings of care & DNACPR form
- Involvement of the palliative care team
This information helps the audience see if the patient was optimally cared for towards the end of their life – a ‘good death’.
Themes & Analysis
Do include a list of potential discussion points based on themes such as the ones above in ‘Events’. These should broadly cover any key events or occurrences that led to the deterioration or factors that if ameliorated, may have prevented any of these events. Usually, there are multiple contributory effects and so ensure you think laterally. Consider the following:
- Human factors: miscommunication, misinterpretation of the clinical status, lack of awareness of local or national guidelines, lack of appropriate escalation/investigations or specialist input
- System factors: understaffing, workload, failure of necessary equipment, deficiencies in training, incorrect prioritisation, failings of existing pathways of care
- Patient factors: rapid deterioration, declining treatment, difficulties in engagement or concordance, biopsychosocial factors that might lead to a higher risk of poor outcomes
Review of Literature and Recommendations
Review & appraise any relevant literature or guidelines with a focus on key learning points for future practice.
Discussion & Case Evaluation
Following your presentation, the case will be discussed by the team and they may ask for further details. The MDT will analyse the themes and factors discussed above and evaluate the care.
NCEPOD (National Confidential Enquiry into Patient Outcomes and Deaths) or CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy) scoring are often used to grade the care provided. Originally, NCEPOD looked into surgical issues and CESDI into neonatal deaths, but their classification systems have spread to all specialties.
| NCEPOD Classification | CESDI Classification |
|---|---|
| Good Practice A standard that you would accept from yourself, your trainees and your institution. | Grade 0 No suboptimal/substandard care |
| Room for Improvement Aspects of clinical care and/or organisational care that could have been better. | Grade 1 Suboptimal care, but different management would have made no difference to the outcome. |
| Less than Satisfactory Several aspects of clinical and/or organisational care that were well below that you would accept from yourself, your trainees and your institution. | Grade 2 Suboptimal care; different care might have made a difference (possibly avoidable death). |
| Insufficient Data Insufficient information in the case notes to assess the quality of care. | Grade 3 Suboptimal care; different care would reasonably be expected to have made a difference (probably avoidable death). |
The attendees of the meeting will decide which of these categories they feel the case best fits. Finally, the team should discuss if there was preventable harm, or if further investigation is required to determine whether there was.
Once again, it is important to note that no part of this process is focused on finding an individual to blame. The aim is to systematically review deaths and to learn from them.
Further Action
Cases may be escalated beyond the routine M&M meeting to more senior leadership if the attendees feel they need their support in dealing with a matter, such as drastic alterations to service delivery. The case may be reported as an incident – this would allow for possible detection of trends that aren’t easily visible without clinical governance input.
Further Reading
- Scottish M&M Programme
- Royal College of Surgeons: M&M Meetings
- NCEPOD Grading
- Mortality Review Tool in Elderly Care
Written by Dr Michael Johnstone (FY2)
Edits by Dr Akash Doshi (ST3)
