Reviving your M&M rounds

Transcription

1 Reviving your M&M rounds Using incidents to teach quality improvement, clinical reasoning, and reflective practice. Tom MacMillan Shail Rawal Stephen Gauthier Rodrigo Cavalcanti Saturday October 1, 2016

2 We do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization. Nous n avons aucune affiliation (financière ou autre) avec une entreprise pharmaceutique, un fabricant d appareils médicaux ou un cabinet de communication.

3 Introductions Steve Gauthier Tom MacMillan Rodrigo Cavalcanti #ICRE2016

4 My experience with M&M rounds Student Senior Resident Chief Resident

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6 Objectives Articulate the objectives of M&M rounds. Apply the principles of quality improvement, clinical reasoning, and reflective practice to analyze cases. Identify opportunities and strategies to enhance learning during rounds.

7 What are M&M rounds? Other names: quality of care rounds/review/ conference. Regular meeting to review patient safety incidents. Traditionally was focused on mortality cases and included only physicians. Has expanded to include morbidity and near-miss cases.

8 Objectives of M&M rounds Mandated review of medical errors (by a healthcare facility or by law) Debriefing of adverse events Case-based teaching and continuing education Generating potential solutions to problems Feedback to individuals

9 Competing objectives of M&M rounds Design of M&M rounds often prioritizes the hospital s need to systematically review and analyze adverse events and deaths. The educational potential of these rounds may take a secondary role.

10 An existing model to enhance M&M rounds. Calder, Lisa A., et al. Academic Emergency Medicine 21.3 (2014):

11 Key domains of focus for M&M rounds facilitators 1. Systems improvement 2. Clinical knowledge and reasoning 3. Reflective practice

12 The case of Mr. G.

13 M&M: Systems thinking

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15 Systems thinking principles 1. Incidents result from system failures and are rarely due to individual performance. 2. Incidents have a wide range of contributing factors. 3. Incidents usually involve failure of multiple safeguards.

16 William Holman Hunt, Wikimedia Commons

17 Blame and shame We have a tendency to blame individuals when incidents occur. Historically, incidents were often attributed to individual human error. This resulted in shallow analysis and failure to recognize important contributing factors. Systems thinking shifts the focus away from the individual.

18 Mas614, Wikimedia Commons

19 Normalization of deviance Deviations from operating rules can over time become normalized. Increase the risk of a system failing. Often seem benign and become entrenched and part of culture on a unit.

20 Normalization of deviance 1. Rules are stupid and inefficient 2. Knowledge is imperfect and uneven 3. Breaking rule for the good of your patient 4. Rules don t apply to me / you can trust me 5. Workers are afraid to speak up Banja J, Bus Horiz ; 53(2): 139

21 Individual performance issues Three questions 1. Was there a deliberate violation of sound policy by an individual? 2. Is there a concern about the health of the provider? 3. Is there a concern about the clear lack of knowledge or skills or significant unprofessional conduct by an individual provider? CMPA. Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and healthcare institutions

22 Individual performance issues Substitution test Would another individual coming from the same professional group, possessing comparable qualifications and experience, behave in the same way in similar circumstances? Canadian Incident Analysis Framework, CPSI, 2012

23 Example policy list

24 Systems thinking 1. Incidents result from system failures, and are rarely related to individual performance. 2. Incidents have a variety of contributing factors. 3. Incidents usually involve failure of multiple safeguards.

25 Contributing system factors 1. Care team 2. Task (care/work process) 3. Equipment (including technology & communication systems) 4. Organization 5. Work environment 6. Patient characteristics Canadian Incident Analysis Framework, CPSI, 2012

26 Systems thinking 1. Incidents result from system failures, and are rarely related to individual performance. 2. Incidents have a variety of contributing factors. 3. Incidents usually involve failure of multiple safeguards.

27 Multiple safeguards CMPA, Good Practices Guide, Adverse Events [online]

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29 Fixing safety/quality problems Criteria for selecting interventions Scope of the problem (prevalence; severity) Effectiveness Need for vigilance Implementation issues (cost; complexity) Momentum and synergy with other interventions Ranji S. Implementing Patient Safety Interventions in Your Hospital: What to Try and What to Avoid. Med Clin N Am 92 (2008)

30 Fixing safety/quality problems Cafazzo, Healthc Q. 2012;15 Spec No:24-9. From discovery to design: the evolution of human factors in healthcare

31 Fixing safety/quality problems Langley GL et al.. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition).; 2009

32 Fixing safety/quality problems LEAN Scoville R, Little K. Comparing Lean and Quality Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2014

33 Return to the case

34 M&M: Clinical reasoning A key opportunity to identify errors in clinical reasoning and teach about them

35 Clinical reasoning Definition: skills used to arrive at correct diagnosis and appropriate therapy Difficult to teach because: complex, situation specific based on tacit knowledge automatic processes of pattern recognition

36 M&M: Clinical reasoning Objectives: Appreciate that MMC is an opportunity do discuss role of clinical reasoning in Medical error Discuss a taxonomy of CR biases and its shortcomings Apply a framework

37 A Taxonomy of Clinical Reasoning Biases Anchoring Availability Confirmation bias Diagnostic momentum Premature Closure Representativeness Ying Yang Out Zebra retreat

38 Teaching a list of reasoning biases is unlikely to improve diagnostic reasoning in a particular case.

39 Diagnosis = Race

40 Pitfalls

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42 How to improve clinical reasoning 1 Knowledge Clinical entities Confusable diagnoses Key diagnoses by presentation

43 How to improve clinical reasoning 2 Rules of thumb to check thought process: Common and deadly Always generate a differential diagnosis How am I wrong? If this is not the correct diagnosis where would the error be? If you are trying to convince yourself = red flag

44 Rules of thumb = uncovering bias Rules of thumb to check thought process: Common and deadly availability bias Generate a ddx premature closure How am I wrong? framing bias Convincing yourself confirmation bias

45 How to improve clinical reasoning 3 Combine knowledge and tip: When assessing a patient with Chest pain remember to ask about cocaine use Never forget MI and PE 10/24/2016

46 Return to the case

47 M&M: reflective practice

48 Philosophically, the conference can be understood as a forum to pose the eternal question that faces any doctor who, despite his or her best efforts, encounters an adverse outcome: could I have done things differently? Prasad V. Reclaiming the morbidity and mortality conference: between Codman and Kundera. J Med Ethics; Medical Humanities 2010.

49 M&M rounds as collective reflection. Tension between the needs of the system(s) and the needs of learners. Balancing system learning to individual learning. Affective dimensions of M&M rounds second victim, etc.

50 M&M rounds as collective reflection. Experiential learning= learning by having an experience. Reflection is a means of learning from the experiential and affective dimensions. Viewed as critical to developing and maintaining competence in practice over time integration into curriculums.

51 Defining reflection. Reflection is a metacognitive process that occurs before, during, and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters. Sandars J. The use of reflection in medical education: AMEE Guide No ; Medical Teacher

52 Defining reflection. Reflection is a way of turning an experience into learning.

53 Defining the reflective practitioner. The reflective practitioner is one who uses reflection as a tool for revisiting experience both to learn from it and for the framing of murky, complex problems of professional practice. Schon, 1983

54 Knowledge in Action Reflectionin-action Reflection-onaction Surprise Experimentation Schon, 1983.

55 Disorienting dilemmas A situation that cannot be resolved using previous problem solving strategies. 1. Situation where they did not have the necessary knowledge or skills. 2. Situation that went well but they are not entirely sure why. 3. A complex, surprising, or clinically uncertain situation. 4. Situation in which they felt personally or professionally challenged. Schon 1983

56 Philosophically, the conference can be understood as a forum to pose the eternal question that faces any doctor who, despite his or her best efforts, encounters an adverse outcome: could I have done things differently? V. Prasad, 2010.

57 A function of M&M rounds 1. Linking past, present, future experience. 2. Integrating cognitive + emotional experience. 3. Considering the experience from multiple perspectives. 4. Reframing. 5. Stating the lessons learned. 6. Planning for future learning or behaviour. Macaulayy CP, Winyard PJ. Reflection: tick box exercise or learning for all? BMJ Careers. Hatton N, Smith D. Reflection in teacher education: towards definition and implementation. Teach teach educ 1995;11:33-49.

58 An ideal setting for reflection Story-telling. Motivation for reflection. Strong emotions can influence change. Feedback. Therapeutic dimension. Safe spaces. Guided by a facilitator.

59 Facilitating reflection in M&M The story What happened? The affective dimensions What surprised you in that case? What were you feeling? Individual and collective analysis Why does it make you feel that way? What are alternative ways of doing this? Future experiences What will we do differently next time?

60 M&M rounds as collective reflection. Critical reflection may be an overarching framework with which to understand and improve the educational experience of M&M rounds. Making reflection explicit. 10/24/2016

61 Return to the case

62 Let s try it out!

63 Key domains of focus for M&M rounds facilitators 1. Quality improvement and patient safety 2. Clinical knowledge and reasoning 3. Reflective practice

64 In the final 60 seconds What is one thing that you plan to take away from today s workshop

65 Thank you! Steve Gauthier Tom MacMillan Rodrigo Cavalcanti #ICRE2016

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