How does your institution do QA/M&M?

[throwitaway]

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Curious how others do QA, M&M, whatever else you call it.

At my (academic) institution, QA is a big deal. There's a computer database in which anyone can enter a case. It's supposed to be anonymous, but 80% of the time it's entered by the docs who come on shift after you. There's a faculty committee who reviews these cases, and a selection is presented at a monthly 2 hour conference. The conference is pretty good, but usually devolves into Monday morning quarterbacking.

We are actively encouraged to enter cases into the database by the committee (you are lightly reprimanded if you don't), so there ends up being 30-50 cases a month. Many of these cases are ticky-tack or personal variations in practice or just unavoidable.

It may be just me, but this has created somewhat of a culture of fear of getting submitted to QA. If a committee member is coming on shift after you, you have a very good chance of getting submitted. (To nobody's surprise, the committee members themselves rarely have QA cases.)

I have no problem with QA/M&M. It's very important that we recognize our errors and correct them. But with the system we have, I feel as if we're constantly encouraged to rat out our colleagues. On shift, you always hear grumblings about QA. Somebody's always complaining about a case of theirs that got put in. The department (at least those involved) takes a lot of pride in the QA process, and I feel like there's political pressure not to speak poorly of it. (Thus the anonymous online post.)

Or maybe I'm just weak. Is this a common system other people are using? Do I just need to man up and get over it? Is there better ways to do this?

 

[future_dr_house]

This is how my current program does it. I'm actually wondering if we're at the same program. If so I don't think they will truly reconsider the entire QA process. As you said, it's a source of pride among the QA faculty who make up most of the leadership. To speak against it is kind of like heresy.

I'm actually a semi fan. It beats the hell out of m&m I saw ob away rotations in 4th year. Those weren't just Monday morning qb-ing. They seemed out for blood.

 

[Arcan57]

We had M&M which were cases that were (mostly) automatic triggers. Return admits within 72 hrs, deaths in the department, and deaths within 24 hrs of admission. Occassionally we would have a case referred to us by the in-patient side although this was much rarer. We'd have 15-30 cases a month, and most of the "came in dead, stayed dead" cases were mentioned just in passing. If the return admit was one of the predictable ones, it too would be glossed over.

I imagine your current system makes sign-out somewhat tricky and contentious.

 

[southerndoc]

We have set trigger points (return visits, admissions, deaths or rapid responses within 24 hours of admission, etc.), but also get referrals from ED docs, nurses (ED, ICU, floor), and consultants.

Our goal is not to be punitive although the hospital does track reviewed cases with inappropriate care being assigned numerical ratings based on severity (most JC-accredited hospitals use this scoring system).

QA should never be punitive. It's an educational opportunity.

 

[bonez318ti]

My institution runs a set of monthly reports (for indications similar to those listed above) to screen for cases, cases are distributed to resident teams who will go through the cases. We meet monthly to discuss these cases and interesting/controversial cases are flagged for M&Ms. Ive probably learn more during one of these sessions than i do in a shift (maybe up to a week of shifts), interns don't seem to be a fan of them (seeing it as more work) - i hope as they learn more they will realize this is a great way to increase exposure to more difficult cases.

 

[Old_Mil]

Curious how others do QA, M&M, whatever else you call it.

At my (academic) institution, QA is a big deal. There's a computer database in which anyone can enter a case. It's supposed to be anonymous, but 80% of the time it's entered by the docs who come on shift after you. There's a faculty committee who reviews these cases, and a selection is presented at a monthly 2 hour conference. The conference is pretty good, but usually devolves into Monday morning quarterbacking.

We are actively encouraged to enter cases into the database by the committee (you are lightly reprimanded if you don't), so there ends up being 30-50 cases a month. Many of these cases are ticky-tack or personal variations in practice or just unavoidable

If most of your QA cases are ticky-tack and personal variations then the process isn't working as it is meant to work. Some Monday morning quarterbacking is unavoidable, so long as it doesn't devolve into aim and blame. Set triggers for qa would be better (adverse outcomes, bounce backs, and so on) but the odds of getting anything changed in an academic practice where the people running qa are in charge is a little less than zero.

Remember that however it is run, qa is better than an a letter from an attorney and defensive medicine is appropriate palliative care for both.

 

[throwitaway]

Remember that however it is run, qa is better than an a letter from an attorney and defensive medicine is appropriate palliative care for both.

Funny you say that. Because we're in a state with tort reform, I feel people tend to practice defensively against QA as opposed to malpractice. I absolutely change my management depending what attending is coming on shift, especially if it's a QA committee member.

 

[bonez318ti]

by the way.. practice variability seems like a poor reason for QA (maybe better suited as a topic for journal club?).

is the reason the QA committee flag these cases so they would have something to review? It seems the most objective way to flag case would be to let the computer do it via reports/paremeters, unless there was a really complicated case that someone was aware of with a bad outcome and confusing/controvertial management (aka. a **** show) which requires further evaluation (should be rare, 1-2/month tops)

 

[throwitaway]

by the way.. practice variability seems like a poor reason for QA (maybe better suited as a topic for journal club?).

To clarify, "practice variability" isn't formally a reason to submit to QA -- this is just my personal perception of some of the cases that get submitted.

 

[Zanegray]

I don't know how M&M is done for the faculty, but in my residency it was done separately. 3rd year residents each gave an M&M "lecture" during grand rounds (1hour). Usually you picked 3-4 cases where an error occurred and just talked about it. I found usually in these cases the residents were hardest on themselves - often faculty present would make you feel better about what happened. I also liked it as a resident because it made me feel like - wow, other people make mistakes too and I'm not the only person who has done something that caused (or had potential to cause) harm. It also feels less punitive to select your own cases. Occasionally we got "tick tacky" cases as someone said above, but mostly there was really good stuff that all of us could learn from.