• Darlene B Tad-Y, Read G Pierce, Jonathan M Pell, Lindsie Stephan, Patrick P Kneeland, and Heidi L Wald.
• D.B. Tad-y is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. R.G. Pierce is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. J.M. Pell is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. L. Stephan is clinical data analyst, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. P.P. Kneeland is assistant professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado. H.L. Wald is associate professor, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
• Acad Med. 2016 Sep 1; 91 (9): 1239-43.

ProblemThe morbidity and mortality (M&M) conference is a vital event that can affect medical education, quality improvement, and peer review in academic departments. Historically, M&M conferences have emphasized cases that highlight diagnostic uncertainty or complex management conundrums. In this report, the authors describe the development, pilot, and refinement of a systems-based M&M conference model that combines the educational and clinical missions of improving quality and patient safety in the University of Colorado Department of Medicine.ApproachIn 2011, a focused taskforce completed a literature review that informed the development of a framework for the redesigned systems-based M&M conference. The new model included a restructured monthly conference, longitudinal curriculum for residents, and formal channels for interaction with clinical effectiveness departments. Each conference features an in-depth discussion of an adverse event using specific quality improvement tools. Areas for improvement and suggested action items are identified during the conference and delegated to the relevant clinical departments.OutcomesThe new process has enabled the review of 27 adverse events over two years. Sixty-three action items were identified, and 33 were pursued. An average of 50 to 60 individuals participate in each conference, including interprofessional and interdisciplinary colleagues. Resident and faculty feedback regarding the new format has been positive, and other departments are starting to adopt this model.Next StepsA more robust process for identifying and selecting cases to discuss is needed, as is a stable, sufficient mechanism to manage the improvement initiatives that come out of each conference.

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