Rethinking the Modern Cardiology Morbidity and Mortality Conference: Harmonizing Quality Improvement and Education

[...]a shift from blame directed at individuals to that of systems-level problems occurred (5). Committee members may then refer cardiology-specific cases to the Chief Cardiology Fellow for consideration in the M&M. Examples of automatic trigger systems include computerized adverse drug event surveillance (e.g., administration of naloxone), specific laboratory values (abnormal potassium or coagulation parameters), death or intensive care unit transfer within 24 h of hospital presentation, or unexpected death following a procedure, to name a few (13,14). [...]we found that commonly encountered conditions provide better educational value than uncommon diagnoses.A FIT-run, faculty-sponsored conference We deidentify M&M cases and aim to have a pragmatic impartial presenter. Select diverse cases Discuss 2 to 3 cases over 60 min Present a conference that is fellow-led and faculty-sponsored Poll audience to enhance participation Employ cause-and-effect diagrams for system improvement efforts Review guidelines to enhance provider education Involve cross-departmental input if needed Conclude with action items to improve the quality and value of care provided Table 1 Components of a Pragmatic M&M Conference Case Systems Issue Identified Process Improvements Implemented Death following a diagnostic angiography