WS41 - 01: FROM EARTH TO MARS AND BACK: QI TOOL FOR M&M CONFERENCE
Vihas Patel, MD, FACS, Anthony Antonacci, MD, SM, FACS, Jeffrey Nicastro, MD, FACS; LIJMC-Northwell Health

Topic Area, Background:  The 2017 ACGME mandated common program requirements, enumerated in Section VI.A.1.a), are replete with references to “must” haves for quality and patient safety issues.  Of the new program requirements, many deal specifically with including residents in a “safety culture.”  Historically, surgical training programs conduct the morbidity and mortality (M&M) conference for its importance as a quality improvement educational activity.  However, the M&M conference has traditionally provided more a venue to assess quality of clinical care and less feedback to the participant on the accuracy of their assessment of the root of perceived error, opportunities for improvement of the system and trends of quality over time.

Program Description , Objectives:  This past academic year we introduced the Morbidity Mortality Adverse Event Reporting System (MARS), a novel relational database that creates a standardized, algorithm-based methodology for reporting unexpected/undesired outcomes.  MARS incorporates not only the traditional components of clinical case review but also allows the trainee to assign cause of error and automatically query scientific literature to facilitate the moderated discussion among faculty.  Additionally, it allows a senior moderator to “grade” the trainee’s evaluation and provide realtime formative feedback directly related to practice-based learning and improvement and systems-based practice (see attached figure).

Evaluation, Key Findings:  This methodology can readily be used to standardize this QI educational activity as a logical approach to self-assessment in the context of residency training and accrue data on trends over time.  The purpose of the workshop is to demonstrate MARS as both a QI and educational tool as well as a prospective database that can be easily interrogated for research purposes.

We will focus on the Resident Evaluation portion of the system to encourage workshop participants to explore components of the formative feedback process that should be emphasized.  For example, over twenty types of cognitive bias have been identified.  We believe MARS can help to identify common types of bias (aggregate, anchoring, ascertainment, commission, confirmation, omission, overconfidence, premature closure, etc.) in adverse event reporting and improve our trainees’ performance with contemporary evaluation.