Tobias Wasser, MD


An elderly man with bipolar disorder and a complicated medical history is admitted to inpatient psychiatry in the context of an acute manic episode. He is transferred to medicine for hypotension and rapid atrial fibrillation. He unexpectedly stays on the medical floor for several days for medication titration. On transfer back to the inpatient psychiatric unit, psychiatric nursing discovers he has significant hypotension, and immediately calls a rapid response.


A middle-aged man with chronic pancreatitis, diabetes, and polysubstance dependence (alcohol, opioids, and other substances) presents to the pain team for an opioid prescription. Given the patient’s significant improvement in function on opioids, but history of aberrant use, he receives weekly refills from his addiction psychiatrist. Although suboptimal, no adequate supervised housing was available following a recent inpatient admission. He presented to the outpatient office appearing sweaty, anxious, and admitting to alcohol relapse. He was walked to the emergency department, where he was found to be in diabetic ketoacidosis (DKA).

For decades, medical specialties such as internal medicine and surgery have engaged in morbidity and mortality (M&M) conferences-but very few in psychiatry. Only a handful of academic institutions have incorporated some type of M&M-like experience. In 2009, Goldman et al

 found only 9 reports in the literature over the past 40 years of psychiatric M&M endeavors. Numerous potential explanations include the "blaming" culture sometimes associated with these forums, the relative rarity of mortality as a result of psychiatric illness, and the difficulty in clearly defining other adverse outcomes in mental health.

Regulatory bodies that oversee hospitals and graduate medical education have begun to place an ever growing importance on patient safety (PS) and quality improvement (QI), from which psychiatry is not immune.

 This movement has focused on improving PS by decreasing the number of “medical errors” and on using QI to improve clinical care through assessment and systems-level changes at health care institutions.

 The Accreditation Council for Graduate Medical Education (ACGME) has identified this as integral to residency education, including the assessment of proficiency in QI and PS. In the Psychiatry Milestone Project, recently implemented by the ACGME, residency training directors are asked to assess resident proficiency and advancement during training in these areas.

Additionally, the ACGME has created the Clinical Learning Environment Review (CLER) to ensure that hospitals engage residents in QI and PS improvement measures.

 Involving residents in this process is educational and pragmatic, because they can be keenly aware of factors that adversely impact clinical decision-making, such as poor communication, culture of blame, lack of supervision, inexperience, excessive workload, and duty hours.

 Some residency programs have started to implement QI curricula that utilize experiential learning as a key component of resident education.

 A select few programs have even encouraged trainees to take on leadership roles in the development of QI initiatives.

One opportunity to use QI is via systematic and structured reflection on the quality of clinical care. Ideally, M&M conferences provide timely and structured peer review, prompt reporting, analysis of adverse events, and education on the latest evidence-based practice.

 Factors that lead to an adverse outcome are analyzed with the promise of implementing specific changes to address those causal factors. Numerous factors, however, may impede implementation. These include non-standardized presentations, inadequate discussion time, degeneration into a lecture, or a perception that great ideas are “dismissed at the door” on the way out of M&Ms.

 Despite these concerns, there is evidence that M&Ms focused on patient safety can positively influence the culture of large health care organizations.

Perhaps the most salient impediment to successful conferences is their association with a culture of blame, bullying, and disrespect. Unfortunately, these still permeate much of the medical field.

 described this dysfunctional culture as “a substantial barrier to progress in patient safety,” inhibiting collegiality and cooperation, decreasing communication, undermining morale, and hindering compliance with and implementation of new practices. Unfortunately, this attitude continues, despite almost 30 years of evidence that improved communication and open discussion of errors lead to improved patient care.

A change in culture will require adjusting expectations to understand that medical errors are not an anomaly. Instead, they are an inevitable result of imperfect humans performing clinical duties, even when operating to the best of their abilities. Shifting focus from blaming individuals to considering instead the system-level factors that lead to errors can enable the identification of targets for improvement in care.

 described a system-centered approach as opposed to a person-centered approach in which individuals are blamed. This model operates on the premise that “humans are fallible and errors are to be expected, even in the best organizations.” Errors are seen as consequences, rather than causes, and have their origins in “upstream” systemic factors. After an adverse event, countermeasures aim to change the environment, not the individual.

 expanded on Reason’s model, describing a broad framework for “systems analysis” in health care settings-the investigation and analysis of a clinical incident in which potential contributors to outcome are identified, an approach founded on root cause analysis (RCA), a systematic process for identifying “root causes” of problems or events.

Initiation of a psychiatry M&M conference series


With these factors in mind, the Mental Health Systems Improvement Series (MHSIS)-a resident-led M&M-style conference series for the mental health service line at VA Connecticut in West Haven, Connecticut-was established to create a safe, interdisciplinary forum for the structured discussion of unfavorable outcomes and near-misses. The focus of the conference was to assess the need for factors such as revision of policy, reallocation of resources, or additional training of staff, that might enhance timely and optimum care. Also central to these forums is an interdisciplinary discussion with representation from all “shareholders”-persons with a stake in institutional changes.

MHSIS established core learning objectives for participants who presented their cases:

• discuss freely their errors and communicate with colleagues in an atmosphere of mutual respect
• recognize systemic influences on adverse outcomes
• gain insight into the needs, strengths, and vulnerabilities of other disciplines and specialties
• acquire a sense of agency to improve systemic coordination of care

The MHSIS is currently organized and lead by the authors of this paper, with support from the associate chief of psychiatry for the institution. The MHSIS is convened during the time of an existing protected hour for the staff psychiatrists at the VA Connecticut Health Care Services (VACHS). Sessions are one hour long and occur once every 2 months. We begin with a brief primer on the goals and structure of the gathering. Individual-level blaming is strongly discouraged and expressly identified as not being the goal of the forum. Alternate avenues exist within the system to identify and support practitioners in decreasing their own true medical errors. The concept of an RCA is explained and the group is asked to listen for potential contributors to the adverse outcome they are about to hear, utilizing the 6 subheadings of potential etiologies (

The presenting physician then gives a brief recap of a case in which an adverse event or a near miss has occurred. Attendees are encouraged to listen for contributing factors that could fall under any of the categories identified in 

. They are encouraged to document these thoughts on a fishbone diagram (

) and then use this analysis to participate in an informed discussion.

Participants then raise questions and suggestions for contributing factors to the adverse event. Conference leaders work with the group to use these contributing factors to fill in a large fishbone diagram displayed in the front of the room. The final portion of MHSIS is to brainstorm and collaborate. The end result is the discovery of concrete proposals for systems-level improvements that address the issues identified in the analysis. We utilize the multidisciplinary nature of the session to try, when possible, to agree to these changes in the room and thus, in real time, have the potential to impact institutional policy.

At the time of publication, two MHSIS forums have been convened with an additional third MHSIS scheduled. 

 details these first two cases, as well as prominent discussion points and outcomes. 

 are examples of completed fishbone diagrams from these sessions.


Hospitalized for an acute manic episode, the patient in 

 (above) transferred from inpatient psychiatry to inpatient medicine and then back to inpatient psychiatry. He was clinically stable but hypotensive and, upon return transfer to the inpatient psychiatric unit, the admitting nurse called a rapid response. Although the patient was never in true medical danger and an extensive existing safety net ensured this, it was determined through M&M conference analysis that a better handoff would have obviated the need for rapid response. Future handoffs would include alerting consult-liaison psychiatry during all transfers to and from medicine. Also, all parties agreed that intern-to-intern handoff should be a part of the transfer process. These policy changes were agreed upon in the room and, after brief review outside of the meeting, put immediately into effect.

 (above), the patient had polysubstance dependence, chronic pancreatitis, and diabetes. As a result, he was involved with multiple providers throughout the hospital system. He was discharged without sufficient supportive housing and subsequently presented to his outpatient provider’s office inebriated and in DKA. MHSIS conference review determined that the outpatient plan had inadequate case coordination to meet the needs of the patient for medication supervision and sobriety support. A collaborative approach with support from a dedicated case manager, consisting of inpatient and outpatient teams-pain management, psychiatry, and medicine, among others-would have improved patient outcome. A breathalyzer for the outpatient pain team was identified as useful and was obtained for the clinic shortly after the meeting. The pain management teams considered educating the hospital about resources on pain within the hospital.

The MHSIS was designed as a novel M&M-like conference series in which adverse events and nears misses are presented voluntarily by staff, systematic analysis of the event is conducted via RCA, and sessions culminate in proposals for interventions to address identified system vulnerabilities. In short, the MHSIS enables us to clarify what decisions lead to favorable and less favorable outcomes. The discourse has been collegial, respectful, and pragmatic. In all cases thus far, the safety net that already existed within the system had been able to prevent a true adverse outcome. We hope providers are encouraged to discuss undesired outcomes openly and honestly long before a true adverse outcome need occur.

 Our associate chief of psychiatry provided the resources (time and space) and encouraged faculty participation. This was essential to avoid the perception that great ideas were being “dismissed at the door,” a criticism of other M&M activities.

Interdisciplinary discourse and the inclusion of key players from multiple disciplines and services.

 These components helped minimize the temptation to assign blame to others and ensured that recommendations for change were in fact possible to implement across the system.

Framing the purpose as collegial seemed to be effective. Although participants’ perception of a change in the culture at our institution was not formally assessed, feedback we have received suggests a positive impact. We plan to assess this formally in future sessions.

To our knowledge, this is one of the first resident-led initiatives to implement an M&M-like conference series in an interdisciplinary mental health department that involved both trainees and faculty. Recognizing the importance of experiential learning in QI, a growing number of training programs have begun to implement experiential QI projects into the residency curriculum.

 Forums such as the MHSIS provide a unique and novel opportunity to gain experience in the practice of QI, while also taking on administrative and leadership roles in an interdisciplinary health care setting.

Institutions may benefit from the inclusion of trainees in the QI process; residents have first-hand knowledge and experience on the front lines of health care delivery. Further, engagement in this work could assist academic institutions in complying with the CLER requirements and help residents meet specific systems based practice and practice based learning milestones as part of the ACGME Psychiatry Milestone Project.

Although we are optimistic about the results thus far, clearly there are limitations. We have not yet administered a formal assessment of whether our intervention achieved its stated goals and objectives. Another limitation is the authors’ lack of significant experience or training in QI and RCA. Although we have highlighted numerous potential advantages to the resident-led aspect of this intervention, and were closely supervised by a faculty mentor with experience in these areas (associate chief of psychiatry), it is certainly possible that this intervention would have been more efficiently and effectively run by more seasoned leaders.

Finally, it would likely be beneficial to increase the frequency of meetings, as this may have obviated significant time spent re-orienting participants to the purpose and nature of the meeting. Increasing the frequency could increase the chances of achieving our stated objectives but would have to be balanced with the desire to not overburden participants.


For those considering implementing similar QI initiatives, we offer a number of suggestions:

• successful implementation requires significant administrative support and follow-up on generated suggestions for protocol adjustment
• faculty within the institution must be willing to discuss their own clinical cases in a public forum
• make the experience gratifying and safe for presenters. Otherwise, enthusiasm may quickly dissipate
• the ability to be interdisciplinary and to invite all key players involved in a particular case decreases the chances of assigning blame to absent parties
• focus on systems of care and examine which systems-related factors will allow practitioners to provide the best care possible for their patients in the future

The authors would like to thank Louis Trevisan, MD, for his enthusiastic mentorship and support in the development of this project.

Drs Wasser and Grunschel are residents (PGY-4) at 

Yale University School of Medicine, Department of Psychiatry, in New Haven, Connecticut. The authors report no conflicts of interest concerning the subject matter of this article.

1. Goldman S, Demaso DR, Kemler B. Psychiatry morbidity and mortality rounds: implementation and impact. 

 2009;33:383–388.
2. Glover GR. The audit of mental health services. quality assurance in health care. 1990;2:181-188.
3. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the veterans affairs health care system on the quality of care. 

 2003;348:2218-2227.
4. Woolf SH. Patient safety is not enough: targeting quality improvements to optimize the health of the population. 

 2004;140:33-36.
5. Sanders K, Servis M, Boland R. The four general competencies. 

 2014;38:268-274.
6. Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy-and occasionally hazardous-intersection. 

 2006;145:592-598.
7. Volpp KG, Grande D. Residents’ Suggestions for reducing errors in teaching hospitals. 

 2003;348:851-855.
8. Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. 

 2005;165:2607-2613.
9. Arbuckle MR, Weinberg M, Cabaniss DL, et al. Training psychiatry residents in quality improvement: an integrated, year-long curriculum. 

 2013;37:42-45.
10. Reardon CL, Ogrinc G, Walaszek A. A didactic and experiential quality improvement curriculum for psychiatry residents. 

 2011;3:562–565.
11. Patel M, Hardy DW, Ravi Chand R. Peer review for residents. 

 2005;29:490-494.
12. Dickey C, Dismukes R, Topor D. Creating opportunities for organizational leadership (COOL): creating a culture and curriculum that fosters psychiatric leadership development and quality improvement. 

 2014;38:383-387.
13. Benzer JK, Bauer MS, Charns MP, et al. Resident/faculty collaboration for systems-based quality improvement. 

 2013;37:433-435.
14. Orlander JD, Fincke BG. Morbidity and mortality conference: a survey of academic internal medicine departments. 

 2003;18:656-658.
15. Gordon LA. Can Cedars-Sinai’s “M M matrix” save surgical education? 

 2004;89:16-20.
16. Biddle C, TR O. Investigating the nature of the morbidity and mortality conference. 

 1990;65:420.
17. Szekendi MK, Barnard C, Creamer J, Noskin GA. Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. 

 2010;36:3-9.
18. Yurkiewicz I. Medical disrespect. 

http://aeon.co/magazine/being-human/why-rude-doctors-make-bad-doctors

. Accessed July 16, 2014.
19. Leape LL, Shore MF, Dienstag JL, et al. A culture of respect, part 2: creating a culture of respect. 

 2012;87:853-858.
20. Knaus WM, Draper EA, Douglas PW, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. 

 1986;104:410-418.
21. Chassin MR, Becher EC. The wrong patient. 

 2002;136:826-833.
22. Reason J. Human error: models and management. 

 2000;320:768-770.
23. Vincent C. Understanding and responding to adverse events. 

Articles

Regulatory bodies that oversee hospitals and graduate medical education have begun to place an ever growing importance on patient safety and quality improvement, from which psychiatry is not immune. More in this case study.

A Novel Approach to Morbidity and Mortality Analysis in Psychiatry Residency

[[{"type":"media","view_mode":"media_crop","fid":"15926","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7726486098555","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"866","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]I am a third year resident in adult psychiatry at 

. I have lived in Connecticut for most of my life, so remaining here for my psychiatry residency has been a very enjoyable and comfortable experience. I attended Wesleyan University in Middletown, Connecticut, as an undergraduate to study psychology and then went on to the University of Connecticut School of Medicine.

As a PGY-2 resident at Yale, I served as a co-president of the Psychiatry Residents Association (PRA), a group made up of all of our psychiatry residents. In this role, I acted as an advocate for my fellow residents and liaison between the residents and administration. I was recently chosen to be one of the 2 program-wide chief residents for our residency in my PGY-4 year and hope to continue to advocate for my fellow residents in this role.

I was originally looking to move to New York for residency after spending most of my life here in Connecticut for college and medical school. Yale was my final residency interview and I thought my rank list was all set with the New York programs. Then I came for my interview here and I loved it, so I had to do some rearranging.

I chose Yale because I felt it was the best balance of everything I was looking for in a residency. I wanted a program with a multitude of training sites to ensure a diversity of patients and patient care experiences. We train at the Connecticut Mental Health Center (CMHC), Yale-New Haven Psychiatric Hospital, the West Haven Veterans Administration, and Yale University Health Services. I also wanted a program that had an association with a psychoanalytic institute to strengthen and balance my psychotherapeutic training (many of our psychodynamic instructors come from the Western New England Psychoanalytic Institute, where residents can take elective courses). Lastly, I was interested in learning more about forensic psychiatry, so I wanted a program with a forensics fellowship, which we have here.

In our third year of training, our work is entirely outpatient with overnight calls taking place every 10 to 12 days in the psychiatric emergency department. For outpatient training, we can request to be placed at either the West Haven VA (which sees veterans with a wide variety of ages, races, and diagnoses); Yale University Health Services (which treats Yale undergraduates with psychotherapy and psychopharmacology); or CMHC (serving the indigent and chronically mentally ill of New Haven).

Because of my interest in treating chronic mental disorders, I chose to work at CMHC, which runs outreach programs for persons at serious risk for mental illness or involved in the criminal justice system. I have my own office and see patients individually for psychotherapy and medication management. I spend 80% of my time working with patients; attending weekly didactics; and meeting with supervisors (we are assigned individual supervisors for psychodynamic therapy, CBT, brief therapy, and medication management). The other 20% of our time is made available for electives, such as research, clinical, or academic courses.

A typical day for me involves getting up at around 6 in the morning to go to the gym before work. I don’t like waking up that early, but I feel good starting my day knowing I have already gotten something accomplished. I arrive at work at around 8:30 AM and spend the rest of my day involved in a variety of activities. A large percentage of my day is spent seeing patients for psychotherapy, medication management, or a combination of the two. I also meet with my supervisors to discuss individual cases. I usually get done between 5 and 6 PM and head home for the day.

What I really enjoy about the third year is autonomy in molding my own schedule. I decide when I see patients, for how long and how often. It really gives me the opportunity to craft a patient’s treatment with them. The other great aspect of creating your own schedule is that you can build in time for additional interests (thanks to the 20% elective time our program guarantees in your schedule). Right now I devote one morning a week either to work on my forensic research project or to gain clinical experience working in the court clinic. There I learn how to do competency to stand trial evaluations. I also have carved out an afternoon a week free from patient care responsibilities so that I can take classes with the forensic psychiatry fellows.

One lesson I have learned from my time working in the outpatient clinic is not to underestimate the positive impact we can have in the lives of our patients. This really came to light for me, as represented in the following vignette. (Certain descriptions and scenarios have been changed to protect patient confidentiality).


A depressed and socially withdrawn female patient I worked with, who inconsistently attended her appointments, called one day after missing her appointment the week before. She said that she felt depressed and was having thoughts of hurting herself, but felt that she could remain safe, and we rescheduled her appointment for the next day. When she again failed to show up and did not respond to numerous phone calls, I became concerned and arranged for a mobile crisis visit to check on her at home.

My first priority was of course to ensure the patient’s safety. I also wondered, assuming she was safe, what we would find and how she would respond to this intervention. Given her propensity to isolate, I worried she would be upset about this intrusion into her private life. Fortunately, when we arrived, she greeted us at the door looking somewhat sleepy and in her pajamas, but otherwise appeared her usual self. She said she was feeling better and no longer had thoughts to harm herself. She apologized for missing our appointment, stating she had overslept, and we agreed to reschedule for the following day.

The next day I waited anxiously to see if she would come and, if so, what she would say about our previous encounters. My thoughts vacillated between expecting her either to be angry or self-conscious about my having seen her in a vulnerable state. She did come to our appointment and, to my surprise, was extremely grateful. She said that having a doctor who cared enough about her to come to her home and check to make sure she was safe, at a time she was feeling particularly sad and alone, had made her feel like she “mattered.” She said that she was no longer feeling so depressed and in our work together we were able to explore further her reaction to this event.

As I reflect on my time working with her, I continue to be struck by how differently we experienced this interaction. To me, the actions I had taken were part of my “job” as her psychiatrist to ensure her safety and an effort to alleviate my own anxiety about her disappearance. To her, this had been evidence that she had value and had a significant positive influence on the way she viewed herself and our relationship. As a trainee, this was an important lesson for me-that our work in the field of psychiatry can often positively affect our patients in ways we may not anticipate or fully understand.


I have loved my time working and living here in New Haven and wouldn’t trade it for anything. It is a wonderful small city with plenty of restaurants, culture, and exceptional events associated with Yale University.

I would also say that as far as Residency Program Directors go, you can’t do much better than Dr Robert Rohrbaugh. I have been amazed during my time here; particularly while working with him as PRA co-president. He thoughtfully and carefully listens to the thoughts and concerns of residents and makes adjustments to the program based on their feedback. He puts his residents first and that is a wonderful quality to have in the person running your training program. I look forward to continuing to work closely with him in my role as chief resident in the upcoming year.

[Editor's note: If you are a psychiatry resident and would like to submit a Day in the Life article, please forward it to 

. Your article will be reviewed, and if accepted, it will be published online]

Dr Wasser is a resident at Yale Medical School in the department of psychiatry. Thanks to Yale for granting permission to adapt 

From his time working in the outpatient clinic, this psychiatry resident has learned not to underestimate the positive impact psychiatrists can have in the lives of their patients. 

Tobias Wasser, MD

Articles

A Novel Approach to Morbidity and Mortality Analysis in Psychiatry Residency

A Day in the Life of a Resident: Yale Psychiatry