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.
Figure 1. Fishbone diagram
Figure 2. Fishbone diagram (Case 1)
Figure 3. Fishbone diagram (Case 2)
Consider the following cases:
CASE VIGNETTE 1
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.
CASE VIGNETTE 2
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 al1 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.2
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.3 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.4 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.5 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.6-8 Some residency programs have started to implement QI curricula that utilize experiential learning as a key component of resident education.9-11 A select few programs have even encouraged trainees to take on leadership roles in the development of QI initiatives.12,13
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.14 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.15,16 Despite these concerns, there is evidence that M&Ms focused on patient safety can positively influence the culture of large health care organizations.17
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.6,18 Leape19 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.20
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.2To understand error etiology, Reason22 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.22 Vincent23 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 (Table 1).
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 Table 1. They are encouraged to document these thoughts on a fishbone diagram (Figure 1) 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. Table 2 details these first two cases, as well as prominent discussion points and outcomes. Figure 2 and Figure 3 are examples of completed fishbone diagrams from these sessions.
Findings from the MHSIS sessions
Hospitalized for an acute manic episode, the patient in Case 1 (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.
In Case 2 (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.
Lessons learnedAdministrative support is key. 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.15,16
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.
Open and respectful discussion. 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.9-13 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.5
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
Acknowledgement: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.
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