Thursday, July 2, 2015

Critical Care Morbidity and Mortality Conferences: Improving Educational Quality by Examining the Effect of Written Case Structure on Physician Comprehension

Sarah Norris, MD, MEd
Cincinnati Children's Hospital Medical Center

Purpose: The Morbidity and Mortality Conference (M&M) is a required forum to discuss medical error and adverse events in the Pediatric Intensive Care Unit (PICU) at Cincinnati Children's Hospital Medical Center (CCHMC). The structure and format of such conferences vary depending on the academic programs, but the design of the M&M at CCHMC is to discuss selected cases based on educational interest or potential teaching value. In an effort to investigate and improve educational quality of the M&M, we decided to examine how physician case comprehension is affected by the structure of the written case.

Method: An on-line survey was developed to assess current practice and needs assessment of CCHMC M&M. Then semi-structured cognitive interviews were conducted in two phases, before (Phase 1) and after (Phase 2) written case structure was altered via the introduction of a case-writing guide and electronic template. This study used a mixed methods design with both quantitative and qualitative approaches. We obtained quantitative data through an online survey that assessed current practice and identified deficiencies. Qualitative data was collected from the open-ended questions within the survey and from the interview transcripts. Quantitative data was analyzed using descriptive statistics (e.g., frequency counts, and percentages). Qualitative data was thematically analyzed using a grounded theory approach.
Results: Fifteen physicians participated in the on-line survey (75%). The majority of respondents favored the use of a standard question template to guide case writing and the use of a standard presentation format. Additionally respondents ranked improving patient safety as the number one perceived priority of M&M. Twelve physicians (60%) participated in both phases of the semi-structured cognitive interviews. The themes identified using an unstructured written case included: incomplete information, frustration, and lack of confidence. When interviews were analyzed after a case had been structured using a case-writing guide and electronic template, the themes revealed were considerably different including: satisfaction, inductive reasoning, and reflection. Participant consensus and confidence were deemed poor in Phase 1 and significantly higher in Phase 2.
Conclusions: Adding structure, through the use of a case writing guide and an electronic template, to a written case significantly improves physician comprehension. This resulted in an increased demonstration of shared understanding and allowed for thorough case analysis. Cognitive aids such as a case-writing guide and electronic template improve the educational quality of M&M by increasing consensus of responses and confidence amongst pediatric critical care physicians.