CHPSO June Newsletter

June 2013

In this issue:

Causal Analysis Learning Series: Conducting a Thorough Investigation and Team Response

CHPSO monthly member call

June 10, 2013 - 10:00am - 11:00am

Register for this event

A thorough investigation and team response are essential first steps for a successful causal analysis. We will identify some of the pitfalls associated with a poor investigation and response to an adverse event and ways to conduct your causal analysis using a consistent approach.

We will be joined by Lisa Ramthun, RN, MSN, CPHRM, Associate VP, Risk Management at St. Joseph’s Health to discuss their process and review tools that may be helpful for you to adopt.

For more information on this learning series, visit analysis.

This call is for members only. Registration is available at (note registration is required). Registrants will receive an email a minimum of 24 hours before the event. Members registering within less than 24 hours of the event should contact CHPSO for participation information at (916) 552-2600.

Five Aspects of Transparency

“Transparency—the free, uninhibited sharing of information—is probably the most important single attribute of a culture of safety. In complex, tightly coupled systems like healthcare, transparency is a precondition to safety. Its absence inhibits learning from mistakes, distorts collegiality and erodes patient trust.” (Leape, et al. 2009)

Each type of transparency has its subject matter and its goals. For each of these, there are specific practices that will maximize the benefit to patients, providers and other stakeholders. The Hospital Quality Institute and CHPSO can assist with identifying and implementing these practices.

Patients: It is a moral imperative to inform patients when they are harmed, even when harm is minor or accidental.

Coworkers: Individuals must be able to report errors without fear of punishment or embarrassment.

Within the organization: Each problem should be seen as having the potential to make the entire organization safer.

Other organizations: Organizations should not let other patients be harmed when they know how to prevent it.

Public: The public spends over two trillion dollars annually on health care and trusts their lives to us—they deserve to know how well we are doing.


Leape, Lucian L., et al. “Transforming healthcare: a safety imperative.” BMJ Quality & Safety, 2009: 424-428.

Leape Report: Through the Eyes of the Workforce

“Workplace safety is inextricably linked to patient safety. Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.”

The Lucian Leape Institute at the National Patient Safety Foundation has released a Report of the Roundtable on Joy and Meaning in Work and Workforce Safety. Through the Eyes of the Workforce: Creating Joy, Meaning and Safer Health Care is a white paper focusing on the emotional and physical harm of which health care workers suffer during the course of providing care and how an organization can work to improve workplace safety and thus improve patient safety.

Through the Eyes of the Workforce helps identify harmful physical and psychological obstacles within a health care worker’s environment and provides strategies in reducing and removing these obstacles. The white paper encourages commitment from the governing board and CEO all the way through the organization. “Knowing that their well-being is a priority enables the workforce to be meaningfully engaged in their work, to be more satisfied, less likely to experience burnout, and to deliver more effective and safer care.”

This 30-page report includes seven recommendations as strategies on what an organization can do to start the process of improving workplace safety and also provides practical tactics and best practices from the field using those same strategies:

  • Strategy 1: Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom through the front lines.
  • Strategy 2: Adopt the explicit aim to eliminate harm to the workforce and to patients.
  • Strategy 3: Commit to creating a high-reliability organization (HRO) and demonstrate the discipline to achieve highly reliable performance. This will require creating a learning and improvement system and adopting evidence-based management skills for reliability.
  • Strategy 4: Create a learning and improvement system.
  • Strategy 5: Establish data capture, database, and performance metrics for accountability and improvement.
  • Strategy 6: Recognize and celebrate the work and accomplishments of the workforce, regularly and with high visibility.
  • Strategy 7: Support industry-wide research to design and conduct studies that will explore issues and conditions in health care that are harming our workforce and our patients.

Download the report at

Morbidity and Mortality Conferences

From QA to QI

by Marc T. Edwards, MD, MBA

In my last column, we took an evidence-based look at the value of multi-specialty clinical peer review committees. Now we’ll examine the role of Morbidity & Mortality (M&M) conferences. In my first national study of peer review practices, we found that 58% of 339 facilities responding included M&M conferences within the scope of peer review.(1) This ranged from 54% among non-teaching facilities to 75% among academic medical centers (previously unpublished data).

The M&M conference serves a dual role as a platform for revealing the learning opportunities in adverse events and as a vehicle for graduate medical education. In hospitals with post-graduate training programs, residents and fellows predominate as both the presenters and the primary audience. At academic medical centers, surgical M&M conferences are held weekly and average 60-90 minutes.(2) Surgical training programs tend to have shorter case presentations (12 minutes) and a greater focus on adverse events than do internal medicine programs (34 minutes).(3)

Several investigators have found that traditional M&M conference methods significantly under-report surgical deaths and complications compared to occurrence screening and National Surgical Quality Improvement Program (NSQUIP) methods.(4, 5, 6) At the patient level, the sensitivity may be as low as 25%. The M&M conference may also under-report issues with procedure appropriateness, pathology discrepancies and diagnostic errors.(5) Other potential limitations of the M&M model have been noted including lack of participation by the involved clinicians, avoidance of the “tough issues”, and the difficulty of creating a non-punitive environment for learning.(7)

Some have developed effective mechanisms for identifying and tracking surgical adverse events, such as mandatory resident reporting, which have been integrated with the M&M process and other peer review activity.(8-10) These models may include a reconciliation of the root cause when the identified adverse event is a symptom (e.g., hypotension as a sign of sepsis, hemorrhage, etc.), classification of preventability, and attribution of causality (to a care-giver, the patient, and/or the system of care). Moreover, there are several reports in which the M&M conference was believed to have made a contribution to improved clinical performance.(11, 12) The time requirement may, however, be substantial. One group reported an average of 2 hours per week, and noted that conferences could go as long as 4 hours.(12) Thus, the M&M conference has potential to make a valuable contribution in support of peer review and quality improvement, but requires appropriate design. The QI Model and the Peer Review Program Self-Evaluation Tool give additional guidance regarding key parameters that should influence M&M program designs to obtain the most effective contribution to peer review and improved clinical performance.

I’d recommend that physician leaders who are redesigning their M&M process ask the following questions:

  • How will the M&M conference fit with the rest of our peer review program?
  • How will we identify, track and monitor adverse events?
  • How will we select cases for presentation and discussion at M&M?
  • How will we create a non-punitive environment that supports self-reporting and the identification of opportunities for improved clinical performance, while maintaining personal accountability?
  • If we can’t accommodate review of at least 1% of our service volume through M&M, what will be the process to manage review of these additional cases?
  • What information will be recorded regarding the findings and conclusions?
  • How will we handle the situation in which an involved clinician is not present?
  • How will we recognize excellent performance?
  • How will we assure that opportunities for improvement are acted upon, whether individual, group or system of care?
Coming Next: Clinical Peer Review in relation to Ongoing Professional Practice Evaluation


  1. Edwards MT, Benjamin EM. The process of peer review in US hospitals. J Clin Outcomes Manage. 2009(Oct);16(10):461-467.
  2. Gore DC. National survey of surgical morbidity and mortality conferences. Am J Surg 2006;191:708-714.
  3. Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA 2003;290(21):2838-2842.
  4. Hutter MM, Rowell KS, Devaney LA, Sokal SM, Warshaw AL, Abbott WM, Hodin RA. Identification of surgical complications and deaths: an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program. J Am Coll Surg. 2006;203(5):618-624.
  5. Thompson JS, Prior MA. Quality assurance and morbidity and mortality conference. J Surg Research. 1992;52(2):97-100.
  6. Orlander JD, Barber TW, Fincke G. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med. 2002;77(10):1001-1006.
  7. Miller DC, Filson CP, Wallner LP, Montie JE, Campbell DA, Wei JT. Comparing performance of morbidity and mortality conference and National Surgical Quality Improvement Program for dection of complications after urologic surgery. Urology. 2006;68(5):931-937.
  8. Antonacci AC, Lam A, Lavarias V, Homel P, Eavey RA. A morbidity and mortality conference-based classification system for adverse events: surgical outcome analysis, part I. J Surg Res. 2008:147(2):172-177.
  9. Healey MA, Shackford SR, Osler TM, Rogers FB, Burns E. Complications in surgical patients. Arch Surg. 2002;137(May):611-618.
  10. Hamby LS, Birkmeyer JD, Birkmeyer C, Alksnitis JA, Ryder L, Dow R. Using prospective outcomes data to improve morbidity and mortality conferences. Curr Surg. 2000;57(4):384-388.
  11. Stanford JR, Swaney-Berhoff L, Recht KE, Orsagh-Yentis DK. Improved cardiac surgical outcomes with use of total quality management. J Clin Outcomes Manage. 2009;16(9):405-409.
  12. Antonacci AC, Lam A, Lavarias V, Homel P, Eavey RA. A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II. J Surg Res. 2009;153(1):95-104.

CHPSO Webinars Now Require Pre-Registration

CHPSO will now require pre-registration for webinars. We plan to offer continuing education (CE) on some of the webinars and this will help us prepare to offer and distribute the CE certificates.  Also, this will help provide participation data for conferring future Vanguard awards.

The registration link will be located on each webinar webpage at Please note that a website member account is a requirement to sign up for member-only webinars.

If you have any questions about registering for a webinar or for a website user account, please contact Andee at or (916) 552-7651.

Webinar Recording Available: Are You Ready?

On May 21, CHPSO invited members and non-members to join Rory Jaffe, MD, MBA, Executive Director of CHPSO, as he helped demystify one of the Affordable Care Act’s (ACA’s) least-understood mandates during a free webinar, “Are You Ready? Demystifying the Affordable Care Act’s PSO Mandate”.

The 43-minute webinar is now available to the public at If you have additional questions or need further assistance, please do not hesitate to contact CHPSO.

CHPSO members may also access the Webinar Archive, which includes members-only webinar recordings and slide presentations.

Upcoming Patient Safety Events

California Hospital Patient Safety Organization

Unless noted, all CHPSO events are for members only, are free and require registration. The registration link will be located on each webinar’s webpage. All times are for the Pacific Time Zone. For more information, contact or call (916) 552-2600.
June 10
10–11 a.m.
Causal Analysis Learning Series: Conducting a Thorough Investigation and Team Response
(CHPSO Monthly Member Call)
July 8
10–11 a.m.
Causal Analysis Learning Series: Identifying Contributing and Root Causes
(CHPSO Monthly Member Call)
July 15
Who’s Behind That Mask in Your OR—Managing Vendors in the Operating Room
(CHPSO / ECRI Webinar)

Hospital Council of Northern and Central California

June 18
11 a.m.–3:30 p.m.
Patient Safety First: Luncheon and Education Program, Fresno Convention Center, 848 M Street, Fresno, CA 93721
June 20
11:30 a.m.–1 p.m.
Improving Patient Care Transitions to Reduce Readmissions—A Multifaceted Approach

Hospital Association of Southern Cal‚Äčifornia

July 16 Southern California Patient Safety First Collaborative meeting, Hyatt Regency, Orange County. Please contact Julia Slininger for more information.

Hospital Association of San Diego and Imperial Counties

For more information visit or contact Alicia Muñoz.

June 3–7 SimSuite Sepsis Simulation Training.
Location: Kindred Hospital
(Reservation-only Event) (Note: FULL)
July 12
HASD&IC Quality and Patient Safety Program
Networking lunch, presentations and workshops. Speakers from Joint Commission TST, Patient Safety First, Hospital Engagement Network and Hospital Quality Institute.
Location: Handlery Hotel

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