Like anyone in healthcare, emergency physician Dr. Mark Wahba has seen things go wrong that shouldn't have.
However, it wasn't until his father was dying, that he truly realized the importance of patient safety and quality improvement.
"I'm ashamed to admit it," says Wahba. "But that was the moment that I realized we could be doing a much better job of things."
Since then, Wahba has been a champion for quality improvement. When he was approached to take on the task of re-examining Mortality and Morbidity (M&M) rounds for Saskatoon Health Region, he jumped at the chance.
Dr. Mark Wahba
Typically, Mortality and Morbidity rounds are used as a discussion format for physicians to present and discuss the circumstances and outcomes of unexpected adverse events or deaths that occurred in-hospital.
"Morbidity and Mortality rounds have been a part of the medical and physician culture for many years," explains Wahba. "Traditionally this has been a 'blame and shame' experience and environment with very little concrete and sustainable change arising from the rounds. I think people currently go into M&M rounds now expecting confrontation."
Wahba is aiming to change that mindset with the eight core principles he developed to guide the structure of the rounds. He also changed the name of the M&M rounds to Clinical Quality Improvement rounds.
"The name change itself isn't the important thing," says Wahba. "The important thing is a new mindset and approach." Wahba developed the principles with a theme in mind; what can healthcare professionals do better next time to prevent an adverse event or unexpected death from happening to someone else? "Ideally we'd like people to walk into these rounds thinking 'Let's see what systems were at play when things went wrong and hopefully we can think of some ways to improve.'"
The main difference between traditional M&M rounds and Clinical Quality Improvement Rounds is the outcome. "In M&M rounds there is little, if any, process and/or structure change to prevent the same incident from happening again," explains Wahba. "In Clinical Quality Improvement rounds, improvement ideas generated from front line staff are suggested to department leaders and/or the Saskatoon Health Region Quality of Care Committee to implement definitive change and help prevent a similar adverse event from happening again."
Wahba based a lot of his Clinical Quality Improvement rounds work on the Ottawa OM3 (Ottawa Morbidity and Mortality Model) model of M&M rounds.
"I was introduced to the Ottawa OM3 model by Dr. Brie Alport from Radiology," he says. "We then brought Dr. Lisa Calder from Ottawa to share the OM3 model with Saskatoon Health Region physicians in November 2015. The CQI rounds are adapted from and based heavily on the OM3 model."
Wahba also worked with ICU Manager Betty Wolfe on the role of the facilitator and Samantha Mitchell from the Quality Improvement Office helped keep the process running and developed the package of information on the CQI rounds.
Of the eight core principles that Wahba has developed, the principle of a "just culture" is the one that may be the most challenging to implement. "I think the first thing about a just culture is getting people to know what it is," says Wahba. A just culture recognizes that competent professionals are only human and mistakes can be made but has zero tolerance for reckless or dangerous behaviour.
"A just culture of safety allows an organization to support healthcare providers to report adverse events without fear of reprimand or punishment," explains Wahba. "Instead, they are praised for drawing attention to unsafe conditions. Here in the Region, we're getting there with the establishment of the Safety Alert System phone line."
Wahba says that there are some places within the Region where good processes for quality improvement already exist and that it's important that everyone understands that these principles aren't meant to replace those processes.
"Some departments have effective M&M processes already in place. Anesthesia is an example thanks to the great work of the late Dr. Neil Cowie. Paediatrics also has a robust process," he says. "Other departments are building their M&M process or trying to improve what they are currently doing. Hopefully this gives them a structure from which to start."
Wahba hopes that his work will help further develop the Region's safety and quality improvement structure to help support system wide improvements and break down barriers between departments. "In order for the Clinical Quality Improvement structure to be successful frontline physicians and staff must see change and improvement coming out of the rounds so that they will stay engaged."
The Eight Core Principles for Clinical Quality Improvement Rounds
- Legality: facts discovered during the review are shareable through the disclosure process; opinions discussed during the review process are legally protected (Evidence Act, section 10) and won't be disclosed
- Privacy: protecting the privacy of patients and families is paramount so rounds much be strictly confidential
- Just culture: a just culture recognizes that competent professionals can make mistakes but has zero tolerance for reckless behaviour
- Interprofessional teams: all team members are invited and welcome to be part of the presentation, discussion and future planning
- Presented by attending staff involved in case: attending staff are expected to model leadership
- Case selection based on three criteria
- Adverse outcome (death, disability, harm, injury)
- Lessons to be learned about system or cognitive issues
- "Bottom lines": concrete suggestions for system improvement
- Structured follow-up: suggestions for improvement are presented to the Region's Quality of Care Committee for implementation