Guiding Principles of Morbidity and Mortality (M&M) meetings in action podcast series
To support implementation of the CEC M&M guidelines, the Guiding Principles of Morbidity and Mortality (M&M) meetings in action podcast series was developed to explore the guiding principles of effective M&Ms in action. In implementing the guiding principles, there are often significant challenges in relation to culture and leadership and the podcasts emphasis ways in which teams can work together to enhance their M&Ms as a safe space for learning and improvement.
Each podcast captures an engaging narrative with clinical leaders around their practical experiences and insights from leading M&M meetings. Conversations highlight the significance of psychological safety and explore the importance of effective leadership and facilitation to enable open discussions that engage the diversity of perspectives within a team.
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Season one - Creating safety in M&M discussions
This first series of CEC's M&M podcasts provides insight into the power of effective facilitation to enable psychological safety in M&M meetings.
David Sweeney as the Director for Leadership at HETI reflects on the HETI standards of facilitation and highlights the powerful link between the targeted use of facilitation and the exercise of leadership and Dr Andrea Christoff as a medical Co-director and leader of M&Ms gives practical insights into her experiences of facilitating M&Ms to enhance the diversity of perspectives and enable learning from past experiences of clinicians.
The three-part series explores key themes around facilitation standards, psychological safety and lessons learnt from experience of supporting the leadership in M&Ms.
David Sweeney explores the HETI Facilitation Standards with Dr Andrea Christoff who shares her experiences of how effective facilitation can really support and enhance M&M discussions. Andrea explores her early experiences of M&Ms and the challenges of using a systematic approach to review cases.
The discussion includes the significance of facilitation skills in enabling a diversity of perspectives to understand the complexities of the system in which patient care is delivered. Andrea highlights the importance of establishing functional relationships and a culture of openness and transparency which is nurtured outside the M&M meetings.
David and Andrea explore how facilitation enables psychological safety in M&M meetings. This includes highlighting the importance of relationships and trust and fostering a culture of speaking up for safety within teams. The structure of an M&M is also explored in terms of developing transparency and openness of what will be discussed and ensuring clinicians know what to expect before coming to a meeting.
This includes the engagement of clinicians' feedback and not only ensuring that the right people are in the room but that they are engaged in advance in relation to the meeting agenda and cases to be discussed.
David and Andrea explore key lessons learnt around managing difficult conversations including using reframing and inquiry techniques and to ensure everyone has a voice in the room even if some of the voices are controversial. Key strategies are discussed around managing difficult conversations and emotions that may surface.
This includes the importance of reframing any blaming and establishing shared agreements about how the meeting's going to run, what is acceptable behaviour, and what constitutes being respectful.
Season two - Right material and right people: M&M leadership and case selection
This season of the Guiding Principles of Morbidity and Mortality (M&M) meetings in action podcast series provides insight into the importance of effective leadership to enable psychological safety in M&M meetings.
Dr Clare Skinner and Dr Dane Chalkley talk about their experiences of M&Ms as emergency physicians and reflect on the power of choosing the right cases and the importance of the M&M leadership in establishing a safe space for discussion and learning.
The four-part series goes through the key themes around choosing the right cases, the importance of the leadership in M&Ms, safety sciences and human factors and the importance of multidisciplinary participation and modelling vulnerability by the M&M leadership.
Clare and Dane talk about the importance of choosing the right cases and ensuring you have the right people engaged in the meeting.
Clare describes the importance of empathy and her determination that no one would ever have a surprise in the M&M by ensuring that clinicians are clear on what cases are being discussed.
Dane emphasises that making the meeting psychologically safe is about choosing the 'right case for the right person' and thinking carefully of the timing of case selection as this will impact on the capacity to learn.
Clare and Dane talk about their experiences with the safety sciences and human factors to enable safe discussions from a systems perspective. This includes identifying cases that include positive learning experiences.
Clare and Dane emphasise the importance of the M&M chair as a senior leadership responsibility. They describe M&M leadership as an opportunity for setting the culture within a department and role modelling safety and quality principles.
Dane and Clare discuss the evolution of medical education, and their experiences of moving away from traditional styles of learning to an exposure of contemporary principles and a greater understanding that people learn more when they are psychologically safe.
This discussion includes practical examples of the importance of M&M leadership and the role of facilitation in building and protecting teams and ensuring everyone's voice is valued and heard. Clare and Dane also emphasise the importance of tailoring the M&M Guidelines to the needs of each group.
Clare and Dane discuss the importance of the M&M Chair having a good understanding of safety sciences, Human Factors and cognitive bias. They both give examples of what a good M&M meeting looks like with a strong focus on learning from when things go well (Safety II) and exploring in a safe way the learning from when things go wrong (Safety I).
The discussion includes recommendations around an introduction into safety sciences and human factors. Whilst historically M&Ms have focused on Safety I, Clare and Dane emphasise the importance of learning from when things go well and ensuring teams know they are valued, important and appreciated.
Clare and Dane discuss the importance of normalising human error and reframing it as a learning opportunity rather than alienating clinicians who made the error. This is a growth moment and supporting clinicians enables that growth and learning.
This discussion emphasises the importance of the M&M leadership to model vulnerability and share and demonstrate their own learning experiences from errors. Dane and Clare also talk about civility and tribalism and the importance of multidisciplinary engagement in M&M discussions.
Practical examples are shared around understanding the context of incivility and bad behaviours and ways to address this to enhance connections and empathy across teams and disciplines.
Series three - Listen up for safety
This podcast provides insight into the importance of moving from 'speaking up for safety' to 'listening up for safety' to enable learning from clinicians who are actually doing the work and understand and experience the system firsthand. Dr George Douros takes us on a journey in a four-part series exploring his passion for patient safety and how Human Factors science has supported his work as an emergency physician in improving M&Ms.
George shares his experience and insight into the importance of Human Factors in understanding the context in which errors occur. This four-part series includes conversations around building an understanding around error and the importance of the context which error occurs in, discussion around cognitive bias in understanding error as well as the importance of listening to clinicians and their experiences of the complex systems they work in as we explore the gap between work as imagined versus work as done.
This conversation includes an introduction into the Human Factors and George's journey in understanding the importance of Human Factors science to complement his medical training. George talks about the limitations of clinical knowledge to understand clinical errors and emphasises the importance of engaging with safety sciences, in terms of improving and enhancing the role of M&Ms in supporting changes and enhancing staff capacity to make good decisions.
He uses practical examples from both healthcare and manufacturing industries to explain how systems can be set up to support and enhance better and safer decision making.
In this conversation George describes the War on error and emphasises how, rather than trying to eliminate errors, we can focus on eliminating harm from errors. This war on error includes the limitations of cognitive bias which is understood in hindsight.
George uses practical examples of systems-thinking and highlights the importance of approaching clinicians with humble curiosity to fully understand the systems they work in. This includes curiosity about why they made the decisions that they made and what seemed really obvious to them at the time looks different with the cognitive biases becoming apparent in hindsight.
There are significant learnings from this and George explores opportunities and examples where our learnings around cognitive biases can change the systems we work in to try and accommodate for those biases in what's called 'nudges and fail safes'. George gives examples of how we cannot prevent errors but can redesign the systems to accommodate for errors to ensure that there's no harm.
George talks about communication as a two-way street and the importance of listening up for safety. Whilst we encourage our clinicians to speak up for safety this is not effective unless our senior clinicians and administrators are listening up for safety.
George gives some practical examples of the importance of M&M chairs to be trained facilitators establishing in what Amy Edmondson calls a psychologically safe space in M&Ms where senior staff listen up for safety. George describes M&M reviews as an opportunity to understand the systems from the clinician's perspective and a good M&M facilitator will have the mindset that enables "a good understanding of the messy details of the work as done, rather than the perfect world as imagined."
George emphasises the facilitator's role to be aware of how blame can happen and it's their responsibility to call it out and control it and create a psychologically safe space.
George talks about the difference between a complicated and complex system and describes the importance of Safety II in understanding the complexities of health care. We spend a lot of time focusing on what went wrong and there are significant opportunities in learning from when things go well.
George uses the analogy of limitations of Safety I with how we don't understand how to have a successful marriage by just looking at divorce. The key to understanding the complexities in healthcare is focus on when things go right and why they go right. Compliance in a complex system is not always relevant. Clinicians have this incredible capacity to perpetually adapt in complex systems and go off script.
Season four - Restorative Just Culture
This podcast series is another stimulating conversation and explores Restorative Just Culture (RJC) with two senior psychiatrists who have led the way in their respective roles in mental health. It is a privilege to introduce Dr Nick O'Connor who is the Clinical Lead Mental Health Patient Safety Program at the NSW Clinical Excellence Commission.
Nick facilitates this discussion with Dr Kathryn Turner who is a Psychiatrist and Executive Director of Metro North Mental Health in Brisbane. Kathryn has led the way in the implementation of a RJC framework with her teams in Brisbane and she shares her experiences.
In this four-part series, Nick and Kathryn will take you on a journey to RJC and will explore why it is important and how its been instrumental in improving how we manage incidents and move away from a culture of blame to one of restoration and true accountability.
Kathryn provides practical examples of implementation of RJC demonstrating its importance in providing support for consumers, carers, clinicians and the organisation to heal, learn and improve following an incident.
In this episode, Journey to RJC, Nick explores with Kathryn what restorative just culture is and why it's important in health care. This includes a historic overview of RJC and its origins from indigenous culture and how it has evolved as a 'social movement' across different settings from criminal justice and education and its relevance in healthcare settings. Kathryn describers what restorative justice and learning culture looks like in a district service as we move away from a culture of blame and very linear models of managing incidents.
Kathryn and Nick both share their personal journey with RJC and how instrumental it is in supporting a genuine culture change from that of blaming and shaming when things go wrong to a culture of healing and restoration which further enables learning, improvement and accountability.
In this episode, Why is RJC important, Nick explores with Kathryn why we need a different approach to responding to incidents. Both Kathryn and Nick highlight the emergent properties of complex adaptive systems in health care and the importance of actively changing our culture to better understand and consider these systems when errors occur. This includes a deep commitment to restoration and identifying who is hurt and how the whole of the system is accountable for this.
A key issue that often happens is the perception that when the emphasis is on the system and away from individuals there is risks of no accountability and disempowering victims. Kathryn describes how RJC enables a deeper accountability and responsibility of the whole of the system.
This conversation also highlights the importance of psychological safety of staff and using RJC in supporting all harm caused by incidents including harm to staff. Kathryn describes an example of implementing RJC by addressing the safety and wellbeing of staff and through concept of a clinician peer support model.
In this episode, Implementation of RJC, Nick explores with Kathryn how does responding, learning and improving happen in a restorative, just health culture? Katherine provides practical examples of implementation of RJC in review of incidence guided by the key principles around who was hurt, what do they need, whose responsibility is it to meet those needs and engagement of all stakeholders. Kathryn emphasises the significance of involving both families and clinicians directly involved in the incidents to fully understand why things happened the way that they did.
This inevitably enables healing, learning and improvement bridging the gap from work as imagined and work as done. Clinicians and families involved in the incident have a level of insight and understanding that can help generate practical and relevant recommendations and improvement ideas that reflect their experiences. Kathryn highlights how this really ensures clinicians and family do not feel dismissed or are defensive about the incident and we can always learn something when this happens.
In this episode, Insights from experiences implementing RJC, including a reflection on the barriers and challenges for health services that are wanting to implement a restorative justice culture. Kathryn talks about the significant challenges of building that understanding of RJC and the level of accountability required across the organisation. Feedback from clinicians involved in the implementation have expressed that they have felt safe really being engaged in a different approach where they feel heard and considered in building the understanding what actually happened.
Kathryn also described some positive changes in the Gold Coast Mental health service with positive outcome related to fewer people fearing disciplinary action; it seemed that there was more trust in the organisation and those people who had had involvement feel a greater sense of organisational support.
This is a tremendous shift particularly when people have felt traumatised by incidents in the past and strengthening the individual and relational resilience following incidence. There has also been a shift in the quality and strength of recommendations which will continue to grow through sustaining and keeping to the principles of RJC and the challenge of maintaining what Katherine describes as a tough accountability.