M&M Structure, Execution, and Function
A total of 56 respondents participated in the survey, and responses were received from 30/121 (25%) of ophthalmology residency program directors and 26/1989 (1%) ophthalmology residents across all 4 years of training. These respondents universally noted their institution held these sorts of sessions, whether that be under the umbrella or name of M&M, QI/Patient Safety conference, themed grand rounds (quality/safety/surgical complications), or themed case presentations.
The demographic makeup and structure of M&M sessions seen in Table 1 shows the majority of respondents (56%) reported their M&M sessions took place on a quarterly basis, with the monthly sessions being the next most common frequency (29%). Almost all respondents reported residents and faculty were in attendance at these sessions, while 55% reported medical students were in attendance. Optometrists, nurses, and administrators were not widely included as participants at these sessions. Eighty-two percent of respondents reported that their sessions were typically one hour long. Audio/Visual components were almost universally utilized at these sessions, with only one respondent reporting otherwise. Most frequently the ophthalmology M&M sessions were only attended by those involved with ophthalmology; however, 41% of responses indicated other specialties were involved. Often times, the presenter leading the M&M session was a resident involved in the patient’s care (51%), and sometimes a faculty working alongside that resident (21%). Figure 1 demonstrates the criteria used to decide which cases would be presented at M&M. Most often, cases would be picked based on severity of outcome, cases that involved errors regardless of patient outcome, or an interesting disease presentation. Referral from another department for presentation or a regular rotation of subspecialty cases discussed (i.e. “Retina M&M”, “Cornea M&M”, etc) was not often utilized by the respondents’ programs.
Table 1
Demographics and Structure of M&M sessions
| Variable | Respondent Frequency, n (%) |
| Frequency Weekly Bi-weekly Monthly Quarterly Never | 3 (5%) 0 (0%) 16 (29%) 31 (56%) 2 (4%) |
| Participants Residents Faculty Medical Students Optometrists Nurses Administrators | 52 (35%) 54 (36%) 31 (21%) 8 (5%) 1 (1%) 3 (2%) |
| Duration 30 minutes 1 hour 2 hours | 9 (16%) 45 (82%) 1 (2%) |
| Audio/Visual Components Video Pictures No Audio/Visual Drawings | 33 (33%) 46 (51%) 1 (1%) 11 (12%) |
| Other Specialties Involved No other specialty Neurology Neurosurgery ENT Plastic Surgery Other | 25 (58%) 1 (2%) 1 (2%) 1 (2%) 1 (2%) 14 (33%) |
| Presenters Resident involved in patient’s care Faculty involved in patient’s care with resident involvement Faculty presenting their own patient without resident involvement Director of quality/safety PD or Chairperson Other | 41 (51%) 17 (21%) 9 (11%) 6 (7%) 2 (2%) 6 (7%) |
Table 2 illustrates the oversight and quality improvement data collected from the survey. Cases for discussion at these M&M sessions were most often identified by a provider-generated list (53%), and less frequently by a hospital-mandated patient safety reporting system (14%) or a regular review of all surgical cases in the department (14%). Often, the cases were selected in a joint decision made by the resident and attending (47%), though sometimes by the resident alone (35%). Seventy-five percent of respondents indicated their institution had a method for anonymous case submission. Figure 2 shows attendings and residents involved in the case are often identified by name and present the case. Attendings involved in the case are frequently asked to comment on the case during the session and an analysis of systems errors contributing to each case is almost always performed. M&M is often overseen by the residency program director (33%), but less frequently by the associate/assistant program director, director of quality/safety, department chair, or other faculty.
Table 2
Oversight and Quality Improvement Data
| Variable | Respondent Frequency, n (%) |
| Case Identification Provider-generated list Hospital’s patient safety reporting system Referred from risk management Regular review of return visits/readmissions Regular review of all surgical cases in department Other | 43 (53%) 11 (14%) 6 (7%) 5 (6%) 11 (14%) 5 (6%) |
| Anonymous Case Submission Method Yes No | 13 (25%) 40 (75%) |
| Case Selection Residents Attending Joint decision or resident and attending QI committee Other | 13 (35%) 5 (9%) 25 (47%) 6 (11%) 4 (8%) |
| Who oversees M&M Residency program director Associate/assistant program director Director of quality/safety Medical director Department chair Other faculty Other | 33 (33%) 15 (15%) 13 (13%) 6 (6%) 14 (14%) 13 (13%) 5 (5%) |
| Formalized process for following up on systems issues identified in M&M Yes No | 16 (31%) 36 (69%) |
| Are changes that are made reported back to trainees Yes, at a future MM Yes, by a member of the residency administration Yes, by a chief resident Yes, by other methods (email) No | 12 (24%) 9 (18%) 2 (4%) 14 (27%) 14 (27%) |
| Formal M&M evaluation process Yes No | 20 (39%) 31 (61%) |
| Who formally evaluates M&M Attendings Residents Department chair Director of quality/safety | 9 (47%) 7 (37%) 1 (5%) 2 (11%) |
A majority of respondents (69%) noted there was no formalized process for following up on the systems issues identified in M&M. Respondants from institutions with a formalized process submitted open-text responses that included: “QI committee that looks into it with relevant stake holders”, “a safety committee of the hospital is notified”, “QI committee starts a root cause analysis”, “if [case] is severe enough we host a “learning from defects” session”, “sometimes a subsequent M&M session is used as an update to a previous presentation”, and finally “QI safety director and the hospital work together for solutions”. Changes that are made are often reported back to trainees (73%) whether that be at a future M&M, by a member of the residency administration, by a chief resident, or by email. Only 39% of respondents reported that their program had a formal M&M evaluation process, with that evaluation being conducted mainly by attendings (47%) and residents (37%).
According to the survey, the respondents reported the objectives of their M&M were most often to discuss adverse outcomes (patient deaths/readmissions/surgical complications), identify systems errors, discuss interesting cases, disseminate medical knowledge and surgical best practices, role model professional accountability for trainees, and finally identify cognitive errors. When asked to rank what was most represented in their M&M sessions, the following topics were ranked from most to least discussed: technical aspects of surgery, preoperative assessment, communication, postoperative management, indication, medications, and equipment. The respondents were then asked to identify if a set of goals were met by their M&M. All respondents indicated that their sessions identified areas of risk, provided tools for managing future events, improved quality of care, improved safety of care, disseminated medical knowledge, showcased personal work, allowed a safe space to talk about and learn from mistakes, that there was attendee collaboration/participation and engagement, and finally that systems issues were identified and led to change in management. The only goal that was rarely met by the respondent’s M&M was identifying problem providers. Participants agreed that they found M&M to be of educational value, contribute to the culture of safety at their institution, and that their sessions focused on cognitive errors as seen in Fig. 3.
M&M Obstacles and Best Practices
There were few but significant obstacles noted by participants that might prevent effective M&M sessions. Most often, participants believed there was a fear of judgement/embarrassment involved with presenting or repercussions and some participants believed a lack of attendance was an obstacle. However, most participants agreed the hierarchical nature of medicine, lack of structure/oversight, and lack of accountability were not problems that needed to be addressed at their program. Updating/standardizing objectives of M&M sessions was most frequently chosen as a way to improve M&M sessions, as seen in Table 3. Most participants also agreed training speakers/facilitators on preparing for an M&M session, including interprofessional participants (social work, nursing, optometry, etc), usage of an anonymous audience response system/polling mechanism, and increasing the frequency/duration of M&M sessions were all ways to in which M&M sessions could improve. In fact, no participant agreed that decreasing the frequency/duration of M&M sessions would lead to improvement. Finally, some respondents mentioned utilizing a teach-back and/or Socratic-style methods could be beneficial in M&M sessions.
Table 3
Ways in which M&M sessions can improve
| Improvements | Respondent Frequency, n (%) |
| Increase frequency/duration of MM sessions | 12 (11%) |
| Decrease frequency/duration of MM sessions | 0 (0%) |
| Updating/standardizing objectives of MM sessions | 25 (22%) |
| Train speakers/facilitators on preparing for a MM session | 24 (21%) |
| Inclusion of interprofessional participants (social work, nursing, optometry, etc) | 19 (17%) |
| Using the Socratic method (shared dialogue between speaker and attendees) in MM sessions | 5 (4%) |
| Usage of an anonymous audience response system/polling mechanism in MM sessions | 17 (15%) |
| Using the teach-back method (attendees summarize learning points to speaker at end of session to ensure correct understanding) in MM sessions | 12 (11%) |
Focus Group Findings
The majority of the discussion in the focus groups centered around best practices. A common theme discussed and agreed upon by most participants in the focus group was M&M sessions should include presentations from both faculty and resident cases, and not just residents. Someone described why this was important by noting that “you have to build a culture where everyone feels comfortable saying what happened” and another participant added this shows “…[mistakes] happens to the best of us”. They went on to note it is important for residents to know faculty are capable of making mistakes and learning from them, and mistakes are not just made by trainees.
Another commonly agreed upon best practice was a mandatory reporting system of all complications. Several participants noted their institution does not have a formal reporting system, and that selection of cases for M&M was an informal solicitation of “interesting cases anyone would like to present”. They noted sometimes they filed reports with a “safety reporting system, but not for every complication, only if there were systemic errors, or things could have happened better”. One participant noted mandatory reporting provides a “de-stigmatization of complications… and it lessens the gravity of each complication, as every complication by everyone in the department is reported”. There was further discussion around reporting complications and the participants came to the consensus that if institutions were to adopt such a system, there needed to be measures in place to maintain a level of anonymity.
Several participants expressed an interest in increasing the frequency of their department’s M&M conferences, but there were other sessions also competing for this time like “grand rounds and cataract surgery complication discussions”. Time was universally noted among focus group participants to be the biggest challenge facing universal adoption of M&M across all ophthalmology departments. Many of the participating institutions noted their M&Ms often started at 7am, requiring the attendees to come in early before their day in the clinic or operating room started. This extra time burden, competing obligations, and the transition to online meetings since the COVID-19 pandemic era were all noted to be obstacles to conducting more frequent and effective M&M sessions. The online meetings were noted to be a particular area of strife as attention and focus from participants were decreased when compared to in-person meetings.
A frequently emphasized point during these focus groups was the tone and culture surrounding M&Ms needs to remain non-judgmental, as this is “not a confessional, but a learning opportunity” and “it should be about the process, not the person”. One participant noted “participants can come up with a better solution for future patient care”. Disseminating knowledge, breaking down barriers to care, performing root cause analysis, and looking for ways to improve the system were all noted to be the most important goals of M&M conferences.