Hospital morbidity and mortality conferences: how can a moderator help the team learn?

The meeting’s purpose and the scope of the case

A morbidity and mortality conference gives a team a chance to analyze a case and look for ways to improve care. Before preparing the presentation, it helps to decide what question the meeting should answer. Is the aim to understand a decision made at a particular moment, identify a barrier in how work was organized, or plan a change in practice? Defining the scope this way helps separate learning from matters that require a separate review of potential breaches. A review of seven studies of team-based perioperative conferences highlights case preparation, facilitation, presentation, and post-meeting action. The studies differed, however; no meta-analysis was conducted, and they did not provide conclusive evidence that conferences improve patient outcomes. Simply holding a meeting should not be credited with an effect that has not been demonstrated.

What information was available at the time

The case is best presented in the order events occurred, rather than starting with the outcome everyone now knows. At each important decision, the moderator can ask which signs had been recognized, what information was available, and what constrained the team’s actions. Records should, where possible, be shown in the order they could have reached the people making decisions. A test result received later should not change the account of what was known earlier. If the records contain a gap or participants remember events differently, that should be made clear rather than piecing together a seemingly certain story. This chronology allows the team to discuss decisions without judging them solely by their consequences.

Perspectives from different professions

The doctor presenting the case may not know every stage of other people’s work. It is therefore worth inviting members of the professions who saw the event from different points in the care pathway; the available review specifically examined team-based perioperative conferences. Presence alone, however, does not ensure a complete account. The moderator can plan the speaking order in advance so that professional status does not determine whose voice is heard. A nurse and a doctor may have noticed different signs of a patient’s deterioration. It is worth asking each person what they observed, when they passed the information on, and to whom. This is a suggested way to guide the discussion, not a research-validated method for improving treatment outcomes. It does, however, help gather the perspectives needed to understand how the case unfolded.

Questions for the moderator

The moderator can steer the discussion toward the reasons behind a choice: what supported the decision, what alternatives were available, and under what conditions the task was carried out. Rather than asking someone, “Why didn’t you notice?”, it is better to ask, “What could you see at the time, and what information would have changed the decision?” This does not rule out criticism. It allows the group to identify a specific behavior and its consequence instead of publicly attributing a trait or intention to someone. If mockery or a personal attack occurs, the moderator should stop that form of comment and return to the facts. Decisions can still be assessed frankly; humiliating a participant is not necessary. This keeps the discussion educational even when the findings are difficult.

What research says about the format

There is no basis for treating any one conference format as having a demonstrated, consistent effect on patient outcomes. The review of seven studies of team-based perioperative meetings described varying approaches to organization, outcome measures, and study quality, so no meta-analysis was conducted. It highlighted the importance of case preparation, moderation, presentation, and post-meeting action, but did not confirm a definite improvement in treatment outcomes. When assessing their own conference, teams should look beyond attendance to whether the necessary perspectives were gathered and whether the conclusions follow from the course of events. Changing the tone of the discussion may be a sensible approach for a moderator, but it does not in itself justify a promise of lower mortality.

Recognizing the burden on participants

Reviewing an event can be taxing for those involved. A review of research on support for staff after incidents identifies practical, peer, and professional support needs. Before the conference, it is therefore worth telling participants what form the discussion will take and where they can get individual support. Taking part in the analysis should not depend on speaking publicly about one’s emotions. Someone involved in a recent error may need a separate conversation, while the team still needs to understand the course of care. The evidence for assessing the effectiveness of support is limited: the review included 99 studies, but only 11 examined intervention effectiveness. Findings for peer support programs were mixed, and controlled and randomized studies were few.

Turning a finding into change

WHO guidance emphasizes that the value of reporting incidents lies in learning and taking action, not merely collecting accounts. Likewise, a conference should not end with a general statement that “communication needs to improve.” The moderator can record one finding to check, identify who is responsible for the next step, set a deadline, and specify how the team will assess whether the improvement was implemented. It is also worth agreeing when the team will revisit the result. A brief update on earlier decisions at the start of the next conference links case analysis to ongoing work. This is a practical suggestion for organizing the meeting, not evidence that a particular protocol is effective. It does, however, make it possible to check whether a shared conclusion led to the planned action.

A good case review does not start by judging a person. It starts by asking what the team knew when a decision was made and ends with an action the team can revisit.

Using Empatyzer to prepare for a morbidity and mortality conference

A hospital morbidity and mortality conference moderator can use Empatyzer while preparing. In a conversation with Em, they can rehearse questions that establish the timeline: what was known at the first decision, what emerged later, and where gaps remain. They can also prepare a response to a comment that judges a participant as a person, stopping the attack and returning to specific behavior without shutting down constructive discussion. The team view and a conversation with Em about the group can help them plan when members of different professions will speak and account for different speaking styles. In the “About me” view, they can recognize their own tendency to wrap up a discussion too quickly or how they respond to conflict. Micro-lessons can support them in framing questions about working conditions and the course of events. Finally, the moderator can work with Em on a closing sentence that states one finding, who is responsible, the deadline, and how the team will follow up. These are ways to prepare a moderator, not a research-confirmed effect of the tool on patient outcomes.