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Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix

Leo A. Gordon, MD | September 1, 2007 
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There is a slumbering giant- one that carries the potential to transform surgical safety-merely waiting to be awakened and freshened up. I refer to the iconic gathering that so readily evokes the surgical "days of the giants": the traditional surgical morbidity and mortality (M&M) conference.

Now how, you may ask, can a transformation of this tired old remnant of days past help us create a safer medical environment? How can an assembly of surgeons, cloistered in a meeting steeped in the ABCs (abuse, berate, and chastise) of traditional surgical education, help us reach our safety goals by reinventing itself?

The answer lies in the evolving recognition by medical educators, department chiefs, program directors, and patient safety officers that this conference can be transformed into a vibrant patient safety curriculum. To understand the transformation, we must begin by considering today's typical M&M conference the quintessential "one-shot" deal:

  • The collective wisdom of the department assembles.
  • Critical issues of patient safety are discussed. Somewhere in these discussions are the essential patient safety lessons so necessary to the education of the physician; however, these are often glossed over or ignored.
  • The meeting ends.

What happens after the meeting?

What is done to preserve those essential patient safety and error-reducing points—even when they have been raised and debated? The answer is usually straightforward: nothing is done. It is as if a culture arose that never developed a written language—never took the time to memorialize its most important error-reducing insights. This culture—the culture of medicine—never canonized patient safety.

Until now.

My method of tapping the M&M conference's full potential is called the "M+M Matrix"—a patient safety curriculum generated from a reconfigured morbidity and mortality conference. This redesign fosters a culture of safety by constantly reinforcing the lessons learned at the weekly conference. The Matrix concept makes the conference the culmination of a week's effort, rather than a 1-day exercise. Here's how it works:

Cases are submitted to and are screened by a dedicated Matrix moderator. The Matrix concept works best when a specifically dedicated individual is charged with organizing and coordinating the conference. This moderator, a respected physician with strong meeting management and teaching skills, relies on his or her department to support the program. That support will include support for an appropriate fraction of his or her salary, as well as audiovisual and secretarial support for the conference itself and the pre- and postconference work. It must be emphasized that the moderator has to have a strong desire to help improve patient safety by bringing out and then disseminating lessons from the care delivered within the department. He or she need not be a renowned safety expert, but the moderator must stay up to date with current safety initiatives through reading and conference attendance. If the moderator is "volunteered" for the position and sees this as a burdensome administrative responsibility, the conference is likely to fail.

The moderator selects cases of interest to both the resident and the attending staff and then works with the resident staff to produce high-quality error-specific presentations, usually in a PowerPoint format. There is no magic formula to case-finding—once the moderator is well known throughout the department, he or she is likely to become the "go to" person for interesting and illustrative cases. A well-supported moderator should also routinely review departmental deaths, unexpected returns to the OR, or other potential "triggers" that may indicate safety issues.

Once those presentations have been formulated, the moderator works with the resident to polish the presentation. The goal is to present to the division or department a well-planned analysis of a medical error or complication. During the discussion of the case, the moderator does what many moderators do not do—he moderates! This is a talent and a skill that can be learned. It takes neither coursework nor great experience to recognize when a discussion is getting off message. The transition from clearly thought-out opinion to myth and folklore is easily detectable; the moderator needs to be willing and able to steer the conversation back to more productive and evidence-based lessons. Such pointed moderation is essential in converting the prior format into one that takes advantage of the learning opportunities.

The discussion is channeled and refined as the moderator focuses on the patient-safety aspects of the case. A key part of the discussion is the separation of errors arising from a medical system from those that arose primarily from individual errors in process or judgment. Each discussion ends with a list of "Matrix Points"—the error-reducing strategies to be used in the future to prevent the complication or error.

Then the moderator's work really begins. At the end of the conference, the moderator summarizes those patient safety points in outline form and distributes them to the department faculty and residents via e-mail. These are generic error-reducing points. All of the data are de-identified.

If it ended here, it would already be a great step forward. But the Matrix Program goes one step further. For what good are such lessons if they are not woven into the daily fabric of the learner's (whether resident or staff physician) life? How can a department assure itself that these lessons are being learned? The answer lies in quarterly testing.

Using the M+M Matrix plan, the resident staff is tested quarterly on the points made at the conference. Using short-answer, essay-type questions, the moderator designs an examination that assesses the efficacy of the conference. Each of the questions is followed by the date of the Matrix Conference discussion. These examinations are closed book affairs, governed by the honor system. The residents have 1 week to complete them. The examinations are also available to the surgical staff on a voluntary basis. For example questions, see the Table.

The moderator grades the exam and subsequently sits down with each resident to review the answers. We do this one-on-one (more evidence of the significant time required of the moderator), but it could probably work well as a group exercise. These reviews allow the educational leaders of the department to see whether residents and staff are retaining the key patient safety lessons.

On a yearly basis, all of the Matrix outlines are published and distributed to the division in a packet format. New staff members may receive this packet when they join the medical center. Since so many lessons are covered each year, new members no longer have to rediscover gravity! The attached slide presentation outlines the program.

The best way to view the Matrix Program is to think of it as a cyclical upper level university course in patient safety. And just like that upper level course, the "student" must rely on preparation and participation and then submit to examination.

Can the Matrix Program reduce the incidence of specific complications in a department? It is logical to assume that a resident, if exposed to a complication or error in an educationally meaningful manner early in his career, will be less likely to create that complication as his career progresses. Moreover, if that complication arises, he will be more likely to detect it earlier and to treat it more effectively.

Work-hour restrictions, a crowded curriculum, and increasing public demand for an overall patient safety effort have created a pressing need to reconsider the benefits of a well-run, well-moderated, and well-attended morbidity and mortality conference. As pressure mounts on departments to add patient safety education to the curriculum, it is vital to combine didactic education and "book learning" with better ways to learn from one's own cases.(1) Although we do not have data yet to support the value of the conference in terms of error reduction, the impression of all participants is that this is a powerful way to glean and disseminate safety lessons from real-life cases, and to make those lessons into a living curriculum. Future work should aim to measure the satisfaction of participants and the impact of this method on safety outcomes.

The first step in awakening this slumbering giant is to rename him. We should not have morbidity and mortality conferences. We should have Matrix Conferences.

Leo A. Gordon, MDAssociate Director of Surgical EducationCedars-Sinai Medical CenterLos Angeles, California

For further information about the M+M Matrix, please contact Dr. Gordon, Associate Director of Surgical Education, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California, 90020 or via email.


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1. Wachter RM, Shojania KG. Internal bleeding: the truth behind America's terrifying epidemic of medical mistakes. New York, NY: Rugged Land; 2004:281.


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Table. Example Questions(Go to table citation in perspective)

Question #1—A 58-year-old man undergoes an elective sigmoid resection for recurrent diverticulitis.A. Describe in detail your technique for mobilizing the sigmoid colon.B. What structures are in jeopardy?C. What methods do you use to identify those structures?(Matrix Conferences of 7/7/05, 7/14/05, 8/18/05)

Question #2—A 43-year-old woman undergoes an elective laparoscopic cholecystectomy. She is discharged home the evening of surgery. She reports to the ED the following morning. The main findings are a hemoglobin of 8.0 grams and abdominal pain. Her liver function tests are normal.Please provide your main differential diagnosis and plans for work-up.(Matrix Conference of 7/7/05)

Slide Presentation

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An Overview of the M+M Matrix Program (PDF, 25K).(Go to slide presentation citation in perspective)

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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