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Novel Grading Scale Incorporating Quality Improvement Principles Into Routine Surgical Morbidity and Mortality (M&M) Conference
Seth A. Alpert, MD, Kelly E. Kersey, BS, CPHQ, Christina B. Ching, MD, Daniel G. DaJusta, MD, Molly E. Fuchs, MD, Daryl J. McLeod, MD, MPH, Venkata R. Jayanthi, MD.
Nationwide Children's Hospital, Columbus, OH, USA.

Background: Morbidity and mortality (M&M) conference is a staple of surgical training programs but can potentially have an unhealthy focus on assessing blame and making recriminations. Our hospital has been at the forefront at promoting the importance of reducing preventable harm to children and expanding novel quality improvement initiatives. With that background, our surgery department developed a new method of classification of surgical morbidity, in an attempt to assess whether best practices were followed when evaluating unexpected outcomes with the potential for implementation of real change to prevent future such outcomes.
Methods: We retrospectively reviewed the records of every case discussed in our Urology department's M&M conference over the past 27 months (December 2019 - February 2022). When appropriate, we assigned a Clavien-Dindo score to each case, but also applied our novel internal grading scale. The internal scale is shown in Table 1.

Results: Over the study period, 56 Urology M&M cases were discussed. There were 30 males (54%) and 26 females (46%). The median patient age was 4.9 years (range 2 months - 41 years). The complication scores assigned are listed in Table 2.

Discussion: M&M conferences are a vital and time-honored method of discussing unexpected surgical outcomes. The main aim of the Clavien-Dindo grade is to define the seriousness of a complication and degree of harm suffered by a patient. In contrast, our internal score allows us to objectively assess the quality of care we delivered with the goal of improving outcomes. Our internal review suggests that we may not have been thorough enough in identifying potential complications, since we did not record any Level 1 (near miss event) patients. Most of our patients were level 3, due to not identifying "best practices" for many of these conditions, presenting an opportunity to pursue such initiatives in the future. Ultimately, this new scale may allow for the identification and development of novel quality improvement initiatives as well as establishing a standardized approach to care and best practices in pediatric urology. Discussing amongst colleagues in a candid but confidential manner that a patient might not have received best care (Level 4 or 5) requires a needed cultural shift within a department, emphasizing that outcomes are paramount and careful self-reflection is key to continuing improvement.

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