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Description
QUALITY
Background:
Review of Morbidity and Mortality (M&M) events within Heart Centers (HC) is critical for improving patient care. Timely review is important to maintain transparency and accuracy in recall and produce actionable items to reduce the likelihood for similar occurrences. Cardiac-Multidisciplinary Assessment of Performance (C-MAP) rounds and M&M Selection Committee were initiated July 2020 to review surgical patient outcomes, team performance, and events deviating from expected course. M&M selection committee consists of physicians, advanced practice nurses, and quality improvement consultants to determine patients appropriate for review at M&M conference. We aim to analyze timeliness of review following patient events related to institution of C-MAP rounds and M&M selection committee.
Methods:
C-MAP rounds scores patient courses based on outcomes: “on-target” (green) or deviation from the ideal with no significant lasting harm (yellow) or significant harm (red) and team performance: outstanding (4), expected (3), suboptimal (2), or poor (1). C-MAP Rounds occur within 10 days of procedure and frequently provide initial identification of events which require deeper review. Analysis of C-MAP “red ” events was performed between 2022-2023 to identify total patients reviewed at M&M selection committee. No formal procedure coordinating C-MAP and M&M committee existed. Further analysis was performed to elicit timeliness of review between event date and committee review date and was compared to timeliness prior to the initiation of C-MAP and M&M committees.
Outcomes:
“Red” events between 2022 - present were reviewed at M&M committee at a rate of 83.2% (79/95). Prior to C-MAP/M&M committee initiation, all significant patient events were reviewed on average 60.5 days (median 52 days) from event. After establishing C-MAP/M&M committee, cases were reviewed on average within 29 days (median 26 days). Instituting C-MAP rounds and M&M committees improved timely review of patient events. We now formally refer C-MAP “red” events to M&M selection committee to ensure appropriate oversight and communication of recommendations.
Publication Date
9-27-2024
Keywords
Cardiology, Pediatric Cardiology, Cardiatric Nursing
Disciplines
Pediatric Nursing
Recommended Citation
Torzone, Andrea; Moate, Glenda; Groom, Linn; Hart, Mary; Hunter-McPhan, Erin; Conley, Christa; Moore, Kimberly; Zoretic, Sarah; Bhaskar, Priya; Andersen, Nicholas; Butts, Ryan; and Arar, Yousef, "Timeliness of “Red Event” Reviews: Optimizing “Cardiac-Multidisciplinary Assessment of Performance” (C-MAP) Rounds with Morbidity and Mortality Review" (2024). 2024. 16.
https://scholarlycollection.childrens.com/nursing-anf2024/16
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This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.
