Making M&M Better: The Healthcare Matrix

First, I think Michelle Lin must be psychic.  If you didn't catch her post on morbidity and mortality conference yesterday, then read it!  In fact, read her blog daily.  It contains an amazing wealth of information of interest to anyone interested in faculty development and teaching.

At the conclusion of her post, she gave a glimpse into a tool called the Healthcare Matrix.  Always showing the she is leading the curve, her program already uses it in their M&M conferences.  I had this post planned out for several days since our program is just making the switch and I think it is going to be an awesome tool.  So what if you aren't in a residency and don't have M&M conferences?  Take a close look at it, because it very nicely illustrates a method to investigate errors and suggest potential solutions.  Here we go.

The Healthcare Matrix is a tool developed by some brilliant minds at Vanderbilt  University Medical Center.  They linked the Institute of Medicine's "dimensions of quality," which are safe, timely, effective, efficient, equitable, and patient centered, with the ACGME core competencies for residency programs.  Unfortunately for educators, the competencies of professionalism, communication and interpersonal skills, and practice based learning and improvement are very difficult to teach let alone assess.  Since you cannot have quality care without quality education and vice versa, this tool attempts to present a formative approach to this problem.

So how is this tool used?  First, notice the aims across the top and the competencies down the left side.  The first step is to ask a yes/no question about patient care related to the aims.  Was the care we gave safe?  Was the care timely? And so on and so forth.  For each column that receives a "no" answer the specific competency is examined to determine their contributions to the low quality care given to the patient.  The final step occurs beneath the green bar at the bottom.  In the "Practice-Based Learning and Improvement" row, the user attempts to suggest strategies that can be pursued to improve the system of care.

In an article in the Journal on Quality and Patient Safety, Bingham et al give 2 examples of the matrix in use.  In the first case, a resident was asked to provide an account of a case that went poorly.  The resident compiled a list of "important learning topics and issues. . ."  Here is what the resident turned in:

1. DIC—what is it?

2. DIC in pregnancy—what are the causes?

3. Fibrinolysis in DIC (significance of an in vitro clot test)

4. Local anesthetic toxicity

5. Postpartum hemorrhage with regional anesthesia versus general anesthesia

6. Pulmonary edema secondary to massive transfusion/ volume resuscitation

7. Hypocalcemia from massive transfusion

8. Blood-tinged epidural aspirate—significance?

9. Carboprost, misoprostol, and methylergonovine maleate-indications and uses

10. Third-spacing—can specific IV fluids prevent it?

11. Arterial-line indications—use with massive transfusions or not?

12. Who needs a type and cross? Why does it take 30 minutes?

If you apply these 12 learning points to the matrix, you realize that they only cover 4 of the cells within the matrix, most of which fall into medical knowledge.  This is in keeping with the typical discussion that occurs in a M&M conference, with the attending physicians demonstrating how smart they are to the residents who should have "known better."  


In this case the resident was then was asked to complete the matrix and this is what was returned:

As you can now see, the resident was able to identify issues within 17 of the 36 cells.  Even more importantly, 5 cells fall into the PBLI row and have a HUGE potential for translating into improved patient care.

It doesn't take much imagination to see that the use of this tool will uncover care issues and likely will promote learning as a team.  With luck, gone will be the days of severe hindsight bias and the "shame and blame" approach to dealing with medical errors.  While the matrix contains a great deal of information, the cellular approach allows for focused learning.

With a little practice, this tool will be easy to use and will provide a nice forum for improving not only M&M but patient care overall.

If you already use this tool, please comment on it and let me know your experiences.  I'm looking forward to working with our residents with this tool and any advice will be helpful.

Some Tips:
This is best used as a framework for improvement.  Residents seem to do best when they have to relate each cell to their M&M presentation.

All of the cells do not need to be filled.  Improvements in learning will occur simply because the tool provides a guide for reflecting on all of the factors related to the case.

Try having the attending and resident each fill out the matrix and see where the similarities and differences occur.

Keep a copy of the completed record the residents portfolio, this is a great tool to document learning of competencies that have been difficult to assess and document that learning has occurred.


Reference:
Bingham JW, Quinn DC, Richardson MG, Miles PV, Gabbe SG. Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies. Jt Comm J Qual Patient Saf. 2005 Feb;31(2):98-105. PMID: 15791769