Several Yale faculty and recent trainees have chronicled the efforts to improve patient care systems at the West Haven campus of the VA Connecticut Healthcare System.
Their use of a morbidity and mortality (M&M) conference style model known as the “Mental Health Systems Improvement Series” (MHSIS) was recently featured in an article published in the journal Academic Psychiatry.
According to the article, "Transforming Systems of Care Through a Novel Resident-Led Approach to Morbidity and Mortality Conferences," MHSIS was established to create a “safe, interdisciplinary forum for the structured discussion of unfavorable outcomes and ‘near misses’ (an event where an adverse clinical outcome was narrowly avoided) using root cause analysis framework.”
The article describes the MHSIS, highlights the systemic and cultural changes that have resulted from its implementation at the VA, and demonstrates how such a forum can improve residency education in the areas of patient safety and quality improvement while meeting requirements of The Accreditation Council for Graduate Medical Education.
Tobias Wasser, MD, assistant professor of psychiatry and associate director of the Yale Public Psychiatry Fellowship, was the first author. Other authors were Beth Grunschel, MD; Amy Stevens, MD; Noah Capurso, MD; Elizabeth Ralevski, PhD; Andres Barkil-Oteo, MD; and Louis Trevisan, MD.