Tobias Wasser, MD, a Yale public psychiatry fellow, was invited to a meeting of the Western Connecticut Mental Health Network on February 3 in Waterbury to explain details of a quality improvement program used by the Yale Department of Psychiatry.
Wasser, who completed his psychiatry residency at Yale in 2014, discussed the Morbidity and Mortality (M&M) conference style model that was first implemented at the West Haven campus of the VA Connecticut Healthcare System.
The model, which was featured in this 2014 article published online in PsychiatricTimes, is based on the principles of root cause analysis, where a culture of discussion is fostered instead of placing blame when an adverse incident or near miss occurs in a health care setting.
An example of an adverse incident would be if a patient threatened staff or trainees at an outpatient mental health clinic, Wasser said. “No one gets hurt, but it raises concern among staff and trainees,” he said. “People want to know how can we better address this.”
Factors that led to the incident are identified, and systematic changes are proposed to prevent it from happening again. Wasser said someone is then appointed to make sure the change is carried out.
“It is supposed to foster a culture of looking at adverse events as systemic errors as opposed to individual errors,” Wasser said. “The purpose is that when something bad happens, you look at it, look at the factors in the system of care that led to that thing happening, take the focus away from blaming people, but focus on communication issues, resources, protocol, and procedures.”
Wasser was invited to attend the February 3 meeting by Sheila Cooperman, the health network’s medical director.
It is supposed to foster a culture of looking at adverse events as systemic errors as opposed to individual errors.
Tobias Wasser, MD, Yale public psychiatry fellow
The organization is affiliated with the Connecticut Department of Mental Health & Addiction Services, and is responsible for the clinical, fiscal, and administrative oversight of state-operated and contracted agencies that provide mental health services in western Connecticut.
Wasser presented to the organization’s medical staff. He said the agency might collaborate with Yale to use the model to improve the quality and safety of patient care.
“I was really happily surprised at how receptive they were to looking at these kinds of events through a new model,” he said. “The idea that people in a non-academic setting and sort of a real-life setting would be receptive to it … gave me a sense there is some hope that it may have some real world application.”
Adapted from a similar program in the Japanese automotive industry, the M&M model was presented by Yale researchers at the Association for Academic Psychiatry in San Antonio in September, and at the Institute for Psychiatric Services in New York in October.
Wasser worked with a fellow resident and now Assistant Professor of Psychiatry Beth Grunschel, MD, ScM; Andres Barkil-Oteo, MD, MSc, assistant professor of psychiatry; and Louis Trevisan, MD, MEd, associate professor of psychiatry, to develop and present the model.
The program has also been adapted for use at psychiatry training programs at the University of Oklahoma-Tulsa and the University of Arizona. “We’ve had other academic dissemination, as well,” Wasser said.