Enterprise Learning from Morbidity and Mortality

In building out enterprise collaboration systems, I often see implementation practices in one area that can be successfully applied elsewhere.

Lately, I’ve noticed that the hospitals I work with all have regularly scheduled “M & Ms” – Morbidity & Mortality reviews, in which doctors and other clinicians analyze complications in patient care to better understand what went wrong, learn from it, and take appropriate corrective actions. (The practice was pioneered by Dr. Ernest Codman at Massachusetts General Hospital in Boston in the early 1900s – shortly before his colleagues banished him from the hospital, afraid that he’d make them appear incompetent. But don’t let that discourage you.)

What does all this have to do with your organization?

Well, Enterprise 2.0 tools are spreading like wildfire right now, and many large companies have dozens of pilot or early-stage projects underway, exploring the business impacts of various social media (blogs, wikis, social networks, Twitter-like sharing tools, mobile apps). This strategy makes sense, given that social media are clearly going to have a profound effect on how business is conducted, though the specifics are not yet clear.

But a significant proportion of the E2.0 projects underway are doomed to failure, for all the usual reasons, plus a couple of new ones. In many companies, the people involved will simply move on to the next project, with little or no analysis of what went wrong. That’s the perfect moment when the M & M process offers something of value.

To extract that value, you’ll need to manage the M & M review carefully. Specifically:

  • Be impartial. You can only make improvements if you understand what really went wrong, and you’ll never discover the truth if the review is seen as an exercise in attributing blame.
  • Be sensitive. It’s not that “mistakes were made”; the mistakes were made by people, or were inherent in the systems that people designed. People react differently to criticism, so the individual leading the review needs the tact and sensitivity of a family therapist.
  • Be thorough. A seriously ill patient may suffer multiple organ failures, making it difficult to ascertain the most serious problem. An M & M must be thorough to be useful.
  • Be consistent. Use a reporting template that collects and displays all the relevant information uniformly.
  • Focus on the important cases. The M & M process takes time and energy, so reserve it for projects where you’re likely to find “teachable moments” that can be acted upon.
  • Share the results. Communicating the lessons learned isn’t just part of the process; without effective communication the process is just wasting everyone’s time.

Despite the resistance Dr. Codman’s innovation faced a century ago, M & Ms have grown to become a crucial feedback mechanism for hospitals – because they help save lives.

Could your organization use something like that?