Best practices for health care quality control and safety emphasize organizational culture, rather than individual action. According to the Institute of Medicine's 2001 publication "Crossing the Quality Chasm" practices that scrutinize individual performance (i.e. staff training, performance reviews, and performance evaluations) are typically not effective in terms of raising the standard of quality and safety in the health care setting. Instead, health care organizations should focus on global interventions that affect the entire institution. Establishing universal habits, norms, and behaviors in which all staff and personnel fully participate is the best way to improve safety and quality over time.
In his book Complications: A Surgeon's Notes on an Imperfect Science, Dr. Atul Gawande discusses one critical institutional practice adopted by the Brigham and Women's Hospital that both reduces harm and raises quality of care: the morbidity and mortality conference. The M&M conference is a standing weekly meeting during which surgeons disclose their mistakes and brainstorm ways to prevent those mistakes in the future. Since surgeon mistakes sometimes result in patient injury or even death, M&M conferences are tense and emotionally difficult. At the same time, M&M conferences provide a safe, consistent space for doctors to work on improving their craft. Because attendance is mandatory, no one is singled out for his or her "failures." Instead, all doctors participate in this transparent, core process.
Situating medical errors as opportunities to learn and grow is essential to the continual improvement of health care services. The M&M conference is one example of how institutional practices can orient doctors as to how to view, understand, and grow from both critical and minor mistakes.