WTP7.14 Standardising and Navigating the Mortality and Morbidity (M&M) Process in Breast Surgery

Aims This quality improvement project aimed to enhance the efficiency and accuracy of Mortality and Morbidity (M&M) meetings in the Breast Surgery department at an academic tertiary centre. The goal was to standardise the M&M process, addressing challenges related to data collection inefficiencies and time constraints in a busy clinical environment. Methods A standardised Excel spreadsheet with automated coding was developed to capture all relevant M&M data. A PowerPoint template was also created to present this data clearly, in line with GIRFT (Getting It Right First Time) performance benchmarks. A formalised handover process for new resident doctors was introduced, including a step-by-step guide on data tracking, administrative contacts, and resource use. The Excel sheet was made accessible for real-time prospective data entry via a shared drive, and M&M meeting dates were communicated at least six weeks in advance. Results Standardising the data collection process improved accuracy and efficiency of the M&M process. Resident doctors reported higher satisfaction, as prospective data entry reduced errors and saved time. Additionally, the system proved easily replicable, offering a model that could be implemented in other departments. Conclusions The standardised tools introduced enabled more efficient, accurate, and repeatable data collection. The step-by-step guide and PowerPoint template offered a reproducible framework for other departments. This quality improvement initiative demonstrated that standardising the M&M process can enhance surgical practice, lead to higher user satisfaction and stronger clinical governance.