BMJ Qual Saf doi:10.1136/bmjqs-2011-000273
  • Quality improvement report

Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement

Open Access
  1. Duncan Smith-Rohrberg Maru1,4,5,10
  1. 1Nyaya Health Bayalpata Hospital, Achham, Nepal
  2. 2Brown University School of Medicine, Providence, Rhode Island, USA
  3. 3Harvard School of Public Health, Boston, Massachusetts, USA
  4. 4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  5. 5Department of Medicine, Children's Hospital of Boston, Boston, Massachusetts, USA
  6. 6Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
  7. 7Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
  8. 8Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
  9. 9Department of Medicine, Weill Cornell Medical College, New York, New York, USA
  10. 10Boston Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Duncan Smith-Rohrberg Maru, 42 Union Ave., Boston, MA 02130, USA; duncansr{at}
  1. Contributors The authors are professionals who work in varying capacities with Nyaya Health, a non-profit group delivering healthcare services in rural Nepal that is innovating methods of open-access and transparency in the field of global health. The authors' contributions are as follows. DM conceived of the study and guided the initial pilot of the programme, and serves as the guarantor of the article. DS oversaw the programme locally, adapted the initial pilot into a formal programme, wrote the initial draft, and analysed the data. RS analysed the data and contributed to the drafting of the manuscript. BG, AB, RS and MG served as clinicians and managers on the programme and participated in revision of its aims and methods. BA, RR, JA, GK, KM, and DM provided feedback on the operation of the programme and revised the manuscript. All authors read and approved the final manuscript.

  • Accepted 31 August 2011
  • Published Online First 26 September 2011


Problem In hospitals in rural, resource-limited settings, there is an acute need for simple, practical strategies to improve healthcare quality.

Setting A district hospital in remote western Nepal.

Key measures for improvement To provide a mechanism for systems-level reflection so that staff can identify targets for quality improvement in healthcare delivery.

Strategies for change To develop a morbidity and mortality conference (M&M) quality improvement initiative that aims to facilitate structured analysis of patient care and identify barriers to providing quality care, which can subsequently be improved.

Design The authors designed an M&M involving clinical and non-clinical staff in conducting root-cause analyses of healthcare delivery at their hospital. Weekly conferences focus on seven domains of causal analysis: operations, supply chain, equipment, personnel, outreach, societal, and structural. Each conference focuses on assessing the care provided, and identifying ways in which services can be improved in the future.

Effects of change Staff reception of the M&Ms was positive. In these M&Ms, staff identified problem areas in healthcare delivery and steps for improvement. Subsequently, changes were made in hospital workflow, supply procurement, and on-site training.

Lessons learnt While widely practiced throughout the world, M&Ms typically do not involve both clinical and non-clinical staff members and do not take a systems-level approach. The authors' experience suggests that the adapted M&M conference is a simple, feasible tool for quality improvement in resource-limited settings. Senior managerial commitment is crucial to ensure successful implementation of M&Ms, given the challenging logistics of implementing these programmes in resource-limited health facilities.


  • Funding Financial support for the programme was provided by grants to DM from the Frederick Lovejoy Foundation at Children's Hospital Boston and the Brigham and Women's Hospital Center of Expertise on Quality and Safety.

  • Competing interests None.

  • Ethics approval Boston Medical Center in USA; Nepali Health Research Council in Nepal.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The authors commit to sharing all data from the included research. Data can be requested directly from the authors, or accessed directly on the open-source wiki of Nyaya Health (parent organization to Bayalpata Hospital, the site of research) at

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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