The mission of the DOM Systems Improvement (formerly Morbidity & Mortality) Conference is to establish a safe venue to identify areas for improvement in patient care, while promoting professionalism, integrity, and transparency. This conference has long been a step above the traditional M&M model, which focused on error identification without the lens of Just Culture to address opportunities for system changes, rather than individual failures.

This conference is a certified Collaborative Case Review, so residents and fellows may attend and log attendance for the GME Quality & Safety Incentive Program for AY22-23. 



Dr. Arun Kannappan at the PSW M&M Conference, March 2020The DOM Systems Improvement Conference (a certified Collaborative Case Review) occurs monthly on the 2nd Tuesday of each month at noon, beginning in July of each academic year. For AY22-23, the conference will be online.  Please join us at the next conference via Zoom

In March, September & December, conferences are held during DOM Grand Rounds. See the the AY22-23 DOM Grand Rounds schedule for details.








The DOM Systems Improvement Conference has been certified as a Collaborative Case Review (CCR) by the UCH Clinical Quality Department. DOM trainees may attend our conference to earn a GME Partnership Incentive for participating in up to 3 CCRs for AY22-23. To promote inter-departmental collaboration, residents/fellows from any training program may attend any certified CCR including those outside their parent DepartmentClick here to see the active list of available certified conferences.

If your Division has a recurring case review meeting, we can help you obtain certification as a CCR. The DOM Quality & Patient Safety Team has developed a pathway to assist Divisions with their UCH Collaborative Case Review Certification for GME Incentive CCR conferences will be certified by the University of Colorado Hospital Clinical Quality Department.




Date Systems Improvement Conference DOM Division Case Presenter(s) Case Outcome(s)
July 2021 Coordination of Complex Vascular Access in Renal Transplant Patient Infectious Disease David Fraulino, MD;  
Tyler Anstett, DO, SFHM; Brian Montague, DO, MPH, MS
·   Overhaul of discharge order set
·   New orders include device-based care instructions + provider assignment + nursing directives
August 2021 Managing Acute Agitation in Patient with Advanced Dementia Hospital Medicine & Internal Medicine Christopher Caruso, MD; Elena Lebduska, MD ·   Reached out to UCH to implement cumulative sedation notification
September 2021
Perioperative Anticoagulation Prophylaxis in the Setting of Thrombocytopenia
Pulmonary Science and Critical Care & Orthopedic Surgery Jason John, MD; Katie Raffel, MD ·   VTE prophylaxis order set & reminders
·   Increased visibility for policy on patient refusal of medications
October 2021 Shunted to Psych: An Opportunity for Diagnostic Process Evaluation Hospital Medicine & Denver Health Katie Raffel, MD; Julie Knoeckel, MD ·   Discussed trigger to repeat H&P after initial admission, but unclear if that would be effective
November 2021 Stop, Collaborate and Listen: Complex Communication and Role Clarity in a CODE BLUE Cardiology Laura Peters, DNP; Tyler Anstett, DO, SFHM ·   Working with UCH on re-evaluation of push medication policy and expanding nursing roles
December 2021
The Case of Duplicate Charts: Jane Doe x 2 Internal Medicine & Emergency Department Jennifer Barrett, RN;
Emily Gottenborg, MD
·   LInQS fellow project to address duplicate chart creation and optimize duplicate charge mergers
January 2022 TIPS About Statins in Cirrhosis Gastroenterology & Hepatology Eric Swei, MD; Timothy Yen, MD ·   Standardized note template for post-TIPS procedures
February 2022 Why are you so confused? Special Challenges to Anuric AKI Renal Diseases & Hypertension Katherine Rizzolo, MD; Laura Macke, MD
·   BPA notification to avoid cefepime in AKI/iHD
March 2022
Coordinating Multi-Disciplinary Care for Elder Abuse Geriatric Medicine Sarah Tietz, MD; Tyler Anstett, DO, SFHM ·   GME orientation on mandatory reporting
·   Adding VESPA to Amion & FNE consult request
April 2022 Providing Culturally Competent Care in a Patient with Non-Resolving Pneumonia Hospital Medicine Paul Cannon, PA-C;  
Lorna Allen, MSN, FNP-C
·   BPA notification to consider tuberculosis isolation protocol when order quantiferon gold test