Morbidity and Mortality Steering Committee Charter


The mission of the Department of Medicine Morbidity and Mortality Steering Committee (MMSC) is to review the action items identified during monthly DOM and quarterly interdepartmental DOM M&M conferences, case conferences and divisional M&Ms. The MMSC will triage these action items to the appropriate process improvement stakeholder, and prioritize action items for quality improvement activities for UCHealth and the DOM. The MMSC will continually foster a safe and respectful environment for discussion and learning, with a primary objective of identifying quality and process improvement initiatives that align with UCHealth and the DOM


The MMSC reports activities and outcomes to the University of Colorado Hospital Quality Department, the Chair of the Department of Medicine (DOM), the Vice Chair for Clinical Affairs for the DOM, the Clinical Chiefs for each Division within the DOM, and the Clinical Effectiveness and Patient Safety Committee (CEPSC). The MMSC collaborates and aligns hospital based process improvement initiatives with the CEPSC.

Role of MMSC:

Steering Committee members are not directly responsible for presenting the M&M cases, or for managing process improvement activities, but are responsible for providing support and guidance for those who do and reviewing progress of quality improvement activities derived from recommendation of the committee. Thus, Steering Committee members will:

  • Strengthen the culture of safety by guiding open, collaborative discussions within a multidisciplinary forum.
  • Determine the scope and breadth of actionable process improvement (PI) opportunities forwarded to the DOM MMSC from various DOM Division’s M&M presentations, the QPS team, CEPS teams, or Med QT committee.
  • Analyze the degree of difficulty, complexity, cost, risk, and benefit of implementing PI activities to patients and the system, and utilize key stakeholder input prior to making recommendations for or against hospital based projects.
  • Strategically align action items with current and evolving process improvement projects wherever possible.
  • Make recommendations in regards to baseline data, additional metrics and ROI in order to help bolster the argument for intervention in identified M&M issues by various outside stakeholders.
  • Collaborate with the DOM QPS team to forward actionable items to the appropriate CEPS, QI team, or other UCH committee for further review and implementation of key quality initiatives.
  • Communicate with the DOM QPS team and physician learners on progress of M&M driven hospital initiatives via QPS intranet site. This will provide a continuum of education and subsequent loop closure for internal QPS tracking of actionable PI outcomes.
  • The MMSC will meet at least quarterly, and more frequently if the need arises.


1) The MMSC will have delegated authority to determine the priority matrix for implementation of quality initiatives designed to improve systems of care and patient outcomes

2) The MMSC will have two co-chairs representing the UCHA and SOM as well as representatives from key clinical and administrative areas.

3) ‚ÄčThe MMSC will have process improvement, quality improvement and data analyst support from the Medicine pod and the DOM quality team.

4) The MMSC will have a UCH executive sponsor, Jeff Glasheen, MD, CQO, and DOM executive sponsor, Rick Albert, MD, Vice Chair for DOM Clinical Affairs.

5) The sponsors, or assigned delegates, will be responsible for attending meetings, assisting programs with goal setting, primary review of the written reports and ad hoc meetings and support.

6) The MMSC will act as a Steering Committee, and will make recommendations for creation of working groups within the UCH Medical pod or the DOM quality enterprise at their discretion.


1) Semi-annual report of M&M driven hospital-based patient safety initiatives and subsequent progress towards completion to Chair DOM, Vice Chair for Clinical Affairs, DOM, and Clinical Division Chiefs, UC Hospital Quality Department, and CEPSC.


Chair: Michael Ho

Co-Chair/Hospitalist: Anunta Virapongse

CMR (2): Amy Yu & Andrew Berry

Ambulatory Care: Elena Lebduska

Division: James Carter (Cardiology)

Division: Jessica Kendrick (Renal)

Division: David Saxon (Endocrine)

Division: Swati Patel (GI)

Division: Brian Montague (ID)

Nurse Manager: Kaycee Shiskowsky (Director is Jenn Zwink)

Nurse Manager: Mark Yoder (Director is Michelle Feller)

Clinical Quality Specialist, UCH: Sylvia Park (Director is Sue West)

Clinical Quality Specialist, DOM: Lindsie Stephan (Director is Sue West)