The Global Trigger Tool Workshop

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The Global Trigger Tool Workshop
March 2008
Presenters Annette Bartley Jonathon Gray
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Session overview

• Background and context
• Brief presentations from mentor sites
• Julie Ward-Jones
• Cathie Steele
• Kate Hooton
• 15 minute round table discussion
• What are you finding learning?
• Where is the harm in your organisation?
• Report out
• Next steps

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Reliability in Healthcare

• Healthcare is a high hazard industry
• Approximately 10 (900,000) of patients admitted
  to hospital experience a patient safety incident
• 72,000 of these incidents/adverse events
  contribute to the death of patients
• Over 2,000,000 reported patient safety incidents
  /adverse events (NPSA, 2008)
• Many go unrecognised / hidden /accepted

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Risk Culture

• Reactive approach
• Existing good practice
• Focus on mitigation
• Lots of information but where is the improvement?
• Root Cause Analysis
• Delays in closing the loop
• Failing to identify many adverse events
• Disconnected from clinical practice

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Do we really understand where our harm lies?
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Patient Safety The Facts

• One of the main causes of death
• 1. Cardiovascular Disease
• 2. Cancer
• 3. Respiratory Disease
• 4. Adverse Events

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A Safety Culture in Healthcare

• People do not intend to commit errors
• Accidents are rarely due to single errors and are
  often the end product of multiple factors
• Just Culture
• Less focus needs to placed on the individual and
  more on the organisation
• What does this tell us about our system
• Safety is everyones responsibility

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Campaign aims

• Save 1000 lives and reduce 50,000 episodes of
  harm by April 2010
• How will we know that the changes we implement
  are an improvement?
• We need to be able to understand where harm lies
  first

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IHI Global Trigger Tool (GTT)

• Currently used in hundreds of hospitals
• throughout the world
• Undergoing a rigorous comparison to
• other methodologies
• Incorporates identification of events
• across an organisation

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Campaign aims

• Save 1000 lives and reduce 50,000 episodes of
  harm by April 2010
• How will we know that the changes we implement
  are an improvement?
• We need to be able to understand where harm lies
  first

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Why Use Trigger Tools?

• Traditional reporting of errors, incidents, or
  events does not reliably occur in the best of
  cultures in healthcare
• Voluntary methods frequently underestimate events
  and concentrate on what is interpreted as being
  preventable
• Easily identifies events without complex
  technology
• Can be integrated into a good sampling
  methodology

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Global Trigger Tool

• Establishes a baseline of adverse events.
• Types of adverse events can be catalogued
  and prioritized.
• Resources can be focused on those events
• causing the greatest harm.
• Effect of interventions can be monitored when
• adverse event rate is measured over time.

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Global Trigger Tool

• Natural extension from the area-specific tools
• Uses multiple modules of triggers
• Gathers events from the whole hospital
• Establishes a global harm measure for the
  hospital
• Resource friendly and no dependency on high tech

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Basic Principles

• Review with a trained team.
• Select a small, random sample.
• Look for the presence of triggers only.
• Determine whether harm occurred from
• perspective of the patient.
• Assign category of harm.
• Tabulate data and track over time.

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Key Points

• Only allow a maximum of 20 minute per review
• Look for triggers only dont read the entire
  record.
• A a positive trigger is not necessarily an
  adverse event.
• Determine and assign severity of harm rating
  based on
• the perspective of patient Did I suffer
  harm?
• BE CONSISTENT

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Adverse events are best defined from the
viewpoint of the patient

• Would I be happy if the event happened to me?
• An adverse event is harm to the patient
• from the viewpoint of the patient

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A Representative Sample
Population
A representative sample
A positively biased sample
A negatively biased sample
A
C
B
Negative Outcome
Positive Outcome
A properly selected random sample will produce
results very similar to the results you would get
if you collected data on the entire population.
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Drilling Down with the Data

• Modules within the Trigger Tool can be used
  for focused reviews.
• Use the Medications Module to track ADEs.
• This can be reported as an additional measure.
• Drill down when you see areas of concern to
  monitor for specific improvement.
• Example Use those triggers related to adverse
• events for anticoagulants to track ADEs from
• these medications while working to improve.
• Drill-down measures will improve before the
• overall adverse event rate.

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How it is Actually Done

• 1. Select 2 reviewers plus a physician
  adjudicator.
• 2. Choose 20 random charts
• 3. Set your timer for 20 minutes
• 4. Review the coding summary (look for e-codes
  and obvious events)
• 5. Review the discharge summary
• 6. Review the blood/ lab
• 7. Review the x-ray reports
• 8. Review the procedure notes
• 9. Any time left over, review nurse notes

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Events per 1,000 Days
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Summary

• Triggers are merely tools which help you locate
  adverse events
• Offer organisations the ability to measure harm
  in a simple and cost effective manner.
• Measuring yourself against yourself
• This data can then be used to create will in
  your organization for change and enables you to
  understand unique problems that you are facing.
• Primary care settings need to be able to
  understand where their harm lies in order to
  focus improvement efforts
• Challenge is to make this work for Trusts LHBs
  , primary care
• Whole systems review

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Accepting the Harm Burden

• Adverse Event vs. Error
• Error definition bears upon concept of
  preventability, and is therefore process-focused
• Adverse event describes harm to the patient,
  and is thus outcome focused
• Relationship between errors and adverse events

Adverse Events
Errors
Mortality
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Adverse EventsNew (Harm) Vs. Old (Errors)
Concentrates less on people more on
systems Looks at all unintended results Makes
measurement easier Concentrates on harm
and those errors that cause harm
Errors are the focus of discussion and
solutions Tends to focus only on those results
felt to be related to error, ignores other
events Requires judgement Human found
responsible for most of the errors
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IHI Harm Study

• 1) To develop and deploy a standardized record
  review methodology for measuring harm due to care
  in hospitalized patients
• 2) To use this methodology to estimate and track
  the level of harm in the United States over time,
  by applying this record review methodology in US
  organisations.
• 3) Time series analysis will be used to
  rigorously measure trends over time.
• 4) As knowledge in the field evolves, IHI expects
  that this methodology will be refined and
  supplemented with additional data sources.

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Severity of harm
All injuries due to medical care are classified
as categories E though I as follows E.
Injuries that require treatment or monitoring,
but not longer hospital stays (such as most cases
of phlebitis caused by intravenous catheters) F.
Injuries that are temporary, but extend hospital
stay (such as a pressure ulcer) G. Injuries that
lead to permanent harm (such as a large scar from
an infection) H. Injuries that require immediate
intervention to save life (such as a reversible,
but potentially lethal, medication overdose) I.
Injuries that cause or contribute to death (such
as fatal sepsis from a catheter infection)
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Events per 1,000 Days
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Moving your dot

• It wont happen if
• You quietly contemplate the findings and keep the
  information to yourselves
• You only use the info to report
• It requires a deeper understanding of harm
• And appropriate timely action

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Capturing the learning

• Note the issues on the template during reviews
• Adapt the template to suit your needs
• Feedback the issues and trend through the most
  appropriate forum
• Monitor adverse events rate

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Closing the loop
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Progress to date

• Documentation sent out
• Conference calls set up to build upon the
  information
• Repeating and clarifying key aspects
• Faculty support
• Learning from SPI sites

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MENTOR SITES

• Julie WardJones
• Service Improvement Facilitator NEWT
• Cathie Steele-
• Head of Clinical Governance Cardiff Vale
• Kate Hooton-
• Head of Clinical Governance Gwent

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Round table discussion

• What progress have you made?
• What are you learning?
• Where is the harm in your organisation?
• How will you close the loop?
• Report out by teams

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Panel discussion

• Questions for the panel?

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Key learning

• The global trigger tool gives you the ability to
  measure harm in a simple and cost effective
  manor.
• Build it into existing roles (audit, risk,
  safety)
• Remember the most important information deals
  with the adverse event you find and not the
  trigger. Triggers are tools to find adverse
  event.
• This data can be used to create will in your
  organization for change and allows you to
  understand unique problems that you are facing.

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Summary

• Aim so far was to build the will
• Measurement for learning vs measurement for
  judgment
• Understand harm and identify where there are
  opportunities for improvement
• Make hospitals safer for patients
• Exciting times ahead

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Next steps

• Complete the retrospective review of case notes
  using the tool
• 6 month baseline-Oct 07-April 08
• Set up feedback systems to learn from these event
• Get the dots plotted

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Contact details

• Annette.bartley_at_cd-tr.wales.nhs.uk
• jgray_at_ihi.org