The Global Trigger Tool Workshop

1. The Global Trigger Tool Workshop March 2008 Presenters: Annette Bartley & Jonathon Gray Global Trigger Tool

2. 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 Global Trigger Tool

3. 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 Global Trigger Tool

4. 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 Global Trigger Tool

5. Do we really understand where our ‘harm’ lies? Global Trigger Tool

6. Patient Safety – The Facts One of the main causes of death: 1. Cardiovascular Disease 2. Cancer 3. Respiratory Disease 4. Adverse Events Global Trigger Tool

7. 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 everyone’s responsibility Global Trigger Tool

8. 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 Global Trigger Tool

9. 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 Global Trigger Tool

10. 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 Global Trigger Tool

11. 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 Global Trigger Tool

12. 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. Global Trigger Tool

13. 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 Global Trigger Tool

14. 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. Global Trigger Tool

15. Key Points • • Only allow a maximum of 20 minute per review • • Look for triggers only …don’t 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 Global Trigger Tool

16. 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 Global Trigger Tool

17. 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. Global Trigger Tool

18. 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. Global Trigger Tool

19. 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 Global Trigger Tool

20. Events per 1,000 Days Global Trigger Tool

21. 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 Global Trigger Tool

22. 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 Global Trigger Tool

23. 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 Global Trigger Tool

24. 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. Global Trigger Tool

25. 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) Global Trigger Tool

26. Events per 1,000 Days Global Trigger Tool

27. Moving your dot • It won’t happen if… • You quietly contemplate the findings and keep the information to yourselves • You only use the info to report • It requires a deeper understandingof harm • And… appropriate & timely action Global Trigger Tool

28. 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 Global Trigger Tool

29. Closing the loop Global Trigger Tool

30. 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 Global Trigger Tool

31. MENTOR SITES • Julie Ward–Jones • Service Improvement Facilitator NEWT • Cathie Steele- • Head of Clinical Governance Cardiff & Vale • Kate Hooton- • Head of Clinical Governance Gwent Global Trigger Tool

32. 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 Global Trigger Tool

33. Panel discussion • Questions for the panel? Global Trigger Tool

34. 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. Global Trigger Tool

35. 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… Global Trigger Tool

36. 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 Global Trigger Tool

37. Contact details • Annette.bartley@cd-tr.wales.nhs.uk • jgray@ihi.org Global Trigger Tool