Transcript Insert Title here

The Global Trigger Tool Workshop
March 2008
Presenters: Annette Bartley & Jonathon Gray
Global Trigger Tool
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
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
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
Do we really understand where our ‘harm’ lies?
Global Trigger Tool
Patient Safety – The Facts
One of the main causes of death:
1.
2.
3.
4.
Cardiovascular Disease
Cancer
Respiratory Disease
Adverse Events
Global Trigger Tool
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
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
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
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
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
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
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
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
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
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
A Representative Sample
Population
A negatively
biased sample
C
A representative sample
A
B
Negative Outcome
A positively
biased sample
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
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
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
Events per 1,000 Days
Events/1000 Days
Events/1000 days
120
100
80
Events/
1000 days
60
40
20
0
Ju Au Se Oc No De Ja Fe M Ap M Ju Ju Au Se Oc No De Ja Fe M Ap M Ju Ju Au Se
l-0 g- p- t- 0 v- c- n- b- ar- r- ay n- l-0 g- p- t- 0 v- c- n- b- ar- r- ay n- l-0 g- p4 04 04 4 0 4 0 4 0 5 05 05 05 -05 0 5 5 05 05 5 0 5 0 5 0 6 06 06 06 -06 0 6 6 06 06
Date
June-Sept 04
Global Trigger Tool
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
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
Mortality
Errors
Global Trigger Tool
Adverse Events
New (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
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
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
Events per 1,000 Days
Events/1000 Days
Events/1000 days
120
100
80
Events/
1000 days
60
40
20
0
Ju Au Se Oc No De Ja Fe M Ap M Ju Ju Au Se Oc No De Ja Fe M Ap M Ju Ju Au Se
l-0 g- p- t- 0 v- c- n- b- ar- r- ay n- l-0 g- p- t- 0 v- c- n- b- ar- r- ay n- l-0 g- p4 04 04 4 0 4 0 4 0 5 05 05 05 -05 0 5 5 05 05 5 0 5 0 5 0 6 06 06 06 -06 0 6 6 06 06
Date
June-Sept 04
Global Trigger Tool
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 understanding of
harm
• And… appropriate & timely action
Global Trigger Tool
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
Closing the loop
Global Trigger Tool
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
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
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
Panel discussion
• Questions for the panel?
Global Trigger Tool
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
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
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
Contact details
• [email protected]
• [email protected]
Global Trigger Tool