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©2017 ECRI INSTITUTE
Introducing the Global Trigger Tool to Improve Quality and Patient SafetyFrank Federico, RPh, Vice President and Senior Safety Expert, Institute for Healthcare Improvement (Cambridge, MA)
Sandra Almeida, MD, MPH, founder and President of Sandra A. Almeida, MD, LLC Healthcare Consulting; Consultant to the Defense Health Agency (Patient Safety Expert)
February 23, 2017
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For Physicians:
CME Accreditation Statement:This live activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). ECRI Institute is accredited by the ACCME to provide continuing medical education for physicians.
AMA Credit Designation Statement:ECRI Institute designates this live activity for a maximum of 0.75 AMA PRA Category 1 credits tm. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
All faculty members involved in this February 23, 2017, live webinar, Introducing the Global Trigger Tool to Improve Quality and Patient Safety have disclosed that there are no conflicts or financial affiliations.
©2017 ECRI INSTITUTE6
For Nurses:
This activity has been approved for up to 1.0 California State Nursing contact hours by the provider, Debora Simmons, who is approved by the California Board of Registered Nursing, Provider Number CEP 13677. Credit will only be issued to individuals that are individually registered and attend the entire program.
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To be eligible for credits:
Credit will only be issued to individuals that are individually registered and attend the entire program. Each individual participant must log on prior to the start of the program and remain on the line for the entirety of the program. This is how individual timed attendance is verified. In addition you must complete an attestation survey included in the post-webinar evaluation at the conclusion of the webinar. Once all that information is verified, qualified attendees will receive a certificate via e-mail within 60 days of today’s program.
©2017 ECRI INSTITUTE
About ECRI Institute
Independent, not-for-profit applied research institute focused on patient safety, healthcare quality, risk management ECRI Institute resources about quality and safety Obtain username and password by contacting us at [email protected]
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50-year history, 450-person staff Evidence-Based Practice Center under the Agency for Healthcare Research
and Quality (AHRQ) Federally designated Patient Safety Organization
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Learning Objectives
Understand the role of the Global Trigger Tool for quality and patient safety monitoring
Describe methods to conduct medical record reviews using the Global Trigger Tool
Summarize how to use the data collected with the Global Trigger Tool Learn strategies to engage physicians in quality improvement efforts using the
Global Trigger Tool
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Using the IHI Global Trigger Tool for Measuring Patient Safety
FrankFedericoVicePresident
This presenter has nothing to disclose
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Frank Federico, R.Ph.
Frank Federico, RPh, Vice President, Institute for Healthcare Improvement (IHI), works in the areas of patient safety, and reliable design. He is faculty for the IHI Patient Safety Executive Training Program and co-chaired a number of Patient Safety Collaboratives. He has authored numerous patient safety articles, co-authored a book chapter in Achieving Safe and Reliable Healthcare: Strategies and Solutions, and is an Executive Producer of "First, Do No Harm, Part 2: Taking the Lead." Mr. Federico serves as Chair of the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) and Vice Chair of the Joint Commission
Patient Safety Advisory Group. He coaches teams and lectures extensively, nationally and internationally, on patient safety.
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Objectives for This Session
Discuss briefly the history of the IHI Global Trigger Tool, focusing on the principles
Provide example that demonstrates the principles
Describe the methodology for review of a inpatient record
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Accepting the Harm Burden
Concept of moving from a focus on error and the preventable to the measurement of
global institutional harm whether preventable or not
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Definition of Harm
IHI Global Trigger Tool definition for harm:
Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.
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Old (Errors) vs. New (Harm)
Concentrates less on people more on systemsLooks at all unintended resultsMakes measurement easier Concentrates on harm and those errors that cause harm
Errors are the focus of discussion and solutionsTends to focus only on those results felt to be related to error, ignores other events Requires judgmentHuman found responsible for most of the errors
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Why Use Trigger Tools?
Traditional reporting of errors, incidents, or events does not reliably occur in the best of health care culturesVoluntary methods markedly underestimate adverse eventsEvents can be reliably detected without resorting to as yet unproven electronic surveillance methods Can be integrated into a good sampling methodology to follow harm event rates over timeTriggers exist in the chart and are part of routine documentation of care. Does not rely on staff to do anything extra.
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How Much Harm
‘Global Trigger Tool’ Shows That Events in Hospitals May Be Ten Times Greater Than
Previously MeasuredClassen DC, Resar R, Griffin F, Federico, F. et al. Global Trigger Tool shows that adverse events in
hospitals may be ten times greater than previously measured. Health Affairs. 2011 Apr;30(4):581-589
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Amount of Harm
3 tertiary care hospitals in US
795 records from Oct 2003 reviewed
393 adverse events total– 33% of admissions
– 49 / 100 admissions
– 91 adverse events / 1000 patient days
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Global Trigger Tool (GTT) Modules
Cares
Critical Care
Medication
Surgery
L&D
Emergency Department
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Cares Module Triggers
C1 Transfusion or use of blood products
C2 Code/arrest/rapid response team
C3 Acute dialysis
C4 Positive blood culture
C5 X‐Ray or Doppler studies for emboli
C6 Decrease of greater than 25% in Hg or Hematocrit
C7 Patient fall
C8 Pressure Ulcers
C9 Readmissions within 30 days
C10 Restraint use
C11 Healthcare‐associated infection
C12 In hospital stroke
C13 Transfer to higher level of care
C14 Any procedure complication
C15 Other
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RandomRecords
TriggersReviewed
Postriggers
ID
Hospital Days
Portion of record reviewed
AEIdentified
EndReview
End Review
HarmCategory Assigned
AE’s/1000 days OR
100 admissionsOr
# of admissions with an event
Yes
No
No
Yes
Trigger Review Process 21
IHI GTT Categories of Harm (Adapted NCC MERP Index)
E - Temporary harm, intervention required
F - Temporary harm, initial or prolonged
hospitalization
G -Permanent patient harm
H -Life sustaining intervention required
I - Contributing to death
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AHRQ Common Formats Harm Scale Adopted by DoD for Trigger Tool Review
Death: Dead at time of assessment.
Severe harm: Bodily (including pain or disfigurement) that interferes significantly with functional ability or quality of life.
Moderate harm: Bodily injury adversely affecting functional ability or quality of life, but not at the level of severe harm.
Mild harm: Bodily injury resulting in minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay.
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Cross Walk of IHIGTT Severity Scale and AHRQ Common FormatsIHI GTT AHRQ Common Formats
I ‐ Contributing to death Death: Dead at time of assessment.
G ‐ Permanent patient harm Severe harm: Bodily (including pain or disfigurement) that interferes significantly with functional ability or quality of life.(Permanent or Temporary)
F ‐Temporary harm, initial or prolonged hospitalization
G ‐ Permanent patient harm
Moderate harm: Bodily injury adversely affecting functional ability or quality of life, but not at the level of severe harm.(Permanent or Temporary)
E ‐ Temporary harm, intervention requiredMild harm: : Bodily injury resulting in minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay.
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Triggers and Events
When a trigger is found, review appropriate portion(s) of record to determine if adverse event occurred.
Some triggers will not lead to an event. A few triggers are also adverse events (e.g., post-op pulmonary embolism).
Adverse events can be found without detecting a trigger first.
Some events can be detected by multiple triggers.
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Example Case: Positive Trigger
Polling Question: A patient on chronic anticoagulation has an INR of 8.2.
Does that represent an adverse event?
A) Yes
B) No
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Analysis of a Trigger (INR 8.2)
Elevated INR is not an adverse event – only a trigger.
Review of appropriate portion of the record revealed that a large retroperitoneal bleed was noted.
The event clearly caused a prolongation of the hospitalization and should be classified as a category _____
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Examples of “E” or Mild Harm
Bladder perforation secondary to surgery
Pressure ulcer
Dissection of artery during procedure
Post-op wound infection
4th degree vaginal laceration
Hypoglycemia
Acute renal failure secondary to drugs
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Steps in Review Process Set a timer for 20 minutesReview:
Coding summary (look for e-codes and obvious events)Discharge summaryOrdersMedication administration recordLaboratory resultsX-ray reportsprocedure notesNursing / multidisciplinary notes (if time left)
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Key Points
Follow recommended sequence for review.
Look for triggers only …don’t read the entire record.
Remember that a positive trigger is not necessarily an adverse event.
Unintended consequences are usually adverse events, even if not preventable.
Determine and assign harm based on perspective of patient: “Did I suffer harm?”
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A Few Definitions to Consider
Omission vs. Commission
Preventability
Psychiatry
“Erps”
Cascade of events
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Using the Data:Leadership Concerns
“Big Dot” (High System Level) measurement - performance over timeIs this actionable information (need 12 to 24 data points) ?How does this align with other harm measures?What resources do we require to execute GTT?Be prepared for “shock & awe” with number of harms found!– Hospital Brand– Transparency
How do we achieve real time/near time intervention to prevent harm?
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Improving Performance & Process
Use your current Quality & Safety Improvement infrastructureTrack & Trend rate of patient harmData should be part of a larger set of measuresForm & Empower Performance Improvement Team based on area of focusCreate a Project Charter to include Scope, Opportunities, Barriers, Resources required, Members of Team, Measurements, Expected Outcomes, Milestones and TimelinesAsk Leaders for input and to support Project Charter and implement improvement cycle (PDSA)
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For more information visit:
www.ihi.org
Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute
for Healthcare Improvement; 2009
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The Global Trigger Tool in the Military Health System
Sandra Almeida, MD, MPHConsultant, DoD Patient Safety Program
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What Are the GTT Benefits to Your Facility? Supports your efforts to achieve high reliability
Provides a patient safety measurement strategy focused on systems issues, not individual blame
Can be used to monitor impact over time of your safety improvement activities
Complements other measure sets (e.g., JPSR, Culture Survey) to help you fully understand patient safety at your facility and improve
A recommendation from the 2014 SECDEF 90-Day Review of Access, Quality and Patient Safety
Helps you achieve existing requirements (e.g., TJC, ACGME)
MHS method minimizes data collection burden to facilities
Pilot studies show GTT effective in identifying patient harm in MHS
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MHS Experience with the GTT
Two pilots, 10 different facilities, different sizes
Wide range of patient harm detected
No correlation to reports from JPSR or administrative data
Pilot 1 (six month period, 4 facilities)
121‐298 harm events/1000 patient days
28‐91 harm events/100 admissions
23‐49% admissions with a harm event
Pilot 2 (two month period, 6 facilities)
212‐297 harm events/1000 patient days
45‐128 harm events/100 admissions
30‐63% admissions with a harm event
Classen et al Study (2011)
91 harm events/1000 patient days
49 harm events/100 admissions
33% of admissions with a harm event
Baylor Study (2011)
68 harm events/1000 patient days
51 harm events/100 admissions
40% of admissions with a harm event
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How Will GTT Be Implemented at Your Facility?Review Process – contracted out
20 randomly selected records from each facility monthly
2 nurse reviewers, 1 physician adjudicator
Reporting to Facilities
Monthly teleconferences with each site first 12 months then as needed
Harm/1000 patient days
Harm/100 admissions
Percent of admissions with a harm
Additional information to allow facilities to investigate further if desired
Patient name
Location of trigger/harm in chart
Type of harm
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GTT Implementation: What is Your Role?
Subject Matter Experts & Educators
Patient safety – principles, solutions, resources
GTT – understand/interpret data
Change management
Project Managers
Facilitators
Help influence others (leaders, physicians, frontline staff ) to become involved, to adopt harm reduction strategies
Help “make it easy” for frontline staff
Patient Safety Managers can help frontline teams implement harm reduction strategies and assess effectiveness by providing support as:
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GTT Implementation: What is Your Role?
Attend the monthly call
Review and interpret findings
Communicate findings to key facility leadership and staff members
Assist with (or lead) the design, implementation, and evaluation of harm reduction strategies
Engage frontline staff members, particularly
physicians, in harm reduction efforts
Physician “Champion” is highly recommended to provide clinical expertise and engage facility staff members in harm reduction strategies:
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What is “Physician Engagement” and Why Is It So Important?
Attempts to define “physician engagement” in quality/safety:
“Physicians working to reduce unjustifiable variation in care, considering the processes and systems in which they care for their patients.”
“…is about physicians owning the most optimal way in which healthcare is delivered so that it is focused, smooth, effective, and achieves desired patient outcomes.”
Sources: Taitz et al. BMJ Qual Saf.2012 Wachter. Understanding Patient Safety; 2012
“…the presence or absence of such engagement frequently predicts whether an organization’s safety program is a smashing success or dismal failure.” (Wachter, 2012)
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Why is Physician Engagement the Key to “Smashing Success” of Your Safety Program?
Physicians’ legal authority: Very little happens in patient care without physician approval
More influence on variations in clinical processes and patient outcomes than any other group
A unique perspective and skill set: they understand the clinical processes, the environment, and all the nuances
Best able to engage their peers
So how do we engage physicians? What motivates them?
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Polling Question #1
What is the # 1 reason for physician professional satisfaction?
1. Autonomy and control over their work2. Collegiality and respect3. Economic gain4. Physician fashionwear – clogs and scrubs5. Ability to provide high‐quality patient care
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What Motivates Physicians?
“…being able to provide high‐quality care to their patients is the primary reason for job satisfaction among physicians….” American Medical Association (AMA) Wire, 2013*
* Quoting findings AMA/RAND study: Freidberg et al. Factors Affecting Physician Professional Satisfaction; 2013
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WIIFM: What Other Factors Motivate Physicians?
Autonomy and control over pace and content of clinical work
Leadership values aligned with their own – particularly regarding approaches to patient care
Collegiality, fairness, and respect
Manageable work quantity and pace
Work consistent with training
Well trained, capable allied health professionals and support staff
So why are so few physicians fully engaged in organizational PS/Q/PI efforts?
Friedberg et al. Factors Affecting Physician Professional Satisfaction; RAND; 2013
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What Motivates Physicians… and What Stresses Them?
“…being able to provide high‐quality care to their patients is the primary reason for job satisfaction among physicians, while obstacles to doing so are a key source of stress in the profession.” (AMA Wire, 2013*)
* Quoting findings AMA/RAND study. Freidberg et al. Factors Affecting Physician Professional Satisfaction;2013
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How Physicians Can Perceive Organization-driven PS/Q/PI Improvement Efforts
Physician Satisfiers Physician Perceptions of Many PS/Q/PI Efforts
Autonomy/control • Excessive standardization removes physicians’ clinical decision‐making flexibility (“cookbook medicine”)
Aligned leadership values • Mixed messages • Persistent productivity and cost containment pressures
Fairness & respect • Often feel they are not consulted in the design of improvement activities, but told what to do. Question effectiveness (question data).
• PS/Q/PI efforts rarely recognized/rewarded
Manageable work quantity and pace
• Not given dedicated time for PS/Q/PI work• Time away from patients
Work consistent with training
• Do not have necessary skill set
Capable support staff • Lack of time• Need capable staff to help them with PS/Q/PI efforts
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Polling Question #2:
Which TWO of the following barriers to physician engagement in PS/Q initiatives MOST apply to physicians at YOUR organization?
1. Burn out – overwhelmed, lack of time2. Lack of improvement science knowledge and skills 3. They question the evidence‐base, effectiveness4. Fear of excessive standardization, losing control5. Resistance to any patient care changes they do not lead
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So How Do We Engage Physicians in PS/Q/PI Improvement Efforts?
“None of them [healthcare systems] claims to have the answer to physician engagement in quality. But many of them have achieved stunning results.” *
What can we learn from top‐performing healthcare systems?
* Source: Reinertsen et al. Engaging Physicians in a Shared Quality Agenda.IHI;2007
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Example Strategies to Engage Physicians
Shift your mindset:
Ask not “How can we engage physicians in the facility’s safety agenda?”
but ask “How can the facility engage in the physicians’ safety agenda?”
Leverage leadership with credibility to inspire physicians
Ideally other physician thought-leaders
Get to know your physicians – adopters, resistors
Barriers can vary by age, values, years practicing
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Example Strategies to Engage Physicians (cont’d)
Appeal to their desire to improve their patients’ outcomes
Provide valid, clinically relevant data (GTT)
For GTT, engage physicians with expertise most directly related to the harm events and associated processes
Explain how their involvement/expertise can improve patient outcomes within their clinical units
Respect their limited time
Consider time commitments
Provide support for activities that do not require physician expertise
“Segment” the engagement plan
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“Segment” the Engagement Plan – Start Now
Which interventions require physician engagement and at what level?
What specific roles should physicians take? Who has the time to do it? Who has the skill set?
Champion – inspires others to participate
Structural leader – existing department head, chief
Project leader – organizes/executes the change plan
Adopter – applies the intervention at work
“Cautious laggard” – identifies flaws in the change plan
Source: Reinertsen et al. Engaging Physicians in a Shared Quality Agenda.IHI; 2007
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Example Strategies to Engage Physicians
Reward/recognize physician involvement in safety improvement efforts
Make the right thing easy to do
ASK: “Does the change require more physician time and effort than the old way?”
ASK physicians about feasibility
ASK early adopters to pilot test
Provide physicians the resources, processes, and tools they need to engage in improvement efforts. Structure them for success
Communicate often and transparently
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Polling Question #3:
Which of the following strategies do you think would be
MOST useful for engaging physicians in GTT efforts at YOUR
organization?
1. Demonstrate how it will improve their patients’ outcomes2. Reward/recognize their participation3. Respect their time – minimize time needed or provide time 4. Leverage the “cautious laggards” – ask for their opinions5. A physician GTT champion to “recruit” his/her peers
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Recommended Reading – Physician Engagement
Friedberg et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation, 2013.
Hayes C, Yousefi V, Wallington T, Ginzburg A. Case study of physician leaders in quality and patient safety, and the development of a physician leadership network. Healthc Q. 2010 Sep;13 Special No:68-73.
Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2007.
Rosenstein, A. Physician engagement: A multistep approach to improving well-being and purpose; accessible at http://www.psqh/com/
Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf. 2012 Sep;21(9):722-8.
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Additional References Addressing the Best Way to Implement Global Trigger Tool Reporting,
MHS CQM Special Study Report, FY 2016
Audet AJ, Doty MM, Shamasdin J, Schoenbaum SC. Measure, learn, and improve: Physicians’ involvement in quality improvement. Health Aff(Millwood). 2005 May-Jun;24(3):843-53
Classen DC, Kilbridge PM. The roles and responsibility of physicians to improve patient safety within health care delivery systems. Acad Med. 2002 Oct;77(10):963-72.
IHI Global Trigger Tool for Measuring Adverse Events, Innovation Series 2009, Second Addition
Pilot Testing of the IHI Global Trigger Tool, MHS CQM Special Study Report, FY 13
Wachter RM. Understanding Patient Safety (2nd ed). New York, NY: McGraw-Hill;2012.
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