Wednesday, October 29, 2008

Global Triggers

My regular readers know that, at BIDMC, we keep track of lots of clinical outcomes and post our progress towards our goal of eliminating preventable harm for all to see. But there is a problem. Even with the best of reporting systems and even with a strong no-blame environment that encourages people to report errors and bad outcomes, things go on every day that are undetected or unreported.

So, even though we think we are doing a pretty good job in monitoring our progress, it would be great to triangulate our current methods of reporting and collecting adverse events (aka "harm") with other analytically rigorous approaches. One that we have started to use was developed by the Institute for Healthcare Improvement and is called Global Triggers.

This is a thoughtful and interesting method that is based on reviewing a sample of clinical records each other week to look for "triggers", which are basically clues that a patient may have experienced an adverse impact during his or her treatment. The harm that has occurred to the patient is not necessarily in the category of preventable harm. Rather, it is simply an indication of something going wrong from the patient's point of view.

In a way, the method is similar to the kind of sampling that a manufacturing company uses by taking a small number of widgets out of its assembly line and measuring how many are defective. It turns out that you don't have to take very many to get a statistically valid result. And, if you do it every week in a consistent way, you can see through the week-to-week variation and watch trends over time.

We've just been doing this for a few months now, and IHI says you need at least a year's worth of data to have sufficient observations to have a useful tool. Even though the Global Triggers approach captures all kinds of harm and not just preventable harm, there should be some correlation between the direction of the two categories. We are looking forward to getting those results and monitoring them over time as a way of validating our other reporting tools and feeling more confident about measuring our progress.

Are there others of you out there who have used this IHI methodology and would like to share what you have learned or how it has helped you in your quality improvement programs? If so, please comment.


Christian Sinclair said...

Thanks for sharing your hospitals approach to these issues.

In looking at global triggers as harm as perceived by the patient, how do these triggers take into account disease progression which may not be amenable to any therapy? Some patients may accept that as 'that is the way things are' to the other end of the spectrum that perceives that 'medicine should be able to stop this.' I would imagine patients along that spectrum would see varying degrees of harm in that. How do these global triggers account for patient subjectivity/perspective?

Anonymous said...

Good question, but that is more detailed that this approach gets into. This tool is really just a statistical tool. Certain markers on the patient record have been found to be correlated by IHI over time with the existence of adverse events. The markers represent actions of commission, i.e.. things that have taken place, not acts of omission, i.e. failure to engage in certain therapies.

I'll let others more expert than I expand on this -- in case I am getting it wrong or not explaining it right.

Anonymous said...

In response to the reader’s question, we do not count harm that is caused by the underlying disease process. To quote directly from the IHI website: “In determining whether an adverse event has occurred, consider that an adverse event is defined as unintended harm to a patient from the viewpoint of the patient. There are several important aspects:

Would you be happy if the event happened to you? If the answer is no, then there was harm.

Was the event part of the natural progression of the disease process, or a complication of the treatment related to the disease process? The harm identified should be the result of some medical treatment.

Was the event an intended result of the care (e.g. a permanent scar from surgery)? If so, then this is not considered harm.

Psychological harm by definition has been excluded as an adverse event.”

Your readers may take some issue with the last two points. But as you have noted, even if the tool is not perfect, it is much better than most current systems that rely on voluntary reporting.

Anonymous said...

Does IHI have comparative data from similar institutions to share? Why are your sister hospitals so silent? Why don't insurance companies pay for such tools and reward institutions based on their performance?

Anonymous said...

Great questions and discussion on our Global Trigger Tool! At IHI we have seen data collected with this tool, some via our own chart reviews (publication in progress) and much by hospitals themselves who have worked in our projects. The overall findings are generally very similar with harm detected in approximately 35% of charts or 40-50 harm occurrences per 100 admissions.

This is how we determined our goal for the 5 Million Lives Campaign. Using the more conservative figure of 40 occurrences per 100, applied to 37 million annual admissions in US hospitals, that would indicate 15 million occurrences of harm to patient per year. The Campaign interventions do not address all types of harm, so we set the goal at protecting 5 million lives from harm.

Our first publication on our methodology and process for inter-rater reliability was published last month in the Journal of Patient Safety. We hope to have our paper on results of reviews published in the near future.

Fran Griffin, IHI

Anonymous said...


I realize this comment will be read by nobody since it's so late, but I wanted to thank you for making me aware of this program and in doing so, "forcing" me to register to join the IHI in order to read the Global Triggers tool! I learned quite a bit from their website. I just wish that someday there could be a one-stop shop website for performance (and process) improvement; right now there are multiple organizations doing similar things (Leapfrog, IHI, AHRQ, JC, etc.) and I bet it's difficult for the poor hospitals to stay abreast of it all and pick the best methodologies.
Anyhow, rock on - keep talking long enough and the rest of Boston medical care will be forced to listen!