What is the Global Trigger Tool?
The Global Trigger Tool (GTT) is a tool co-developed by clinicians and researchers at the Institute for Healthcare Improvement that enables the calculation of a rate of patient harm for a large health system. As cited literature indicates, the GTT has been used to measure patient harm all over the world, including Australia, Denmark, New Zealand, Norway, Sweden, the United Kingdom, the United States, and elsewhere.
The GTT consists of a manual chart review tool and a clinical review process in which clinicians sample approximately 20 patient charts per month to identify “global” harm, or what is now referred to as “all-cause harm.” Using sound epidemiology, they then apply a standardized clinical review method using “triggers,” or pointers to potential patient harm, and then clinically confirm adverse events if harm has occurred. Inter-rater reliability is assessed and monitored to support validity.
Following its rise to popularity approximately 15 years ago, many leading health systems in the 2000s implemented the GTT and used it to measure harm system-wide such as the Mayo Clinic, Kaiser Permanente, Baylor Scott & White Health, Adventist Health System, and others.
While ultimately the consensus was that, while an “automated GTT,” or sometimes referred to as an electronic trigger tool (ETT), was a naturally required next step, this pioneering tool accomplished much.
What did the Global Trigger Tool (GTT) accomplish?
The GTT was a key milestone in the history of patient safety, because of a number of accomplishments:
Defined Harm. One of the most significant challenges in recent decades for patient safety has been the lack of a definition of patient harm. Relying on evidence and sound epidemiology, leading health systems defined harm using a commonly accepted and embraced clinical methodology founded on scientific evidence. This set the “gold standard” for defining harm and proved seminal.
Generated Rates. Before the GTT, even leading health systems did not know what their rates of harm were; coding and claims data were insufficient to provide the clinical clarity and accuracy desired. Healthcare – like nuclear power, petrochemicals, and aviation – is a high-risk industry. If those industries could calculate a rate of defect, why couldn’t healthcare? GTT addressed this, and health systems were able for the first time, even if not perfectly, to answer the question, “Are we safer?”
Early Lens. Just as the state of art in automated all-cause harm detection is now demonstrating every day, the GTT provided an early “lens” for clinicians into the safety and reliability of care. Patient harm that was assumed to be “there” and occasionally identified in the paper chart era, or even voluntarily reported, now was documented. The GTT showed to be a useful source of insight on care delivery, and its success spawned other evidence-based attempts to develop “triggers” pointing to other harms (versus all-cause harm).
But then these health systems and others, for the most part, ceased investment in the GTT. Why?
What were the shortcomings of the GTT?
The drawbacks of the GTT are summarized as follows:
Narrow. Considering that a good-sized hospital with 10,000 admissions per year, being able to view harm that affects up to 20 patients per month is, at best, narrow. It is but a “keyhole view” into care delivered and, while better than the alternative, undoubtedly missed understanding broader safety vulnerabilities.
Retrospective. Because of the manual nature of the review process, clinical teams using the GTT would often be authenticating adverse events that had occurred many months prior. Therefore, the GTT was not an actionable tool and, moreover, was just that: merely a tool versus a system that integrated into care delivery and quality improvement.
Costly. The most significant reason that most health systems reported ceasing to use the GTT actively on an ongoing basis was cost. Given the lack of actionability, GTT initiatives became cost centers that leadership teams were unable to justify on the basis of simply knowing months after the fact what their rate of harm was.
This led to a growing desire in the patient safety and quality improvement community for an “automated GTT,” to somehow address these limitations.
What is automated all-cause harm detection, and how has it moved the field beyond the GTT?
Automated all-cause harm management built on the foundation of the automated GTT as an early all-cause harm tool, but delivered a superior approach in terms of methodology and technology to move the patient safety field to value – or what Pascal terms “value-based patient safety.” This required more than an automated GTT, or other electronic trigger tools (ETT), because something much more significant was required to support management of harm of over time that is integrated into real-time care delivery.
Highlights of all-cause harm management, which in an enterprise-grade form Pascal calls real-time patient safety, include:
- Comprehensive. Real-time patient safety ingresses data from the EHR and other health IT on all patients receiving care, not just a narrow sampling.
- Systematic. Moving from a narrow sampling of patient charts and having the data on all patients in real- or near real-time enables clinical reviewers, analysts, and caregivers to be systematic in their understanding not only of
- Actionable. The fundamental “game-changer” as compared to the GTT, however, was that with comprehensive and systematic real-time EHR data flowing into a protected patient safety event management workflow, real-time patient safety enables actionability: both with respect to (1) concurrent patient-specific intervention opportunities and (2) broader patient-specific patterns of harm useful for more rapid cycles of improvement.