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Building a Quality and Safety Culture by Addressing What Matters Most to Clinicians

By Robin Moulder | Tuesday, March 2, 2021
Building an Improvement Culture by Addressing What Matters Most to Clinicians Photo by congerdesign | Pixabay

While the IHI Global Trigger Tool provides many organizations with an invaluable way to identify adverse events (harm) and measure the rate of adverse events over time, it may not fit the needs of all organizations. The team at the Memorial Sloan Kettering (MSK) Cancer Center, an IHI Leadership Alliance member, used the concept of “triggers,” or clues, to identify adverse events to develop their own oncology-specific tool. In the following interview, Robin Moulder, RN, MBA, CPHQ, MSK’s Senior Manager, Quality & Safety, explains how developing their trigger tool increased clinician engagement and joy in work, even amid the COVID-19 pandemic.

On why they adapted the Global Trigger Tool

We recognized that IHI’s [Global Trigger Tool] was groundbreaking, but we realized we had to refine it to get the information we need [for oncology patients]. In IHI’s [standard] library of triggers, for instance, some of them — like elevated glucose and neurology consults — happen routinely in our patient population. They aren’t cause for alarm. We didn’t want the triggers we used to 1) result in data that was not meaningful for us or 2) produce so much data that [follow up would be] a drain on our people resources.

On how this effort has been different from other improvement projects

There’s been a shift. Clinicians’ perception of quality work is (sometimes) a department coming to them saying “Here’s the project du jour. Here’s a data collection tool. Please fill this out, we’ll be back to you in six months, and we’ll make some assumptions about what’s going on.” With this project, we were able to communicate that we’re using preexisting data that is a representation of invested clinical time and resources.

The fact that we’re using preexisting data in a different way has been key. Bringing our clinicians in from the start allowed us to identify their pain points and work collaboratively on this project. We showed them their input was integral and — instead of adding something new — the project was capitalizing on what they already do. We’ve seen the enthusiasm. People are coming to us to request to have their teams involved. We receive emails saying, “Hey, we heard about this great project. Can we be part of it?”

On joy in work

The enthusiasm and excitement during the meetings with our clinicians were the [first] indicators that something special was happening. People engage fully in the meetings, they’ve got lots of questions, and there’s a rich idea exchange that occurs in these conversations.


Learn more about engaging clinicians in improvement at the IHI Patient Safety Congress


During the pandemic, this project is bringing some joy in work because it addresses what [clinicians] most clearly care about, which is patient outcomes. This project is not an extra burden for the clinicians, and it supports their motivations for why they got into this profession. We’re using the science to support the caring.

On supporting what matters most to clinicians

I remember a conversation with one of our clinical department quality chairs. As the discussion evolved, we framed the trigger tool project by saying, “Doctor, tell us what keeps you up at night. What do you lose sleep over concerning patient care?” We then dive into the record to extract the data and measure this. Together, as a team, we use the data to guide improvements for our patient care systems which is what matters most to all of us.

On the value of doing improvement work in the middle of a pandemic

Part of why this project has been a real bright spot is because we’ve set a solid foundation for the institution to make positive change. We’re providing an encounter that balances some of the other experiences during the pandemic, which can be so draining. Both our clinicians and non-clinicians are exhausted. Everyone is facing so many challenges, both personally and professionally, and we’re able — even if it’s a small part of their day — to help people say, “I’m making a difference.”

On building a culture of safety and quality

  • Understand the value of strong leadership support. Getting [executive] leadership support is Quality and Safety 101, right? You need committed leadership to generate enthusiasm and keep this kind of project in the forefront. This helps you secure the required resources and the momentum to keep it moving.
  • Be open to learning from others. There was institutional interest in the IHI Trigger Tools from the outset, but in 2019 we dedicated our resources to designing and implementing a model for our oncology population. We launched the journey with a meta-analysis/literature review of some ~40 papers (referencing many experiences) and teamed up with MSK’s internal experts in epi-biostats to lay the foundation for the work. Also, in 2019, I was at the IHI Forum and attended a session called “Measuring Harm: Tools for Today, Tips for Tomorrow” presented by people from Massachusetts General Hospital and Brigham and Women’s Hospital. It was fabulous. I spoke with the presenters after the session and got some great information which I was able to bring back and share. This information provided valuable insight on the design of our data collection tools for this population. Getting answers to some of the queries we were struggling with gave us a lot of momentum.
  • Build quality and safety into your organization’s infrastructure. Often, quality and safety work are viewed as isolated and siloed. The challenge is to bring quality and safety into the fabric and culture of an organization. Ideally, we want the paradigm to shift so people think together [throughout an organization] about quality and safety. The incredible talent of our team and their efforts in the relatively short timeframe of this project has accelerated that process.

Our division networks with our clinical departments to focus on the culture of safety and quality at Memorial Sloan Kettering. In positioning the Division of Quality & Safety at the executive leadership level, the institution reinforces their commitment to this vital work. Quality and safety are not just one department’s job.

Editor’s note: This interview has been edited for length and clarity.

You may also be interested in:

IHI Global Trigger Tool for Measuring Adverse Events white paper

Root Cause Analysis Won’t Work If People Fear It

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