Editor's note: This content was presented at the 2017 Quality and Safety in Children's Health Conference, and was originally published in the summer 2015 issue of Children's Hospitals Today.
Kamishibai cards (K-cards) are a tool used in daily rounding to provide real-time data, foster rounding with a purpose, improve bundle compliance and hopes to prevent patient harm from hospital acquired infections. Here's how.
By Leslie Jurecko, M.D.
K-cards reside next to the managing for daily improvement boards on each inpatient unit. The
cards housed in the left slots are waiting to be used for an interaction. The cards on
the right are completed interactions with the green side facing out to denote all elements were
compliant or the red side facing out indicating an opportunity for improvement.
Many hospitals are attempting to find the right blend of safety culture, quality improvement and process improvement work. Some organizations have been on the path to transform their safety culture for years and are now incorporating lean methodologies into their work. Others have lean thinking ingrained in their teams and are now starting safety culture work. Finding the intersection of these areas, though similar, can be challenging.
Spectrum Health Helen DeVos Children's Hospital in Grand Rapids, Michigan, is 10 years into its safety culture journey. With a new focus on hospital acquired conditions (HACs), the goal is to increase reliability with the elements of bedside care that are known to reduce harm to patients. When these elements are grouped together, they're known as a bundle.
Ideally, incorporating bundles as standard work throughout the inpatient setting will reduce preventable harm from HACs.The hospital's objective was to creatively use both process and outcome data to empower teams. But early in the project, it became evident that technology was a limiting factor to obtaining real-time bundle compliance data. Therefore, leaders looked to the hospital's safety culture tools and challenged teams to round with a purpose while at the same time collecting data around bundle compliance.
The safety and quality teams at Helen DeVos Children's Hospital partnered with the process improvement team to develop rounding cards to audit standard work on inpatient units and to provide a template for leaders to round with a purpose. The team utilized a lean tool called Kamishibai cards (K-cards) that provide scripting for a short interaction between staff and leadership. Kamishibai is a Japanese term for "storytelling," originating from ancient monks who used display of cards to tell a story. Centuries later, the Toyota Lean Production System adapted the idea as a way to perform audits within the manufacturing process.
Supervisors place a series of cards on a board and select at random or according to schedule. This ensures employees maintain safety standards, keep the workplace clean and perform quality checks. At Helen DeVos Children's Hospital, the cards include short statements that read like a checklist of bundle elements. Each interaction takes approximately five minutes and involves a component of conversation that happens at the computer workstation and at the patient's bedside.
The purpose of these cards is to initiate conversation and to see if each bundle item on the card is compliant. If all care elements are performed correctly, the rounder provides in-the-moment-recognition, such as verbal praise, to the nurse. If an element is not completed correctly, it provides an opportunity for a discussion around the barriers the nurse faced that prevented him or her from completing the desired or expected care.
These interactions are about influencing vital behaviors in staff members as well as collecting process data. The focused elements on the K-card provide real-time compliance data and in-the-moment correction of bundle elements not completed. They also give staff members the ability to connect their work to preventing harm.
In addition to the K-cards, managing daily improvement (MDI) boards are another lean tool that displays process and outcome metrics for use in data-driven huddles with the goal of continuous daily improvement. The huddles help teams focus on problem solving and eliminating barriers to providing the expected standard of care.
Helen DeVos Children's Hospital has a small patient safety team in place, and engaging middle management in supporting this project was a key to its success. "Each and every staff member at our hospital is expected to be a patient safety champion," says President Bob Connors, M.D. This perspective gives teams the necessary support to lead outside of individual comfort zones and ask others to do more.
Nursing managers embraced this effective lean tool because they know the safety of patients is the most important goal. They also agreed it helps them to better connect with their teams and the scripting on the card keeps the interaction efficient. The expectation is that each unit completes four cards each day, seven days a week, both day and night shift.
Once engaged, teams began rounding on five prevention bundles, including catheter-associated urinary tract infections (CA-UTI), central line-associated bloodstream infections (CLABSI), ventilator associated pneumonias (VAPs), falls and pressure ulcers. The bundles have shown that when all elements are completed, harm is reduced. The hospital initially adapted a CLABSI bundle from the Children's Hospital Association Quality Transformation Network, and now utilize the Children's Hospitals' Solutions for Patient Safety (SPS) collaborative work for bundle development and data submission.
K-card interactions are beginning to have a positive impact on patient families, too. One parent says, "These cards are great! My child has a central line, and I usually serve as a verbal checklist for the nurse to ensure care is consistent with my expectations. I'm glad to see there is a standard that matches what I do for my child."
Rounding with a purpose also offers face-to-face interaction with executive and nursing leaders and gives staff members a voice to identify barriers and make suggestions on improvements. Since K-cards provide a template on how to perform the rounding audit, little to no education is necessary to implement their use. This means anyone, a bedside nurse or a CEO, can pick up a K-card and perform an interaction at any time.
K-card rounding fosters the high reliability principle of "deference to expertise," which means making every effort to see what those at the bedside know and encouraging decision making informed by their expertise. Nurses have grown to appreciate the opportunity to demonstrate the important work they do. "I like that executive leadership gets to see what my day looks like, including the increased amount of computer charting that is done," one nurse says. "Leaders also get to meet the patients through this process, which is great."
Since the launch of the program in November 2014, the hospital has had 3,468 interactions on HACs. Rounders range from charge nurses to managers and executive leadership. The hospital has already seen a significant increase in bundle compliance and expects harm metrics will also improve. One immediate outcome of the program is increased staff awareness around HACs. The hospital's event reporting system and daily safety check-ins include more language around HACs than ever before, and individual units are starting to complete apparent cause analysis on HACs, too.
The idea of using K-cards has rapidly spread to other areas of the hospital. Units are taking their own initiative by developing K-cards based on specific areas needing improvement. One unit developed a K-card surrounding the "five rights" of medication administration and bar code scanning. Other units are working on cards for bedside nursing reports and safe sleep practices.
A healthy culture and a learning environment for continuous improvement is important. The melding of patient safety with lean tools has enabled the hospital to motivate staff members to focus on harm prevention. This will continue to foster reliability and problem solving at the front-line and advance the hospital toward its ultimate goal of healing and never harming patients.
Leslie Jurecko, M.D., is medical director, Safety and Quality, at Spectrum Health Helen DeVos Children's Hospital inGrand Rapids, Mich.
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