KP Painscape Testing Packet by Innovation Consultancy

KP PAINSCAPE testing packet

VERSION 1.0 | January, 2011

THE INNOVATION CONSULTANCY

Copyright © 2011 Kaiser Permanente These testing materials were developed by Kaiser Permanente’s Innovation Consultancy with support from the Gordon and Betty Moore Foundation and Kaiser Permanente’s NCAL Community Benefits Program. As a part of our commitment to improve the health of communities around us, you may use and reproduce these copyrighted materials. Any questions or feedback can be emailed to: innovation.consultancy@kp.org

The Innovation Consultancy is a team of creative people within Kaiser Permanente who leverage design thinking to develop and implement innovations at the frontlines of health care delivery. We work with a broad range of people on the ground level to design and implement innovative processes, tools, roles, and spaces that improve patient care and the work experiences of our care providers. For more information about us and our work, please consult our website:

http://xnet.kp.org/innovationconsultancy

welcome to the KP PAINSCAPE testing packet KP Painscape was developed as a part of the Destination Bedside project funded by the Betty Moore Foundation and Kaiser Permanente NCAL Community Benefits. Designed by nurses in Sacramento and Santa Clara Kaiser Permanente medical centers, KP Painscape outlines enhanced practices for managing pain as the 5th vital sign by highlighting best practices to help nurses minimize unnecessary pain. It focuses on practice patterns, communications between nurses and their patients, and coordinated collaboration between nurses to help them stay ahead of their patients pain. This book is designed to support further testing of KP Painscape concepts using processes, tools, and ideas that are showing strong promise in four pilot units.

whyPAINmanagement Untreated or under-treated pain causes unnecessary suffering and negatively impacts patient recovery.1 Of the 23 million surgery patients in the US every year, approximate 50% of post-operative patients report having received adequate pain relief during the course of their recovery.*1,2,3 To address this, in 2001, The Joint Commission required all accredited hospitals to begin treating pain as â&#x20AC;&#x153;The Fifth Vital Signâ&#x20AC;? standardizing practices around appropriate pain assessment and the management of pain using the 0-10 scale.4 However, despite improvements brought upon by hospitals responding to Joint Commision requirements, the practice of managing pain still remains challenging in a clinical setting - with varied and inconsistent results around receiving adequate comfort. 3,5,6 "Chapter 17." Patient Safety and Quality- An Evidence-Based Handbook for Nurses. Ed. Ronda G. Hughes. Rockville: Agency for Healthcare Research and Quality, 2008. Print. http://www.ahrq.gov/clinic/medtep/acute.htm#acuteintro 3 McCaffery M. Pain management; problems and progress. In: McCaffery M, Pasero C. Pain: Clinical Manual. 2nd ed. St. Louis, MO: Mosby; 1999. p. 1 - 14 4 JCAHO. Comprehensive Hospital Accreditation Manual. Oakbrook Terrace, IL, 2001. 5 Apfelbaum JL, Chen C, Mehta S, et al. Postoperative pain experience: results from a national survey suggesting postoperative pain continues to be undermanaged. Anesth Analg 203:97:534-40 6 Hutchinson, RW. Challenges in acute post operative pain management. Am J Health Systm Pharm 2007; 64(6 Suppl): S2- S5. 1

*23 million in a 1992 report and 16.1 million in a 2004 report. Both state 50% or more getting inadequate pain relief.

[

] 5

to adequately manage pain

LITERATURE is calling for... When examining the body of knowledge on pain management, literature says there are opportunities to go beyond the 0-10 scale and focus on key evidence-based areas of improvement such as: •

More regular assessment of acute pain and reassessment after each intervention1

•

Timely documentation to facilitate better interdisciplinary communications amongst clinicians2,4

•

Better nursing communications to determine patients’ needs to achieve adequate pain relief and better relational coordination (frequent communications, shared goals, shared knowledge, mutual respect amongst clinicians)5,6

•

Better treatment patterns to prevent severe pain and control continuous pain3,4

•

Better collaboration amongst clinicians, patients and family to manage post-surgical pain2

•

More comprehensive pain history evaluations before surgery2

•

Collaborative pain management planning involving patients and family2

•

Better patient and family education in pain management2

•

Employing multi-modal approaches to pain management4

•

Use of Complementary Alternative Methods to achieve pain relief7,8

But, where can we focus to make the most impact when looking at nursing practice? JCAHO. Comprehensive Hospital Accreditation Manual. Oakbrook Terrace, IL, 2001. 2 Car DR, Jacox AK, Chapman CR, et al. Acute Pain Management: operative or medical procedures and trauma, No. 1. Rockville, MD: AHCPR pub. No. 920032; Public Health Service; U.S. Dept. of Health and Human Services, 1992. 3 American Pain Society. Quality improvement guidelines for the treatment of acute and cancer pain. JAMA 1995; 247:1874-1880 4 Gordon, DB, Dahl J, Miaskowski C, et al. American Pain society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med. 2005; 165:1574-1580. 5 Gittell JH, Fairfield K, Bierbaum B, et al. Impact of Relational coordination on quality of care, postoperative pain and functioning, and length of stay: A nine-hospital study of surgical patients. Med Care. 2002; 38 (8):807-819 6 Horsley J, Crane J, Reynolds MA. Pain: Deliberative Nursing Interventions. New York: Grune & Stratton, 1982 7 Kwekkeboom K. Pain Management strategies used by patients with breast and gynecological cancer with postoperative pain. Cancer Nurs. 2002;24 (5): 378- 386. 8 Pellino TA, Gordon DB, Engelke ZK, et al. Use of nonpharmacologic interventions for pain and anxiety after total hip and total knee arthroplasty. Orthopaedic Nurs. 2005;24(3):182-190.

why patients FALL onBEHIND their pain In our observations of nurses and patients, we saw that the practice of managing pain is multi-faceted and very complex. We observed 6 common situations that cause patients to get behind on their pain.

WHAT WE SAW:

Trust is key Patients need reassurance that their nurses are proactively looking after their pain and are acutely aware of signs that indicate whether or not that is the case.

Already behind Even when instructed to call at the first sign of pain, patients often donâ&#x20AC;&#x2122;t call for pain meds until they are already behind on their pain.

Miscommunication

Morning Agony

Patients often donâ&#x20AC;&#x2122;t understand what nurses want when asked to describe their pain on a 0-10 scale.

Patients can very easily sleep through their pain at night, and find themselves in unnecessary pain in the morning.

Remembering to Reassess In the rush of the day, it can be difficult to remember to reassess patients and document the reassessment.

The pills donâ&#x20AC;&#x2122;t work Patients often lose faith in their oral pain meds because of perceived ineffectiveness- this can happen when patients are transitioned off IV pain meds and not given adequate doses of oral pain meds.

why patients FALL BEHIND storyboard Here is your Norco Let’s start off with one and see how it works. I can always bring in another one.

I don’t want the pill. It didn’t work. Just bring me the IV stuff please.

I suggest we give you Norco because we want to transition you off of IV pain meds.

Okay

The pills don’t work Patients often lose faith in their oral pain meds because of perceived ineffectiveness associated with inadequate dosing when patients are transitioned off IV pain meds.

i nee meds pd pain am likelease. i a ten. good morning

I will get you something right away. Did you not get anything at night? i was sleeping.

i am so behind....

Morning Agony Patients can very easily sleep through their pain at night, and find themselves in unnecessary pain in the morning.

How come he didn’t tell me earlier?

Make sure you call me as soon as you start to experience pain so that we can stay ahead .

it’s a 7.

how is your pain?

Already behind Even when instructed to call at the first sign of pain, patients often don’t call for pain meds until they are already behind on their pain.

here is your pain pill

after i set up this transfusion i will go reassess room 12

I gotta reassessroom 12 after i get this report

thanks

Remembering to Reassess In the rush of the day, it can be difficult to remember to reassess patients and document the reassessment.

let’s get you out of bed.

Are you in any pain?

It hurts to try to get i up.

no, I am doing great. No pain at all.

Miscommunication Patients often don’t understand what nurses want when asked to describe their pain on a 0-10 scale.

So you said you were in pain. Let me check what is available to you...... OKay, you can get percocet or dilaudid I am worried about my pain

So, I will go get you some percocet Oh, Actually you are due for dilaudid for another hour

I am scared

How come she doesn’t know this?

Trust is key Patients need reassurance that their nurses are proactively looking after their pain and are acutely aware of signs that indicate whether or not that is the case.

what KP PAINSCAPE is about KP Painscape is about staying ahead of our patientsâ&#x20AC;&#x2122; pain and standardizing best practices to manage pain as the fifth vital sign. Good pain management relies on great communication between patient and nurses, as well as around-theclock collaboration between clinicians to ensure patient pain levels stay within controlled limits. KP Painscape emphasizes six essential behaviors that improves pain management through enhancing individual nursing practice and team nursing practice.

INDIVIDUAL NURSING PRACTICE PREPARE BEFORE GOING INTO THE ROOM

PROBE PAIN SCALE RESPONSES (considering functional goals and ADLS)

USE THE MOST APPROPRIATE DOSE FOR INITIAL TRANSITION TO PO PAIN MEDS

REASSESS ON A TIMELY BASIS

TEAM NURSING PRACTICE

ENCOURAGE AROUND THE CLOCK DOSING (even if PRN is ordered)

WORK AS A TEAM TO KEEP PAIN REGIMEN GOING AT NIGHT

INDIVIDUAL NURSING PRACTICE PREPARE BEFORE GOING INTO THE ROOM

PROBE PAIN SCALE RESPONSES (considering functional goals and ADLs)

USE THE MOST APPROPRIATE DOSE FOR INITIAL TRANSITION TO PO PAIN MEDS

REASSESS ON A TIMELY BASIS

TEAM NURSING PRACTICE

ENCOURAGE AROUND THE CLOCK DOSING (even if PRN is ordered)

WORK AS A TEAM TO KEEP PAIN REGIMEN GOING AT NIGHT

IN PRACTICE: ENHANCED PAIN ASSESSMENT

Before going into the room take a time-out: Know the dose and schedule for pain meds Anticipate upcoming activities for patients Review opportunities to advocate for patient comfort

TOOLS:

Reassessment Reminders (KPHC coming 2011)

Go into patient room: Ask patient if in pain and what number on a scale of 0-10 and comfort level Probe for pain level considering functional goals and ADLs Recommend pain interventions as appropriate given upcoming activities Explain recommendations Intervene Within 60 minutes: Reassess for efficacy, side effects, and patient safety

IN PRACTICE: CROSS SHIFT TEAMWORK

TOOLS:

Cross shift teamwork is about two things: 1. During shift change (NKE), review the last given pain medication and the next available dose. 2. Establishing specific roles to keep pain regimen going at night. The roles are outlined as follows: Evening Shift: Establishes plan with patient for managing pain at night. Night Shift: Executes plan established by evening shift and advocates for pain meds at night. Day Shift: Reports out if they had to catch up with pain in the morning.

Last Given/Available Next Patient Poster

Patient Pain Agreement

KP PAINSCAPE in action next available percocet is 1200, every 4 hours....I should start encouraging po pain meds only.

your percocet is available soon and can be taken every 4 hours. we should really try to be staying on the percocet so you can go home tomorrow. Sounds

like he knows what he is talking about.

Do you want me to go get your 12 o’clock percocet>

yeah, thank you. Prepare before going into the room

How about when you move?

Are you in any pain?

It hurts to try to get i up.. That’s more like a 7.

no, I am doing great. No pain at all.

I suggest we medicate for your pain when moving, that way you can participate in your PT today. okay.

Probe pain scale responses (considering functional goals and ADLS)

Here is your Norco Let’s start off with two and see how it works. If it is too much, we can always try out one pill.

I suggest we give you Norco because we want to transition you off of IV pain meds.

Okay

The norco is working well to manage my pain. Use the most appropriate dose for initial transition to PO pain meds

How is your pain now? It’s been about 45 minutes since your pain pill, is it working to relieve your pain?

oh, time to reassess room 15.

Reassess on a timely basis

I am just coming to check how your pain is doing. Your last pain pill was 3 hours ago and you have another available if you need it.

it’s really important to stay ahead of the pain. I suggest you take a pain pill now so your pain doesn’t get too out of control.

yeah, my pain is just starting to come back. It’s not much though.

okay.

Encourage around-theclock dosing (even if PRN is ordered)

Rest is important, but it’s more important that you are comfortable in the morning. How about I have the RN

it’s really important to manage pain at night. I suggest making a plan now and then I will coordinate with your night RN to execute it.

come in at 2am with your percocet?

i really feel i need my rest. okay, sounds good.

Work as a team to keep pain regimen going at night.

.... after hours of observation

2 Medical Facilities 4 Med-Surg Units 200 Staff RNs

A JOURNEY revisited

.”

ice t c a r p e h t n o s cu ager o f o t d e “We ne ne, Unit M an - Justy

in e pa n fi e ’s d actices, t e l : al pr w go nt best cesses to e n e A o agem tools/pr . n a m uild ort them b n the supp

“You gotta stay ahead of the pain.” - Tom, RN

keep o t e t a c o v d a a t t o “You g ls!” il p e h t n o m e th Amanda, RN This is so muc h fu n! Now, let’s take all of these best practices and put them together to teach everyone on our pilot units

the on s cu fo o t d ee n e W “ e.” ap sc in a P P K f o s r io behav r -Tracy,, Unit M anage

Tracy creates the first iteration of 6 Patterns of Effective Pain Management

NAG

ERS,

PHY

SICIA

N AS

SIST

ANT

ideas !

We go live Painscape on with KP 4 units!

E MA

eas d i e s e h t f o t we tested a lo

“By the tim e we get her already asleep e the patient is ” - NOC R N ape rap sc in a P P K es t ri w a Rhond to “Paul Revere”! “You need your patient’s trust to manage pain.” - Lllyod, RN

PATIE NTS, HOSP ITAL L EADE RSHIP , DESIG NERS

URS

great

But, we kept emphasizing tools. And, it was not sticking.

S, N

a e d a m h! a t t e r Lo ain grap p

h ad

, RN

one every

MDS

Over 60 frontline staff come together to ideate around pain management

Susan made a reassessment reminder!

Evening RNs start working with NOC RNs to manage pain through the night

iring KP

eloping, and insp Co-designing, collaborating, dev Painscape, special thanks to:

t 220, Kaiser Permanente Santa Clara Medical Center, thanks to Uni amento, Unit 235, and all of the hospital leadership support. KP Sacr support. 4-West, 4-East, 1-West, and all of the hospital leadership

Funding KP Pains cape an project, dt special t hanks to he Destination Bedsid :

The Betty Moore Foundation and Kaiser Permanen te NCAL Com munity Benefits

initial PILOT UNIT da ta RN Surveys: MORE DISCUSSIONS WITH PATIENTS

Patient Surveys: MORE INFORMED PATIENTS

+44% POST GO-LIVE Average Across Four Pilot Units

MORE COLLABORATION WITH PATIENTS

POST GO-LIVE Average Across Four Pilot Units

+25% POST GO-LIVE Average Across Four Pilot Units

Survey question: My nurse taught me that medication for pain after surgery is effective when given: best answer of "Fixed Schedule" (Minimum pilot unit increase of neutral, average across the four pilot units increase of 19%) 2 Survey question: I have a pain management discussion with my patients during the first half of my shift. (Minimum pilot unit increase of 12%, average across the four pilot units increase of 44%) 3 Survey question: Planning my workflow for the shift and anticipating patient needs, I find the most helpful person on the pain management team is: best answer "Patient" (Minimum pilot unit increase of 17%, average across the four pilot units increase of 25%)

Other Clinicians Surveys: 5

ABILITY TO EFFECTIVELY MANAGE PAIN

ABILITY TO SAFELY MANAGE PAIN

MAKES MY JOB EASIER

+13%

+27% POST GO-LIVE Average Across Four Pilot Units

POST GO-LIVE Average Across Four Pilot Units POST GO-LIVE Average Across Four Pilot Units

Morning Pain Variance: 4-WEST- SACRAMENTO MEDICAL FACILITY

The Pain Variance reports from our four pilot units show the following:

Pain Variance

DEEP DIVE

GO-LIVE AND PDSAs

FINAL VERSION

•

Pain variances of greater than 1 have more opportunity for improvement Pain variances of 1 and under will not likely show much improvement There seems to be a “sweet spot” between .5 and 1 as a range for optimal pain variance

I am confident in the nurses ability to effectively manage the pain of the patients on this unit (Minimum pilot unit increase of 16%, average across the four pilot units increase of 27%) 6 The way patients pain is managed on this unit makes it easier for me to do my job (Minimum pilot unit increase of 11%, average across the four pilot units increase of 15%) 7 I am confident in the nurses ability to safely manager the pain of the patients on this unit (Minimum pilot unit increase of 4%, average across the four pilot units increase of 13%)

testing

KP PAINSCAPE timeline TIMELINE Implementing KP Painscape involves a 6-step process lasting approximately 8 weeks. The KP Painscape workbook provides the full description of the process.

2 WEEKS GET READY!

MANAGEMENT TEAM MEETING

1 DAY KICK-OFF

RN CHAMPION KICK-OFF MEETING

4 WEEKS* PDSAs

1 WEEK PREP GO-LIVE

1 WEEK GO-LIVE

TRAINING FOR GO-LIVE

*Suggest the first unit of a hospital that goes live with KP Painscape consider having a longer time period (6 Weeks) to run PDSAâ&#x20AC;&#x2122;s to ensure that system isses are resolved.

ONGOING SUSTAIN

e p a c s n i a KP P K O O B K WOR Your guide to test in

g out KP Painscap

e on your unit

Hello! Welcome to the KP Painscape workbook! This workbook is designed for project co-leads to test out concepts of KP Painscape. It is intended to guide you through the process of emotionally engaging your staff, testing KP Painscape, and making KP Painscape work for your unit. In this workbook you will immerse them in the solutions, help them try out the solutions, guide them through small tests of change to adapt them to the needs of the unit, and how to try out KP Painscape. It also provides tips and thought-starters throughout to inspire you. Have a read through before you start and have fun!

How to use the workbook: This workbook is designed to guide you throughout the entire process. Broken out into 6 sections, each section has a part that outlines project manager preparations and a part with activities. Lastly

Table of Contents GET READY! • •

Part 1: Preparing Yourself Part 2: Unit Management Team Meeting

KICK-OFF • •

page 53

Go-Live

WORKSHEETS •

page 47

Part 1: Preparing Yourself Part 2: Unit Management Team Meeting

GO-LIVE! •

page 41

Part 1: Preparing Yourself Part 2: Managing PDSAs

PREPPING FOR GO-LIVE • •

page 33

Part 1: Preparing Yourself Part 2: Kick-Off Meeting

MANAGING PDSAS • •

page 27

page 57

Worksheets for RN Champions and Unit Management Team to copy and use throughout the process

What this process will look like: 2 WEEKS GET READY!

MANAGEMENT TEAM MEETING

1 DAY KICK-OFF

RN CHAMPION KICK-OFF MEETING

4 WEEKS* PDSAs

1 WEEK PREP GO-LIVE

1 WEEK GO-LIVE

TRAINING FOR GO-LIVE

*Suggest the first unit of a hospital that goes live with KP Painscape consider having a longer time period (6 Weeks) to run PDSA’s to ensure that system isses are resolved.

ONGOING SUSTAIN

GET READY! with unit management tea m Arrange a one hour meeting with your unit management team and co-lead to understand the unit culture and the staff that you will be working with, and make plans for implementing KP Painscape.

PART I:

Preparing yourself

PART II:

Unit Management Team Meeting KP PAINSCAPE OVERVIEW (A) Get to know KP Painscape (B) facilitate “In my own words” activity PAST IMPLEMENTATIONS Facilitate discussion on what’s worked in the past and what’s not DETERMINE NURSE CHAMPIONS Establish and build a team of nurse champions BASELINE METRIC COLLECTION Plan how baseline metrics will be collected TALK ABOUT SCHEDULE AHEAD

PART I:

Preparing yourself

nded Review the KP Painscape Overview so you are grou in the materials.

Pages 8-17 are the

e a lot over You are going to be talking about KP Painscapsom time to the next couple weeks- make sure you take scapee! think about how you would explain KP Pain

Think about the schedule ahead and the timing of 2 WEEKS GET READY!

1 DAY

the key activities.

4 WEEKS*

KICK-OFF

MANAGEMENT TEAM MEETING: RN CHAMPION KICK-OFF _____________ MEETING: E DAT

What will be involved?

Why are we doing this?

What is KP Painscape?

PDSAs

key pages to share

1 WEEK PREP GO-LIVE

1 WEEK

ONGOING TRAINING FOR IN STA SU GO-LIVE! GO-LIVE (hold _____________ within 3 days of DATE Go-Live) consider having a live with KP Painscape es go t tha ility fac al of a medic issues are resolved. *Suggest the first unit to ensure that system â&#x20AC;&#x2122;s SA PD run to ) eks . 6 We longer time period (i.e GO-LIVE

e copies of the Unit Management Prep mad have you sure e mak ent, agem man t uni the Before meeting with ge 59) for everyone at the meeting. (pa rk ewo Hom ff k-O Kic and 58) ge (pa eet Worksh

PART II:

Unit Management Team Meeting

KP PAINSCAPE OVERVIEW Review the KP Painscape Overview with the leadership team so they are grounded.

Pages 8-17 are the key pages to share

IN MY OWN WORDS To ensure the leadership team has a strong understanding of KP Painscape. Have each participant fill out the top section of Unit Management Prep Worksheet (page 58).

PAST IMPLEMENTATIONS

Understand the unit’s approach to change, what has been successful in the past, and what can change to ensure a strong pilot test.

In the past, what’s worked? ________________________________________________________ ________________________________________________________ _______________________

What hasn’t worked? _____________________________________________ _____________________________________________ _____________________________________________

This time around, we will: 1. __________________________________________________ 2. __________________________________________________ 3. __________________________________________________ 29

DETERMINE NURSE CHAMPIONS Identify nurses who will explore pain management best practices, advocate for KP Painscape, and collaborate with the entire unit to adapt KP Painscape to unit workflow. NS TING CHAMPIO TIPS FOR SELEC

Willing

1. _________________________________

Passionate

2. _________________________________

Amazing!

3. _________________________________

Looked up to

4. _________________________________

Good

Respected

Our KP Painscape Nurse Champions

Recommendation: 2 RN champions per shift per unit

Amazing!

5. _________________________________

Good

Well Liked

Influential social

Amazing!

6. _________________________________

Good

BASELINE METRIC COLLECTION

Review metrics and plan for who will be collecting each metric. Itâ&#x20AC;&#x2122;s really important that the unit management team collects metrics to truly understand their unitâ&#x20AC;&#x2122;s current state. For tracking metrics, use the KP Painscape Excel Metrics Tracker (download from http://www.kpinnovation.org)

MORNING PAIN COUNT: Have an Assistant Nurse Manager or Charge RN for each shift check with their RNs approximately 1-2 hours into their shift to see how many of their patients needed pain medications for breakthrough pain at the beginning of their shift.

REASSESSMENT RATES: For KP Painscape, it is best to track reassessment rate by shift for each day. Explore ways your hospital currently reports reassessment rates and arrange for these reports to be accessed by the unit management team.* * If you are a Kaiser Permanente facility you may want to arrange access to Crystal Reports. Connect with your facility to arrange access and get trained on how to use these reports.

How we will collect: ____________________________________________ ____________________________________________ Who will collect: ____________________________

Have each participant fill out the middle section of Unit Management Prep Worksheet (page 58)

PLAN SCHEDULE Talk to the unit management team about the schedule ahead and lock down any key dates you can.

2 WEEKS

1 DAY KICK-OFF MANAGEMENT 4 WEEKS* TEAM MEETING: RN CHAMPION 1 WEEK PDSAs 1 WEEK KICK-OFF PREP GO-LIVE _____________ MEETING: DATE GO-LIVE TRAINING FOR ONGOING _____________ GO-LIVE (hold SUSTAIN DATE(S) GO-LIVE! _____________ DATE within 3 days of _____________ Go-Live) GET READY!

DATE

_____________ DATE

*Suggest the first unit of a hospital that tests KP Painscape consider having a longer time period (i.e. 6 Weeks) to run PDSA’s to ensure that system issues are resolved.

KICK-OFF HOMEWORK Before the Kick-Off, have the RN Champions and management team ‘See it for themselves’- this means actually going out onto their unit to collect pain management stories and emotionally connect to the current status of the unit. You should work with the department team to facilitate this exercise or use committee time or backfill for the RN Champions. After conducting the observations and interviews, have the RNs and unit management team make posters about their experiences to share at the Kick-Off.

Have the RN Champions and Unit Management Team Kick-Off Homework (page 59)

KICK-OFF with RN Cha mpions Hold a half-day Kick-Off to ground them in KP Painscape, and conduct the first round of PDSAs to tailor ideas to meet the needs of the unit.

PART I:

Preparing yourself

PART II:

Kick-Off Meeting UNDERSTAND THE CURRENT STATE (A) storysharing about the issues (B) Share baseline metrics KP PAINSCAPE OVERVIEW (A) Share what KP Painscape is about (B) What does it look like in practice DEFINE CHAMPION ROLE CONDUCT 1ST PDSA CYCLE Get started with small tests of change for 3 of the concepts PLAN UNIT COMMUNICATION SET UP NEXT STEPS

PART I:

Preparing yourself

room, and invitees for Finalize the date, time, meeting tees have the homework the Kick-Off. Make sure all invi plete the assignment. For and have time available to com-da y session is suggested; the Kick-Off meeting, a half stm meeting however, make the necessary adju ents to your agenda based on available time.

â&#x20AC;&#x2122;t just story-TELL, have Review story-sharing activity. doDonthis , review the storythe group story-SHA RE! To how best to facilitate this sharing activity to think about exercise.

(4 HOUR MEETING) KICK-OFF AGENDA it Management Team RN Champions and Un ries/Baseline metrics (45 minutes) Share sto Overview (1 hour) KP Painscape ampion Role (10 minutes) Define Ch Metrics 101 (5 minutes) PDSA and cle Cycle/Try First PDSA Cy (1 hour) Plan 1st PDSA (45 minutes) Debrief ps (15 minutes) Next Ste

ilitate this discussion:

How am I going to fac

_________________

____________________

_________________

____________________

_________________

____________________

_________________

____________________

_________________

____________________

ment Team and Loop back with your Unit Managehave collected. have them share what data they Kick-Off. If Prepare this data to share at theg the Painscape your management team is usin just KP e mak sure you Metrics Excel Spreadsheet, then ff. have the most recent version to share at Kick-O

What baseline metrics

I want to share:

_________________

____________________

_________________

____________________

_________________

____________________

PART I:

Preparing yourself (pg. 2) Refer to the KP n Painscape in Actio ) 17 6(1 rd oa yb Stor

ain each of the KP Prepare how you are going to explconc look in practice- i.e. Painscape concepts and how theesses, epts key questions to ask, new proc tools, etc. Concept

ize

What you will emphas

Prepare before going into the room

Probe Pain scale responses considering ADLs and functional goals Use the most appropriate dose for initial transition to PO pain meds Reassess on a timely basis

Encourage around the clock dosing

Work as a team to keep pain regimen going at night

PART II: 1A

Kick-off Meeting

UNDERSTAND THE CURRENT STATE: SHARE STORIES Have an open discussion about what everyone saw on the unit, what they heard from their peers and patients. Use this time to also introduce the Why We Fall Behind Storyboard and see how the RN Champions feel about it.

TIPS FOR EN GAGING TH

EM EMOTI ONALLY

Hear it

Feel it

Good

Amazing!

Hear it fro

m you

What did you learn on the unit? What suprised you?

Which of these are most frustrating? Why?

UNDERSTAND THE CURRENT STATE: SHARE BASELINE METRICS Share the current state of pain management on the unit and discuss how KP Painscape might impact the unit.

KP PAINSCAPE OVERVIEW: WHAT IS KP PAINSCAPE? Familiarize the Kick-Off participants with all of the elements of KP Painscape.

Hear it fro

m each oth

Good

Amazing!

Why we fall behind storyboard.....

What we saw...

IN THE ISS UES:

Do you have a specific story related to these?

Do you identify with these stories? Do they resonate?

How do we feel about where we are based on the data? Do you think KP Painscape will have a beneficial impact on this unit?

Pages 8-17 are the key pages to share

KP PAINSCAPE OVERVIEW: WHAT KP PAINSCAPE LOOKS LIKE

For the discussion, refer to the KP Painscape Storyboard (page__)

Give participants a mental vision of what KP Painscape looks like in practice by sharing storyboards, more detailed descriptions, and even acting it out.

Act 1: Time-out, Probing

Act 2: Most Appropriate Dose

Introduce the problem: _______________________________________

Show them! Practice â&#x20AC;&#x153;I noticed...â&#x20AC;? verbal follow-up, practice physical manipulation.

Show them! Practice explanation to patient as to why, letting them know you can always decrease dose

_____________________________________________________________

Reiterate the solution: _________________________________________

Act 3: Around-The-Clock Dosing

Act 4: Pain Regiment At Night

Introduce the problem: _______________________________________

Show them! Practice using active voice to encourage around the clock dosing.

Show them! Practice how to talk to patients to make night time plan using an active voice.

_____________________________________________________________

Reiterate the solution: _________________________________________

DEFINE CHAMPION ROLE

What does being a champion mean? supportive! willing to try

Reiterate the solution: _________________________________________

As a group, define the champions role, what the expectations are, and how everyone will work together.

What are the expectations of this group?

ideas! 37

CONDUCT FIRST PDSA CYCLE

Kick-off the PDSA cycle by trying the Initial PDSAs for 3 concepts.

THE INITIAL TESTS: The first round of PDSA tests have been designed for your team. During the Kick-off, start out by testing these three concepts: 1. Probe pain scale responses considering ADLs and functional goals (page 61) 2. Encourage around the clock dosing (page 64) 3. Work as a team to keep pain regimen going at night (page 65) AFTER THE INITIAL TESTS: Come back together as a group and talk about what happened, how it felt, and fill out the PDSA Tracker (page 43) and plan the next test.

Encourage your RNs to set up a PDSA Journal to take notes in throughout the PDSA process. Refer to page 66 to see how to set one up.

What happened?

How did it feel?

PLAN UNIT COMMUNICATION

Plan how the team is going to be communicating what is being testing to the entire unit during the PDSA cycles. Throughout the PDSA process, have the RN Champions continue to update and create new unit communication assets. Use the Unit Communication Worksheet (page 68) at your weekly check-ins to make sure the team is communicating with the entire unit.

LE TO RESPOND: HOW WE WANT PEOP • Be open • To try out ideas ible • Be patient and flex k • Give feedbac

ster KP Painscape Po

WHAT WE NEED TO

• • • •

TELL EVERYONE: Working on pain mana gement Trying out KP Painscape ideas What KP Painscape is We will be asking for fee dback and participation

Huddle Message for Date _____

At a glance! are trying....We

CREATE A POSTER:

CREATE HUDDLE MESSAGES:

CREATE A CRIB SHEET:

What will it say:________________

What will they say:______________

What will it say:________________

____________________________

Who will make it:_______________

Setting up regular check-ins is critical to managing the PDSA cycles. As a group, come up with a plan to stay connected and collaborating.

SET UP NEXT STEPS

WHAT THE NEXT COULD OF WEEKS WILL LOOK LIKE: PDSAs WEEK 1

1 WEEK WEEK 2

WEEK 3

WEEK 4

PREP GO-LIVE

1 WEEK

GO-LIVE WORK AS A TEAM TO KEEP PAIN REGIMEN GOING AT NIGHT

PROBE PAIN SCALE RESPONSES CONSIDERING ADLS

ENCOURAGE AROUND THE CLOCK DOSING

PLAN

PREPARE BEFORE GOING INTO THE ROOM

PLAN

REASSESS ON A TIMELY BASIS

PLAN

HIGHEST DOSE FOR INITIAL TRANSITION TO PO PAIN MEDS

SET UP WEEKLY CHECK-INS:

E-MAIL CHECK-INS:

INFORMAL CHECK-INS:

Set up a time that works best for the RN Champions and management team to meet weekly over the next 4 weeks:

It is important to keep the team in touch with each other. Collect the RN Champions e-mails so that the team can correspond via e-mail.

Let everyone know that you will be visiting the unit often to see how things are going and help guide the process.

________________________________

M anaging

PDSAS

This is a time to make KP Painscape yours. The guidelines and activities in this section will provide you with the structure and tools to successfully run PDSAs around KP Painscape, and continue to guide the RN Champions on the PDSA cycles. PART I:

Preparing yourself

PART II:

Managing PDSAs TRACKING PDSAs WEEKLY CHECK-INS Meet with unit champions on a weekly basis to do formal check-ins INFORMAL CHECK-INS Round floor informally on a daily basis to check in.

PART I:

Preparing yourself

weekly Make sure you have scheduled allduleofd the each for check-ins and have a room sche meeting. SA process, As you prepare to guide the PD environment an ing port make sure you are sup g, and gets more nnin begi the that is explorative at definitive near the end. CREATE SOLUTIONS

Organized, Directive, Explaining, up Decisive, and Scaling

EXPLORATIVE

ive,

Open, Flexible, Support Messy, and Organic

PDSA PLANNINGworksheet

the PDSA Before each check-in, make sure be. In addition, tracker is as up to date as it can es of the unit make sure you have plenty of copi communication worksheet and PDSA planning worksheet. WEEK 2: CHECK-IN

WEEK 1: CHECK-IN

Get feedback and pla next test: Cross Shift Probing Around-The-Clock Introduce: Time-out Reassessment

n Get feedback and pla t: next tes Cross Shift Probing Around-The-Clock Time-out Reassessment Introduce: Highest Dose

HOW THINGS ARE NOW:

HOW YOU WANT THINGS TO BE:

cation Use the Unit Communi and PDSA 68) ge (pa t hee rks Wo (page 67) at Planning Worksheet . your weekly check-ins

WEEK 3: CHECK-IN

Scale up all tests

WEEK 4: CHECK-IN ve

(refer to Prep for Go-Li section)

Make decisions Plan for Training Rehearse Training Plan for Go-Live

PART II: 1

TRACKING PDSAs

Concept

First Test

Managing PDSAs

Use the PDSA tracker to help run your check in meetings and coordinate your multiple tests. It will help keep your champions on track to developing and establishing Painscape for the floor. Results of First Test

Second Test

Results of Second Test

Prepare before going into the room

Probe Pain scale responses considering ADLs

Use the most appropriate dose for initial transition to PO pain meds

Reassess on a timely basis

Encourage around the clock dosing

Work as a team to keep pain regimen going at night

TRACKING PDSAs (CONTINUED)

Concept

Prepare before going into the room

Probe Pain scale responses considering ADLs

Use the most appropriate dose for initial transition to PO pain meds

Reassess on a timely basis

Encourage around the clock dosing

Work as a team to keep pain regimen going at night

Third Test

Results of Third Test

Fourth Test

Results of Fourth Test

WEEKLY CHECK-INS

Use the PDSA tracker during your weekly check-ins. Keep the check-in meeting casual and really try to understand how everyone is reacting to the tests and change.

Weekly Check-In A genda: do? 1. What did we ?

ed 2. What happen

e the story

learn? Try â&#x20AC;&#x153;Fram 3. What did we right) activityâ&#x20AC;? (to the

Gworksheet

PDSA PLANNIN

do 4. What will we

next? Fill out PD

heet (page 67) Planning Works

icate to going to commun 5. What are we t Unit ing week? Fill ou the unit this com ksheet (page 68) Co

or mmunication W

HOW YOU HOW THINGS

WANT THINGS

TO BE:

ARE NOW:

I overheard

someone do

ing it

People talked about it at the huddles

Key Insight: On people are do ly some ing the prob ing

Som me to eone ca me ask m up to e abou t it

Some people give me blank loo ks when I ask them about it.

FRAME THE STORY: A great exercise to help your RN champions share what they learned is to create a frame of supporting arguments around the key learning. Bring post-its and scissors to the meeting and have the RN Champions cut a square in the post-it note, post the post-it note on a piece of paper, and write they key insight on the piece of paper. Then, on the post-it frame, write the supporting quotes, observations, or comments that lead to the key insight.

INFORMAL CHECK-INS

Date

Who?

Itâ&#x20AC;&#x2122;s important to keep checking on the unit throughout the PDSA process. Try to visit the unit daily, checking in with management, Champions, and RNs who are testing ideas.

What am I looking for?

What did I see?

PREPPING for Go-Live Use your last PDSA weekly check-in to make decisions as a team about KP Painscape, plan for training, and plan for go-live. Then, it is time to train the unit and connect the nurses frustrations around pain to the solutions that KP Painscape provides and showing the nurses what it looks like.

PART I:

Preparing yourself

PART II:

Prepping for Go-Live with your team MAKE DECISIONS Final decisions on what KP Painscape is for your unit PLAN FOR TRAINING REHEARSE TRAINING Create KP Painscape skits for training TRAINING SIGN-UP PLAN FOR GO-LIVE

PART I:

e sure people Finish up all of the PDSAs andPDmak lk are comfortable with the final ChaSA.mpWa and ions the floor to check-in with RN managers.

e for Lock down the date, times, andtraispac sign-up ning post you training. Make sure . ning trai the t sheets and flyers abou

plate and Review the training presentation tem will be you , team the agenda (page 50). As a ning session, designing the KP Painscape traid in the agendabutand it is important to get grounde cha mpions. assets before you meet with the

Preparing yourself

cker Make sure the PDSA Tra d. ate upd is 43) (page

PART II: 1

Prepping for Go-Live with your team

MAKE DECISIONS After so many iterations of KP Painscape, it is important for all of the RN Champions to come back together and make final decisions about what they want KP Painscape to be for their unit. Concept

Whatâ&#x20AC;&#x2122;s will this look like on our unit?

This is important to pain management because:

How could we support this with policy?

Prepare before going into the room

Probe Pain scale responses considering ADLs

Use the most appropriate dose for initial transition to PO pain meds

Reassess on a timely basis

Encourage around the clock dosing

Work as a team to keep pain regimen going at night

PLAN FOR TRAINING With the RN Champions and Unit Leadership, plan out the agenda for the Go-Live Training.

Sample Agenda

Key Assets

How long will this take?

Who will lead this?

Welcome (Suggestion: unit management or hospital leadership)

23 million page (screenshot) Why Pain

6 trademark stories (screenshot) Frustration Activity

We tried..we heard (screenshot) Making KP Painscape Ours (Suggestion: RN Champions)

(Overview) Our KP Painscape

KP Painscape Skits (Suggestion: RN Champions)

Next Steps

REHEARSE TRAINING As a group, outline and create a skit to present at the training session to show the unit KP Painscape. Have each RN champion fill out their own skit exercise, so that they can refer to it before their respective training sessions.

ACT 1: TIME-OUT, PROBING

Have RNs write out the skits on their Training Skit Planning Worksheet (page 69)

ACT 2: APPROPRIATE DOSE

Introduce the problem: __________________________

_______________________________________________

Show them! Practice “I noticed...” verbal follow-up, practice physical manipulation.

Show them! Practice explanation to patient as to why, letting them know you can always decrease dose.

_______________________________________________

Reiterate the solution: ___________________________

_______________________________________________

ACT 3: AROUND-THE-CLOCK DOSING

ACT 4: PATIENT PAIN AGREEMENT

Introduce the problem: __________________________

_______________________________________________

Show them! Practice using active voice to encourage around the clock dosing.

Show them! Practice how to talk to patients to make night time plan using an active voice.

_______________________________________________

Reiterate the solution: ___________________________

_______________________________________________

TRAINING SIGN-UP

Make sure you have champions at each of your training sessions! Have your champions sign up for the session they can attend. Recommend at least 2 champions per session.

TRAINING DAY 1:__________ Date

Session 1:__________ Time

Session 2:__________ Time

Session 3:__________ Time

Champions:

1. ___________________

2. ___________________

3. ___________________

TRAINING DAY 2:__________ Date

Session 1:__________ Time

Session 2:__________ Time

Session 3:__________ Time

Champions:

1. ___________________

2. ___________________

3. ___________________

PLAN FOR GO-LIVE

As a group, talk about expectations for Go-Live and brainstorm ideas to make it memorable!

As much as you can, make RN champions available during the next 3 weeks! (i.e. backfill, break relief, committee time)

MAKE IT MEMORABLE!

What we want to do to make it: FUN: _______________________________

____________________________________ ____________________________________ ____________________________________

Have all of the unit management team as available as possible to round and talk to staff!

IMPACTFUL: ________________________

____________________________________ ____________________________________ ____________________________________

Use all mechanisms available to maintain communication and feedback. Daily huddles, e-mail, posters, informal check-ins.

INCLUSIVE: _________________________

____________________________________ ____________________________________ ____________________________________

GO-LIVE! with KP Painscape After all of the dedication and hard work to make KP Painscape your own, it is time to Go-Live. Remember, make it fun, make it memorable, and continue to celebrate the successes!

Go-Live Activities KEEP IT TOP OF MIND (a) Daily Rounding (b) Daily Huddles SHOW PROGRESS AND CELEBRATE SUCCESS WEEKLY STANDING MEETINGS

DAILY ROUNDING Round on RNs during a ‘down-time’ in their shift (i.e. right after morning med pass), and check-in to see what they are trying, what’s working, and what challenges they are having in regards to KP Painscape. The Project Manager and unit management team needs to set aside time to do this during the first few weeks post go-live.

A GREAT ACTIVITY FO R DAILY ROUNDING: Print out the 6 KP Pains cape concepts in sticker for mat and as you round have each RN pick a sticker to represent the concept they will be working on that day. Talk to them about wh at they worked on the previous day in addition to what they will be working on today.

NS TO ASK: What GOOD QUESTIO pain doing today? ’s nt tie pa ur yo ve done • How was previous shift) ha could you (or the mitment differently? of what their com n tio ta re rp te in • Get RN’s them? haviors means to to one of the be up on your ning on following orking at • How are you plan rs how othe are w to at re (G ? ts en commitm making changes) Did it save you doing working? • Is what you are rol your patient’s pain? (Be sure time? Did it cont them on the stories and write and capture the story template they use and from nurses that • Determine Tips other nurses (i.e. how they ese stories share these with ion). Capture th sh fa y el tim a in huddles. reassess share with unit at d an es at pl m te on story

DAILY HUDDLE MESSAGES

CK ET FEEDBA HUDDLE: G ommit at did you c h w sk A • ’ve been to, how you it, improve on planning to been going and how its e it, encourag when trying re tips with them to sha each other. , w behaviors • Of the ne st different than what’s mo sed to do? what you u you these have • Which of have the most found to e patients? impact on th ant others you w • What do re of, the most? to do mo

Plan the first week post go-live daily huddle messages. Day Shift

Evening Shift

NOC Shift

Day 1

Day 2

Day 3

Day 4

HUDDLE: CELEBR ATE SUCCESSES • Share results of patient pain in the early morni ng and reassessment rate s with tips for documenting on time • Share patient st ories and feedback collect ed during customer service • Share RN storie rounds. s gathered from other RNs during rounding

Day 5

Day 6

Day 7

SHOW PROGRESS AND CELEBRATE SUCCESSES With change, it is important to show progress and celebrate successes to reinforce the positive change.

CAPTURE AND SHAR E STORIES Story capture sheets an d use them at huddle

WEEKLY STANDING MEETINGS Set up weekly standing hallway meetings (15 minutes or less) where champions and leadership can touch base, and anyone else who wanders by can participate.

ED IENT INVOLV GET THE PAT card engagement Use a patient

TIPS • Think about ways to free up the champions so they can participate (break relief for those shifts, committee time for those who are not normally scheduled) • Leaders must always show up. It’s 15 minutes! • Leaders must take away some action items, but not all.

KP Painscape

WORKSHEETS A collection of worksheets for you to copy and use throughout the process of testing KP Painscape on your unit. These worksheets are designed for the unit management team and the RN Champions.

Additional Resources: KP PAINSCAPE WEBSITE: A collection of tools and assets are available on the KP Painscape website: http://xnet.kp.org/ innovationconsultancy/painscape.html

GET READY!

unit management team worksheet

IN MY OWN WORDS:

What is KP Painscape? ___________________________________

Why are we doing this ?

___________________________________

____________________________

__________________________________

____________________________ ____________________________

What will be involved?

___________________________________ ___________________________________ __________________________________

METRICS COLLECTION Reassessment Rates:

For KP Painscape, it is best to track reassessment rate by shift for each day. Work to find the best way to track reassessment rates.

“Morning Agony” Count:

For each shift, check with RNs approximately 1-2 hours into their shift to see number of patients that needed breakthrough pain medications.

How we will collect:

____________________________________________

Who will collect: ____________________________

SCHEDULE AHEAD 2 WEEKS GET READY!

1 DAY

KICK-OFF MANAGEMENT TEAM MEETING: RN CHAMPION KICK-OFF _____________ MEETING: DATE

_____________ DATE

4 WEEKS PDSAs

1 WEEK PREP GO-LIVE

_____________

TRAINING FOR GO-LIVE (hold within 3 days of go-live)

DATE(S)

_____________ DATE

1 WEEK GO-LIVE

GO-LIVE! _____________ DATE

ONGOING SUSTAIN

KICK-OFF HOMEWORK

See it for yourself

Before the KP Painscape Kick-off, get emotionally connected to the current status of pain management on your unit by talking to your peers, observing pain management practices, and interviewing patients. After you have finished collecting stories and observations, make a poster to share what you experienced.

My Notes:

See it:

LOOK FOR: • RNs who are playing catch-up on pain management • Patients who are in morning pain. Find out what happened the night before... • Examples of when RNs get called back for pain meds even though patient initially said no pain. • Patient’s not being able to participate in PT or ADLs because of pain. • Patients who have been going back and forth between IV and PO pain meds.

_____________________________________ _____________________________________ _____________________________________ _____________________________________

Hear it: ASK RNS: • What words come to mind when it comes to pain management? • What frustrates you most about pain management? • What does falling behind on your patient’s pain mean to you? • How does that happen? ASK PATIENTS: • Is the 0-10 scale easy to respond to? • How do you help your nurse understand your pain level? • What do you think your RNs mean when they ask about pain? • Do you feel like you understand your pain management plan?

______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________

Show it: Share what you learned by making a poster with quotes, pictures, drawings, and stories. Have the poster ready to share at the KP Painscape Kick-Off.

______________________________ ___________________________________ ___________________________________ ___________________________________

INITIAL PDSA TEST:

Prepare before going into the room

When busy, it can be hard to p roactively demonstrate that we are on top of our pat ients’ pain.

To take a “time out” to sort out sc he before we go into the room, dule a the room to c h nd dosing. When going into eck in with pat ients on pain, u noticed...I want se “I ed to...” to show that you are on top of the patie nts’ care. .

To build a habit of demonstrating and communicating to patients that we are on top of their pain and their care.

Better rapport with pat ients Better compliance Better trust YOUR FIRST TEST: 1. Use Floor Dots- put them on the floor at the doorways of patient rooms 2. Explain to RNs that are trying this to stop and look at their “brain” or MAR before going into the room when checking in with them on their pain. 3. Take a Time Out for pain during: • Hourly rounds • When patients call you • Med passes 4. Talk to RNs about how it worked, ask them: • How did it feel to pause before you went in the room? • How did you feel the conversation went between you and your patient? • What did you prepare before going into the room?

INITIAL PDSA TEST:

probe pain scale responses

KICK-OFF PDSA TEST

Patients often don’t understand what nurses are asking when they are asked to describe their pain on a 0-10 scale. To make sure that we don’t walk away thinking our patients are okay, but in reality, they are in more pain When asking pat ients about their than we realize, because of pain, always follo their initial resp w up and explo onses by: re • Ask follow miscommunications. up qu

estio (i.e., what is it ns regarding ADLs or function al goals if you’re trying to shift around in try to sit up? bed, if you • Physical m If you’re trying to walk to the b anipulation (i.e. , does it hurt th athroom?) if I do this? [ge e sa me or more ntly perform ap propriate manip ulation])

More accurate pain treatm ent based on normal levels of ADLs. Fewer un anticipated call-backs from patients in pain. YOUR FIRST TEST: 1. Practice how to probe well. 2. Demonstrate how to probe well to RNs that will be trying it as a test of change: • Using follow up questions (i.e., “what about when you’re trying to shift around in bed?” “what if you are trying to sit up?” Etc) • Using physical manipulation (i.e., “Does it hurt the same if I do this? [gently perform appropriate manipulation]) 3. Have RNs try for entire shift every time they assess a patient for pain: • Initial assessment • Follow up hourly rounds and reassessment 4. Work with them to demonstrate probing and coach them for at least the initial assessment, and then let them try on their own for rest of the shift 5. Get feedback

INITIAL PDSA TEST: use the most appropriate dose for initial transition

Inadequate dosing at initial tran sitions from IV to PO pain meds is the most comm on reason why patients lose trust and refuse PO pain meds.

For surgical pat ients, offer patie nts most approp dose as allowed riate by orders when g oing from IV to PO pain meds , rather than st arting them on lowest dose, and the trying to ra mp up if not enoug h.

More consistent equianalgesic transitions going from IV to PO pain meds

Less anxiety from patients regarding PO pain meds. Less unnecessary back and forth between IV and PO pain meds. M inimizes delay of disc harge due to use of IV pain meds. YOUR FIRST TEST: 1. Identify patients who are ready (or will be ready) to be transitioned to PO pain meds from IV. 2. Determine max dose on order 3. Advocate with patients for starting them on highest safe dose, as appropriate. 4. Talk to RN and patients afterwards about how it went.

INITIAL PDSA TEST:

reassess on a timely basis

In the rush of the shift, it can be difficult to reassess and document on a timely basis.

Use a kitc hen t imer t document within o remind you to reassess and the reassessment pr time specified for your unitâ&#x20AC;&#x2122;s otocol (For KP, 1 hour for PO hour for IV) and 1

To consistently reassess on a timely basis to ensure pain medication efficacy and patient safety.

Increase in reassessment rates. People finding it easier to remember to reassess and document within specified timing protocol. YOUR FIRST TEST: 1. Find a RN who is going to be administering multiple pain meds to multiple patients throughout the day. 2. Teach RN how to use the timer. 3. Set timer for time that allows you to reassess and document within your unitâ&#x20AC;&#x2122;s reassessment policy (i.e., 45 minutes for 1 hour, 20 minutes for half an hour). 4. When time is up, reassess patients for pain medication efficacy and safety. 5. Document reassessment 6. End of the day: Ask RNs if timers helped.

INITIAL PDSA TEST:

encourage around-the-clock dosing KICK-OFF PDSA TEST

Even when nurses instruct pat ients to call early at the first signs of pain, patients of ten don’t call until they are at a 6 or a 7, making it m ore difficult for nurses to stay ahead of their patiemts ’ pain.

Establish a pattern of practice with patients in continuous pain that makes it easier for nurses to stay ahead of patients’ pain.

For patients in contin call you when t uous pain, rather than relying hey n on patients to them BEFORE eed pain meds, proactively c hec k pain medication s become availab in with they need pain le to see if medication. Use last given n ext due board t o help establish with patients on expectations timing and sc he dule.

Less reliance on breakthrou gh IV pain medication. Better control over patien ts’ pain.

YOUR FIRST TEST: 1. Look for patients who are in continuous pain post-surgery 2. Put up Last Given, Next Due board. Explain to RNs what it is, and how to use it. 3. Coach nurses to explain the board to patients (to help you keep track of when you’re pain medications become available, but to make sure you let RNs know about pain even if your scheduled pain medication is not available yet). 4. Coach nurses to check in with their patients proactively, BEFORE their medications become available, even if you’ve told patients to call you. Look for ways to combine with hourly rounds and other scheduled check-ins with patients. 5. If pain medication administered, update last given, next due board, accordingly after medication administration. 6. Review last given next due during shift change to oncoming shift RN. 7. Get feedback from RN and patients.

INITIAL PDSA TEST:

keeping pain regimen going at night KICK-OFF PDSA TEST

Patients can very easily sleep th rough their pain at night and find themselves in unnecess ary levels of pain in the morning. For patients in continuous pain, keep pain regimen going at night.

M ake an agreem ent with patien ts in continuous before they go t pain o bed for nightt im e pain medicat regimen. ion

Fewer cases where patien ts are behind on their pa in in the morning. Morning R Ns have to spend less tim e playing “catch-up” in th e mornings. Less variance in pain in the mornings. YOUR FIRST TEST: 1. 2.

Plan: Figure out best time to make night time pain plan with patients before they fall asleep or go to bed (i.e., during evening med pass, or before administering sleeping pills). Execute: • If 2 shift unit: Execute on pain plan as agreed with patient during the night, and report outcomes to morning RN during shift change. • If 3 shift unit: Most likely, if plans are being made before patients fall asleep, it will be the afternoon shift that would have made the nighttime plan. Have afternoon shift write nighttime plan on “Patient Plan Pain Agreement” sheet. Then, at shift change, review with NOC shift and pass it on to NOC shift RN. NOC shift RN executes plan accordingly. Report results to morning shift RN at morning shift change. Get feedback. Ask morning shift: • Patients in pain? Any pain catch up? • Ask patients as well, especially if there are patients that struggled with pain at night previously. Ask how having a pain plan at night helped or didn’t.

PDSA JOURNAL template

A great tool for the RN Champions to use during the PDSA cycles is a simple journal. Have RNs use it for notes, testing observations, and new ideas! Here is a template of what a RN Champion PDSA Journal could look like.

Date:____________________ AIM Statement: _______________________________ _______________________________ _______________________________ _______________________________ I am testing: _______________________________ _______________________________ _______________________________ _______________________________ How do you know it is working because we are tracking: _______________________________ _______________________________ _______________________________ _______________________________

When testing I saw: _______________________________ _______________________________ _______________________________ _______________________________ I learned: _______________________________ _______________________________ _______________________________ _______________________________ What I think we should do next is Adapt___________ Adopt___________ Abandon_________

PDSA PLANNING

worksheet

HOW THINGS ARE NOW:

HOW YOU WANT THINGS TO BE:

UNIT COMMUNICATION worksheet

WEEK: __________

LE TO RESPOND: HOW WE WANT PEOP • Be open • To try out ideas ible • Be patient and flex • Give feedback

KP Painscape Po

WHAT WE NEED TO

• • • •

TELL EVERYONE:

Working on pain mana gement Trying out KP Painscape ideas What KP Painscape is We will be asking for fee dback and participation

ster Huddle Message for Date _____

At a glance! are trying....We

CREATE A POSTER:

CREATE HUDDLE MESSAGES:

CREATE A CRIB SHEET:

What will it say:________________

Who will make it:_______________

TRAINING SKIT

planning worksheet

ACT 1: TIME-OUT, PROBING

ACT 2: HIGHEST DOSE

Introduce the problem: __________________________

_______________________________________________

Show them! Practice “I noticed...” verbal follow-up, practice physical manipulation.

Show them! Practice explanation to patient as to why, letting them know you can always decrease dose.

_______________________________________________

Reiterate the solution: ___________________________

_______________________________________________

ACT 3: AROUND-THE-CLOCK DOSING

ACT 4: PATIENT PAIN AGREEMENT

Introduce the problem: __________________________

_______________________________________________

Show them! Practice using active voice to encourage around the clock dosing.

Show them! Practice how to talk to patients to make night time plan using an active voice.

_______________________________________________

Reiterate the solution: ___________________________

_______________________________________________

KP Painscape and the

NURSING MODEL

Focusing on nursing practice, KP Painscape is consistent with the Kaiser Permanenteâ&#x20AC;&#x2122;s National Nursing Model. The effective patterns of pain management identified by KP Painscape and the solutions developed reflect the values inherent in the Relationship-Based model of care, as well as the principles underscored in the Caring Theory and Comfort Theory. KP Painscape emphasizes clearer and better communications between nurses and patients, trust, advocacy, and better cross-shift teamwork to elevate the consistency of pain management to minimize unnecessary suffering during the recovery process in clinical settings.