NKEplus Change package
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Version 1.0 August, 2010 Copyright Š 2010 Kaiser Permanente This innovation and its implementation materials were developed by Kaiser Permanente’s Innovation Consultancy with support from the Gordon and Betty Moore Foundation. 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 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
A new frame for a solid door
“What you need is rarely there where you need it – it’s like you’re told install a door and all you get is the door. You also need the door frame or the door won’t do you no good.” - RN
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Welcome to the NKEplus Change Package
NKEplus is a build on the original Nurse Knowledge Exchange (NKE) designed in 2004. The original NKE was a big step toward involving patients in their care by moving shift change to the bedside – improving communications between nurses as well as between nurses and patient. Four years after it was implemented, however, nurses still struggled with two areas: interruptions and disruptions during shift change that prevented them from engaging patients in a safe handoff the way NKE was originally envisioned. Designed by nurses in Sacramento and Santa Clara Kaiser Permanente hospitals, NKEplus aims to address this problem of interruptions and disruptions. By putting in place measures to support focused time at the bedside during shift change, NKEplus gets nurses off to a strong, safe start with their patients. This book is designed to support the spread of NKEplus using a process, tools, and ideas that have been successful in pilot units. Have fun, and good luck!
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TABLE OF CONTENTS
Part 1: NKEplus Overview
Stage 3: Trying out small tests
• Background stories
• 1. Letting the unit know what you want to try and why
• NKEplus: 6 parts
• 2. Trying out NKEplus
• How NKEplus was developed • Qualitative feedback • Pilot Data • Implementation Timeline and Cost
Part 2: The NKEplus Playbook • Getting started: Establish NKEplus team • Meet with unit management • The Playbook process
Stage 1: Kicking off NKEplus • 1. Establishing a small team & familiarizing them with NKEplus • 2. Immersing the team • 3. Deciding on an approach
Stage 2: Plan for NKEplus
• 3. Collecting feedback on the test
Stage 4: Rolling-out NKEplus • 1. Staff training • 2. Committing managers to see it in action • 3. Going live
Stage 5: Sustaining NKEplus • 1. Measuring with NKEplus Tracker • 2. Ongoing Manager presence • 3. Regular Check-Ins • 4. Celebrating successes
Part 3: The NKEplus Toolkit Glossary
• 1. Deciding on the specifics of NKEplus • 2. Planning out the test cycle • 3. Knowing where you started
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Stories and background A few stories that inspired the original NKE...
The need to arrive early
The oncoming Charge Nurse was having to arrive 30 to 45 minutes prior to official shift start time to prepare for the oncoming staff.
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Cold Hand-offs
“Ghost Town”
GOAL OF THE ORIGINAL NKE:
Off-going shift recorded shiftreport onto a tape recorder left in the break room for the oncoming RN to listen to at start of shift.
Patients characterized the unit during shift change as a “ghost town” with no care-givers to be found for up to 90 minutes at a time.
Take nurses out of the conference room, and bring them to the bedside to exchange information safely and involve the patient in their own care!
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Fast forward four years... recenT sTories of hecTic sTarTs
The original nke resulted in greater patient involvement, but also left many nurses vulnerable to patient requests at the already chaotic time of shift-change. nurses felt a bit like the picture on the right, and a common cry for support sounded like this:
“oh my gosh. if you really want to help, can you make sure there are no patients that need pain meds or need to go to the bathroom at the beginning of shift? i just started my shift, and i have two pain meds to deal with…” ...and two other nurses chimed in:
“And make sure that patients have already gone to the bathroom, and that all their needs are met before shift change. And enough iv too!”
“The worst possible shift you can come into is with patients in pain.” -RN
goal of nKeplus:
gET NuRsEs oFF To A sTRoNg sTART bY REduciNg disRupTioNs ANd suppoRTiNg FocusEd TimE AT ThE bEdsidE duRiNg shiFT chANgE.
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What NKEplus is about...
NKEplus builds on NKE by incorporating proactive measures to support nurses during the essential and often chaotic time of shift change.
ProacTive PreParaTion
coordinaTed roles
nkeplus is about better ways to prepare for the coming shift.
it is about coordinating roles to minimize disruptions during shift change.
PaTienT engagemenT & safeTy it is about in-room patient engagement focused on safety and strong communications. overview 11
Proactive preparation The last hourly round and pre-shift assignments help the unit prepare for the coming shift.
Overview of NKEplus Nurse Role
NKEplus consists of six components designed to leverage teamwork on the unit level and support nurses during shift changes. Components marked with a * are designed to be customized to fit the unique needs and dynamics of each unit.
Supporting Staff Roles
* 1. Last Hourly Round
2. Pre-shift Assignments Chaboyer, W., McMurray, A., Johnson, J., Hardy, L., Wallis, Marianne., & Chu, FY, 2008. Bedside Handover Quality Improvement Strategy to “Transform Care at the Bedside�. Journal of Nursing Care Quarterly, 24(2), 136-142.
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During End of shift
Patient engagement & safety The three in-room components support interaction between the nurse and patient while emphasizing safety and strong communication.
In-Room Nurse-Patient Engagement RN invites patient to participate in exchange of information.
*3. In-Room SBAR
*
*4. In-Room Safety Check
5. Careboard with Shift Goals & Teachback Coordinated roles
6. Unit Support
The unit works together to minimize interruptions to nurses and help them to get off to a strong start.
During handoff
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The 6 parTS oF nkeplus:
LaST hourLY rounD
whaT is iT? The Last hourly round consists of rns and pCTs purposefully rounding on patients to anticipate and take care of patient needs before shift change. This involves: • addressing patients’ 4ps – pain, potty, positioning, personal items. • rns double-check to ensure iv fluids have at least a 2-hr supply. • patients are offered hot towels and water to refresh themselves.
“patients really like the hot towels. They’re in a hospital, after all. often times, they’re feeling gross and grimy. This is a nice way to help them freshen up.” - pcT
who does This? rns and pCTs (roles to be coordinated at the discretion of the unit) whaT’s so greaT aBouT iT? helps minimize avoidable interrupts during shift change so that rns can focus on taking report, get up to speed, connect with their patients, and set goals with them for the coming shift. patients get a refreshing “spa moment” offering from off-going care team; hot towels and water help patients feel alert for shift change. *Custom Fit: units may coordinate roles and indicate “who does what” at their discretion.
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* Last Hourly Round
Pre-shift Assignments
In-Room SBAR
In-Room Safety Check
Unit Support
Careboard with Shift Goals & Teachback
The 6 parTS oF nkeplus:
pre-ShiFT aSSignMenTS whaT is iT?
Timely, visible information to quickly get staff started!
minimize “waiting around” that results from having multiple hand-offs between nurses.
Last Hourly Round
Pre-shift Assignments
In-Room SBAR
In-Room Safety Check
Careboard with Shift Goals & Teachback
pre-shift assignments consists of the off-going Charge rn assigning patients to oncoming rns, striving for 1:1 hand-offs between nurses when possible (off-going rn hands over all patients to one oncoming rn.) The off-going charge rn should work with unit clerks to get assignments clearly posted prior to shift change. who does This? Charge rns, anMs, unit assistants whaT’s so greaT aBouT iT? rns are prepared to start as soon as they arrive and know exactly who of the nurses to take report from. off-going nurses know who to give report to. By minimizing multiple hand-offs between different nurses, rns aren’t “waiting around” as much and can spend more time with patients in the room during shift changes. (ideally 3 to 5 minutes per patient).
Unit Support
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The 6 parTS oF nkeplus:
uniT SupporT whaT is iT? unit Support consists of coordinating support staff and unit management to minimize disruptions to nurses during shift change. This involves: • Support staff to answer call lights and clarify patient needs. • Support staff and unit management to respond to call light requests when possible and get help from others as appropriate. • unit management to assist in managing incoming admits during shift change and activities related to admits (i.e., taking report from off-unit nurses). who does This? unit clerks, pCTs, Break relief rns, Charge rn, and anMs whaT’s so greaT aBouT iT?
Last Hourly Round
Pre-shift Assignments
In-Room SBAR
*
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In-Room Safety Check
Unit Support
Careboard with Shift Goals & Teachback
a coordinated support effort helps prevent nurses from being taken out of the room during shift change and allows them to focus on exchanging information and setting expectations with their patients.
*Custom Fit: units may coordinate roles and indicate “who does what” at their discretion.
The 6 parTS oF nkeplus:
in-rooM SBar whaT is iT? in-room SBar is a structured way to hand off information at the bedside while keeping the patient as the focal point of the exchange. This involves: 1. in-room reporting process • introduce new rn to the patient • Treat the patient as the focus of the conversation – include patients in the conversation rather than just talking in front of them. 2. Structured Communications • use the per, Mar, and order history views to review critical patient information • SBar reporting – Situation, Background, assessment, and recommendations as the structure for communicating patient status who does This? oncoming rn and off-going rn (with the off-going rn leading conversation) whaT’s so greaT aBouT iT?
Last Hourly Round
Pre-shift Assignments
*In-Room SBAR
In-Room Safety Check
Unit Support
Careboard with Shift Goals & Teachback
SBar is an efficient, safe way to ensure that all parties involved (rns and patient) are on the same page regarding the status of the patient and that the patient feels reassured that his/her information is being exchanged accurately. *Custom Fit: units may decide specific information they wish to include in SBar. nkepLuS overview 17
The 6 parTS oF nkeplus:
in-rooM SaFeTY CheCk
whaT is iT? The in-room Safety Check involves the off-going and oncoming nurses together conducting visual checks of the following: iv lines, iv sites, wound sites, and one other “unit-decided transitional safety check”. examples of the unit-decided transitional safety check for pilot units include: • groin check (chosen by cardiac telemetry unit) • verification and conversations with patients about room safety signage (e.g. diet restrictions, piCC line warnings, etc.) who does This? rns whaT’s so greaT aBouT iT? The check ensures that key safety issues are addressed at every shift change by two nurses at the same time. *Custom Fit: each unit gets to decide what safety issues they can and want to address in addition to checking iv lines and sites in the room with their patient during shift change.
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Last Hourly Round
Pre-shift Assignments
In-Room SBAR
*In-Room Safety Check
Unit Support
Careboard with Shift Goals & Teachback
The 6 parTS oF nkeplus:
CareBoarD goaLS anD TeaChBaCk whaT is iT? During the hand-off, rns set expectations with the patient regarding their care for the coming shift with the following: • write rn name and number on careboard, and note with patient. • review the plan of care with the patient for upcoming shift and set specific goals with them. • write/update goals and patient plan of care on careboard. • Conduct a verbal teachback to ensure patients understand their goals and specific instructions.
Examples of good goals: good pain control, walk 3 times before dinner, soft food only, breathing exercise 4 times an hour.
who does This? rns whaT’s so greaT aBouT iT? patients understand what is happening with their care for the coming shift and are clear about specific goals and instructions.
Last Hourly Round
Pre-shift Assignments
In-Room SBAR
In-Room Safety Check
Careboard with Shift Goals & Teachback
goals stay updated so that any member of the care team (or family) understand what the plan is for every patient.
Unit Support
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How NKEplus was developed
Through The hard worK of our fronTline sTaff. nkeplus is a system designed through collaboration between kaiser permanente’s Sacramento and Santa Clara Medical-Surgical units and The innovation Consultancy.
• over 500 hours of observing, shadowing, and interviewing frontline staff! • 2000+ hours of field testing, refining, and piloting ideas • 2 full days of ideation w/ more than 70 collaborators, including: nurses, unit assistants, pCTs, unit Managers, assistant Managers, Charge rns, patient Care Coordinators, hospitalists, Bedhub, pharmacy Tech, engineering, Biomed, Telemetry, evS, and more!
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Qualitative feedback whaT paTienTS anD STaFF are SaYing aBouT nkeplus...
“This is the first shift change i can remember that i haven’t heard a call-light.“ – rn
“i really enjoyed the experience with the nurses, they are professional... shift change and everything. i’ve been at the kaiser hospital before... and this definitely makes a big difference.” – patient
“Before, we’d come on to shift and we were doing a thousand things. now, it’s clear that the priority is on getting a good safe report and being with our patients; and there are other people helping take care of things during that time. it’s very clear now.” – rn
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Pilot data The measurable effects of NKEplus More overall time at the bedside Since initial piloting of NKEplus, the amount of time nurses are spending at the bedside with patients over the course of a shift has increased significantly. Averaging across two pilot sites (Sacramento and Santa Clara), time at bedside increased by 19.6% after the first implementation of NKEplus. It is worth noting that a large chunk of this increase came from time nurses were previously spending at the nurses’ station.
Nurse Time in Patient Room (average across two pilot sites)
300
Minutes at bedside 200 (10-hr shift) 100
+19.6%
329.5
275.5 baseline
post-implementation
• Of the additional 54 minutes per 10-hr shift that nurses were able to spend at the bedside with patients, 34 of those minutes came from time they were previously spending at the nurses’ station.
*Data collected using RFID tagging over the course of a minimum of seven days. For more information about how this is done, please see http://xnet. kp.org/permanentejournal/sum08/time-study.html
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Time at Nurses’ station (average across two pilot sites)
200
Minutes at bedside (10-hr shift) 100
-18.7% 181.5 baseline
147.5 post-implementation
An improved NKE
The NKE composite demonstrates how well a unit is doing all the parts of NKEplus put together. Within the first four months, according to composite measures, all participating units have improved from baseline.* Also worth noting: • Participating units with low starting baseline benefited significantly from NKEplus (122% increase).
*NKE composite combines the following measures: Both RNs go into Room, RN Introduced
• Even units that start with a high baseline (SCL 220) show significant improvement (33% increase).
to patient, Pt Engaged, Safety Check, RN name is written on Careboard, Updated Goals on careboard, RN performs teachback, # of min w/ patient during shift exchange (3-5=optimal).
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more Time wiTh PaTienTs during handoff at baseline, prior to implementing nkeplus, three of four units were spending one minute or less in patient rooms during report, enough time for a brief introduction of the nurse, but not enough time to fully involve the patient.
The “sweeT sPoT” of 3-5 minuTes as a result of nkeplus, time in the room during handoff rose to a “sweet spot” range of 3-5 minutes per patient that allows for good patient engagement and involvement. Since nurses typically have 30 minutes to exchange information about all their patients, the “sweet spot” of 3-5 minutes per patient gives nurses enough time to fully involve patients without running overtime. .
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Implementing NKEplus: Timeline Go-Live
Implementing NKEplus involves a 5-step process lasting approximately 6-8 weeks. The NKEplus playbook provides a full description of this process in the following section.
KICK OFF nkeplus
Plan the roll-out
Try things out
Full roll-out
Evaluate & Sustain
(6-8 weeks before Go-live)
(5 weeks before Go-live)
(3-4 weeks before Go-live)
(1 week before Go-live)
(After Go-live)
1. Decide on NKEplus
1. Inform the unit
1. Staff training
1. Measure how the
1. Engage a small team about NKEplus.
2. Immerse them in the issues.
3. Decide on an approach for trying NKEplus.
specifics (small team).
2. Plan out the test (small team).
3. Establish baseline metrics.
about trials (small team).
2. Try out small tests of change of NKEplus (small team).
3. Get feedback on tests of change & make adjustments (small team).
2. Get managers to commit to see it in action.
3. Go-Live!
unit is doing using NKEplus Tracker.
2. Encourage ongoing manager presence.
3. Have regular unit check-ins.
4. Celebrate successes.
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Implementing NKEplus: Cost What it takes to Implement NKEplus
These are preliminary, known costs for implementing NKEplus. • One FTE Project Manager (recommend full-time for six months and quarter-time for an additional six months) to help adapt, implement, and sustain NKEplus. • Backfill for at least 2 full-time staff per shift for every unit that will implement NKEplus. The project manager and hospital leadership will need to determine the amount of time needed for running NKEplus as small tests of change leading up to full-scale implementation. NKEplus is not all-or-nothing; costs will vary depending on the approach (piecemeal vs. full-scale blast). • Cost of craft supplies and materials to make the process fun and engaging. • Cost of celebrations and tokens of thanks for recognizing individuals and success milestones. • Full-time hospital leadership support as sponsors.
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