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NKEplus Change package

Overview overview 1

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: 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.

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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4 overview

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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6 overview


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

overview 7

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.

8 overview

Cold Hand-offs

“Ghost Town”


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.

10 overview

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.

12 overview

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)


Minutes at bedside 200 (10-hr shift) 100



275.5 baseline


• 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.

22 overview

Time at Nurses’ station (average across two pilot sites)


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. .

24 overview

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.

26 overview




k o o b y a l p s lu

p E k N The



Welcome to the NKEplus Playbook! This Playbook provides a step-by-step process for implementing NKEplus. It is designed for those who are doing the actual NKEplus implementation (project manager, local improvement advisor, unit manager, etc.). Created by nurses and other frontline staff, NKEplus is designed to support focused time at the bedside during shift change and get nurses off to a strong, safe start with their patients. It includes a set of tested ideas to support smooth, warm hand-offs by minimizing unnecessary interruptions during shift changes. This allows nurses to focus on exchanging information and really getting to know patients and their needs for the coming shift. The Playbook follows a simple 5-step process, supported by examples of ideas that worked from other units that you might try or improve upon. Throughout the Playbook, you’ll also find reference to tools we have designed to help you engage the frontline staff and roll out NKEplus. These tools are marked with a symbol, and more information about how to use them can be found in the NKEplus Toolkit that follows this section. Before you start, we suggest you read through the entire Playbook to understand the entire process. Then use this Playbook as your reference guide along the way as you roll out NKEplus. Have fun, and good luck! INTRO 29

Getting started Establish your nkeplus team

The first thing to do is to assemble a team of motivated people and give them the challenge of creating system-level change, the permission to do it, and the resources they will need to get going. Here’s the team you will need and the roles that they can play.

30 Getting started

Hospital Champions: CNO, COO, Dept Directors, Union Leaders Overall role: vision, allocate hospital resources, support

Nurse Managers/ ANMs/ Asst. Dept. Director: Unit-level leadership who have HR and budget responsibilities Overall role: allocate unit level resources, address road blocks, monitor and communicate metrics

Improvement Advisors/ Project Managers: 1-2 people trained to manage, facilitate, measure and troubleshoot projects across multiple units Overall role: support cross-unit collaboration and learning, address common issues, support units with facilitation and tools

Unit/Dept. based teams: A team on an individual hospital unit consisting of front-line staff and unit-level leadership who support the implementation on their unit Overall role: represent staff voice, make decisions on unit customization, serve as implementation champions Staff clinicians/ implementers Overall role: understand purpose of initiative, actively participate, provide feedback, share stories, offer suggestions

Getting started 31

Meet with unit management

One of the most important pieces of your NKEplus team is the unit manager. The manager is your key partner for NKEplus, and along with their assistant managers, they can provide valuable insight into what it takes to make successful changes on their unit. They also know their staff best and can help you identify staff champions to help bring NKEplus to the unit. When you are ready, set up an initial meeting with the unit manager that includes the following: • Overview of the process: Talk to them about NKEplus, the schedule ahead, and what will be involved in getting NKEplus up and running. • Find out what works: Take the time to determine what changes have worked for them in the past (or haven’t) and why. • Lay down logistics going forward: Start identifying staff champions to be part of the champions team. This could be your Performance Improvement Team or Unit Based Team as well. We recommend 2 frontline staff members per shift. 32 Getting started

Work with the manager in the first meeting to set up regular times to check-in with them going forward!

Tips & Tricks: Figuring out what works for the unit

Here are some questions you might use in speaking with managers on the unit about what has worked for them… • What changes have stuck for this department? Why? • Where is staff morale? Can they take on another change well? What can they take on? • If the unit is overwhelmed with lots of changes, what needs to happen to help “level load” the change? • Is there a unit based improvement team in place? What “stage” is the team at?

Establishing and developing NKEplus Champions

Build a team of champions by posting up fliers around the unit asking for volunteers. Reach out to those you feel would be great champions for this project. Consider approaching the union lead about staff representatives they would suggest.

• Champions need a simple but powerful way to contribute. • Spend time training them about what it means to be a champion. • Trust your champions and go to them for insight into how you can implement change efficiently. • Champions need leadership support. Meet with the leadership team on the unit to talk about how to support them. Have them role play how they would interact with difficult or resistant staff. • Try to create and protect opportunities for champions to work together, learn from, and support each other as much as possible.

Getting started 33

kick Off NkEpLUs

The playbook process Once you’ve lined up your NKEplus team and met with managers on the unit, you are ready to start the 5-step process for rolling out NKEplus on a unit. The process is designed to help you kick off NKEplus by engaging a small team of staff and managers, work with them to tailor it to their unit by trying out parts and getting feedback, and ultimately get NKEplus up and running with everyone on the unit.


(6-8 weeks before Go-live) 1. Engage a small team about NKEplus. 2. Immerse them in the issues. 3. decide on an approach for trying NKEplus.





(5 (5 weeks weeks before before Go-live) Go-live)

(3-4 weeks before Go-live)

(Final week before Go-live)

(After Go-live)

1. decide on NKEplus specifics (small team).

1. Inform the unit about trials (small team).

1. staff training

2. Plan out the test (small team).

2. Try out small tests of change of NKEplus (small team).

1. Measure how the unit is doing using NKEplus Tracker.

3. Establish baseline metrics.

2. Encourage ongoing manager presence.

3. Go-live!

3. Have regular unit check-ins. 4. Celebrate successes. go-live

3. Get feedback on tests of change & make adjustments (small team).

2. Get managers to commit to see it in action.


Roles throughout the process

Each member of the NKEplus support team plays a vital part in collaborating to implement and sustain NKEplus successfully. Share this overview with others so they know what to expect in terms of how they can support NKEplus throughout its roll-out. Kickoff Hospital Champions: CNO, COO, Dept Directors, Union Leaders

• Set overall vision and talk about project at leadership meetings, vocalize and show support.

role: vision, allocate hospital resources, support

• Allocate resources and set expectations w/ direct reports.

Nurse Managers/ ANMs/ Asst Dept. Director: Unit level leadership who have HR and budget responsibilities

• Begin to identify project champions.

role: allocate unit level resources, address road blocks, monitor and communicate metrics

Improvement Advisors/ Project Managers: 1-2 people trained to manage, facilitate, measure and trouble shoot projects across multiple units

role: support cross unit collaboration, learning, support unit with facilitation and tools, addressing common issues

Plan • Check in with managers and IAs.

Try Out • Visit the test, show support.

• Participate in celebrations.

Sustain • Round on unit 1x/month during roll out. • Celebrate milestones.

• “Drop in” on champions, or at kick-offs. Show support.

• Work with IA/PM to plan roll-out process.

• Establish mechanisms for communications with staff (huddles, daily messaging, etc.).

• Facilitate and enable UBTs/PI teams to conduct small tests of change.

• Celebrate the Go-live. • Spread optimism about the change. Support staff as needed with the transition.

• Start talking about NKEplus with staff at staff meetings.

• Understand how NKEplus implementation is going on the ground level. • Work with staff to make adjustments.

• Understand staff’s current frustrations around shift change. • Coordinate and communicate expectations w/ entire NKEplus team. • Facilitate initial unit level kickoff, and guide teams through engagement process.

• Work with UBT/PI teams to • Guide unit in small tests of • Plan and participate in develop PI plan/project plan as change. Go-live and celebrations. appropriate. • Coordinate with leadership to • Guide UBT/PI teams to figure show support. out how to customize and test NKEplus.

• Provide guidance and tools for implementing and sustaining change. • Check in with unit weekly.

• Work with UBT/PI teams to establish baseline metrics.

Unit/Dept. based teams: A team on an individual hospital unit consisting of front-line staff and unit-level leadership who support the implementation on their unit

• Immerse selves in issues that impact shift change.

role: represent staff voice, make decisions on customization, serve as implementation champions

• Share learnings with others.

• Learn from other units that have gone live.

• Work with managers and PI/IAs to make key decisions regarding NKEplus customization and rollout. • Establish baseline metrics.

• Post communication materials. • Celebrate the Go-live. • Work with managers and PM Share stories. to make adjustments and • Keep eyes out for adjustments sustain NKEplus. • Conduct small tests of change. that may be necessary. • Get feedback from staff • Get feedback from staff • Share stories. regarding sustaining NKEplus; regarding test of change. represent their voice.

Staff clinicians/ implementers

• Try out ideas over and over.

role: understand purpose of initiative, actively participate, provide feedback, share stories, offer suggestions

• Provide feedback to champions and managers.

36 process roles

Full roll-out

• Share stories.

• Embrace the change with an • Continue to provide feedback open mind. Provide feedback to champions and managers regarding implementation to to make adjustments as champions and managers. necessary. • Share stories.

Overview of the Process:

f f o g n i Kick s u l p E K N )

fore Go-Live

be (6-8 weeks

What’s invo

lved in this


Here the goal is to work wit h a small team managers, en of staff and gage them in the reasons w important to th hy NKEplus is em, and help them make de they want to b cisions on how ring NKEplus to their own e this section: nvironment. In 1. Engag e a small team 2. Immers e them in the issues 3. Decide on an approac h for trying NK Eplus


Proactive preparation The last hourly round and pre-shift assignments help the unit prepare

1. Engaging a small team

for the coming shift.

Get a small team familiar with NKEplus

Nurse Role Supporting Staff Roles

The first part of kicking off NKEplus involves getting a small team together (managers + staff champions) and familiarizing them with the goals and details of NKEplus. By giving them the opportunity to familiarize themselves with NKEplus and see how the issues are relevant to them, they will be able to effectively spread excitement about it internally and come to decisions about how they want to approach rolling it out on their unit. Begin by helping them understand background, context and what’s to come. Share with them the goals of NKEplus and refer them back to the overview of NKEplus in the introductory section if necessary.


Last Hourly Round

Pre-shift Assignments During End of shift

* Custom fits:

Units are able to

customize these parts of NKEplus based on the unit’s unique needs and dynamics.

38 Kick-off

Patient engagement & safety The three in-room components support interaction between

Throughout this playbook, look for this symbol to indicate tools that are available to help you with each part of the process. More details about each tool can be found in the NKEplus Toolkit.

the nurse and patient while emphasizing safety and strong communication.

In-Room Nurse-Patient Engagement RN invites patient to participate in exchange of information.

* In-Room SBAR

* In-Room Safety Check

Careboard with Shift Goals & Teachback Coordinated roles


The unit works together

Unit Support

to minimize interruptions to nurses and help them to get off to a strong

During handoff


Tool(s)that are available to you

• Roll-out schedule poster • NKEplus Think-tank poster • NKEplus goals poster • NKEplus overview poster kick-off 39

2. Immersing the small team talK With each other

The small team can start by sharing their thoughts and concerns around shift-change. What are the issues? What’s working? What’s frustrating?

tool(s) that are available to you

• Interview Guide


ideas that WorKed:

firsT HAND rEsEArcH

Rather than telling the staff about the experiences of others, having them do research is a way for them to discover the issues for themselves and in a way that is relevant to them. Try having RNs: • Talk to RNs from other units that have gone live with NKEplus already. • do some internet research on the pros and cons of bedside reporting (internet search “bedside reporting”). • Talk with their peers on their unit about the prospect of doing bedside reporting. • Talk with their patients about whether they’d like the ability to listen in and be included in the information that’s being exchanged at shift change. also try having managers talk with fellow managers.

Poster boards are a great way for members of the small team to share their learnings with others and get conversations going!!!


see it oN the uNit

seeing things in context can help the team better understand the current situation on their unit. How are the issues around shift change impacting the staff and patients on the unit?


ideas that WorKed:

DiAGNOsTic WALk-THrOUGH Many of the issues that impact a smooth shift change are things that your frontline staff might be so used to that it might be hard for them to tell you about them. so, go see for yourselves through fresh eyes! (and take pictures!)

results of oNe WalK-through: Nurses giving reports mostly in hallways, and therefore lots of “walk-by” interruptions.

• What are examples of good things that are helpful? • What’s slowing people down? • What’s the current status quo on how shift change happens? • supplies and equipment missing? Or not in good working order? after the walk-through, have everyone share stories about what they saw and identify priorities to be addressed.

tool(s) that are available to you

• Walk-through guide


Get together, share what you learned!

Now that the small team has spent the time observing patients and peers and talked to them about shift change, get the team together and have them spend time sharing these stories with each other. Give stories provocative titles and use pictures to inspire productive responses and share what you saw. Consider using the following questions to guide the group: • What did we learn? • What’s working and what is not? • What are some big issues we need to address?

44 Kick-off

Address other issues

“What if there are certain issues we found in the kick-off that are not specifically addressed by NKEplus that the staff feel are important to address?” Consider addressing a few quick wins at this point to gain buy-in and reduce existing interruptions and frustrations!

Ideas that worked:

Diagnostic Workshop If after a walk-through, the team has identified a number of issues that need addressing, work with the team to highlight priorities and brainstorm solutions. Issues may be as simple as “we need more carts for delivering water to patients”, or how to minimize the impact of admits coming on to the unit during shift change (see the admit line idea). Make prototypes now! While issues are fresh in people’s minds, work together to create simple prototypes to address the issues that really impact the staff!

Results of one Workshop: PCT Planning Sheets Sheets passed around amongst RNs at the beginning of the shift to note what they anticipate needing help with (initiated by the UA). • PCTs use sheet to plan out their activities for the shift. • Includes unit level hour-by-hour needs (i.e., cover call lights and get patients up in the morning) Admit Line A single phone line dedicated for all admits to the unit. The phone is always held by the Charge RN or ANM who can then direct calls based on their current knowledge about RNs availability, buffering nurses from interruptions during shift change.

kick-off 45

3. Deciding on an approach Make decisions about how many and which parts

Have the small team discuss how each component of NKEplus will help the unit, taking into account the parts that will have the most impact versus what might be hard to do. Have the small team come to a decision about which pieces of NKEplus they want to try as small tests of change. They will plan these out more thoroughly in the next section. While the goals is to get every piece of NKEplus up and running eventually, not every unit may be ready to roll out NKEplus all at once. Trying a few discrete parts of NKEplus at a time can be a good option for many units.

46 Kick-off

Suggestions for breaking it up

If you are going to break it up, we suggest you: • Start with the supporting pieces first (Last hourly round, pre-shift assignments, unit support).


• Once those are in place, try out the in-room SBAR. This can be the biggest and most significant change if the RNs are not used to bedside reporting. • Then once that’s in place, build in the rest of the in-room engagement components.

* Last Hourly Round


Pre-shift Assignments



Unit Support


In-Room SBAR


In-Room Safety Check

Careboard with Shift Goals & Teachback

kick-off 47

48 Kick-off

Overview of the Process:

r o f g n Planni s u l p E NK fore (5 weeks be


What’s invo

lved in th

is section? Now that you have worked with the small them in the is su te unit first-hand es and see how the issues am to engage , work with th e small team impact the changes. In th to plan out th is section: e 1. Decide on the specifi cs of NKEplus 2. Plan o ut the test cyc le 3. Capture baseline metr ics

1. Deciding on the speciďŹ cs tailor the NKePlus comPoNeNts to the uNit

sit down with the team. Work with them to surface how they feel the details of each of the NKEplus components they are planning to try as a small tests of change should be handled. Use the following pages as reference to help make decisions and provide tips for how to try each of the components. you may also find inspiration from examples of what other units have done. This is where the unit gets to make NKEplus their own!

50 PlaN

Ideas that worked:

Tools to support the specifics As this unit tailored NKEplus to fit their unit, they created tools to support some of the things they decided to do. What tools might you need to support ways you are doing NKEplus on your unit?

NKEplus Nurse Role


* In-Room

Ready room cards

Pre-shift Assignments During End of shift



Last Hourly Round

Standard signage Signage can be inconsistent and difficult to find, so this unit created five standard signs in every room for their safety check (ensure signage is up to date and have a conversation with the patient about it).

In-Room Nurse-Patient Engagement RN invites patient to participate in exchange of information.

Supporting Staff Roles


* In-Room Safety Check

Careboard with Shift Goals & Teachback

Unit Support

During handoff

Custom fits: Units are able to customize these parts of NKEplus based on the unit’s unique needs and dynamics.

Learn more about how to try out each part of NKEplus and adjust it to fit your unit on the following pages.

Part of unit support, one unit used these cards to ensure and communicate a room is completely “ready” for a new patient. Unit assistants check to make sure rooms are both cleaned and have the necessary equipment (IV pump and pole, SCD pumps, suction, etc.) before admits arrive.

Plan 51

The Last Hourly Round Address patient needs during final hour to help minimize disruptions later on during shift change.


Tips for trying it:

1. List out what all staff are currently doing one hour before shift change (UAs, PCTs/CNAs, RNs, resource RNs, Charge RNs, ANMs, Mgrs). 2. Work with team to outline how the unit wants to distribute responsibilities with an emphasis on: • Enabling appropriate staff to check in and take care of 4Ps (pain, potty, positioning, personal items).

Custom Fit: What’s the best way for your unit to coordinate roles at the end of shift to proactively address patient needs? How one unit did it: • PCTs/CNAs round for potty, positioning, and personal items. Distributes hot towels. • RNs round for pain, checks on IV supplies.

• Enabling appropriate staff to prepare/distribute hot towels and water (likely PCTs/CNAs); ensure you have necessary towels, carts, etc. • Enabling RNs to close out their shift and proactively set nurses up on next shift (making sure 2 hour supply of IV, etc.). • Making sure equipment (computers, scanners, etc.) needed during shift change is charged and “ready”. 3. Use workflow cards and role-coordination worksheets to clarify roles and communicate them clearly to staff prior to getting this up and running. 4. Find opportunities to role play working with patients to proactively anticipate their needs (i.e., not just “do you need anything”…more like “Shift change is coming. Can we take you to bathroom now before we begin giving reports?”). Tool(s) that are available to you

• Role Coordination Worksheet • Workflow cards 52 Plan

Pre-shift assignments Off-going Charge nurse works with unit clerk to get assignments clearly posted in a timely fashion prior to shift change.


Ideas that worked:

Tips for trying it:

1. Off-going Charge RN gets draft staffing list from staffing office as early as possible (we’ve seen this happen 4 hours in advance). 2. Get finalized staffing list as early as possible (we’ve seen this happen an hour before shift change). 3. Off-going Charge RN makes assignments, striving for 1:1 hand-offs when possible. 4. Work with the unit clerk to post assignments as early as possible (keeping in mind that some nurses come in early to prepare).

Previous shift-assignment board One unit got a second small whiteboard to display assignments from the off-going shift next to new assignments. This allows oncoming RNs to know who previously had their patients so they don’t have to rely on the off-going nurse finding them in order to begin reports.

Plan 53

UNIT support Create clear, well-coordinated roles to effectively address common issues that tend to disrupt nurses in their hand-off and take them out of patient rooms.


Common issues can include: admissions, phone calls, call-lights from patients.

Custom Fit: How do you want to coordinate support roles to enable RNs to focus on bedside reporting during the hand-off? How one unit did it: • Charge/ANM Admit line • PCT covers call lights while passing out fresh water. • UA rounds for equipment, readies rooms for admits.

Tips for trying it:

1. List out what everyone on the unit is currently doing during shift change (including unit clerks, PCTs/CNAs, RNs, resource RNs, Charge RNs, ANMs, Managers). 2. Work with team to outline how the unit wants to distribute responsibilities, with an emphasis on: • “Ground Control” - Who’s responding to call light requests, phone calls, and how is that being triaged? • “Air Traffic Control” - Who and how are admits and transfers handled to minimize impact to staff RNs during shift change? • What key things need to happen outside shift report for shift to start well (i.e., water jugs filled before med pass)? 3. Use workflow cards and role-coordination worksheets to clarify roles and communicate them clearly to staff prior to getting this up and running. 4. Use the ”UA call-triage protocol” tool to practice how to best address phone calls and call light requests during shift change.

Tool(s) that are available to you

• Role Coordination Worksheet

54 Plan

IN-ROOM sBaR Create a uniform reporting structure for delivering patient reports at the bedside that ensures all on-coming RNs have the right information to start their shift strong.


tiPs for tryiNg it:

1. Video tape reports, listing out all the components. Have staff provide input and vote on the components they feel are most important to include in an sBaR report for the unit. determine what sBaR will be for the unit based on input. 2. Role-play sBaR.

custom Fit:

3. Practice in the room with patients using Health Connect views (PER, MaR, Order history).

What does SBAR mean for your unit?

hoW oNe uNit did it: Put up a big poster and use dot-voting to come to a decision about what should be included in sBaR.

PlaN 55

IN-ROOM saFETy CHECK Increase safety by ensuring that key safety issues are addressed by two nurses together at every shift change.


tiPs for tryiNg it:

1. Pull relevant reports and analyze data to identify key safety issues the unit would like to focus on during shift change. 2. solicit input from staff on the unit regarding how they feel about these issues.

custom Fit: What kind of safety check makes sense for your unit? hoW oNe uNit did it: In addition to checking IV lines & sites and checking wound sites, one unit decided to review in-room signage with patients and make sure it is up to date. a separate cardiac unit decided to do regular groin checks.

56 PlaN

3. Jointly decide on what the safety check will be and how to work it into the flow of the report. 4. Communicate with staff and role-play as a team to practice this interaction.

CaREBOaRd GOals & TEaCHBaCK Patients understand what is happening with their care for the coming shift and are clear about specific goals and instructions.


tiPs for tryiNg it:

1. Explain to RNs and PCTs about updating the careboard at the time of Bedside Rounds. 2. allow time for RNs and PCTs to review and practice using Careboards. Train RNs to note: RN name, contact info, patient goals, upcoming procedures, important reminders. 3. Help RNs understand the importance of teachback and how to do it in a way that works for them.

Teachback Can you remind me of the goals we’re working on for you today Mr. smith? yeah, I need to walk three times and do my breathing exercises ten times an hour.

4. Use role-play to help RNs learn for themselves how to integrate updating board, reviewing with patient, and getting teachback.

ideas that WorKed: This unit created an insert for their careboards to help prompt 3 simple goals for the nurse to update during shift change. The box at the bottom also indicates when the board was last updated.

PlaN 57

2. Planning out the test cycle Now that the team is familiar with the specifics of NKEplus and how to make it fit their unit, you’ll want to help them plan out a small tests of change to help smooth the transition to implementation. The small tests of change will help the team understand how the approaches they have proposed work for the unit including what they might need to further adjust. Help them: • set Goals: what is it that they want to accomplish with NKEplus? Be specific, measurable, actionable, realistic, and time-bound. • define the current state and the future state. Make predictions about what will happen and why. • define who’s doing what, by when, and what resources will be needed.

tool(s) that are available to you

• Project Improvement planning form • Project snapshot worksheets • Workflow cards

58 PlaN

Ideas that worked:

Draw the process

Work in teams

Make planning more fun by having team members draw the process. Convey the excitement by also having them draw how it would look or feel!

When possible, have people work in pairs. Team members can provide support and help each other get through stumbling blocks.

Plan 59

3. Knowing where you started establish baseliNe metrics

you need to know the state of shift changes on the unit before you start implementing NKEplus. Use the data collection tool (part of NKEplus Tracker) to collect metrics about the unit before you start implementing changes. This will help you clearly see the effects of NKEplus after you have rolled it out. We suggest using this observation tool to collect 30 data points. • Collect over the course of one month, but ideally within one week. • Observations can be spread out between different shifts (e.g. 10 for each shift). • Each report counts as one data point (e.g., if following one nurse taking five reports in one shift, you will have five data points).

60 PlaN

tool(s) that are available to you

• NKEplus Tracker (data collection tool, period worksheets) to help you collect and enter data.

Overview of the Process:


s u l p E K N t u o g n before (3-4 weeks


What’s invo

lved in this


Here the goal is to try out N KEplus as sma before full im ll tests of cha plementation. nge This will help change and a s taff ease into llow the small the team to make decisions abo adjustments a ut how to fit N nd KEplus to the have the sma unit. In this s ll team: ection, 1. Inform the unit what they want to tr 2. Try out y and why small tests of change of NK 3. Get fe Eplus edback on tes ts of change & make adjustm ents

Intro 61 61

1. Letting the unit know let PeoPle KNoW What you WaNt to try

By now, the small team has talked with their peers and patients and seen the current state of shift change, so they have a point of view on how to tailor NKEplus to the unit. Have them share what they learned with the rest of the unit and propose trying NKEplus out. Work with them to:

1. “show and tell� what they learned using the boards they created in their first-hand research (p. 41). a picture is worth a thousand words; a good story paints that picture forever. 2. Practice clearly articulating proposed tests they feel would create a positive impact on shift change. Emphasize this is just a test. 3. Practice delivering their proposal in an open way that invites input from the rest of the staff.

62 TRy

Ideas that worked:

Hallway of conversation KEEP WHAT’S IMPORTANT IN FRONT OF PEOPLE Find a place in the unit where you can put up all the input from nurses and patients that was gathered during the kick-off phase. Put up pictures and stories of things the small team observed during their diagnostic walk-around that spoke to them. Post announcements and information about what is about to be tested. Hold daily huddles here, keeping learnings in front of people so that they can be reminded of what’s being tried and why it is important to them (in their own words). Start and end huddles on a positive note and hold them regularly. Regular standing huddles are good for keeping updates and communications short and to the more than 5-10min...and work well either at the beginning of shift or part way through the shift when workloads dip, but before nurses go on breaks. If mid-shift, consider having the break relief nurse cover for nurses.

try 63

2. Trying out NKEplus Try out small tests of change

Try a few things or everything. Try it for a day, or for a week. The goal here is to address concerns and issues before going live with NKEplus and to make sure what you’re trying works for the unit. When trying out a test of change, consider testing the ideas on a small scale (a few people, a few shifts, etc.) and then building up to eventually running a large scale test with the whole unit. Post announcements of the change throughout the unit so that everyone knows what’s being tried. Again, make sure people know that it is just a test and that they will be expected to provide feedback!

64 Try

“thiNgs We’re tryiNg” sheets Fill out these half-sheets and post them on the unit, or hand them out to staff directly. This sheet is a good place to write down specifically what you want people to try and can therefore be easily communicated between shifts. tools that are available to you

Test of change tools: • “Trying new things” tags • “Things we are trying” sheets

Use these tags (or ones you make yourself) to communicate in a fun, colorful way that you are trying something new on the unit.

additional NKEplus tools for use in tests: • Question Card (sBaR) NKEplus Essentials

“tryiNg NeW thiNgs” tags

• Preparing Hot Towels Card (Final hourly round) • Ua Message Pad (Unit support) • Ua Call Triage Protocol (Unit support) • Ua Checklist (Unit support) • Final Hourly Round Times flyer TRy 65

“This is the first time anyone asked me what I thought!”

3. Collecting feedback on the test Get Clear, honest, and specific feedback

While you’re trying out NKEplus, think about the best way to get clear, honest, and specific feedback. The key to understanding your test is to get specific comments about what is working and what isn’t. Responses like “I like it” are better replaced by “I like the way ____ is working, but I’m having trouble with ____”, or something similar. You may find it helpful to provide a choice between two options and ask why or simply ask people to comment on their favorite part and their least favorite part. Keep in mind that most people have opinions, but many are too shy to provide them. Think about how you can gather responses regularly and anonymously from everyone.

66 Try

Ideas that worked:

Feedback Sheets

Question of the Day

Big sheets of paper posted up in a place where staff see them regularly are a good simple way to solicit input from staff members. Giving people a few distinct scenarios to choose from makes it simple and easy for staff to respond.

A good way to get anonymous feedback from staff members is to put up a “Question of the Day” drop box. Circulate questions that you want people’s feedback on and refresh them daily.

Tool(s) that are available to you

• Question of the Day board

try 67

68 Try

Overview of the Process:


s u l p E K N t u o g n )

fore Go-Live

e (One week b

What’s invo

lved in this


Once the sma ll team and se lected groups NKEplus out a have tried nd made nece ssary tweaks, implement NK it is time to fu Eplus with the lly entire unit. Th is 1. Staff Tr in v o lv e s : aining 2. Get ma nagers to com mit to see it in 3. Go Liv action e!


1. Staff Training clarify the Process

Once the unit has tried out NKEplus and decided on how they want to customize it for the unit, you’ll want to make sure staff are all clear about what the process now looks like so they can implement it.

tool(s) that are available to you

• NKEplus Badge Cards • NKEplus Overview poster • NKEplus Goals poster • Imagine your day worksheet • Cards of various uses 70 ROll-OUT

Tips & Tricks:

Suggested training agenda (1.5 hours) : • Explain the goal of NKEplus to the entire unit and help them

Staff training set-up

understand why it is important. • Have the small team share stories about what they learned and heard throughout their immersion and small tests of change so far. Invite others to chime in with their own stories and perspectives. • Have the small team propose what they’d like to implement, emphasizing that they have tailored it to fit the unit to the best of their ability. • Clarify actions of NKEplus by role-playing and having staff practice discrete parts.

How might you make training feel more like a conversation...

Helpful guidelines for effective trainings • Sign people up...simply announcing the time and expecting attendance can result in low turnout. Provide two days for people to choose from to ensure everyone has an opportunity to participate. • Set a fun, open, and relaxed tone. Set up the training to be more of an inspiring conversation and a role-playing experience than a lecture. • During training, open up the conversation and invite people to participate. How do people relate to the issues? Do they have similar stories?

...than a lecture?

Roll-Out 71

Ideas that worked:

Role-playing during training Role-playing is a great way for staff to “get a feel” for new processes and behaviors in a safe environment. Physically experiencing new behaviors is the first step toward internalizing them. There’s a lot going on in NKEplus, consider role playing the components and how to best integrate them to make them feel seamless: • Bedside introductions • Use of the question card • Talking to patients about their plan of care • Doing data reporting with patient as focus • Teachback There’s also a lot of situations that might impact NKEplus, consider role-playing: • Including doctors in shift change • What to do if the patient is in a shared room or has visitors

Tool(s) that are available to you

• How to deal with demanding patients during shift change

• Pop-up Video library

• What to do if the patient is asleep or on the phone

• Tips for HIPPA compliance

72 Roll-Out

2. Planning for Go-Live commit to seeiNg it iN actioN

The most important thing managers can do to ensure the success of NKEplus is to be present on the floor during shift change. There is no replacement for seeing the process in action first-hand. Before going live, sit down with the manager to commit to rounding on the floor before and during shift change – supporting and seeing how things are going. Work out ahead of time amongst the managers, support (i.e., educators) , and champions how best to provide on the floor visibility and coaching support during the first few weeks in particular. In addition, having hospital leadership make random visits to the unit is a great way to show system-wide commitment to the change. This can be especially powerful the first week after Go-live.

tool(s) available to you

• Manager sign-up calendar

ROll-OUT 73

3. Go Live highlight the begiNNiNg

When you’re ready to roll out the NKEplus process, you’ll want to mark the change as visibly and memorably as possible in the staff’s minds so they know it is time to start doing things differently.

74 ROll-OUT

Mark the day you will go live ahead of time, and count down to it as a moment when the unit will get to roll out THEIR NKEplus.

Then, celebrate the kick-off day with a party. (smoothies, shakes, funny hats, streamers, patient engagement cards.) This is their NKEplus after all!

ROll-OUT 75

PatieNt-rN aPPreciatioN card you can also involve patients in your Go-live celebration. Have them recognize the staff for the great job they are doing with NKEplus. Use the Patient appreciation Cards found in the NKEplus toolkit, or make up your own way to involve patients in the Go-live celebration!

NKEplus Essentials

other tools you may Need for go-live

• Question Card • Preparing Hot Towels Card • Ua Message Pad • Ua Call Triage Protocol • Ua Checklist • “We made it ours” tags • NKEplus Overview poster

76 ROll-OUT

Overview of the Process:

s u l p E K N g n i p e Ke going beyond (Sustaining


What’s invo

lved in th

is section? Beyond the firs t goals is to sus week or two of implemen tation, the tain NKEplus fo combination o f tracking tools r years to come through a , observations check-ins. In , and regular this section: 1. Gather metrics using NKEplus Track 2. Encoura er ge ongoing m anager presen 3. Have re ce on the floo gular unit che r ck-ins 4. Celebra te Successes!

Evaluate & Sustain 77 77

1. NKEplus Tracker Be in the know!

Regular period measurement using the three tools of NKEplus Tracker will help you measure and understand the state of NKEplus. As the timeline indicates, you will use the NKEplus tracker to collect 30 data points every month until you have reached “Green light status� three months in a row, at which point you can collect quarterly. Further details about the NKEplus Tracker can be found in the NKEplus Toolkit. As you go, keep in mind that every bit of feedback is a chance to act. Use the data you collect to celebrate what the unit does well, and create interventions to address issues and parts of NKEplus the unit struggles with.

78 Evaluate & sustain


Data collection tool

Period worksheet

Dashboard (Tables and charts)

*Recommendation: Consider adding an analyst from your quality department to assist with data collection and analysis!


collect 30 data PoiNts:

Once a month

goal: 3 consecutive months of Green-light status

collect 30 data PoiNts:

Once every quarter

EValUaTE & sUsTaIN 79

2. Ongoing manager presence encourage leadership support

Manager presence on the unit floor before and during shift change is an important component of sustaining NKEplus. The managers’ presence provides opportunities for them to see real-time how things are going, and it keeps them in the know regarding how the metrics actually manifest themselves on their unit. Being on the floor also provides good opportunities for managers to show the unit that they are committed to NKEplus and that NKEplus isn’t just another “flavor of the month.” Work with the unit managers (Asst. managers and Charge RNs too) to build presence on the floor into their daily workflow.

80 Evaluate & sustain

ideas that WorKed:


Regular manager rounding has consistently been pointed to as the most effective way to sustain NKEplus during shift change. Examples of things managers can do: • Identify top things each person can do in 15 minutes a day to support NKEplus (Charge RN checklist). • Use this time to conduct your customer service rounds. • Create a checklist to help you be consistent in what you look for. • Help sort/direct incoming admits and other issues that emerge so staff can focus on giving and receiving bedside reports. tool(s) that are available to you

• Charge RN checklist

EValUaTE & sUsTaIN 81

3. Regular Check-ins listeN, learN, aNd adJust

Help the unit keep up the attention to NKEplus. set up weekly check-ins with them.

Talk to them about: • How things are going? What’s going well and not going well? Why? • What do they want to do/focus on for coming week? • Who wants to do what?

82 EValUaTE & sUsTaIN

Ideas that worked:

15-minute standing meetings

No one has time!!!

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.

Tips for 15-min standing meetings:

• Think about ways to free up the champions so they can participate (break relief for those on shift, 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. • Champions need to be allowed to take away some action items themselves. • Leaders should be self aware of facial/physical expressions. Ensure facial/physical presence expresses staff support and open-mindedness. • Consider holding the meetings during a dip in the workflow but before staff begins taking breaks.

Evaluate & Sustain 83

4. Celebrating successes Recognize small wins!

To sustain change, it is important to recognize successes. Look for every opportunity to recognize your staff meaningfully and thoughtfully. Gather up as many stories as you can about successes, and share, share, share!!!

84 Evaluate & sustain

ideas that WorKed:

cELEBrATiON BOArD milestoNes to celebrate:

• Improvements in key service measures or nursing communication measures in HCaHPs • Noteworthy examples of model behaviors observed during shift change • Positive patient comments and impacts as a result of RNs involving patients in their care. (Managers can solicit this during customer service rounds.) a Place to celebrate

This unit put up a magnetic whiteboard to display successes from NKEplus for everyone on the unit to see. The board then went on to become a permanent fixture for celebrating other successes on the unit!

Ways to celebrate:

• Huddle announcements! • Invite hospital leadership to honor successes! • Patient appreciation week! • Pizza parties! • starbucks cards!

EValUaTE & sUsTaIN 85

additioNal tools for sustaiNability...

The following tools may also be helpful to you as you sustain NKEplus. • NKEplus Float RN tool • Call-light dashboard

Bedside Tidbit Cards Help remind staff of the goals of NKEplus in a fun way through these tidbit cards.

• Bedside Tidbit cards • Make your own dashboard • Further sustainability Tips

Make your own dashboard Celebrate successes and help staff reach goals with a dashboard you can make yourself.

These tools and more in the NKEplus Toolkit! 86 EValUaTE & sUsTaIN

t i k l o o T s u l p KE

The N


Tools, Tools, Tools! In the following pages you will find a collection of posters, guides, flyers, and other tools that were called out in the Playbook to help you successfully implement NKEplus. These tools will help you plan, educate, reinforce behaviors with staff, and sustain NKEplus for years to come. You will find the tools in digital form at the end of this book. Many of them are ready to print right away, while others are templates meant to be customized to the unit before being printed and are marked as such.

Toolkit 89

Tools by stage Having the right tools when you need them can make all the difference. in the following pages, you will find all the tools called out in the Playbook as well as a few more. For simplicity, tools are grouped by the stage in which they may first be useful, but many of the tools will come in handy more than once as you implement NkEplus on your unit. Feel free to use any tool wherever and whenever you need it. They are here for you!

PREPARE • U1: Unit Self-Assessment Tool

KICKOFF • K1: Roll-out Schedule poster

• P1: Role Coordination Worksheet

• K2: NkEplus Think tank poster

• P2: Pi Planning form

• K3: NkEplus Goals poster

• P3: Project Snapshot worksheet

• K4: NkEplus overview poster

• P4: Workflow cards

• K5: interview guide (cards) • K6: Walk-through guide (cards)

90 ToolkiT


NKEplus Essentials




• T1: “Things we’re trying” sheets

• R1: NkEplus Badge Cards

• S1: NkEplus Tracker Tool

• T2: “Trying new things” tags

• R2: imagine your day worksheet

• S2: Charge RN checklist

• T3: Question Card

• R3: Cards of various uses.

• S3: NkEplus float tool

• T4: Preparing Hot Towels Card

• R4: Pop-up Video library

• S4: Bedside Tidbit cards

• T5: UA Message Pad

• R5: Tips for HiPAA compliance

• S5: Call-light dashboard

• T6: UA Call Triage Protocol

• R6: Manager sign-up calendar

• S6: Create your own dashboard

• T7: UA Checklist

• R7: “We made it ours” tags

• S7: Further sustainability tips

• T8: Final Hourly Round Times flyer

• R8: Patient-RN Appreciation clips

• T9: Question of the Day

ToolkiT 91


Prepare Note: “Prepare” is not a stage in the Playbook, but this tool is so useful, we couldn’t stand to leave it out! Use it to make sure a unit is ready to start rolling out NKEplus.

HOW TO USE IT Use this self-assessment tool to see how ready the unit is to introduce NkEplus.

92 ToolkiT

Kickoff Tools • K1: Roll-out Schedule poster • K2: NKEplus Think tank poster • K3: NKEplus Goals poster • K4: NKEplus Overview poster • K5: Interview guide (cards) • K6: Walk-through guide (cards)

Toolkit 93




HOW TO USE IT Put up a big poster to communicate project schedule. Use this to help set expectations with staff regarding timing and roles.

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Use this fun poster to build excitement about NkEplus and convey that the unit is “making it theirs�. Put the poster up on a conference room door or somewhere that marks a designated space where the champions team can explore and immerse themselves in NkEplus, make decisions, hold diagnostic workshops, and create additional posters to put up on the unit.





6 Essential Parts

Nurse Role Supporting


Staff Roles

1. Last Hourl y Round

5. Pre-shift Assignmen ts

HOW TO USE IT Use this poster to communicate the goals of NkEplus. Point to it during training, post it up on the walls, keep it around for reference throughout the soft-start process. Having everyone understand the overarching goals of NkEplus will keep the unit striving for the same outcomes while allowing individuals to be flexible in their approach.

In-Room Nur se-Patient Nurse invites Engageme patient to part nt icipate in exc hange of info rma




2. In-Room SBAR

3. In-Room Safety Check

4. Careboar d with Shift Goals & Teachback

* 6. Unit Supp

or t

During En d of shift During han dof f

* CUSTOM FITS: Customize these part

s of NKEplus


based on the

unit’s unique need

s and dynamics


Use this poster to share a summary of NkEplus with the unit. Post it up in one or more obvious places where staff can see it an get familiar with it. Staff bathrooms, staff conference rooms, nurse stations, computer carts, and hallways are all good places for this information.

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HOW TO USE IT HOW TO USE IT Use these cards as guides for interviewing patients and peers about shift changes to discover and understand the issues and concerns first-hand.

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Use these cards as guides for what to look for while performing a walk-through of the unit. The prompts are meant to help the observer see first-hand and better understand the issues on the unit around shift-change.

Planning Tools • P1: Role Coordination Worksheet • P2: PI Planning form • P3: Project Snapshot worksheet • P4: Workflow cards

Toolkit 97




HOW TO USE IT Use this sheet to help staff coordinate roles on the unit during shift change. Using initial input from nurses, make a sheet that shows who might do what at different times during the shift change. letting the unit decide how to coordinate roles helps them feel ownership of the process and gets them thinking critically about how to get things done in a way that works for everyone.

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HOW TO USE IT Use this form to help think about and set specific goals around how NkEplus will positively impact the unit.




HOW TO USE IT Provide this tool to nurses to help them think through problems and ideas they want to try out and communicate them clearly to each other. This sheet can also be used for future projects that involve getting nurses involved in making changes they want to see on the unit.

HOW TO USE THEM Capture and communicate what staff will be trying (NkEplus processes & behaviors) using these half-sheets. Tack them to computer carts or hand them out directly to provide staff with the specifics they need.

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“Trying Things Out” Tools • T1: “Things we’re trying” sheets

NKEplus Essentials

• T2: “Trying new Things” tags • T3: Question Card • T4: Preparing Hot Towels Card • T5: UA Message Pad • T6: UA Call Triage Protocol • T7: UA Checklist • T8: Final Hourly Round Times flyer • T9: Question of the Day

100 Toolkit



HOW TO USE THEM Fill out these half-sheets and post them on the unit, or hand them out to staff directly. This sheet is a good place to write down specifically what you want people to try. The written instructions can easily be communicated between shifts. You can never have enough communication materials when it comes to trying new ideas. Staff will be able to provide better feedback about their experience when they are clear about what they are being asked to try.

HOW TO USE THEM Post these cultural reminder tags up on the unit during the “customize and try” phase to indicate ideas the unit is trying out and needs feedback on.

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NKEplus Essentials T3 QUESTION CARD







IONS A hos FOR Y OUR pit RN/D be ha al can be a OCTO rd to re confu R sing p memb lace. er wh Often at you Use th it want e spac to ask can you h e belo ! av w to w HOW TO USE IT remem e (or anyth ri te d ing ow b questi er). Check else you w n questio ns ons yo o a u mig ut the bac nt to k h of this For patients who have a lot of questions during shiftt report, not ha ca ve tho ught a rd for bout. nurses can give them this card to write things down and

remember for later. This allows the nurse to stay on track getting the rest of reports and follow up on patient questions when he or she returns during assessments.

Sample introduction: “I have to take report on my other patients right now, but I definitely want to know about any questions or concerns you have. I’m going to give you this card to down any questions you might have for me. I’ll be back within an hour to assess you. And that’s the perfect time for us to talk about any questions you might have.”

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IONS A hos FOR Y OUR pit RN/D be ha al can be a OCTO rd to re confu R sing p memb lace. er wh Often at you Use th it want e spac to ask can you h e belo ! av w to w remem e (or anyth ri te dow ing b questi er). Check else you w n questio ns ons yo o a u mig ut the bac nt to k ht not have th of this card fo ought about. r


NKEplus Essentials T5 UA MESSAGE PAD


HOW TO USE IT Tack this to the hot towel cart when first starting NkEplus. instructions like this may seem unnecessary, but they can go a long way to helping make the transition as easy as possible in the early stages of a new process.

Use these brightly colored, self-stick message pads to ensure nurses get messages passed to them about family, patient, and other clinician needs during shift change. Stick them to computer carts where nurses won’t miss them. Pads pictured here are available at most office supply stores.

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NKEplus Essentials T7 UA CHECKLIST



HOW TO USE IT Provide this to the Unit Assistant to help establish a consistent way to triage calls from different parties (family members, doctors, patients, etc.).

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Post this checklist near unit assistants/clerks workstations to provide clear instructions for what they can do to support nurses during shift change. The goal is for any unit assistant, including floats, to be able to see it and understand it easily. Bright colors will help it stand out and maintain a fun feel.






Use this tool to encourage staff to complete their final hourly round within the last hour of their shift by calling out a specific time for staff to start final rounds.

Make your own board and solicit feedback from the staff. The key is to create a public forum that gets people’s attention with a way for them to answer privately. Some tips: • Post board on staff-room door to get people’s attention.

other good reminders include: sending automatic text messages to nurse Spectralink phones, calling all nurses directly (UA), manager rounding, dimming lights or turning lights back on. Make up your own!

• Hand out strips of paper at huddles. • Display answers in a fun format.

ToolkiT 105

Roll-Out Tools • R1: NKEplus Badge Cards • R2: Imagine your day worksheet • R3: Cards of various uses. • R4: Pop-up Video Library • R5: Tips for HIPAA compliance • R6: Manager sign-up calendar • R7: “We made it ours” tags • R8: Patient-RN Appreciation clips

106 Toolkit






Provide these cards to nurses and PCTs to attach to their badges as a reminder of the process. This will serve as a reference they can always have on hand.

Use this worksheet to help staff think about the general schedule of their day now and any adjustments they might make adjustments to make NkEplus work for them.

ToolkiT 107



HOW TO USE THEM Use this card template to make fun cards that can be used in multiple settings. Here are two occasions where cards can be useful: 1) Story Capture during training The training kickoff meeting should involve a lot of listening and sharing. Help nurses build excitement around NkEplus by sharing stories that highlight the issues that NkEplus is trying to address. Capture these stories on cards so they can be easily shared across shifts.

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2) Quiz Cards Make meetings fun with quizzes. Ask questions to get staff thinking more deeply about the process. The goal is to get them thinking about why you are doing this and asking themselves, “How well do i know this?” Throw in questions that are obvious, don’t matter, or don’t have a right answer to keep it from feeling like a test. Provide candy or small prizes to winners.



HOW TO USE IT Use any one of this series of tips and tricks videos to demonstrate nursing best practices during shift change to staff. Videos are taken from real nurses with real patients in a live setting. Topics include: engaging patients during shift change, showing as a way of telling, dealing w/ doctors and family members during shift-change, etc.

HOW TO USE IT Use this document to help nurses understand and practice protecting patient privacy while involving them in shift change in cases where others are in the room during the bedside handoff.

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HOW TO USE THEM HOW TO USE IT Use this sign-up calendar to help managers commit to seeing NkEplus in action during implementation.

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Use these tags on handouts and giveaways during the Golive to remind nurses that NkEplus is a process designed by them and customized for them.


HOW TO USE THEM Hand out these cards and clips to patients on the floor to get them engaged in the process of going live with NkEplus. Hold a contest to see which nurse can get the most clips for involving their patients in the bedside handoff.

ToolkiT 111

Evaluate and Sustain Tools • S1: NKEplus Tracker Tool • S2: Charge RN checklist • S3: NKEplus float tool • S4: Bedside Tidbit cards • S5: Call-light dashboard • S6: Create your own NKEplus dashboard • S7: Further sustainability tips

112 Toolkit


Data collection tool

Period worksheet

Dashboard (Tables and charts)

HOW TO USE IT The NkEplus tracker consists of three tools. The details for how to use each of these tools are outlined on the following pages. --->

ToolkiT 113

S1 NKEplus TRACKER: Data Collection Tool Use the data collection tool during period observations to see how NkEplus is going. it is meant to be printed and photocopied so it can be filled out by hand. X O X

FREQUENCY: To get a sufficient read on how NkEplus is going, you will need to collect 30 data points per month -– ideally in the same week per month. one data point equals one shift change on one patient.


Use three codes to collect the data properly: • X = the task was completed • o = the task was not completed • N/A = not applicable...the task could not be completed.

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if you have 2 shifts, collect 15 med passes from AM and 15 from PM. if you have 3 shifts, collect 10 from morning, 10 from afternoon, and 10 from the night. HOW TO USE IT: The observer tracks the number of interruptions using hash marks and use an X or o to mark which steps of NkEplus have been completed.











in the example above, for Data Point #1, the oncoming nurse was not introduced to the patient so an “o” was placed into the box since this step should have been performed.

S1 NKEplus TRACKER: Period worksheet

After the 30 data points are collected they need to be entered into the correct Period worksheet (see Excel file). The correct Period is the next Period that is blank. For example, if Period 2 is filled out, and Period 3 is empty, then the period to enter the data is Period 3. To enter the data, use an “x” to indicate the process step was completed, “o“ (not a zero!!) if it was not, and blank if the nurse was unable to complete it. This should be direct data entry from the Data Collection Tool to the Period worksheet.

ToolkiT 115

S1 NKEplus TRACKER: Dashboard (Tables and charts)

The Table and Charts worksheet is your guide to understanding the state of NkEplus on the unit. lucky for you, this worksheet automatically tabulates and creates the charts based on your data entry in the period worksheet. Therefore, the Table and Charts worksheet is only for viewing and printing, so no data should be entered here.


in this example, see the unit moving from

The first section is the “Green light” table. Based on the data, the table will calculate a result and automatically turn it red, yellow or green.

showing improvement!

red to yellow/green, meaning that they are

GREEN indicates success- the task was completed ≥90% of the time or time in the room is between 3 and 5 minutes. YELLOW indicates that more work needs to be done -– the task was completed between 80% and 90% of the time, or time in the room is between 1 and 3 or between 5 and 7 minutes.

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RED indicates that a “more heroic” intervention may be needed. The task was completed < 80% of the time or time in the room is less than 1 or greater than 7 minutes.

S1 NKEplus TRACKER: Dashboard (Tables and charts)

PART 2: CHARTS The second section of the Table and Charts worksheet is composed of four charts to make it easier to visualize the state of NkEplus. Remember that all data points in the future are zero, thus the charts â&#x20AC;&#x153;plungeâ&#x20AC;? to zero after the last entered data point.

ToolkiT 117



HOW TO USE IT HOW TO USE IT Have Charge RNs and managers use or modify this checklist of daily activities that includes top things each person can do to support NkEplus. The goal is to help them build supporting the unit into their daily workflow.

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Having float RNs that don't know how to participate in NkEplus can be disruptive to the process. For a good implementation, use this tool to walk your float RN through what NkEplus is about and help them understand that at the bare minimum they are expected to participate as a member of the frontline staff in your unit.



s... GO



Call lights

during shift change

HOW TO USE THEM Use these cartoons to convey the “whys” of bedside reporting in a refreshing and fun way. Post them up on the unit, hand them out to nurses, place them around in conspicuous places, etc. This is especially useful as reminders as you’re trying to sustain NkEplus.

Average # of calls before NKEplus :

12 11 10 9 8 7 6 5 4 3 2 1 0 -

AM PM EVE Sunday

Other rea

sons to



AM PM EVE Monda y

AM PM EVE Tuesday

AM PM EVE Wednesda y

AM PM EVE Thursday

AM PM EVE Friday

AM PM EVE Saturday

HOW TO USE IT Having trouble with your final hourly round and call lights during shift change?

Use them a few at a time and make them last. Pick one that’s relevant to what you’re working on.

Put this up on the unit to give a live readout of “how we’re doing” on NkEplus during your roll out.

You can also use them as a fun way to get staff to share stories that are related to these topics.

Track call lights to show how well your final hourly round is impacting call lights during shift change.

ToolkiT 119


HOW TO USE IT When sustaining NkEplus, pick a few focus areas that you want to put in front of your staff as reminders of what the unit is working on. Here’s a fun way to show the data you’ve collected: • Go to a fundraiser thermometer generator on the internet. This one is good: thermo/ • Create a thermometer chart using data you have pulled from NkEplus Tracker that you want to show your unit. Pick and choose the area you want your unit to focus on. • Enter the number from your NkEplus Tracker data as “current” and use 100 as “goal”. • Click on “Save Graphic” and save it to your computer. it will save as JPG. Paste it into Powerpoint or Word, and make a poster out of it. • label your thermometer so that it’s clear, along with messages you want to convey to the staff.

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Make sl

Tips an d tricks


• Reac t at



first sig : Don’t let ns to m slippag ake it cle e beco ful not ar that me the to be to feedbac returning norm. o nega k wher to old wa tive, bu e it is ne t ys in no • Rem at the sa eded. ove old t desirab me tim structu le. e don’t sh ral supp y away orts as from giv sociate Keep up ing d with the atte the old way. ntion: Do n’t let th • Keep e atten on mea tion sli su p away ring an a priority , keep d feedin . it on pe g back: improv Set up a syste ople’s m Measu ement m that inds. remen effort, t comm • Reco never re assures auto unicate gnize an m ally let s that so d celeb it settle atic re-measu • Set th methin rat into sim re e main e bar ev g is taining ple main . Make it a co en highe improve perform nt tenanc r, try to even mo ance. e mode. inuous improv re. • Re-tr e even ain, re-ed more. e.g. Create ucate, • Educ frie re -ca ndl y compet mpaign ate new ition bet staff. Qu ween uni NKEplus ts to ickly ed Float To ucate fl ol. • Cont oat RN inue to s or staff create unfamilia unit. the posit r with NK ive em Eplus us otional • Use th ing the story of e excit what NK ement • Cont Eplus ha of impr inue to ovemen s brough listen to t to keep t to the being he staff, lea up the dership, attentio Keep me ard. e.g. Share n. an d cham ssages fre stories in pions to sh with huddles humor. or post the ensure m up on that th the wall. eir storie Try to sha Structu s are re stories re it: Bu every oth er week ild the or so. improv ement • Standa into the rdize: Inc fabric of orporat daily wo • Establi e the ne rk and sh on-go w way system ing traini into po s • Create licies an ng. new ro d proced les and ures. • Make respon someo sibilities ne acco that su previou untable pport th s levels to see e new . that th • Have proces e new s. bite-size proces bu s • Make t consist does no proces ent task t degrad ses cle unit. s ever yd e back ar and to ay to su transpa pport NK rent. e.g Eplus. . Outline the

Sustain ability

• Be ca re






unit sup

port respon

to supp

• Involv e other people • Supp in it so ort cham


or t: The



not rely

they co


on just


and post

one pe

for sust ntly rem to deve aining ind each lop their NKEplus other to role. Co • Work . keep up ntinue with loc

it on the

rson fo


Use these tips to help guide you as you sustain NkEplus on different units. Many of these tips are can be applied to sustaining other initiatives as well. al orga



to includ


e them


to get


the wo

rk. e to focu s

in wher

on creati

ng chan


ToolkiT 121

Glossary of Terms ANM- Assistant Nurse Manager Careboard- A patient-caregiver communication board that lives in each patient room. CNO- Chief Nursing Officer COO- Chief Operation Officer EVS- Environmental Services IA- Improvement Advisor NKE- Nurse Knowledge Exchange PCT- Patient Care Technician (same as CNA, nurse aide, nursing assistant, etc) PI- Project Improvement PM- Project Manager RN- Any certified nurse SCL- Santa Clara Kaiser Permanente Hospital SAC-Sacramento Kaiser Permanente Hospital UBT/DBT- Unit Based Team/Department Based Team UA- Unit Assistant (same as unit clerk) 122 Glossary

Congratulations & Good luck!

NKEplus Change Package v1.0