KP Painscape Testing Packet

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PAIN

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VERSION 1.0 | January, 2011

Copyright © 2011 Kaiser PermanenteThese testing materials were developed by Kaiser Permanente’s Innovation Consultancy with support from the Gordon and Betty Moore Foundation and Kaiser Permanente’s NCAL Community Benefi ts Program. As a part of our commitment to improve the health of communities around us, you may use and reproduce these copyrighted materials. Any questions or feedback can be emailed to: [email protected]

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

3

KP PAINSCAPEwelcome to the

test in g pa cketKP Painscape was developed as a part of the Destination

Bedside project funded by the Betty Moore Foundation and Kaiser Permanente NCAL Community Benefi ts.

Designed by nurses in Sacramento and Santa Clara Kaiser Permanente medical centers, KP Painscape outlines enhanced

practices for managing pain as the 5th vital sign by highlighting best practices to help nurses minimize unnecessary pain.

It focuses on practice patterns, communications between nurses and their patients, and coordinated collaboration between

nurses to help them stay ahead of their patients pain.

This book is designed to support further testing of KP Painscape concepts using processes, tools, and ideas that are showing

strong promise in four pilot units.

4

Untreated or under-treated pain causes unnecessary suffering and negatively impacts patient recovery.1 Of the 23 million surgery patients in the US every year, approximate 50% of post-operative patients report having received adequate pain relief during the course of their recovery.*1,2,3

To address this, in 2001, The Joint Commission required all accredited hospitals to begin treating pain as “The Fifth Vital Sign” - standardizing practices around appropriate pain assessment and the management of pain using the 0-10 scale.4

However, despite improvements brought upon by hospitals responding to Joint Commision requirements, the practice of managing pain still remains challenging in a clinical setting - with varied and inconsistent results around receiving adequate comfort. 3,5,6

PAINwhy man agement

1"Chapter 17." Patient Safety and Quality- An Evidence-Based Handbook for Nurses. Ed. Ronda G. Hughes. Rockville: Agency for Healthcare Research and Quality, 2008. Print.

2 http://www.ahrq.gov/clinic/medtep/acute.htm#acuteintro 3 McCaffery M. Pain management; problems and progress. In: McCaffery M, Pasero C. Pain: Clinical Manual. 2nd ed. St.

Louis, MO: Mosby; 1999. p. 1 - 14 4JCAHO. Comprehensive Hospital Accreditation Manual. Oakbrook Terrace, IL, 2001.5 Apfelbaum JL, Chen C, Mehta S, et al. Postoperative pain experience: results from a national survey suggesting

postoperative pain continues to be undermanaged. Anesth Analg 203:97:534-406 Hutchinson, RW. Challenges in acute post operative pain management. Am J Health Systm Pharm 2007; 64(6 Suppl):

S2- S5.

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

5

[ ]

6

to adequately man age pa in

7

LITERATUREi s c a ll in g fo r. . .When examining the body of knowledge on pain management, literature says there are opportunities to go beyond the 0-10 scale and focus on key evidence-based areas of improvement such as:

• More regular assessment of acute pain and reassessment after each intervention1

• Timely documentation to facilitate better interdisciplinary communications amongst clinicians2,4

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

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

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

• More comprehensive pain history evaluations before surgery2

• Collaborative pain management planning involving patients and family2

• Better patient and family education in pain management2

• Employing multi-modal approaches to pain management4

• Use of Complementary Alternative Methods to achieve pain relief7,8

But, where can we focus to make the most impact when looking at nursing practice?1 JCAHO. Comprehensive Hospital Accreditation Manual. Oakbrook Terrace, IL, 2001.2 Car DR, Jacox AK, Chapman CR, et al. Acute Pain Management: operative or medical procedures and trauma, No. 1. Rockville, MD: AHCPR pub. No. 920032; Public

Health Service; U.S. Dept. of Health and Human Services, 1992.3 American Pain Society. Quality improvement guidelines for the treatment of acute and cancer pain. JAMA 1995; 247:1874-18804 Gordon, DB, Dahl J, Miaskowski C, et al. American Pain society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med.

2005; 165:1574-1580.5 Gittell JH, Fairfi eld K, Bierbaum B, et al. Impact of Relational coordination on quality of care, postoperative pain and functioning, and length of stay: A nine-hospital

study of surgical patients. Med Care. 2002; 38 (8):807-8196 Horsley J, Crane J, Reynolds MA. Pain: Deliberative Nursing Interventions. New York: Grune & Stratton, 19827 Kwekkeboom K. Pain Management strategies used by patients with breast and gynecological cancer with postoperative pain. Cancer Nurs. 2002;24 (5): 378- 386.8 Pellino TA, Gordon DB, Engelke ZK, et al. Use of nonpharmacologic interventions for pain and anxiety after total hip and total knee arthroplasty. Orthopaedic Nurs.

2005;24(3):182-190.

8

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

FALL BEHINDon their pa inw hy pat i ents

9

WHAT WE SAW:

MiscommunicationPatients often don’t understand what nurses want when asked to

describe their pain on a 0-10 scale.

Trust is keyPatients need reassurance that

their nurses are proactively looking after their pain and

are acutely aware of signs that indicate whether or not that is

the case.

Remembering to ReassessIn the rush of the day, it can be diffi cult to remember to

reassess patients and document the reassessment.

describe their pain on a 0-10 scale.

The pills don’t workPatients often lose faith in their oral

pain meds because of perceived ineffectiveness- this can happen when

patients are transitioned off IV pain meds and not given adequate doses of

oral pain meds.

Morning AgonyPatients can very easily sleep

through their pain at night, and fi nd themselves in unnecessary

pain in the morning.

Already behindEven when instructed to call at the fi rst sign of pain, patients often don’t call for pain meds

until they are already behind on their pain.

10

I suggest we give you Norco because we

want to transition you off of IV pain meds.

Okay

I don’t want the pill. It didn’t work. Just

bring me the IV stuff please.

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

one.

I will get you something right away.

Did you not get anything at night?i need pain meds please. i am like a ten.

good morning

i was sleeping. i am so

behind....

it’s a 7.

how is your pain?

How come he didn’t tell me earlier?

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

stay ahead .

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

Morning AgonyPatients can very easily sleep through their pain at night, and fi nd themselves in unnecessary pain in the morning.

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

FALL BEHINDstoryboa rdwhy pat i ents

11

after i set up this transfusion i will go reassess

room 12

I gotta reassess-room 12 after i get this report

here is your pain pill

thanks

let’s get you out of bed.Are you in

any pain?

no, I am doing great. No

pain at all.

It hurts to try to get i

up.

So, I will go get you some percocet

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

I am worried about my pain

Oh, Actually you are due for dilaudid for another hour How come

she doesn’t know this?

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

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

Remembering to ReassessIn the rush of the day, it can be diffi cult to remember to reassess patients and document the reassessment.

12

KP PAINSCAPEwh at

KP Painscape is about staying ahead of our patients’ pain and standardizing best practices to manage pain as the fi fth vital sign. Good pain management relies on great communication between patient and nurses, as well as around-the-clock collaboration between clinicians to ensure patient pain levels stay within controlled limits.

KP Painscape emphasizes six essential behaviors that improves pain management through enhancing individual nursing practice and team nursing practice.

i s about

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PROBE PAIN SCALE RESPONSES(considering functional goals and ADLS)

USE THE MOST APPROPRIATE DOSE FOR INITIAL TRANSITION

TO PO PAIN MEDS

REASSESS ON A TIMELY BASIS

INDIVIDUAL NURSING PRACTICE

TEAM NURSING PRACTICE

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

WORK AS A TEAM TO KEEP PAIN REGIMEN GOING AT NIGHT

PREPARE BEFORE GOING INTO THE ROOM

14


INDIVIDUAL NURSING PRACTICE

TEAM NURSING PRACTICE

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



PROBE PAIN SCALE RESPONSES(considering functional goals and ADLs)

USE THE MOST APPROPRIATE DOSE FOR INITIAL TRANSITION

TO PO PAIN MEDS

15

Cross shift teamwork is about two things:

1. During shift change (NKE), review the last given pain medication and the next available dose.

2. Establishing specific roles to keep pain regimen going at night. The roles are outlined as follows:

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

Go into patient room:Ask patient if in pain and what number on a scale of 0-10 and comfort levelProbe for pain level considering functional goals and ADLsRecommend pain interventions as appropriate given upcoming activities Explain recommendationsIntervene

Within 60 minutes:Reassess for efficacy, side effects, and patient safety

IN PRACTICE: ENHANCED PAIN ASSESSMENT TOOLS:

IN PRACTICE: CROSS SHIFT TEAMWORK TOOLS:

Reassessment Reminders(KPHC coming 2011)

OR

Evening Shift: Establishes plan with patient for managing pain at night.Night Shift: Executes plan established by evening shift and advocates for pain meds at night.Day Shift: Reports out if they had to catch up with pain in the morning.

Last Given/Available NextPatient Poster

Patient Pain Agreement

16

I suggest we give you Norco because we

want to transition you off of IV pain meds.

Okay

The norco is working well to manage my

pain.

Here is your Norco Let’s start off with two and

see how it works. If it is too much, we can always

try out one pill.

Use the most appropriate

dose for initial transition to PO

pain meds

Probe pain scale responses

(considering functional goals

and ADLS)

How about when you move?Are you in

any pain?

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

I suggest we medicate for your pain when moving,

that way you can participate in your PT

today.

no, I am doing great. No

pain at all.

okay.

Prepare before going into the

room

Do you want me to go get your 12

o’clock percocet>your percocet is

available soon and can be taken every 4 hours.we should really try to

be staying on the percocet so you can go

home tomorrow. Sounds like he knows what he

is talking about.

next availablepercocet is 1200, every4 hours....I should start

encouraging po painmeds only.

yeah, thankyou.

KP PAINSCAPEin a ct i on

17

Rest is important, but it’s more

important that you are comfortable in

the morning. How about I have the RN

come in at 2am with your percocet?

i really feel i need my rest.

okay, sounds good.

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

coordinate with your night RN to execute it. Work as a team

to keep pain regimen going

at night.

Encourage around-the-clock dosing

(even if PRN is ordered)

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

of control.

I am just coming to check how your pain is doing. Your last

pain pill was 3 hours ago and you have another available if

you need it.

yeah, my pain is just starting to

come back. It’s not much though.

okay.

oh, time to reassess room 15.

How is your pain now? It’s been about 45

minutes since your pain pill, is it working to relieve your pain?

Reassess on a timely basis

18

after hours of observation....2 Medical Facilities4 Med-Surg Units200 Staff RNs

“We need to focus on t

he practice.”

- Justyne, Unit Manager

“You gotta stay ahead of the pain.” - Tom, RNA new goal: let’s defi ne pain

management best practices,

then build tools/processes to

support them.

“You gotta advocate to keep

them on the pills!” -

Amanda, RN

This is so much fun!Now, let’s take all of

these best practices and put them together to teach everyone on our

pilot units“We need to focus on the behaviors of KP Painscape.”

-Tracy,, Unit Manager

Tracy creates the fi rst iteration of 6 Patterns

of Effective Pain Management

A JOURNEYrevis ited

19

everyone had great ideas!

Susan made a reassessment reminder!we tested a lot of t

hese ideasBut, we kept emphasizing tools. And, it was

not sticking.

Rhonda writes KP Painscape rap

to “Paul Revere”!

“By the time we get here the patient is already asleep” - NOC RN

Over 60 frontline staff come together to ideate around pain management

PA

TIEN

TS,

HO

SPIT

AL

LEA

DER

SHIP

, DESI

GN

ER

S

Evening RNs start working with NOC RNs to manage

pain through the night

“You need your patient’s trust to manage pain.”- Lllyod, RN

We go live with KP Painscape on 4 units!

Co-designing, collaborating, developing, and inspiring KP

Painscape, special thanks to:

Kaiser Permanente Santa Clara Medical Center, thanks to Unit 220,

Unit 235, and all of the hospital leadership support. KP Sacramento,

4-West, 4-East, 1-West, and all of the hospital leadership support.

Funding KP Painscape and the Destination Bedside

project, special thanks to:

The Betty Moore Foundation and Kaiser Permanente NCAL Community Benefi ts

Loretta made a

pain graph!

MDS, RNS, NURSE MANAGERS, PHYSICIAN ASSISTANTS,

20

1 Survey question: My nurse taught me that medication for pain after surgery is effective when given: best answer of "Fixed Schedule" (Minimum

pilot unit increase of neutral, average across the four pilot units increase of 19%)2

Survey question: I have a pain management discussion with my patients during the first half of my shift. (Minimum pilot unit increase of 12%, average across the four pilot units increase of 44%)3

Survey question: Planning my workflow for the shift and anticipating patient needs, I find the most helpful person on the pain management team is: best answer "Patient" (Minimum pilot unit increase of 17%, average across the four pilot units increase of 25%)

POST GO-LIVEAverage Across Four Pilot Units

MORE INFORMED PATIENTS1

MORE DISCUSSIONS WITH PATIENTS2

MORE COLLABORATION WITH PATIENTS3

RN Surveys:

Patient Surveys:

PILOT UNITda tainitial

+44%

+25%POST GO-LIVE

Average Across Four Pilot Units


21

5 I am confident in the nurses ability to effectively manage the pain of the patients on this unit (Minimum pilot unit increase of 16%, average across

the four pilot units increase of 27%)6

The way patients pain is managed on this unit makes it easier for me to do my job (Minimum pilot unit increase of 11%, average across the four pilot units increase of 15%)7

I am confident in the nurses ability to safely manager the pain of the patients on this unit (Minimum pilot unit increase of 4%, average across the four pilot units increase of 13%)

ABILITY TO EFFECTIVELY MANAGE PAIN5 ABILITY TO SAFELY MANAGE PAIN7

MAKES MY JOB EASIER6

Other Clinicians Surveys:

Morning Pain Variance:




+27%+13%

GO-LIVE AND PDSAsDEEP DIVE FINAL VERSION

The Pain Variance reports from our

four pilot units show the following:

• Pain variances of greater than

1 have more opportunity for

improvement

• Pain variances of 1 and under

will not likely show much im-

provement

• There seems to be a “sweet

spot” between .5 and 1 as a

range for optimal pain variance

4-WEST- SACRAMENTO MEDICAL FACILITYPain Variance

22

KP PAINSCAPEt imel inetest in g

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

GET READY! KICK-OFF PREP GO-LIVE GO-LIVE SUSTAINPDSAs

MANAGEMENT TEAM MEETING

RN CHAMPION KICK-OFF MEETING

TRAINING FOR GO-LIVE

2 WEEKS 1 DAY 4 WEEKS* 1 WEEK 1 WEEK ONGOING

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

23

WORKBOOKKP Pa insc ape

Your guide to testing out KP Painscape on your unit

24

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

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

25

GET READY!

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

KICK-OFF• Part 1: Preparing Yourself• Part 2: Kick-Off Meeting

MANAGING PDSAS• Part 1: Preparing Yourself• Part 2: Managing PDSAs

PREPPING FOR GO-LIVE• Part 1: Preparing Yourself• Part 2: Unit Management Team Meeting

GO-LIVE!• Go-Live

WORKSHEETS• Worksheets for RN Champions and Unit

Management Team to copy and use throughout the process

Table of Contents

page 33

page 41

page 47

page 53

page 57

page 27

26

GET READY! KICK-OFF PREP GO-LIVE GO-LIVE SUSTAINPDSAs

MANAGEMENT TEAM MEETING

RN CHAMPION KICK-OFF MEETING

TRAINING FOR GO-LIVE

2 WEEKS 1 DAY 4 WEEKS* 1 WEEK 1 WEEK ONGOING

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

What this process will look like:

27

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

GET READY!with un it man agement tea m

KP PAINSCAPE OVERVIEW(A) Get to know KP Painscape (B) facilitate “In my own words” activity

PAST IMPLEMENTATIONSFacilitate discussion on what’s worked in the past and what’s not

DETERMINE NURSE CHAMPIONSEstablish and build a team of nurse champions

BASELINE METRIC COLLECTIONPlan how baseline metrics will be collected

TALK ABOUT SCHEDULE AHEAD

PART II: Unit Management Team Meeting

PART I: Preparing yourself

28

Review the KP Painscape Overview so you are grounded in the materials.

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

Think about the schedule ahead and the timing of the key activities.

Before meeting with the unit management, make sure you have made copies of the Unit Management Prep

Worksheet (page 58) and Kick-Off Homework (page 59) for everyone at the meeting.

Pages 8-17 are the key pages to share

What is KP Painscape? Why are we doing this? What will be involved?

*Suggest the fi rst unit of a medical facility that goes live with KP Painscape consider having a

longer time period (i.e. 6 Weeks) to run PDSA’s to ensure that system issues are resolved.

GET READY!KICK-OFF

PREP GO-LIVEGO-LIVE

SUSTAIN

PDSAsMANAGEMENT

TEAM MEETING:

_____________

RN CHAMPION

KICK-OFF MEETING:

_____________

TRAINING FOR

GO-LIVE (hold

within 3 days of

Go-Live)

2 WEEKS

DATE

1 DAY4 WEEKS*

1 WEEK1 WEEK

ONGOING

DATE

GO-LIVE!


29

PART II: Unit Management Team Meeting

To ensure the leadership team has a strong understanding of KP Painscape. Have each participant fi ll out the top section of Unit Management Prep Worksheet (page 58).

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

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

KP PAINSCAPE OVERVIEW

PAST IMPLEMENTATIONS

1B

1A

2

Pages 8-17 are the key pages to share

This time around, we will:

1. __________________________________________________

2. __________________________________________________

3. __________________________________________________

In the past, what’s worked?

________________________________________________________

________________________________________________________

_______________________ What hasn’t worked?

_____________________________________________

_____________________________________________

_____________________________________________

IN MY OWN WORDS

30

TIPS FOR SELECTING CHAMPIONS

GoodAmazing!Willing

Passionate

GoodAmazing!Respected

Looked up to

GoodAmazing!Well Liked

Infl uential socially

Identify nurses who will explore pain management best practices, advocate for KP Painscape, and collaborate with the entire unit to adapt KP Painscape to unit workfl ow.

DETERMINE NURSE CHAMPIONS3

Our KP Painscape Nurse ChampionsRecommendation: 2 RN champions per shift per unit

1. _________________________________

2. _________________________________

3. _________________________________

4. _________________________________

5. _________________________________

6. _________________________________

Review metrics and plan for who will be collecting each metric. It’s really important that the unit management team collects metrics to truly understand their unit’s current state.

For tracking metrics, use the KP Painscape Excel Metrics Tracker (download from http://www.kpinnovation.org)

BASELINE METRIC COLLECTION4

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

MORNING PAIN COUNT:

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

REASSESSMENT RATES:

For KP Painscape, it is best to track reassessment rate by shift for each day. Explore ways your hospital currently reports reassessment rates and arrange for these reports to be accessed by the unit management team.*

* If you are a Kaiser Permanente facility you may want to arrange access to Crystal Reports. Connect with your facility to arrange access and get trained on how to use these reports.

How we will collect:

____________________________________________

____________________________________________

Who will collect: ____________________________


____________________________________________

____________________________________________

Who will collect: ____________________________

31

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

Before the Kick-Off, have the RN Champions and management team ‘See it for themselves’- this means actually going out onto their unit to collect pain management stories and emotionally connect to the current status of the unit.

You should work with the department team to facilitate this exercise or use committee time or backfi ll for the RN Champions.

After conducting the observations and interviews, have the RNs and unit management team make posters about their experiences to share at the Kick-Off.

PLAN SCHEDULE

KICK-OFF HOMEWORK

5

6

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

GET READY!KICK-OFF

PREP GO-LIVE

GO-LIVE

SUSTAIN

PDSAs

MANAGEMENT TEAM MEETING:

_____________

RN CHAMPION KICK-OFF MEETING:

__________________________ TRAINING FOR

GO-LIVE (hold within 3 days of Go-Live)

_____________

2 WEEKS

DATE

1 DAY

4 WEEKS*1 WEEK 1 WEEK

ONGOING

DATEDATE(S)

DATE

DATE

GO-LIVE!

_____________

Have the RN Champions and Unit Management Team Kick-Off

Homework (page 59)

32

33

Hold a half-day Kick-Off to ground them in KP Painscape, and conduct the fi rst round of PDSAs to tailor ideas to meet the needs of the unit.

KICK-OFFwith RN Ch a mpi ons

UNDERSTAND THE CURRENT STATE(A) storysharing about the issues (B) Share baseline metrics

KP PAINSCAPE OVERVIEW(A) Share what KP Painscape is about (B) What does it look like in practice

DEFINE CHAMPION ROLE

CONDUCT 1ST PDSA CYCLEGet started with small tests of change for 3 of the concepts

PLAN UNIT COMMUNICATION

SET UP NEXT STEPS

PART II: Kick-Off Meeting


34

Finalize the date, time, meeting room, and invitees for the Kick-Off. Make sure all invitees have the homework and have time available to complete the assignment. For the Kick-Off meeting, a half-day session is suggested; however, make the necessary adjustments to your meeting agenda based on available time.

Loop back with your Unit Management Team and have them share what data they have collected. Prepare this data to share at the Kick-Off. If your management team is using the KP Painscape Metrics Excel Spreadsheet, then just make sure you have the most recent version to share at Kick-Off.

Review story-sharing activity. Don’t just story-TELL, have the group story-SHARE! To do this, review the story-sharing activity to think about how best to facilitate this exercise.

What baseline metrics I want to share:

_____________________________________

_____________________________________

_____________________________________

How am I going to facilitate this discussion:

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________


KICK-OFF AGENDA (4 HOUR MEETING)

RN Champions and Unit Management Team

(45 minutes) Share stories/Baseline metrics

(1 hour) KP Painscape Overview

(10 minutes) Defi ne Champion Role

(5 minutes) PDSA and Metrics 101

(1 hour) Plan 1st PDSA Cycle/Try First PDSA Cycle

(45 minutes) Debrief

(15 minutes) Next Steps

35

Prepare how you are going to explain each of the KP Painscape concepts and how the concepts look in practice- i.e. key questions to ask, new processes, tools, etc.

Concept What you will emphasize

Prepare before going

into the room

Probe Pain scale

responses considering

ADLs and functional

goals

Use the most

appropriate dose for

initial transition to PO

pain meds

Reassess on a timely

basis

Encourage around the

clock dosing

Work as a team to keep

pain regimen going at

night

Refer to the KP

Painscape in Action

Storyboard (16-17)

PART I: Preparing yourself (pg. 2)

36

Share the current state of pain management on the unit and discuss how KP Painscape might impact the unit.

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

UNDERSTAND THE CURRENT STATE: SHARE STORIES

UNDERSTAND THE CURRENT STATE: SHARE BASELINE METRICS

KP PAINSCAPE OVERVIEW: WHAT IS KP PAINSCAPE?

1B

1A

TIPS FOR ENGAGING THEM EMOTIONALLY IN THE ISSUES:

Good

Amazing!

Hear it

Feel it

GoodAmazing!

Hear it from you Hear it from each other

Why we fall behind storyboard.....

What we saw...

PART II: Kick-off Meeting

What did you learn on the unit? What suprised

you?

Which of these are most frustrating?

Why?

Do you identify with these stories? Do they

resonate?

Do you have a specifi c story related

to these?

How do we feel about where we are based on

the data?

Do you think KP Painscape will have a

benefi cial impact on this unit?

Familiarize the Kick-Off participants with all of the elements of KP Painscape.

2APages 8-17 are the key pages to share

37

KP PAINSCAPE OVERVIEW: WHAT KP PAINSCAPE LOOKS LIKEGive participants a mental vision of what KP Painscape looks like in practice by sharing storyboards, more detailed descriptions, and even acting it out.

2BFor the discussion, refer

to the KP Painscape Storyboard (page__)

Act 1: Time-out, ProbingIntroduce the problem: _______________________________________

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

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Reiterate the solution: _________________________________________

Act 3: Around-The-Clock DosingIntroduce the problem: _______________________________________

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

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________


Act 2: Most Appropriate DoseIntroduce the problem: _______________________________________

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

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________


Act 4: Pain Regiment At NightIntroduce the problem: _______________________________________

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

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________


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

DEFINE CHAMPION ROLE3

What does being a champion mean? What are the expectations of this group?

supportive!

willing to try ideas!

38

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

CONDUCT FIRST PDSA CYCLE5

Encourage your RNs to set up a PDSA Journal to take

notes in throughout the PDSA process. Refer to page 66 to

see how to set one up.

THE INITIAL TESTS:The fi rst round of PDSA tests have been designed for your team. During the Kick-off, start out by testing these three concepts:

1. Probe pain scale responses considering ADLs and functional goals (page 61)

2. Encourage around the clock dosing (page 64)3. Work as a team to keep pain regimen going at night (page 65)

AFTER THE INITIAL TESTS:Come back together as a group and talk about what happened, how it felt, and fi ll out the PDSA Tracker (page 43) and plan the next test.

How did it feel?

What happened?

39

PLAN UNIT COMMUNICATION6 Plan how the team is going to be communicating what is being testing to the entire unit during the PDSA cycles.

HOW WE WANT PEOPLE TO RESPOND:

• Be open• To try out ideas

• Be patient and fl exible

• Give feedbackWHAT WE NEED TO TELL EVERYONE:• Working on pain management• Trying out KP Painscape ideas• What KP Painscape is• We will be asking for feedback and participation

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

CREATE A POSTER:

What will it say:________________

____________________________

____________________________

____________________________

Who will make it:_______________

CREATE HUDDLE MESSAGES:

What will they say:______________

____________________________

____________________________

____________________________


CREATE A CRIB SHEET:

What will it say:________________

____________________________

____________________________

____________________________


KP Painscape Poster

Huddle Message for Date _____

At a glance! We are trying....

40

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

SET UP NEXT STEPS7

E-MAIL CHECK-INS:

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

________________________________

________________________________

________________________________

________________________________

INFORMAL CHECK-INS:

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

________________________________

________________________________

________________________________

________________________________

SET UP WEEKLY CHECK-INS:

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

________________________________

________________________________

________________________________

________________________________

WHAT THE NEXT COULD OF WEEKS WILL LOOK LIKE:

PREP GO-LIVE

GO-LIVE

PDSAsWEEK 2WEEK 1 WEEK 3 WEEK 4

1 WEEK

1 WEEK


PROBE PAIN SCALE RESPONSES CONSIDERING ADLS

ENCOURAGE AROUND THE CLOCK DOSING



HIGHEST DOSE FOR INITIAL TRANSITION TO PO PAIN MEDS

PLAN

PLAN

PLAN

41

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

PDSASManag in g

TRACKING PDSAs

WEEKLY CHECK-INSMeet with unit champions on a weekly basis to do formal check-ins

INFORMAL CHECK-INSRound fl oor informally on a daily basis to check in.

PART II: Managing PDSAs


42

Make sure you have scheduled all of the weekly check-ins and have a room scheduled for each meeting.

As you prepare to guide the PDSA process, make sure you are supporting an environment that is explorative at the beginning, and gets more defi nitive near the end.

Before each check-in, make sure the PDSA tracker is as up to date as it can be. In addition, make sure you have plenty of copies of the unit communication worksheet and PDSA planning worksheet.

Use the Unit Communication

Worksheet (page 68) and PDSA

Planning Worksheet (page 67) at

your weekly check-ins.

WEEK 1: CHECK-IN WEEK 2: CHECK-IN WEEK 3: CHECK-IN WEEK 4: CHECK-IN

EXPLORATIVE

CREATE SOLUTIONS

Open, Flexible, Supportive,

Messy, and Organic

Directive, Explaining, Organized,

Decisive, and Scaling up

(refer to Prep for Go-Live

section)Make decisions

Plan for Training

Rehearse Training

Plan for Go-Live

Get feedback and plan

next test:Cross ShiftProbingAround-The-Clock

Introduce:Time-outReassessment

Get feedback and plan

next test:Cross ShiftProbingAround-The-Clock

Time-outReassessment

Introduce:Highest Dose

Scale up all tests

PDSA PLANNINGworksheet

HOW THINGS ARE NOW: HOW YOU WANT THINGS TO BE:


43

Concept First Test Results of First Test Second Test Results of Second Test


room

Probe Pain scale responses

considering ADLs



pain meds


Encourage around the clock

dosing

Work as a team to keep pain

regimen going at night

Use the PDSA tracker to help run your check in meetings and coordinate your multiple tests. It will help keep your champions on track to developing and establishing Painscape for the fl oor.

TRACKING PDSAs1

PART II: Managing PDSAs

44

TRACKING PDSAs (CONTINUED)1

Concept Third Test Results of Third Test Fourth Test Results of Fourth Test


room

Probe Pain scale responses

considering ADLs



pain meds


Encourage around the clock

dosing

Work as a team to keep pain

regimen going at night

45

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

WEEKLY CHECK-INS2

1. What did we do?

2. What happened?

3. What did we learn? Try “Frame the story

activity” (to the right)

4. What will we do next? Fill out PDSA

Planning Worksheet (page 67)

5. What are we going to communicate to

the unit this coming week? Fill out Unit

Communication Worksheet (page 68)

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

PDSA PLANNINGworksheet

HOW THINGS ARE NOW:

HOW YOU WANT THINGS TO BE:

Weekly Check-In Agenda:

Key Insight: Only some people are doing the probingSomeone came up to me to ask me about it

People talked about it at the huddles

I overheard someone doing it

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

46

It’s important to keep checking on the unit throughout the PDSA process. Try to visit the unit daily, checking in with management, Champions, and RNs who are testing ideas.

INFORMAL CHECK-INS3

Date Who?What am I

looking for? What did I see?

47

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

PREPPINGfo r Go-L ive

MAKE DECISIONSFinal decisions on what KP Painscape is for your unit

PLAN FOR TRAINING

REHEARSE TRAININGCreate KP Painscape skits for training

TRAINING SIGN-UP

PLAN FOR GO-LIVE

PART II: Prepping for Go-Live with your team


48

Finish up all of the PDSAs and make sure people are comfortable with the fi nal PDSA. Walk the fl oor to check-in with RN Champions and managers.

Lock down the date, times, and space for training. Make sure you post training sign-up sheets and fl yers about the training.

Review the training presentation template and the agenda (page 50). As a team, you will be designing the KP Painscape training session, but it is important to get grounded in the agenda and assets before you meet with the champions.

Make sure the PDSA Tracker

(page 43) is updated.


49

PART II: Prepping for Go-Live with your team

MAKE DECISIONS1

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

Concept What’s will this look like on our unit?

This is important to pain management because:

How could we support this with policy?

Prepare before going into the room

Probe Pain scale responses considering

ADLs

Use the most appropriate dose for initial transition to PO

pain meds


Encourage around the clock dosing

Work as a team to keep pain regimen

going at night

50

PLAN FOR TRAINING2

Sample Agenda Key Assets How long will this take?

Who will lead this?

Welcome(Suggestion: unit management or hospital leadership)

Why Pain

23 million page (screenshot)

Frustration Activity

6 trademark stories (screenshot)

Making KP Painscape Ours

We tried..we heard (screenshot)

(Suggestion: RN Champions)

Our KP Painscape

(Overview)

KP Painscape Skits(Suggestion: RN Champions)

Next Steps

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

51

REHEARSE TRAINING3Have RNs write out

the skits on their Training Skit Planning Worksheet (page 69)

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

ACT 1: TIME-OUT, PROBING ACT 2: APPROPRIATE DOSE

ACT 3: AROUND-THE-CLOCK DOSING ACT 4: PATIENT PAIN AGREEMENT

Introduce the problem: __________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

Reiterate the solution: ___________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

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

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

52

Session 1:__________ Session 2:__________ Session 3:__________Time Time Time

Champions:

1. ___________________

2. ___________________

3. ___________________

Champions:

1. ___________________

2. ___________________

3. ___________________

Champions:

1. ___________________

2. ___________________

3. ___________________

Make sure you have champions at each of your training sessions! Have your champions sign up for the session they can attend. Recommend at least 2 champions per session.TRAINING DAY 1:__________

Date

TRAINING DAY 2:__________Date

Session 1:__________ Session 2:__________ Session 3:__________Time Time Time

Champions:

1. ___________________

2. ___________________

3. ___________________

Champions:

1. ___________________

2. ___________________

3. ___________________

Champions:

1. ___________________

2. ___________________

3. ___________________

TRAINING SIGN-UP4

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

PLAN FOR GO-LIVE5

MAKE IT MEMORABLE! What we want to do to make it:

FUN: _______________________________

____________________________________

____________________________________

____________________________________

IMPACTFUL: ________________________

____________________________________

____________________________________

____________________________________

INCLUSIVE: _________________________

____________________________________

____________________________________

____________________________________

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

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

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

53

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

GO-LIVE!with KP Pa insc ape

KEEP IT TOP OF MIND(a) Daily Rounding (b) Daily Huddles

SHOW PROGRESS AND CELEBRATE SUCCESS

WEEKLY STANDING MEETINGS

Go-Live Activities

54

DAILY ROUNDING1A

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

GOOD QUESTIONS TO ASK:

• How was your patient’s pain doing today? What

could you (or the previous shift) have done

differently?

• Get RN’s interpretation of what their commitment

to one of the behaviors means to them?

• How are you planning on following up on your

commitments? (Great to how others are working at

making changes)

• Is what you are doing working? Did it save you

time? Did it control your patient’s pain? (Be sure

and capture the stories and write them on the

story template

• Determine Tips from nurses that they use and

share these with other nurses (i.e. how they

reassess in a timely fashion). Capture these stories

on story templates and share with unit at huddles.

A GREAT ACTIVITY FOR DAILY ROUNDING:

Print out the 6 KP Painscape concepts in sticker format and as you round have each RN pick a sticker to represent the concept they will be working on that day. Talk to them about what they worked on the previous day in addition to what they will be working on today.

55

DAILY HUDDLE MESSAGES1B

Plan the fi rst week post go-live daily huddle messages.

Day Shift Evening Shift NOC Shift

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

2

3

SHOW PROGRESS AND CELEBRATE SUCCESSES

WEEKLY STANDING MEETINGS

With change, it is important to show progress and celebrate successes to reinforce the positive change.

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.

GET THE PATIENT INVOLVED

Use a patient engagement card

CAPTURE AND SHARE STORIESStory capture sheets and use them at huddle

TIPS• Think about ways to free up the

champions so they can participate (break relief for those shifts, committee time for those who are not normally scheduled)

• Leaders must always show up. It’s 15 minutes!

• Leaders must take away some action items, but not all.

HUDDLE: GET FEEDBACK

• Ask what did you commit

to, how you’ve been

planning to improve on it,

and how its been going

when trying it, encourage

them to share tips with

each other.

• Of the new behaviors,

what’s most different than

what you used to do?

• Which of these have you

found to have the most

impact on the patients?

• What do you want others

to do more of, the most?

HUDDLE: CELEBRATE SUCCESSES• Share results of patient pain in the early morning and reassessment rates with tips for documenting on time• Share patient stories and feedback collected during customer service rounds. • Share RN stories gathered from other RNs during rounding

56

57

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

WORKSHEETSKP Pa insc ape

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

Additional Resources:

58

IN MY OWN WORDS:

GET READY! unit management team worksheet

METRICS COLLECTION

SCHEDULE AHEAD

What is KP Painscape?___________________________________

___________________________________

__________________________________

What will be involved?___________________________________

___________________________________

__________________________________

Why are we doing this ?____________________________

____________________________

____________________________

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


____________________________________________

____________________________________________

Who will collect: ____________________________

Reassessment Rates:For KP Painscape, it is best to track reassessment rate by shift for each day. Work to fi nd the best way to track reassessment rates.


____________________________________________

____________________________________________

Who will collect: ____________________________

GET READY!KICK-OFF

PREP GO-LIVE

GO-LIVESUSTAIN

PDSAs

MANAGEMENT TEAM MEETING:

_____________

RN CHAMPION KICK-OFF MEETING:

_____________

2 WEEKS

DATE

1 DAY

4 WEEKS1 WEEK

1 WEEK

ONGOING

DATE

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

_____________

DATE(S)

DATE

DATE

GO-LIVE!

_____________

KICK-OFF HOMEWORK See it for yoursel f

59

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

My Notes:_____________________________________

_____________________________________

_____________________________________

_____________________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

______________________________

___________________________________

___________________________________

___________________________________

See it:LOOK FOR:• RNs who are playing catch-up on pain

management• Patients who are in morning pain. Find out

what happened the night before...• Examples of when RNs get called back for

pain meds even though patient initially said no pain.

• Patient’s not being able to participate in PT or ADLs because of pain.

• Patients who have been going back and forth between IV and PO pain meds.

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

Hear it:ASK RNS:• What words come to mind when it comes

to pain management?• What frustrates you most about pain

management?• What does falling behind on your

patient’s pain mean to you?• How does that happen?

ASK PATIENTS:• Is the 0-10 scale easy to respond to?• How do you help your nurse understand

your pain level?• What do you think your RNs mean when

they ask about pain?• Do you feel like you understand your pain

management plan?

INITIAL PDSA TEST: Prepare before going into the room

60

When busy, it can be hard to proactively demonstrate that we are on top of our patients’ pain.

To take a “time out” before we go into the room, to sort out schedule and dosing. When going into the room to check in with patients on pain, use “I noticed...I wanted to...” to show that you are on top of the patients’ care. .

To build a habit of demonstrating and communicating to patients

that we are on top of their pain and their care.

Better rapport with patientsBetter complianceBetter trust

YOUR FIRST TEST:

1. Use Floor Dots- put them on the fl oor at the doorways of patient rooms2. Explain to RNs that are trying this to stop and look at their “brain” or MAR before going

into the room when checking in with them on their pain.3. Take a Time Out for pain during:

• Hourly rounds• When patients call you• Med passes

4. Talk to RNs about how it worked, ask them:• How did it feel to pause before you went in the room?• How did you feel the conversation went between you and your patient?• What did you prepare before going into the room?

INITIAL PDSA TEST: probe pa in sca le responses

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

When asking patients about their pain, always follow up and explore their initial responses by:• Ask follow up questions regarding ADLs or functional goals

(i.e., what is it if you’re trying to shift around in bed, if you try to sit up? If you’re trying to walk to the bathroom?)

• Physical manipulation (i.e., does it hurt the same or more if I do this? [gently perform appropriate manipulation])

To make sure that we don’t walk away thinking our patients are okay, but in reality, they are in more pain

than we realize, because of miscommunications.

More accurate pain treatment based on normal levels of ADLs. Fewer unanticipated call-backs from patients in pain.

YOUR FIRST TEST:1. Practice how to probe well.2. Demonstrate how to probe well to RNs that will be trying it as a test of change:

• Using follow up questions (i.e., “what about when you’re trying to shift around in bed?” “what if you are trying to sit up?” Etc)

• Using physical manipulation (i.e., “Does it hurt the same if I do this? [gently per-form appropriate manipulation])

3. Have RNs try for entire shift every time they assess a patient for pain:• Initial assessment• Follow up hourly rounds and reassessment

4. Work with them to demonstrate probing and coach them for at least the initial assess-ment, and then let them try on their own for rest of the shift

5. Get feedback

61

KICK-OFF PDSA TEST

INITIAL PDSA TEST: use the most appropriate dose for initia l transition

Inadequate dosing at initial transitions from IV to PO pain meds is the most common reason why patients lose trust and refuse PO pain meds.

For surgical patients, offer patients most appropriate dose as allowed by orders when going from IV to PO pain meds, rather than starting them on the lowest dose, and trying to ramp up if not enough.

More consistent equianalgesic transitions going from IV to PO

pain meds

Less anxiety from patients regarding PO pain meds. Less unnecessary back and forth between IV and PO pain meds. Minimizes delay of discharge due to use of IV pain meds.

YOUR FIRST TEST:

1. Identify patients who are ready (or will be ready) to be transitioned to PO pain meds from IV.

2. Determine max dose on order3. Advocate with patients for starting them on highest safe dose, as appropriate. 4. Talk to RN and patients afterwards about how it went.

62

INITIAL PDSA TEST: reassess on a timely basis

63

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

Use a kitchen timer to remind you to reassess and document within the time specifi ed for your unit’s reassessment protocol (For KP, 1 hour for PO and 1 hour for IV)

To consistently reassess on a timely basis to ensure pain

medication effi cacy and patient safety.

Increase in reassessment rates. People fi nding it easier to remember to reassess and document within specifi ed timing protocol.

YOUR FIRST TEST:

1. Find a RN who is going to be administering multiple pain meds to multiple patients throughout the day.

2. Teach RN how to use the timer.3. Set timer for time that allows you to reassess and document within your unit’s reas-

sessment policy (i.e., 45 minutes for 1 hour, 20 minutes for half an hour).4. When time is up, reassess patients for pain medication effi cacy and safety.5. Document reassessment6. End of the day: Ask RNs if timers helped.

INITIAL PDSA TEST: encourage around-the-c lock dosing

64

Even when nurses instruct patients to call early at the fi rst signs of pain, patients often don’t call until they are at a 6 or a 7, making it more diffi cult for nurses to stay ahead of their patiemts’ pain.

For patients in continuous pain, rather than relying on patients to call you when they need pain meds, proactively check in with them BEFORE pain medications become available to see if they need pain medication.

Use last given next due board to help establish expectations with patients on timing and schedule.

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

stay ahead of patients’ pain.

Less reliance on breakthrough IV pain medication. Better control over patients’ pain.

YOUR FIRST TEST:

1. Look for patients who are in continuous pain post-surgery2. Put up Last Given, Next Due board. Explain to RNs what it is, and how to use it.3. Coach nurses to explain the board to patients (to help you keep track of when you’re

pain medications become available, but to make sure you let RNs know about pain even if your scheduled pain medication is not available yet).

4. Coach nurses to check in with their patients proactively, BEFORE their medications become available, even if you’ve told patients to call you. Look for ways to combine with hourly rounds and other scheduled check-ins with patients.

5. If pain medication administered, update last given, next due board, accordingly after medication administration.

6. Review last given next due during shift change to oncoming shift RN. 7. Get feedback from RN and patients.

KICK-OFF PDSA TEST

65

INITIAL PDSA TEST: keeping pa in regimen going at night

Patients can very easily sleep through their pain at night and fi nd themselves in unnecessary levels of pain in the morning.

Make an agreement with patients in continuous pain before they go to bed for nighttime pain medication regimen.

For patients in continuous pain, keep pain regimen going at night.

Fewer cases where patients are behind on their pain in the morning. Morning RNs have to spend less time playing “catch-up” in the mornings. Less variance in pain in the mornings.

YOUR FIRST TEST:1. Plan: Figure out best time to make night time pain plan with patients before they fall asleep or go to bed

(i.e., during evening med pass, or before administering sleeping pills).2. Execute:

• If 2 shift unit: Execute on pain plan as agreed with patient during the night, and report outcomes to morning RN during shift change.

• If 3 shift unit: Most likely, if plans are being made before patients fall asleep, it will be the afternoon shift that would have made the nighttime plan. Have afternoon shift write nighttime plan on “Patient Plan Pain Agreement” sheet. Then, at shift change, review with NOC shift and pass it on to NOC shift RN. NOC shift RN executes plan accordingly. Report results to morning shift RN at morning shift change.

3. Get feedback. Ask morning shift:• Patients in pain? Any pain catch up?• Ask patients as well, especially if there are patients that struggled with pain at night previously. Ask

how having a pain plan at night helped or didn’t.

KICK-OFF PDSA TEST

PDSA JOURNALtemplate

66

Date:____________________

AIM Statement:____________________________________________________________________________________________________________________________

I am testing:____________________________________________________________________________________________________________________________

How do you know it is working because we are tracking:____________________________________________________________________________________________________________________________

When testing I saw: ____________________________________________________________________________________________________________________________

I learned:____________________________________________________________________________________________________________________________

What I think we should do next is

Adapt___________Adopt___________Abandon_________

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

PDSA PLANNING worksheet

67

HOW THINGS ARE NOW: HOW YOU WANT THINGS TO BE:

UNIT COMMUNICATION worksheet

68

HOW WE WANT PEOPLE TO RESPOND:

• Be open• To try out ideas

• Be patient and fl exible

• Give feedbackWHAT WE NEED TO TELL EVERYONE:• Working on pain management• Trying out KP Painscape ideas• What KP Painscape is• We will be asking for feedback and participation

CREATE A POSTER:

What will it say:________________

____________________________

____________________________


CREATE HUDDLE MESSAGES:

What will it say:________________

____________________________

____________________________


CREATE A CRIB SHEET:

What will it say:________________

____________________________

____________________________


KP Painscape Poster

Huddle Message for Date _____

At a glance! We are trying....

WEEK: __________

TRAINING SKIT planning worksheet

69

ACT 1: TIME-OUT, PROBING ACT 2: HIGHEST DOSE

ACT 3: AROUND-THE-CLOCK DOSING ACT 4: PATIENT PAIN AGREEMENT


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

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

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________

_______________________________________________


_______________________________________________

_______________________________________________

NURSING MODELKP Pa insc ape and the

Focusing on nursing practice, KP Painscape is consistent with the Kaiser Permanente’s National Nursing Model.

The effective patterns of pain management identifi ed by KP Painscape and the solutions developed refl ect the values inherent in the Relationship-Based model of care, as well as the principles underscored in the Caring Theory and Comfort Theory. KP Painscape emphasizes clearer and better communications between nurses and patients, trust, advocacy, and better cross-shift teamwork to elevate the consistency of pain management to minimize unnecessary suffering during the recovery process in clinical settings.

Documents

KP Painscape Testing Packet