Tools of the Trade - nebula.wsimg.com

3/28/2016

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Use All the Tools in the Box:

Julie Tuttle MSN, RN-BC Manager of Nursing Education

John Moren BSN, RN Clinical Preceptor

Jared Caron RN Clinical Float Nurse; Data Officer, Quality Clinical Team

March, 2016

In accordance with NH RSA 151:13-a This Foundation Medical Partners’ Improvement Document shall be confidential a nd privileged

Southern New Hampshire Health Southern New Hampshire Health is comprised of Southern New

Hampshire Medical Center and Foundation Medical Partners, and

is Massachusetts General Hospital’s only clinical affiliate in the

region. Through this affiliation, patients have easy access to

advanced clinical expertise in areas including stroke, cancer,

trauma and pediatric specialties.

Foundation Medical Partners • Ambulatory Care at Southern New Hampshire Health is made

up of more than 300 providers in more than 70 practices across

southern New Hampshire and northern Massachusetts. We

serve thousands of patients in areas including:

• Primary Care

• Pediatric Care

• Internal Medicine

• Medical Specialty

• Surgical Specialty

Tools of the Trade

Pneumococcal Toolkit

• ACIP/CDC Vaccine Guidelines

• Engaged staff and Providers

• Clinical Leadership

• Practice Champions

• Quality Team

Pneumococcal Tools

• Algorithms

• CDC educational handouts

• Consent Forms

• Screening Questions

• Standing Orders

• VIS forms

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Pneumococcal Disease

Pneumococcal Disease

• Caused by infection with streptococcus pneumoniae

• Transmission respiratory droplets and

autoinoculation

• Most common infection is:

• Pneumonia

• 900,000 cases annually

• ~ 400,000 hospitalizations

• May also cause ear and sinus infections

Bogart, 2004; CDC, 2009 & 2013

Bogeart, Groot & Hermans, 2004

Adult Risk Factors for IPD

• Decreased immune function from disease or drugs

• Functional or anatomic asplenia

• Chronic heart, lung (including asthma), liver, or renal

disease

• Smokers

• Cerebrospinal fluid leak

CDC, 2015

Prevention

Vaccination!

Pneumococcal Vaccines

Pneumovax (PPSV23)

• Protects against 23 types of pneumococcal bacteria

Prevnar13 (PCV13)

• Protects against 13 types of pneumococcal bacteria

http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/ prinvac.pdf

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Our Story

First Steps…January 2013

Answer the question:

If the appropriate tools are in place:

• Are vaccine decisions within a clinical staff

member’s Scope of Practice?

YES!

Needs Assessment

• CDC/ACIP Pneumococcal Recommendations updated

• Clinical staff (RN, LPN, MA) knowledge of Pneumococcal

vaccines varied

• Not administering Prevnar to Adults….yet

• Need identified:

• Pneumococcal vaccine standard of care

Creating the TEAM

• Identify Stakeholders and Champions

• Engage and motivate clinical staff

• Educate and Empower

• Enhance autonomy

• Change Practice

• “Work smarter not harder”

Choosing a Quality Measure

Quality Metrics

Pneumonia (PN) is a Centers for Medicare & Medicaid Services Quality Core Measure

• PN -2 PNEUMOCOCCAL VACCINATION

• “In the interest of promoting high-quality, patient-centered care and accountability…”• Mortality rates

• Readmission rates

• Complications related to pneumococcal disease

CMS, 2011; 2015

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Introduction of Care Coordination

• In 2013, Care Coordinators were introduced to the Primary

Care setting as part of PCMH

• Embedded Care Coordinator (ECC) is an RN who works with

the adult population to:

• Promote wellness

• Enhance disease management

• Coordinate care across the continuum

• Goal: identify gaps in patient care

"Recognize the talent of others

and acknowledge it."

- Gloria Smith, PhD, RN, FAAN of the W.K. Kellogg Foundation

Define the Problem

Jennifer Thebodeau, RN, ECC identified that

there were potentially missed opportunities to

vaccinate adults at:

• Nurse Visits

• Sick Visits

• Medicare Wellness Visits

Creating Vaccine Opportunities

(Scott-Jones & Lawrensen, 2008)

• Standing Orders are Safe and Effective in Primary

Care

• Benefits of a Pneumococcal Standing Order:

• Enhance Practice autonomy

• Limit Provider interruption

• Capture unvaccinated Adult population

• Improve Patient Outcomes

PDSA

What is a PDSA?

A model for testing ideas that you think may create an improvement.

• Plan

• Do

• Study

• Act

http://www.ihi.org/education/ ihiopenschool/resources/Pages/A udioandVideo/Whiteboa rd5.aspx

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Picture citation: www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html

Pneumovax PDSA Goal #1

Enhance staff education and awareness of

Pneumovax vaccine:

• Best Practice recommendations

• Minimum/maximum intervals

• Improve quality and efficiency of vaccine workflow

Pneumovax PDSA Goal #2

Develop and Implement an Adult Pneumovax

Vaccine Program

• Enhance patient education

• Create vaccine opportunities for Adult patients

• Increase Adult Immunization rates

PDSA

Plan

• Create Pneumovax Standing Order and

Screening Tool

• Provide Pneumovax Education to clinical support

staff

• Implement Pneumovax Standing Order

• Clinical Staff:

• Identify Adult patients due for Pneumovax as part of Nurse

Visits and Pre-Visit Planning

• Screen and vaccinate Adults who meet criteria

PDSA

DO

• Pneumovax Standing Order, Screening Tool,

Consent & Resources created using 2013 ACIP

guidelines

• Reviewed and approved by:

• Infectious Disease

• Quality Assurance

• Risk Management

Pneumovax Standing Orders, March 2013

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Pneumovax Algorithm, March 2013 Screening Tool & Consent, March 2013

Educational Resources

Immunization Action Coalition• www.immunize.org

Centers for Disease Control and Prevention • www.cdc.gov

Vaccines & Immunizations • http://www.cdc.gov/vaccines/

The Pink Book• http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm

PDSA

DO

• Pneumovax tools and resources reviewed at

combined Provider and Clinical staff meetings

• Order implemented on 3-4-13

• Nurse Educator for clinical support as needed

• Jen Thebodeau, RN, ECC & Pam Davis, CMA were

Practice experts for clinical questions

• All staff utilized an independent double-check prior to

vaccination

Stage 1: Utilize Standing Order as

part of Nurse Visits

March 4th to April 3rd, 2013

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PDSA

STUDY

• Pneumovax vaccination was considered for

scheduled nurse visits

• Nurse and Medical Assistant utilized the standing

order to identify Adult patients due for vaccination

• Clinical staff workflow if the patient met criteria:

• Screened for contraindications/precautions

• VIS given & consented signed,

• Administered Pneumovax, and

• Forwarded documentation to Provider for final signature

PDSA

STUDY

Chart Review

• 33 Patients qualified for Pneumovax

• Diagnoses:

• Asthma, Diabetes Mellitus, Current Smoker, Melonoma,

Chronic Heart Disease & Chronic Obstructive Pulmonary

Disease

• 2 received vaccine, no documentation related to refusal

• 6% Vaccination rate

Stage 2: Utilize Standing Order as

part of Pre-Visit Planning (PVP) and

Nurse Visits

April 4th to May 4th, 2013

PDSA

STUDY

• Pneumovax vaccination considered for all

Provider visit types

• RN used standing order to identify Adult

patients due for vaccination

• If patient met criteria, a reminder was added to the

clinical staff schedule to offer vaccine during rooming

PDSA

STUDY

Provider #1

• 10 Patients identified using Standing order as

part of PVP:

• 4 Vaccines given that were identified

• Diagnoses: Chronic Heart Disease, Chronic Obstructive

Pulmonary Disease & Diabetes Mellitus

• 40% Vaccination Rate

PDSA

STUDY Provider #2

• 15 Patients identified by Standing order as part of PVP

• 7 vaccines given

• Diagnoses: Asthma, Current Smoker & Chronic Heart Disease

• 2 declined

• 3 Vaccines given utilizing standing order for Nurse visits

• Diagnosis: Chronic Heart Disease

• 67% Vaccination Rate

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Pilot Summary

Implementation of Pneumococcal Standing Orders:

• Enhanced staff education and awareness of Pneumovax vaccine and best practice recommendations

• Enhanced patient awareness and education regarding Pneumovax

• Created vaccine opportunities for Adult patients

• Increased Adult Immunization rates

PDSA

ACT

Expand Pneumovax vaccine initiative to all

Primary Care and Internal Medicine Practices

Organizational Adoption of Best Practice"Chaos is an essential constituent of all change.

Chaos challenges us to simultaneously let go and to take on.

It reminds us that life is a journey of constant creation."

-Tim Porter-O'Grady, RN, PhD, FAAN, and Kathy Malloch, PhD, MBA, RN, FAAN

Phase 1: Pneumovax September, 2013

Primary-Care and Internal Medicine initiative

rollout:

• Initial Education

• ECC and Vaccine Coordinator and Alternate

Meetings

• Standing orders and screening/consent tools

reviewed at Division and Practice-based meetings

• Patient-Centered Medical Home Collaborative

Phase 1: Pneumovax

Educational Rollout

• Train-the-Trainer model

• Presentation

• Generic Case Studies

• Question and Answer

• Email/Phone

• Individual Practice-based education as

requested

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Phase 1: Pneumovax

Primary-Care and Internal Medicine

• Ongoing Education

• Individual Practice-based education as requested

• Enhance staff knowledge of Pneumovax

• Pneumovax Pre-visit planning

• Create efficiencies in vaccine workflow

Individual Practice-based

Education

• Presentation

• Case Studies using Practice panel

• Question and Answer sessions

• Follow up:

• Email/Phone

Phase 2: Prevnar January, 2014

Introduction of Prevnar13 for Adults 19-64 years

of age with high risk conditions:

• Decreased immune function from disease or drugs

• Functional or anatomic asplenia

• Chronic heart, lung (including asthma), liver, or renal disease

• Cerebrospinal fluid leak

Rapid-cycle PDSA

Goal #1

Enhance staff education and awareness of

Prevnar vaccine:

• Best Practice recommendations

• Minimum/maximum intervals

• Improve quality and efficiency of vaccine workflow

Rapid-cycle PDSA continued…

Goal #2

Develop and Implement an Adult PneumococcalVaccine Program

• Enhance clinical staff education

• Create vaccine opportunities and increase Adult immunization rates:

• Pneumovax and

• Prevnar

Plan: Prevnar13

Prevnar Standing Order, Screening Tool, Consent

& Resources created based on current ACIP/CDC

guidelines:

• Reviewed and approved by:

• Infectious Disease

• Quality Assurance

• Risk Management

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Pneumococcal Standing Order February, 2014 PCV13 and PPSV23 Screening & Consent Tools

February, 2014

Educational Resources

Immunization Action Coalition• www.immunize.org

Centers for Disease Control and Prevention • www.cdc.gov

Vaccines & Immunizations • http://www.cdc.gov/vaccines/

The Pink Book• http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm

Do: Implement

Standing Order and Educational resources

reviewed with Practice Champions:

• ECC

• Vaccine Coordinators

• Vaccine Alternates

Picture caption: http://www.esc.edu/nursing/newsletter/spring-2015/

Study/Act:

• Confusion and uncertainty related to Prevnar

and Pneumovax

• Clinical staff request additional resources to

assist in vaccine decisions

Photo credit: http://www.nursingtimes.net/student-nt

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Stakeholders

Clinical Staff Feedback:

• “Standing Order is confusing.”

• “I don’t know where to start…”

• “I need more help with these vaccines.”

Need identified:

• Pneumococcal decision support tool

Decision Support Tool: Algorithm Attempt #1

February, 2014

Stakeholders

“Too confusing.”

“Too many colors.”

“Too many decisions.”

“I don’t like it.”

Picture citation: http://www.nursingtimes.net/exclus ive-revalida tion-delay-would-be-travesty-say-senior-nurses/5091540.fulla rticle

Pneumococcal Algorithm Re-Design

Developing Decision Support Tools

The OODA loop

Observe

Orient

Decide

Act

Decision Support

What is it?

• Referring to a reference tool providing specific clinical guidance at decision point

• For use at the Point of Care

Why did we need it?

• Asking staff to make more decisions

• Decisions involved several criteria and were conditional

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Observing the Problem

Quality Clinical Team

• ~12 clinical staff representing various specialties within FMP

• Discussed observations at our monthly meeting

• We Decided staff needed more guidance

Then we Acted: A full-color flow chart was drafted

• Looked a lot like the CDC/ACIP flow chart

Decision Support Tool: Algorithm Attempt #2

February, 2014

The pivotal step – “Orient”

• Orienting is the key to successfully using the OODA

loop

• Without Orientation, observations are meaningless

• The resulting Decisions and Actions are then flawed

• Fortunately, OODA is a continuous feedback process

Second Attempt

• Incidentally, an email reminder to Care Coordinators

about the algorithm revealed widespread confusion

about pneumococcal vaccination (“Observe”)

• A thorough review of the current tool and ACIP

guidelines revealed problems

• The guidelines require many steps in the decision

process, most were skipped on our first design

(“Orient”)

Stakeholders

• “Easier to follow.”

• “I’ll still check with the Provider if I have questions.”

• “This is still too confusing…”

Fixing ProblemsApril, 2014

• A new tool was needed with as guidance for as

many steps as possible (“Decide”)

• A second algorithm was drafted with key differences

(“Act”)

• Step-by-Step Design

• Color Coding

• ACIP table of high-risk conditions included

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Step-By-Step Design

Starts with Identifying High Risk Conditions

Step-By-Step Design

Next, Identify

Pneumococcal

Immunization Status

Step-By-Step Design

Then, just “Follow the finger”

Color Coding

• Enhances Readability

• Enhances

discrimination between

different risk groups

ACIP table of high-risk conditions

included• Alternate visual

representation

• Provides clarifying

resource

• Matching color coding

• Actually 2 tools in one!

Part Deux…

• 2014 recommendations released just months after

above process

• Added one time routine dose of PCV 13 for 65+

population

• Initially tried expanding existing algorithm

• Eventually opted for 2 separate tools

• 19-64 high risk conditions tool

• 65+ tool

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2014 revision

• Same style tool, but key differences:

• Vertical Orientation

• No need for high-risk condition selection

• Start with Immunization status, then follow the column

• Kept 19-64 year algorithm the same, added

directions to consult the new tool for 65+

population

• Second time around went smoother and faster

(Same day turnaround!) • Since then 2 more minor revisions with similar results

65+ tool

Color Coded by Immunization Status

Vertical Orientation

New Tools in the Box

A Couple Questions

• Who discusses vaccine eligibility with

your patients?• How and when is eligibility decided?

• What do you (they) say?

• Who answers the questions?

• What happens if patients are vaccine

hesitant or decline vaccination?• Is the declination documented?

• Is it followed up?

Adopting a New Method

How do we get people to use it?

• Address or discover the area worth improving

• Prove effectiveness

• The new method is equal/more effective

• Prove utility

• Anyone can be trained to use the new tool

Immediate Hesitancy

• “I’m not the doctor, I’m not the Provider…this isn’t my decision.”

• “I know the schedules and the recommendations, but the patients start to ask questions and I don’t have the answers.”

• “We see patients every 15 minutes, my clinical staff don’t have time to review the immunization history and go down that rabbit hole…along with all their other responsibilities”

I can’t, I wont.

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Don’t Do It Alone…

Create Champions

• FMP initiative modeled after aspects of CDC

recommendations and strategies

• Clinical education took ownership of the

initiative and employed established resources

• ECCs

• Clinical Preceptors

• QCT

CDC Recommendations in Practice

• Strategies for Increasing Adult Immunization

Rates

• Strong recommendation

• Quality Improvement Projects

• AFIX

• Reminders for Providers

• Strategies for high risk patients

http://www.cdc.gov/vaccines/hcp/adults/for-practice/increasing-vacc-rates.html

CDC: Strong Recommendation

What does that even mean?

Our goal:

• Every patient, every visit!

Process to achievement:

• Give all clinical staff the knowledge and ability necessary to

have the vaccine discussion

• With practice comes efficiency and process improvement

• The algorithms aid in efficiency

• Document declinations


CDC: Quality Improvement Projects

CDC makes several (4) recommendations for

Immunization Quality Improvements

• Increase adult vaccination rates

• Reduce disparities in immunization rates

Our goal:

• Decrease practice to practice, Provider to Provider variability

in vaccination rate for pneumococcal vaccines, thereby

increasing vaccination rates


CDC: Quality Improvement

Projects


• Use technology to our advantage

• Distribute surveys, monthly clinical quizzes and education

through email

• Practice with the algorithm

• Create a culture of question AND answer


CDC: Reminder Systems

CDC outlines strategies for Providers to improve

immunization coverage in their practice

• It cannot be assumed that vaccines are being given to every

eligible patient

Our Goal:

• Review of immunization history becomes part of the

outpatient rooming process

• Increases Provider-Clinical staff discussion of immunizations


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CDC: Reminder Systems


• Review of immunization history and immunization

eligibility becomes part of Clinical Orientation

• Algorithm identification and usage also improves

• Reviewing immunization history becomes part of the

day-to-day rooming process


CDC: Strategies for High-Risk Adults

CDC provided guidance for “targeted immunization” of high-risk adult populations

Our Goal:

• To have clinical staff aid in identification of those high-risk adult populations


• Empower the clinical staff to identify and start this vaccine conversation

• Creation and adoption of 19-64yr and 65+yr Pneumococcal Algorithms


AFIX: Assessment, Feedback, Incentives, and

eXchange

“AFIX is a quality improvement program used… to raise

immunization coverage levels, reduce missed

opportunities to vaccinate, and improve standards of

practices at the provider level.”

http://www.cdc.gov/vaccines/programs/afix/index.html


eXchange

Assessment of the healthcare provider's vaccination

coverage levels and immunization practices.

Feedback of results to the provider along with

recommended quality improvement strategies to

improve processes, immunization practices, and

coverage levels.



eXchange

Incentives to recognize and reward improved

performance.

eXchange of information with providers to follow up on

their progress towards quality improvement in

immunization services and improvement in

immunization coverage levels


Implementation at Orientation

Set the minimum standard

(Training/Empowerment)• Robust immunization education during orientation

• Everyone learns the basics about immunizations, standard and catch up schedules and special populations/considerations

• Everyone learns about PCV13 and PPSV23

• Everyone learns about the algorithms and standing orders

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Orientation continued…

Case Studies• Know how to find the resources

• Vaccine Management and Resource Binders

• Inter/Intranet Resources

• Senior staff

• Providers

• Clinical Education Department

Implementation For Established

Staff

Education from recognizable and accessible

lead staff

• Embedded Care Coordinators (ECC) are established in the

practice

• Familiar with Providers and practice workflows

• Familiar with chronically ill populations

• Existing communication channel with Clinical Education

Department

Float Staff Education and

MentorshipFloat staff – May be scheduled at any of the 70+

FMP practices• Scheduled assignments include both short and long term coverage

• From single day assignment to entire maternity or FMLA coverage

• Deciding immunization eligibility for Family, Internal, or Specialty Medicine

as well as Pediatrics

Immunization Education• Same Clinical orientation

• 1:1 mentor observation and mentorship until demonstrated competence

and skill sign off

• Each patient offers the opportunity for immunization history review

Patient-Centered Care

Ambulatory Care Barriers

Identify potential barriers

• Physical

• Financial

• Psychological

Physical Barriers

• Deciding eligibility could take too long

• Time from immunization decision to

execution could be too long

• Convenience is important

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Financial Barriers

Patients will often decline vaccination if

not immediately aware of financial burden• Making patients aware to investigate potential financial

burden

• Knowing general insurance requirements increases patient

confidence

Basic ideas are instilled during orientation• The algorithm(s) account for some insurance prerequisites

Psychosocial Barriers

Patients that have bad vaccine experiences

tend to avoid further opportunities• This process may limit the bad experiences patients may have

(errors, cost, wait time, unclear recommendations, etc.)

• Inspiring confidence when the patient provides us with the

opportunity to care for them

Questions Answered

Who discusses vaccine eligibility with your

patients?

• All Clinical Staff

How and when is eligibility decided?

• At or before every visit

Questions Answered

Who answers the questions?


If your patient is vaccine hesitant or declines the vaccine, does anyone investigate the rationale?


Is there any follow up?

• Yes, at every visit

Empowering Shared Decisions

Patient Outreach Senior Supper

• Seniors in our community are invited to attend a

monthly health and wellness discussion.

• Offers opportunities to socialize and share a meal.

• Event focused on Adult Immunizations

• Nurses volunteered to be a clinical resource

• 47 Seniors attended

Pictured: Amanda Dyment, RN and Susan Sturrock

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Response Data

N Yes % Yes No % No

Know which vaccines

they need? 31 18 58.1% 13 41.9%

N More Likely % more

Less

Likely % Less

Don't

Know % NA?

Intent to Vaccinate 28 26 92.9% 0 0.0% 2 7.1%

N Yes %Yes No % No

Helpful to have Clinical

Staff? 29 29 100% 0 0

“If you can measure it, you can

improve upon it.”

-Benjamin Franklin

Statistics19 to 64 Population

YearPCV13

DosesPPSV23 Doses

documented not

given

total

opportunities

2012 -2013 31 1211 82 1324

2014-2015 729 1660 318 2707

Total 760 2871 400 4031


0

200

400

600

800

1000

1200

1400

1600

1800

2012 -2013 2014-2015

PPSV23 Doses (19-64)

2012 -2013

2014-2015


0

100

200

300

400

500

600

700

800

2012 -2013 2014-2015

PCV13 Doses (19-64)

2012 -2013

2014-2015

Statistics 19 to 64 Population

0

500

1000

1500

2000

2500

3000

2012 -2013 2014-2015

Documented Opportunities (19-64)

2012 -2013

2014-2015

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Statistics65+ Population

YearPCV13

doses

PPSV23

Doses

Documented not

given

Total

opportunities

2012-2013 16 691 10 717

2014-2015 5571 787 2548 8906

Total 5587 1478 2558 9623


640

660

680

700

720

740

760

780

800

2012-2013 2014-2015

PPSV23 Doses (65+)

PPSV23 Doses


0

1000

2000

3000

4000

5000

6000

2012-2013 2014-2015

PCV13 doses (65+)

PCV13 doses


0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

2012-2013 2014-2015

Documented opportunities (65+)

Total opportunities

Takeaways

Lessons Learned

• Situational Leadership

• Lewin’s Change Theory

• Give clinical staff the tools to be successful

• Celebrate small wins

• Never underestimate the power of positive

feedback

• Teamwork, teamwork, teamwork

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Lessons Learned

• Education is never one and done

• Don’t go it alone, create champions

• Utilize prove strategies

• Initial and ongoing education is key to success

• Case studies and follow up discussions

• Team-based education

• Promote clinical staff – Provider collaboration

Lessons Learned

• Be prepared for and listen to constructive

criticism

• Keep your eye on the prize

• Always remember: Data drives change

• Substantiate/Quantify/Qualify reason for change

• Whenever possible: Share data

Final Thoughts…

Make the Right choice the

Easy choice

Questions?

You may also email questions to: [email protected]

ReferencesBogeart, Groot & Hermans (2004). Streptococcus pneumoniae colonisation: the key to

pneumococcal disease. The Lancet Infectious Disease (4), 144–54. CDC (2015).

CDC, 2016. Adult immunization. Retrieved from https://www.cdc.gov/immunizations

CDC, (2015). Pneumococcal disease. Retrieved from

http://www.cdc.gov/pneumococcal/clinicians/prevention.html

CMS, 2015. Outcome measures. Retrieved from https://www.cms.gov/medicare/quality-initiatives-

patient-assessment-instruments/hospitalqualityinits/outcomemeasures.html

http://www.artofmanliness.com/2014/09/15/ooda-loop/

http://www.forbes.com/sites/davidkwilliams/2013/02/19/what-a-fighter-pilot-knows-about-

business-the-ooda-loop/#33e28bae6650

https://www.rnzcgp.org.nz/assets/documents/Publications/Archive-NZFP/April-2008-NZFP-Vol-35-

No-2/ScottJonesApr08.pdf

IHI, 2010. PDSA cycles. Retrieved from

http://www.ihi.org/education/ihiopenschool/resources/Pages/AudioandVideo/Whiteboard5.aspx

Lewin, 2013. Change theory. Retrieved from

http://currentnursing.com/nursing_theory/change_theory.html

On The Making of History: John Boyd and American Security The Harmon Memorial Lecture, 2012 US

Air Force Academy, Grant T. Hammond.

“Toolkit & Toolbox” (2016).

http://www.oxforddictionaries.com/us/definition/american_english/toolkit

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Tools of the Trade - nebula.wsimg.com