Kamishibai cards (K-cards) are an effective tool used for improving bundle reliability at the front line. K-cards allow measurement of compliance, real-time education, and identification of barriers to compliance. The standard paper K-card system gives a visual representation of compliance, but we noted difficulty with recording and understanding the data among our care team members. A year after collecting bundle reliability data with the standard K-card system, we transitioned to an incentivized electronic system. We aim to describe our evolution to an incentivized electronic K-card system.
We used REDCap (Research Electronic Data Capture) to build out each electronic K-card (Fig. 1). Our infection prevention department was already using Quickbase as their observation tool for hospital-acquired infections, and we collaborated to update these tools. Policies and videos are embedded into each K-card to assist with education; additionally, observers can upload pictures to demonstrate barriers or notable compliant or noncompliant observations. If a standard element is missed, a Kaizen newspaper populates for the observer to comment on barriers to compliance with the bundle. Staff can access K-cards on the hospital intranet or via QR (Quick Response) codes on each unit’s visual management board. Observers can use their tablets or phones to access the K-cards through the QR codes. Monthly audit goals were realigned using outcome data to prioritize hospital-acquired conditions (HACs) with the highest harm burden and/or lowest compliance. The number of K-cards is reduced if a unit’s bundle compliance with a particular HAC is >90% and there has been none of a particular HAC (outcome) measured on the unit for 3 months, or if there has been none of a particular HAC measured on the unit in 1 year. The number of K-cards assigned for each unit and for each HAC varies each month.
Converting our observation tool to an electronic form and incentivizing observation goals has increased the number of K-cards completed each month. In the 6 months before conversion, a mean of 127 K-cards for 11 HACs and 10 inpatient units were completed each month. Six months after the conversion, a mean of 180 K-cards (41% increase) have been completed per month for the same scope of HACs and units. The compliance data can be accessed at any time because the electronic K-cards record in real time. In addition, this provides a more environmentally friendly solution and does not require data entry at the end of each month.
K-cards remain the backbone for collection of process data, collection of barriers to compliance, and education efforts in our quality improvement efforts. Conversion to an electronic incentivized system has allowed our team to continue harm prevention work with more reliable data, eliminate the need for data entry and cataloguing of barriers collected each month, and the ability to expand our efforts to include outpatient areas. Next steps include development of an electronic harm prevention dashboard that hosts outcome and process data in a filterable, real-time, unit-specific forum (Table 1).