Removing Obstacles Is in the Cards at MU Health Care

Tara Sunderland
Tara Sunderland, clinical manager for oncology at MU Health Care.

When you are in the hospital, MU Health Care works with you to create a clear path to recovery. That includes preventing setbacks before they happen.

One potential hazard is a fall, which could lead to injury and add time to your hospital stay.

That’s why MU Health Care is taking additional steps to reduce this risk of falls.

K Card board at MU Health Care's cardiovascular unit
A care team member completes a K card, or safety checklist, for one high-risk patient on every shift.

A project aimed at reducing falls is being tested on MU Health Care’s 30-bed oncology unit that houses many patients at risk for falls. The project, called the “K Card Program,” is one of more than 1,600 quality-improvement projects developed in the past three years. It involves every employee, from physicians and nurses to housekeepers, facilities engineers and food service workers.

K card is short for Kamishibai card, which is a Japanese term for storytelling. In ancient Japan, monks displayed cards to tell a story. In medicine today, K cards are quality-improvement tools. A care team member completes a K card, or safety checklist, for one high-risk patient on every shift. On the oncology unit, the checklist focuses on removing obstacles that can lead to falls.

Tara Sunderland, clinical manager for oncology at MU Health Care, heard about the K cards concept from another unit and worked with Morgan Rioux-Forker, project manager in the Office of Clinical Effectiveness, to implement the program on her floor at Ellis Fischel Cancer Center.

“Several team members worked together to come up with the acronym TUMBLES to describe the risk factors that might contribute to a fall,” Sunderland said. “It stands for toilets, urine, medication, beds, linens, exercise equipment and shoes. We created a checklist of questions focused on that acronym, then we put it on a printed card, posted it on a visible board and we go through the checklist every single day.”

After nearly two months, the results have surprised Sunderland and Rioux-Forker. The oncology unit recorded a 50-percent reduction in falls and went 41 days without a single fall.

Riox-Forker attributes the success to teamwork.

“If you watch their huddle every day, they say, ‘Who is the highest risk of falling today?’ And they create a plan in the huddle to make sure everybody is watching those patients,” Rioux-Forker said. “And if a bed alarm goes off, then everyone knows if it’s a high-risk fall patient, and they take action.”

The K Card Program in oncology has been so successful, additional units plan to adopt it in the coming months. Each unit will focus their initiative around an important safety goal specific to their patients.

“When you get in the group and everybody is ‘on,’ they know what they should be doing, and the checklist becomes routine,” Sunderland said. “That’s how you hard-wire these processes, and they help us ensure our patients get safe, high-quality patient care.”

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