Kamishibai Cards: A Conversation About Patient Safety

Kamishibai (K) cards are a quality improvement process focused on improved bundle compliance and promotion of peer-to-peer feedback that the health system has used for a few years.

Changing personnel structure and an emphasis on patient outcomes prompted a need to revamp the K Card process.

A team approach was used to redesign the process resulting in a program that moved from utilization of champions to engaging all bedside nurses and having a standard completion requirement for all units. In 2 phases spanning 16 weeks, the nurse managers, point-of-care educators, and all bedside nurses were trained in the process using a computer-based training module and validated in the application of the process.

By the end of the 16-week period, the completion compliance target was reached, and the system began to see a decrease in central line and Foley catheter device usage days.

The result of the project design was a peer-to-peer feedback mechanism, which promotes evidence-based practices and system standards.