Redesigning nursing shift change.

Accurate and complete communication of patient care information between nurses at shift change is critical to patient safety. We heard from patients that hospitals feel like "a ghost town" during shift changes. In 2004, we designed a new shift change process called Nurse Knowledge Exchange (NKE) to involve patients in their care by moving shift change to the bedside.

In 2009, we took another look at the shift change experience. Even with NKE implemented, nurses struggled with interruptions and disruptions during shift change that prevented meaningful patient engagement and safe handoff. We worked with frontline staff to create NKEplus, a set of tools and structures that support focused time at the bedside during shift change.



NKEplus elements that support focused time at the bedside


Proactive Preparation

The Last Hourly Round – Patient rounding that takes place to anticipate and take care of patient needs before a shift change.

Pre-shift Assignments — Working to ensure 1:1 hand-offs between nurses by clearly assigning patients to oncoming nurses before a shift begins. 


Coordinated Roles

In a whole-unit approach, support staff and unit management work together to minimize disruptions to nurses during shift change. While nurses focus on shift change, support staff jump in to answer call lights, manage new patient admittances, and other tasks that would otherwise pull nurses away from the bedside.


Patient Engagement and Safety

We built structured ways to understand, post, and share care information at the bedside, including in-room care boards, SBAR conversations, and safety check procedures.



NKEplus was rolled out across Kaiser Permanente.

In 2011, NKEplus was rolled out in all Med-Surg units at all Kaiser Permanente hospital-based regions. As of 2013, in regions like Southern California, it has been adapted locally and implemented in specialty units such as ICUs, NICUs, PICUs, L&D, PP, and Peds. The redesign increases staff time at the bedside, increases patient and nurse satisfaction, and drives shift efficiencies.


Not to mention, this work won a few awards!

NKE and NKEplus was featured in the International Journal of Design and The Service Innovation Handbook. The work was recognized by the Joint Commission and won a Spark Design Award!