Standardized Shift-Change Process Optimizes Time for Transfer of Patient Care Responsibility, Leads to High Levels of Nurse and Patient Satisfaction

Service Delivery Innovation Profile

Standardized Shift-Change Process Optimizes Time for Transfer of Patient Care Responsibility, Leads to High Levels of Nurse and Patient Satisfaction



Nurse Knowledge Exchange Plus (NKEplus) is a six-step process applied to nurse shift changes that is designed to enhance patient safety by conveying vital patient information accurately, concisely, and consistently. Handoff of each patient from one nurse to the next occurs at the patient's bedside and includes patient participation. NKEplus optimizes the time spent transferring patient care from one nursing shift to the next, leading to high levels of patient and nurse satisfaction.

Evidence Rating

Moderate: The evidence consists of before-and-after comparisons of pilot study data on the time it takes incoming nurses to prepare for the shift, post-implementation nurse and patient satisfaction surveys, and pre—post-implementation data on nurse time spent at the bedside.

Developing Organizations

Kaiser Permanente-California

Kaiser Permanente-California is headquartered in Oakland, CA.

Use By Other Organizations

Information provided in April 2011 indicates that NKEplus has been implemented in all 38 Kaiser Permanente hospitals; program developers expect that a minimum of 15 non—Kaiser hospitals will have implemented NKEplus by Fall 2011.

Date First Implemented


The first iteration of the program, Nurse Knowledge Exchange (NKE), was implemented in 2004; NKEplus was implemented in 2009.

Problem Addressed

Accurate and complete communication of patient care information between nurses at shift change (clinical handoff) is critical to patient safety, yet often does not occur.

  • Poor communication leads to adverse events: The Joint Commission cites communication breakdowns as the root cause of more than 60 percent of sentinel events.
  • Standardized approach can improve communication during patient handoffs: Nursing shift changes involve patient “handoffs” between nurses, requiring thorough communication; shift changes are widely acknowledged to be points at which communication breakdowns can occur. In 2006, The Joint Commission developed a formal patient safety goal (Patient Safety Goal 2E) that mandates implementation of a standardized approach to “hand off” communications that include an opportunity to ask and respond to questions.

Description of the Innovative Activity

Information provided in April 2011 indicates that NKEplus now includes six steps in the process (enhanced from the initial four-step process) that facilitates a smooth, safe, and patient-centered shift change. Two steps occur before the change of shift, and four additional steps occur during the shift change. Key elements of the program are described below.

  • Steps taken before the shift change: The following two steps occur approximately 1 hour before shift change:
    • Last hourly round: Nurses and certified nurse assistants (CNAs) perform a final hourly rounding of the shift. During this round, in addition to general patient care duties, nurses ensure that the “four P's” (pain, position, potty, and possessions) are all taken care of for the patient. CNAs distribute hot towels and cold water to patients, which refreshes patients and signals that the shift is about to change.
    • Staff assignments: The outgoing nurse manager assigns patients to the incoming nurses.
  • Steps taken during the shift change: Four steps take place during the shift change:
    • Inroom standardized communication: Incoming and outgoing nurses conduct rounds together at the bedside of patients to whom they are assigned. Offgoing nurses share patient care information with incoming nurses using situation-background-assessment-recommendation (SBAR), a standard method of communication. Patients and family members are included in these discussions, which provide an opportunity for all parties to ask and respond to questions.
    • Inroom safety check: This step involves a review of safety-related clinical care issues that are pertinent to a particular unit. For example, the inroom safety check on a cardiology unit might include a check of each patient's groin area to ensure the integrity of existing catheters; medical–surgical units might check high-alert medications, equipment, and lines. Two nurses at the bedside perform the safety check together.
    • Patient care board: During the bedside round, the caregiver's name, daily patient goals, upcoming procedures, and projected discharge information are listed on a large whiteboard in the patient's room. Goals are written in terms that the patient can easily understand (e.g., “sit in the chair three times today”). Nurses use “teach-back” to assess the patient's grasp of the plan and goals, asking the patient to state what he or she believes are the most important goals and objectives to be accomplished during the next shift.
    • Unit support: All staff members on the unit—including ward clerks, unit assistants, CNAs, charge nurses, the nurse manager, and the department administrator—assume nurse tasks such as triaging patient call lights, handling calls related to new admissions, and other basic functions during the first 30 minutes of the shift so that the nurses can spend uninterrupted time at the bedside.
  • Ongoing monitoring and evaluation: Direct observation and patient and nurse questionnaires are used to determine whether all steps of Nurse Knowledge Exchange are being implemented and how well prepared the nurses feel at the start of their shift. The program is moving toward refining its evaluation to include Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) scores; nurses will also conduct spot audits with the goal of learning best practices and implementing continuous quality improvement.

Context of the Innovation

Kaiser Permanente, a large, nonprofit, national health care organization headquartered in Oakland, CA, comprises health plans, medical groups, medical centers, and their subsidiaries. The headquarters-based Kaiser Permanente Innovation Consultancy worked with leaders in Kaiser Permanente's four hospital regions to identify opportunities for innovation within their hospitals. Nurse communication, especially at shift change, was unanimously identified as a process in need of significant improvement. Four sites were selected to develop, implement, and pilot test a program designed to improve the shift change process.


Pre- and post-implementation comparisons made during a pilot study of the initial iteration of the model show that the model has optimized the time spent transferring patient care from one nursing shift to the next; post-implementation surveys indicate that the model has led to high levels of patient and nurse satisfaction. A pre—post-implementation study of NKEplus indicates an increase in nurse time spent at the bedside. Results are as follows:

  • Optimized preparation time: The pilot study revealed that the time interval between the nurse's arrival on duty and the first patient report remained approximately the same; however, the time was now spent reviewing patient data rather than waiting for patient assignments.
  • Optimized shift report time: The time interval between the nurse receiving the first and the last patient report remained approximately the same; however, the quality of the data exchange was greatly increased. Nurses were discussing detailed patient data and care plans about only their own patients, rather than basic details about all patients.
  • Reduced time to see first patient: The program allowed incoming nurses to see their patients much more quickly after implementation of the model. The average elapsed time between when nurses began their shift and when they first saw their patients decreased from 30 to 60 minutes before the program to as low as 11 minutes after implementation.
  • Increased patient and nurse satisfaction: Both patients and nurses have expressed satisfaction with the program, with nurses reporting that they have better information to care for patients and valuing the opportunity to question outgoing nurses directly. Patients have expressed appreciation for the opportunity to be involved in the shift change and to meet their incoming nurse.
  • Increased nurse time at the bedside: Information provided in April 2011 indicates that pre—post-implementation analyses conducted at two sites reveal NKEplus has increased nursing time at the bedside by 18.9 percent.
  • Increased nurse time spent at the bedside: Information provided in April 2011 indicates that a pre—post-implementation study of sites implementing NKEplus indicated that nurse time spent at the bedside increased by 18.9 percent.

Evidence Rating

Moderate: The evidence consists of before-and-after comparisons of pilot study data on the time it takes incoming nurses to prepare for the shift, post-implementation nurse and patient satisfaction surveys, and pre—post-implementation data on nurse time spent at the bedside.

Planning and Development Process

Key steps in the planning and development process included the following:

  • Understanding of current process: The Kaiser Permanente Innovation Consultancy spent 1 week at each alpha site conducting observational research to understand how nurses gather and manage information at shift changes.
  • Nursing team exchange to identify key program elements: Nursing teams from the four alpha sites met for 2 days to hear the stories gathered from the observational research and to brainstorm and prototype ideas for improving the exchange of information at shift change. This prototyping session resulted in the identification of the key elements of NKEplus.
  • Training and implementation support: Training was provided by the Kaiser Permanente implementation team to hospital leaders, nurses, and other unit staff on process improvement and the key elements of NKE. Training consisted of a 2-hour initial orientation followed by 2 to 4 weeks of unit-based training. An implementation team representative was also made available for troubleshooting for a period of 1 week after the training.
  • Expansion of Kaiser Permanente within a facility: A defined process was used to implement the model throughout a hospital. Initially, NKEplus is implemented on two units. Data are collected and analyzed to determine attainment of goals, what works, and what needs to be adapted. Knowledge gained in this first cycle is used to plan the next cycle. Each subsequent cycle includes more units until all units have implemented the model.
  • Program enhancement: Information provided in April 2011 indicates that in 2009, Kaiser Permanente and the consultancy revised the original NKE model to NKEplus, which reflects a stronger focus on patient safety and a desire to improve nurse comfort with patient care activities at the bedside.

Resources Used and Skills Needed

  • Staffing: Staff involved in the program include a full-time equivalent (FTE) project manager, the trainers, a registered nurse champion per shift, nurse managers (who provide support), an information technology specialist, a quality analyst, and an implementation team member who provides workflow support for 1 to 2 weeks. Staff carry out NKE program responsibilities as part of their regular duties, except for the project manager.
  • Costs: The staff costs of this program include the cost of one FTE project manager and the cost of backfilling for three unit staff during training. Material costs include whiteboards for patient rooms.

Funding Sources

The Gordon and Betty Moore Foundation and Kaiser Permanente.

Getting Started with This Innovation

  • Obtain senior management support: Engage leaders, as their initial support and involvement is a critical factor in the ultimate success of the program.
  • Articulate the rationale for the program: Create and articulate a compelling rationale for revising shift change practices, using stories or observations with which staff can identify.
  • Create a motivated project team: Assemble a manager and implementation team of motivated people; challenge and empower them to create change, and provide the resources they will need to meet this challenge.
  • Pilot the program: Pilot test the program on high-performance units with staff who like to do new things. News of positive results will likely spread, creating interest throughout the organization.
  • Implement the six Nurse Knowledge Exchange Plus steps in weekly phases: First, implement the Unit Support and Shift Assignments in week 1. Then, implement the Last Hourly Round in week 2. Then, implement Inroom Standardized Communication and Safety Check in week 3. Finally, implement Careboard with Teach-back in week 4. Staging it this way allows the nurses and unit to better learn and integrate each piece.
  • Acclimate nurses to information sharing at the bedside: Alleviate nurses & rsquo; discomfort and concerns about sharing information at the patient & rsquo;s bedside. Discomfort can be alleviated by teaching bedside rounding using patient simulation or initiating doorway rounding until the nurses are comfortable moving to the bedside.

Sustaining This Innovation

  • Continue to involve leadership: Keep hospital leaders involved as guides, cheerleaders, and mentors for the program.
  • Observe the process on an ongoing basis: Enlist team leaders and managers for ongoing observation and coaching.
  • Be flexible: Allow individual units to refine aspects of the NKEPlus model to meet their unique needs, as long as each unit maintains the core elements of the four-step process.

Use By Other Organizations

Information provided in April 2011 indicates that NKEplus has been implemented in all 38 Kaiser Permanente hospitals; program developers expect that a minimum of 15 non—Kaiser hospitals will have implemented NKEplus by Fall 2011.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Mike Lin
Innovation Consultancy, Kaiser Permanente
1800 Harrison St 17th Floor
Oakland CA 94612
Phone: (510) 914-6422

Innovator Disclosures

Mr. Lin has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

(Added April 2011) NKEplus Web site. Available at:

Kaiser Permanente. Nursing Pathways. Revolutionary Partnership Brings New Way of Thinking to Kaiser Permanente. Available at:


  1. The Joint Commission. Root Causes of Sentinel Events. Available at:

  2. The Joint Commission. National Patient Safety Goals. 2006 Critical Access Hospital and Hospital National Patient Safety Goals.

Funding Sources

Kaiser Permanente-California


Kaiser Permanente-California

Kaiser Permanente-California is headquartered in Oakland, CA.


By Esther Ong on
Bedside Reporting in my hospital is not successful and no consistency of practice across the board. The concept of bedside reporting involving the patient is not really happening. There is really something wrong and missing the concept. Few weeks ago, I observed the NKE PLUS process in one of the Kaiser Permanente facilities and I was amazed how the nurses are actively interacting with their patients in a friendly and safe approach. I was impressed they way they introduced and touched their patient by hand or shoulder. The Safety check was great and the patients were cooperative with the "teach back" method of teaching. All the 6 components were done in a brief period of time. It's a great initiative and actually I will present it to the leadership of my hospital so we can replicate the process. Are all the posted articles in the internet complete or you really have a training module? Do you think you can share with me.

By I Gladding RN on
I will be the project lead for implementing this initiative in my Mother Baby Unit in Mississauga Ontario (Canada). The above comments have all been concerns voiced by nurses in my workplace mainly worried about the time involved in handover, sensitive information shared in multi bed rooms and how to give report with 'sleeping' patients. Thanks for addressing some of these issues, if anyone has other lit searches or contacts to provide me with more strategies to implement with success please contact me!

By Mike Lin on
Hello Ontario. Great to hear that you are trying this in your Mother Baby Unit. Our regional partners at KP in SCAL have been adapting NKEplus in Mother Baby units (I think). If you are interested in reaching out, email me. - Mike Lin

By Charles Durant on
Mike, I'm a hospital administrator and grad student in health informatics doing an evaluation of a Shift Report tool in an EHR. My question is whether NKE Plus utilizes such a tool? If not, do you have ideas on how an electronic tool in the EHR would facilitate the handoff at the bedside? Did your research team perhaps reject the use of an electronic tool? Thank you, Charles Durant 512-656-8153

By Mike Lin on
Hi Charles. Feel free to hit me up. There is work being done at in our Southern California region to integrate the workflow into the EMR. You can email me for more information.

By Mike Lin on
Dear all. My apologies. For some reason, I am not consistently getting notifications when someone posts here. If you have any questions. Please email me below.

By MLG on
Hi, I am working on improving accuracy and including patient bedside reporting as well as participation. We have three shifts out of which 2 overlap by 30 minutes and the 3rd actually takes our outgoing nurse to work OT to hand off most of the time. This is one issue; the other is that some are reluctant to waking up patients to participate. We need to understand that it is after midnight. How do your work with that? Should a patient be awakened? MLG, RN

By ed coakley on
I am very interested in learning more about the information exchange. I saw this in action in Medellin Colombia a couple of years ago. It seems that this innovation is bucking up against the trend to move clinical reporting to the patient record.

By Tammy Love on
Wonderful work at improving communication at shift change. We are currently working on a standardized shift change form for more accurate and relevant hand-off communication. I have a few questions. Did nurses have to change their hours at all or do they round during the 30 minutes the shifts overlap? Does the nurse leaving and the incoming nurse have mostly the same patient assignment to hasten transition?

By Chris McCarthy on
Hi Tammy: The shift change length (30 minutes) remained the same, with no change in nurse hours. As for patient assignments, the IDEALIZED GOAL is a one-on-one handoff (all patients from one nurse going to one oncoming nurse). However, that is indeed an IDEALIZED GOAL. We rarely see this. We mostly see a 1:2 and 1:3, and rarely 1:4 and 1:5. But even in the rare occasion of 1:4 and 1:5, the nurses are able to effectively do the handoff. If you can get 1:2 or 1:3 it should be smooth sailing!!

By Summer Skeet on
I am very interested in Nurse Knowledge Exchange, do you have more information about this? Was it hard to get administration and staff to get on board? Have you seen a decrease in patient falls and other safety issues? It would be great if you could share some stats with me, so I can get our hospital on board with this idea. Please email me the information if possible.

By sandra wisler on
Will you share your NKEplus tool ? I am looking to implement an improvement in shift report.
Original Publication: 07/07/08

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 08/13/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 07/08/13

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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