Shifting to a Higher Standard

Until last spring, Celeste O’Neal always began her 7:00 AM shift at California’s South Sacramento Medical Center in the break room. O’Neal, an RN in the medical-surgical unit, wasn’t sipping coffee. She was learning how her patients on the unit were doing. “We all had to assemble so the incoming charge nurse could distribute handwritten sheets updating us,” explains O’Neal. The briefing was vital but the information transfer was inefficient and frustrating. The charge nurse had to come in early to fill out a standardized form on each patient. Some data on the sheets were already known because the patient’s condition hadn’t changed. At the same time, says O’Neal, critical new information might be missing if the form didn’t have a place to put it. “In that case, the charge nurse would give us verbal updates that we all had to sit through, even when it wasn’t our patient.”
 
With the previous shift headed out the door and the incoming staff occupied in the break room, nurses were generally scarce on the unit for about 30 minutes during each turnover — as much as 90 minutes a day. The result: hospital activities on hold, patients who referred to shift changes as “ghost towns,” and a process perpetually behind the curve. “Everything was backed up before we started,” says Celeste O’Neal. Then, in early 2004, Kaiser Permanente (KP), the nation’s largest non-profit health plan that owns South Sacramento and 30 other hospitals in California, Oregon, and Hawaii, went looking for new ways to streamline and humanize patient care. Not surprisingly, nursing shift changes looked like fertile ground.
 
Today, break rooms at South Sacramento are strictly for breaks. Nurses on incoming shifts — which now overlap outgoing shifts by 30 minutes — get updates via the Nurse Knowledge Exchange (NKE), a KP innovation, which combines user-friendly electronic record-keeping with a seamless personal handoff of each patient from one caregiver to the next. When Celeste O’Neal arrives for work, she receives a customized electronic report on each of her five or so patients. It’s packaged on a computer desktop by the departing charge nurse — not the incoming one — using a patient-care information system called the Neuron, a Microsoft Access 2000 database. The concise summary — dubbed “My Brain” because “that’s what nurses call the important stuff,” says O’Neal — is tailored both to the patient and the nurse. Fully detailed reports describing everything from allergies to language barriers are generated for new patients or patients transferred to a new nurse, but the typical report in the NKE system contains only fresh data, such as lab results or medication changes.
 
Armed with her My Brain updates, O’Neal then makes bedside rounds with the nurse who cared for each of her patients during the previous shift. The two nurses and, ideally, the patient share news, plans, or other details about treatment and progress. “We all get to ask questions, clarify information, or hear suggestions. It’s only a few minutes at each bedside, but it fosters complete communication and total accountability,” says O’Neal. “It reassures the staff and it reassures the patient that nothing is falling between the cracks.” Indeed, the Joint Commission on Accreditation of Healthcare Organizations — the main accrediting body for hospitals — identifies communication failures as a major source of avoidable harm.
         
Information and accountability continue on the white boards placed in front of each patient’s bed. The boards list the names of all caregivers, phone contacts, scheduled procedures such as lab tests, daily goals such as pain control, and the patient’s expected discharge date. Incoming nurses refresh the boards to keep patients, families, and staff current and involved. “It’s another way to encourage everyone to partner in the patient’s care,” says O’Neal.
 
The NKE was devised by a KP in-house innovation team working with system redesign experts from IDEO, a Palo Alto, California, information technology consulting company. So far it’s been tested in 10 medical-surgical or telemetry units at two of the plan’s hospitals in California —  South Sacramento and Baldwin Park Medical Centers — and at Moanalua Medical Center in Honolulu. Efforts are underway to introduce NKE in obstetric, pediatric, and intensive care units as well. Early data from the pilot sites have shown that NKE shrinks the time it takes for one nursing shift to transfer patient care to the next, reducing overtime and making staff more available to patients.
 
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However, KP has realized that implementing an unfamiliar system across its diverse 30-hospital network will not necessarily be easy. To help prepare those in the vanguard, the organization has formed a strategic partnership with the Institute for Healthcare Improvement (IHI) to educate KP’s nurse leaders in the strategies and techniques of expanding successful change. The eight million enrollees in KP health plans make the alliance especially attractive to IHI, says M. Rashad Massoud, MD, the IHI senior vice president in charge of the project. “We call partnerships like this ‘deep-end’ relationships,” says Massoud, “because the changes we help leverage spread across so many lives.”
 
In early November 2005 teams from nine KP hospitals joined IHI expert faculty to launch the Kaiser Nurse Knowledge Exchange Initiative, in which Learning Sessions will alternate with Action Periods to apply classroom lessons in the field. Coaching and mentoring will continue throughout the six- to nine-month project, via phone conferences, site visits, and monthly reports plus a dedicated listserv and Extranet site, which will remain available to participants after formal training ends.
 
Eventually, KP hopes to have NKE established throughout its extensive hospital network as part of KP HealthConnect, a $3 billion electronic information system which integrates clinical patient records with online patient communication, such as medical appointments and billing. “NKE will make the transition to KP HealthConnect a lot easier,” says KP Innovation Specialist Chris McCarthy, who expects the switchover to be completed by 2008.
 
That doesn’t mean all units will use NKE the same way, says Lisa Schilling, RN, MPH, a Patient Safety Practice Leader at KP. “We encourage individual units to adapt NKE to their own needs and styles.” At Moanaloa, which switched to NKE in mid-2004, incoming nurses on the hospital’s 20-bed medical/surgical unit still assemble — for no more than 10 minutes — to learn of any important changes concerning any patients on the unit. “The floor nurses feel they need to know about one another’s patients to cover during breaks,” says Unit Manager Liz Kiehm, RN, MS.
 
At first, Kiehm’s staff didn’t take to the outgoing and incoming shift bedside rounds. “They worried about violating patient privacy in double rooms and they didn’t feel comfortable saying everything they wanted to say in front of the patient, so they would meet again afterwards — we called it ‘the huddle.’” As the unit’s top manager, Kiehm decided to let the huddles continue while the nurses’ comfort level grew. “We made sure everyone understood what was off-limits for privacy reasons — such as HIV status — and what was okay to discuss, and we kept emphasizing how important it was to involve the patient in the handoff.” Gradually, huddles became less frequent, though Kiehm admits she still observes the occasional tete-a-tete at the nurses’ station. “And I still hear complaints that the patients use the time to ask for fresh water, not to discuss their care — but we’ll get there,” insists Kiehm.
 
The Neuron patient-care database has also generated some resistance. None of the 11 KP hospitals in southern California currently plan to use it for patient updates. Some units will integrate NKE with an earlier electronic system already in use; others will stick with paper. No matter, says Lisa Schilling, “It’s still the NKE model. They’ll prepare for the shift, create the reports, do bedside rounds, fill out the white boards. It’s NKE in a slightly different form.” IHI’s Rashad Massoud agrees, “Before you can spread change, you have to build confidence in the change. We can’t just parachute in and expect things to work. We — and the change we are looking for — must be flexible.”
 
If NKE proves as successful as early indicators suggest, it may well draw the attention of other hospitals struggling with shift changes. If so, they are invited to capitalize on KP’s innovations. Although NKE was developed in-house, the health plan doesn’t plan to keep it proprietary. “Anyone is welcome to adapt our methods,” says Schilling. “We hope they do.” Massoud says IHI is ready: “We’ll put it all up on our website.”
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