Nurse Knowledge Exchange for Kaiser Permanente

Improving nurse knowledge exchange for better patient care

Shift changes in hospitals present one of the biggest challenges to the continuity of patient care. As nurses go on and off a shift, a crucial exchange of information and duties must take place in order to ensure safety, quality of care, and efficiency. Looking to optimize the nursing shift change process within its own hospital network, Kaiser Permanente worked closely with IDEO to develop a system of solutions that could be customized and implemented by the nurses themselves with no risk to patients or staff.

IDEO and Kaiser Permanente conducted observations in four hospitals, watching shift changes around the clock in an attempt to understand the ways that information gets transmitted. In addition, the team looked at other elements that might affect hand-off, including staffing, the lab, bed management, transport, and different nursing roles. The team found that each nurse had their own way of prioritizing and communicating information. In response, IDEO and Kaiser Permanente created a framework that highlighted the key issues to be designed for: schedules, software, information hand-offs, and patient interactions.

Ideation and brainstorming sessions followed in which nurses, doctors, and administrators participated and helped to inspire prototypes. These prototypes were then tested for three weeks in a single unit, during every shift change. Changes to the prototypes were made continuously based on feedback from the nurses, who were excited and relieved to be directly shaping the outcome.

Having proven successful in a handful of hospitals, Kaiser Permanente has implemented the co-developed IDEO/KP program for nurse knowledge exchange in every ward in 35 hospitals. In 2006, Kaiser Permanente opened an innovation center in Oakland, California, that houses a prototyping space, full-scale clinic, and an internal innovation team to continue to create and share tools and best practices. Since implementing IDEO’s program, Kaiser Permanente has reported a reduction in prep time, improved patient safety and praise by the Institute of Healthcare Improvement as “best practice” in health care.

Project date: 2005

Design Thinking 101 with Kaiser Permanente