Clinical Excellence

March 1, 2007

Shifting Perspectives

Kaiser Permanente's Nurse Knowledge Exchange ensures smooth, consistent and positive patient hand-offs

Oakland, Calif. — It's no secret that communication breakdowns among caregivers have long played a central role when it comes to avoidable medical errors, experts say.

But now, new initiatives pioneered by Kaiser Permanente are helping bridge the communication gap between clinicians-especially at the critical time of patient hand-off-and in the process, improving patient safety. In fact, KP's programs are proving so successful that other health care organizations nationwide are adopting the techniques.

Chief among KP's efforts in this area is the Nurse Knowledge Exchange (NKE), which is now being implemented in all 31 KP hospitals in California, Hawaii and the Northwest region. The initiative creates an easy-to-follow protocol aimed at ensuring that vital patient information is conveyed accurately, concisely and consistently during shift changes.

The NKE relies on both a software template and face-to-face interaction between nurses to create a structured pathway for conveying detailed and up-to-date information about each patient's care plan. By sharing knowledge systematically across the entire care team, the often ad-hoc and frequently harried communication that traditionally has taken place during shift changes is eliminated.

One key component of the NKE requires that both the incoming and departing nurse jointly conduct patient rounds. When possible, the nurses are instructed to engage patients and families about treatment and progress.

Another aspect of the initiative that is quickly finding favor across a range of other communications arenas-most notably nurse-physician communication-is a briefing tool developed by Doug Bonacum, Kaiser Permanente's vice president of safety management. Known as SBAR, for Situation, Background, Assessment and Recommendation, the technique draws from procedures Bonacum learned while working on a submarine in the U.S. Navy. SBAR is designed to convey vital information in as little as 60 seconds.

By following the SBAR guidelines (caregivers provide a brief overview of the medical situation at hand; offer background on the patient and his or her condition; give an assessment of the situation; and make a recommendation about a course of action) nurses and physicians are communicating more quickly and succinctly, Bonacum noted.

SBAR's standardized structure makes it easier for nurses to convey patient information without digressing, omitting key information or worrying about how a physician may react. At the same time, the technique quickly gives physicians the key points they need to make an appropriate decision.

The SBAR technique is gaining favor at health care organizations nationwide, and is being used in a variety of communication tools, including email. Some have suggested that the template could be harnessed for use by physicians when communicating with patients at the end of an office visit.

KP's initiatives to improve clinician communication come as the health care industry works to strengthen the patient hand-off process. In January 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for the first time developed a national patient safety goal regarding patient hand-offs. The commission is requiring hospitals to develop communication standards that include question-and-answer opportunities.

Patient hand-offs-between shifts, departments and facilities-long have been an area of vulnerability when it comes to information exchange. One major reason is that hand-off procedures are not taught at most medical schools. Making matters worse, the number of hand-offs between clinicians has increased due to work reduction rules for medical residents that went into effect in 2003.