How to Evaluate Competence in Universal Protocol

Universal Protocols were developed to reduce surgical errors such as operating on the wrong side, or on the wrong patient, or performing the wrong procedure. Joint Commission, the hospital accreditation organization, along with health care professional groups such as The Association of Operating Room Nurses, and the American Medical Association, have developed the Universal Protocol, in an effort to eliminate such occurrences. A review of your facility's current Universal Protocol policy, as well as an analysis of patient data, will help to evaluate compliance and competence with Universal Protocol.

Instructions

• 1

  Establish an ad hoc committee designated to oversee and evaluate the effectiveness of the Universal Protocol, as it is defined within the institution. Choose committee members who are stakeholders in the process, such as perioperative nurses, surgical nurses, surgeons, as well as quality and risk management personnel. Include a member from upper management.

• 2

  Review the facility policy for Universal Protocol, along with any checklists used to assist with compliance. Compare policy and checklists with any updates or changes made by the Joint Commission to their interpretation of Universal Protocols. Make any changes to the facility policy as required, and schedule educational in-service meetings to inform staff of the changes.

• 3

  Review patient driven data such as morbidity and mortality reports, as well as quality and risk management reports, regarding any surgical errors that occurred because the Universal Protocol, or the checklists were not utilized.

• 4

  Conduct a chart review of randomly pulled surgical charts, to determine whether the chart documentation supports staff compliance with Universal Protocols. Charts should reflect that perioperative verification of the patient, the type of surgery and location of the surgery was done, before entering the surgical suite. There should be documentation that the surgical site was marked before the patient was prepped or draped. A time-out should also be documented, which indicates that the surgical team conducted a final verification of who the patient is, what and where the surgery is to performed, and that any other questions addressed.

• 5

  Monitor charts and patient data for one year, and report results of committee findings on a quarterly basis to appropriate parties.

• 6

  Prepare a remedial plan, should the data indicate a problem with competence or compliance with Universal Protocol. Review staff personnel records for Universal Protocol training, and address any educational issues.