Implementing the Universal Protocol hospital-wide

AORN Journal,  June, 2007  by Elizabeth Norton

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The practices outlined in the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery (1) were not entirely new to staff members at Children's Hospital Boston, Mass, when the Joint Commission on Accreditation of Healthcare Organizations, now called the Joint Commission, made them mandatory in July 2004. (2) The term Universal Protocol was new, however, and would require staff member education. The requirement to use this protocol anywhere an invasive procedure was performed required extensive editing of existing hospital policies and hospital-wide implementation. The goal was to have one standard of practice incorporating the requirements of the Universal Protocol in all departments of Children's Hospital Boston.

Clinical experts were nominated as "champions" for each Joint Commission National Patient Safety Goal (NPSG). The individual chosen as the Universal Protocol champion was a level III staff nurse who was recognized as the nurse most involved in patient safety and quality in the OR for her previous work on instituting perioperative time out and site verification procedures. The Universal Protocol champion developed an extensive action plan that included

* appointing nurse and physician representatives from each target area;

* rolling out the new policy;

* creating materials for advertising the policy; and

* formulating an education, monitoring, and evaluation plan.

This process set the "gold standard" for implementing NPSGs hospital-wide.

EARLY SITE VERIFICATION POLICIES

The first OR policy on site verification at Children's Hospital Boston was developed in 1999. At this time, information on site verification in the literature was limited. Recommendations from the American College of Orthopedic Surgeons and the Joint Commission were used as guidelines for the site verification policy. (3,4) The practice change that resulted from this policy required surgeons to initial the surgical site to indicate laterality. Implementation of this practice change was driven primarily by the perioperative nurses.

IMPLEMENTATION CHALLENGES. After the policy was developed and implemented, staff nurses in the OR began to collect data on compliance with marking the surgical site. It immediately became clear that it was necessary to improve overall compliance and educate surgeons and nurses on correct site marking protocol. Some surgeons were marking extremities with the words yes and no. This practice was seen mostly in orthopedics and was not surprising because many of the hospital's orthopedic surgeons had been marking the site this way long before the policy was developed. Many surgeons were marking the site with symbols, such as an "X" or a dot. They now had to be reeducated and learn to change their practice to mark the correct site with their initials. This was a cultural change that took time to be accepted by everyone.

Another struggle involved marking bilateral sites. The policy required site marking for bilateral procedures, and this practice was not widely accepted or understood. Many other hospitals did not require site marking for bilateral procedures, which added to the difficulty in gaining surgeons' acceptance of the practice.

The perioperative policy went through many revisions as the Joint Commission continued to refine its requirements, such as initialing digits requiring surgery. (5) Being on the cutting edge was not always easy and created some frustration as the policy continued to evolve along with the requirements.

Approximately six months after the policy was instituted, data were presented to the surgical chiefs, nursing leaders, and staff nurses that showed how well each service was complying with the policy. The data were displayed in ORs for everyone to view, and a positive competitiveness developed. Most surgical chiefs took it upon themselves to make improvements in their own services. Nursing leaders took a strong stand and gave the circulating nurses the responsibility of preventing patients from entering the OR if they did not have appropriate site marking. Surgical chiefs and nursing leaders counseled individual team members (eg, nurses, surgeons, anesthesia care providers) who were not compliant with the policy. The entire team was considered accountable if a patient was transported into the OR without site initialing. A no-tolerance policy was established and adhered to. Quarterly, the policy champion presented and posted data on site marking compliance, and the data rapidly improved. After the compliance rates reached more than 50%, the rates began to increase rapidly. Those who were not compliant were held accountable, and eventually all departments were routinely following the policy.

REVISING THE POLICY. In. 2003, the policy champion, with approval from nursing leaders and the OR Governance Committee, revised the laterality policy to include time outs and site verification using the Joint Commission recommendations. (6) Departments such as interventional radiology, endoscopy, the intensive care unit, the dental clinic, and the cardiac catheterization laboratory began to develop and implement unit-based policies on time outs and site verification that were based on the OR policy. Again, implementation of the policy was driven primarily by nurses, and staff members in each department monitored their own practice.