Tighten Up Your Universal Protocol!

Accreditation Monthly, December 11, 2007

This past week, we learned of yet another wrong-site surgery at a hospital in Rhode Island-the third such event reported at this hospital. Additionally, The Joint Commission (formerly JCAHO) reported receiving over 150 wrong-patient, wrong-procedure, or wrong-site sentinel event reports during the most recent 12-month period. These disturbing incidences have occurred despite The Joint Commission's National Patient Safety Goal (NPSG) dating back to January 2003 that addresses and requires hospitals to adopt preventive measures to avoid these events. The measures were redrafted in July 2004 and codified in The Joint Commission's Universal Protocol.  
One wonders what the true number of reported and unreported episodes of wrong-patient or wrong-site surgery is nationally. Given what we know about applying principles of effective process design in healthcare, our industry should be capable of totally eliminating the occurrence of this type of medical error. How is it then that we continue to have even one reported case of wrong-patient, wrong-site surgery in this country?  Why do we tolerate even a single failure or single data point representing undesired variation in practice? 
Very simply, I believe the answer rests in our failure as leaders to attend to one or more of what I call the "Five Steps of Doing the Right Thing Well." First, we may not have designed the process properly. For example, perhaps we created a workable process for use in the surgery department but failed to account for how the process needs to be applied in other areas in which invasive procedures are performed. Second, maybe we did a fine job designing a foolproof process (recognizing, as once said by a wise person, that there is no process design outside the capability of a sufficiently talented fool), but we failed to adequately educate the users of the process. Third, we may have a great process and great attendance and attention at our department inservices, but perhaps we failed to follow up and test for staff competency-that is, are staff capable (competent) to consistently apply on the front line what they've learned in the classroom?  Fourth, even though our process, education, and competency validation steps may be stellar, maybe we can trace process failure to management's lax or insufficient measurement of staff member conformance to precisely following the steps in the process we designed and taught. Perhaps staff members left the classroom educated and competent but instantly reverted to old habits that to them seemed as or even more efficient and effective than those that we designed. Or maybe the culture within the OR is one that tolerates lax performance of the protocol or looks the other way when ridicule spewed by one team member creates a culture of fear in the rest of the team. Fifth, maybe processes fail because we failed as leaders to have the backbone, time, or energy to hold staff members accountable to ensure that they perform the process as we designed without variation. 
I hasten to add that when I refer to "staff members" in each of these five steps, I am including physicians. After all, the source of the undesired variation in practice may well be a disinterested, or worse, disruptive physician who's passive or active resistance to change dampens or even swamps efforts to instill a culture of safety among all staff members in a department. 
Applying the five steps to any process design or redesign project increases your organization's odds of sustaining variation-free execution of your new process. I suggest all hospitals use the Rhode Island hospital's mistake as an opportunity to gather staff members from all areas in which invasive procedures are performed and conduct a careful review of your applicable policy, checklists, and forms. Compare these tools to The Joint Commission's Universal Protocol and FAQ found at

Ask yourselves if you've captured each nuance of the Universal Protocol and FAQ in your process design. Did you teach the process design to all applicable staff members and validate their competency? Have you adequately measured staff member conformance to the process design?  If not, have you intervened to ensure staff members are held accountable to perform the process as designed? If you answer yes to each step, you are on the path to sustained execution of the Universal Protocol process.
Speaking on behalf of my colleagues at The Greeley Company, any one of us would be happy to help you improve your organization's performance with this or other Joint Commission NPSGs. We specialize in helping to craft Joint Commission-compliant policies and effective processes designed specifically to fit your organization. It may also be time to schedule an Unannounced Survey Vulnerability Visit by one of our Greeley mock survey teams. For more information, please call Stacey Koch, Director of Client Relations, at 888/749-3054, ext. 3193. Finally, we wish you a safe and happy holiday season.

Most Popular