• E-mail
• Print
• RSS

Universal Protocol compliance isn’t kid stuff

Ambulatory Safety Monitor, December 16, 2004

Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

Surveyors looked for adherence to the JCAHO's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery(tm) by checking the records and charts of current patients during Children's Surgery Center's triennial survey in July.

After the JCAHO established the Universal Protocol, Children's adapted its policies to meet the new requirements but did not change other policies in anticipation of the survey.

"Our goal is to be an organization that does things the same way every day. That shouldn't change because a surveyor is coming," says Alan Tingley, MD, MBA, medical director and administrator.

Make documentation work for you

Surveyors liked the Columbus, OH-based pediatric ambulatory surgery center's (ASC) policies for complying with the protocol. They found a checklist in the front of each patient chart for staff to document site verification and the time out. The one-page list contains sections for preoperative holding, operating room (OR), phase I recovery, and phase II recovery. Nurses easily check the items they must verify, including identification band placement, consent form, and site verification. Placing documentation for all areas on one checklist simplifies the process and ensures that providers (and surveyors) don't have to search for information.

Marking the site

Surveyors were pleased with Children's site-marking process. Using an indelible marker, staff draw a small heart on the surgery site. "We make it fun so [patients] know it's not threatening," says Tingley. The facility previously used ink stamps of smiley faces to mark sites; however, protocol requires that the marking survive surgery preparation, and the stamps would wear off.

Improving staff compliance
In addition to the Universal Protocol, Children's improved staff compliance with not using the JCAHO's prohibited abbreviations by revising its physician's order form for medications and tests. Now, the form lists the names of common medications for physicians to check off and fill in the correct dosage. This form has kept them from using the unapproved abbreviations, says Pam Courter, RN, manager of quality assurance.

Surveyors wanted to see statistically controlled charts and as much outside benchmarking as possible, says Courter. This is challenging because there are few pediatric ASCs, so Children's does not have as much comparison data as other ASCs.

"They were more interested in how we decided what we looked at [rather] than the report," says Tingley. "They wanted to see the process rather than the specific numbers."

A bulletin board in the staff lounge displays observations and trends found in PI project data. If quarterly reports on a project indicate that staff fall short in an area or aren't meeting goals, staff receive updates via a notice posted on the bulletin board, as well as discussions in staff meetings. This way, staff and the PI team can identify possible solutions, such as further staff education. They communicate all PI data to the medical advisory committee and the board of managers, says Courter.

Don't send staff in cold 

A presurvey warm up, including a mock patient tracer and practice question-and-answer handouts, helped staff prepare for the real visit. Since the surveyor spent most of his time with the staff conducting patient tracers, the mock sessions really paid off, says Courter.

Courter compiled a list of sample surveyor questions and answers for each survey area that staff could review in their free time. In addition, she conducted weekly mock tracers beginning about two months before the survey. Staff appreciated this type of preparation, and even encouraged her to ask them more practice questions.

Staff received laminated cards on a key ring to carry in their pockets. These cards were miniature reference sheets staff could use to help answer questions on fire safety protocol, the JCAHO's unapproved abbreviations, and the National Patient Safety Goals.

Want to receive articles like this one in your inbox? Subscribe to Ambulatory Safety Monitor!

• E-mail to a Colleague
• Print
• RSS
• Archive