This past August, The Joint Commission conducted a post-implementation evaluation of the 2010 revisions to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. Respondents to the survey indicated that the revisions, which were effective January 1, 2010, substantially addressed the field’s concerns, which focused primarily on the specificity of the requirements. The intent of the revisions was to address patient safety issues while allowing organizations flexibility in applying the requirements within existing work processes, given the diversity of organizations that need to follow the Universal Protocol. The revisions to the Universal Protocol included simplified pre-procedure verification requirements, clarified site-marking requirements, and streamlined time-out and documentation requirements. Because of the importance and high visibility of this National Patient Safety Goal, The Joint Commission determined that it was necessary to follow up on the field’s experience with the revised Universal Protocol. An online survey was posted on The Joint Commission Web site in August 2010 to determine if organizations were able to implement the 2010 revisions to the Universal Protocol and its value in different settings. More than 2,100 individuals accessed and responded to the survey. Respondents indicated the following:
- 88 percent of respondents agreed or strongly agreed that their organizations were able to fully implement the revised 2010 Universal Protocol.
- The majority of respondents agreed or strongly agreed that the focus of the requirements in the Universal Protocol are appropriate, including the preprocedure verification (92 percent), site marking (87 percent), and the time-out (89 percent).
- Ninety percent or more of the respondents agreed or strongly agreed that there is benefit in using the Universal Protocol in the operating room (94 percent), ambulatory surgery (93 percent), and hospital units where invasive procedures are performed (90 percent). Fewer respondents identified benefits of using the Universal Protocol in ambulatory clinics (80 percent) and physician offices (73 percent).
- Responses were mixed with respect to the necessity to significantly modify policies and procedures as a result of the 2010 revisions to the Universal Protocol. Approximately one third of respondents agreed or strongly agreed that it was necessary to significantly modify policies and procedures; another third indicated they neither agreed nor disagreed; and the final third disagreed or strongly disagreed. Some respondents commented the changes to the UP could be accommodated in existing policies.
- There was not a notable difference in responses based on demographics (for example, hospital versus ambulatory care, bed size, services offered, or professional perspective), therefore, the results represent all respondents.
At this time, no additional changes are planned for the content of the Universal Protocol. (Contact: Maureen Carr, firstname.lastname@example.org)