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Universal Protocol

Universal Protocol. Team Membership Paula Hindle RN, MSN Mary Altier RN, MSN Vice President/Chief Nurse Executive Nursing Quality Specialist Peggy Vorrier RN, MS Jeri Katsaros RN, BSN

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Universal Protocol

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  1. Universal Protocol Team Membership Paula Hindle RN, MSN Mary Altier RN, MSN Vice President/Chief Nurse Executive Nursing Quality Specialist Peggy Vorrier RN, MS Jeri Katsaros RN, BSN Administrative Director Surgical Services Manager Same Day Surgery Jo Quetsch RN, MA-OM Gigi Marinakos-Trulis Manager Operating Room Data Analyst

  2. Main Operating Room Labor and Delivery Newborn Nursery BICU, NICU, PICU, HTU, 3MICU 4SICU, 2WICU, 2CCU Special Procedures Cardiographics EP Lab Cardiac Cath Lab Pulmonary Function Lab Nuclear Medicine Women’s Imaging Homer Glen Lagrange Ultrasound GI Lab Breast Imaging Dermatology Pain Clinic ENT Clinic Oak Brook Terrace 1 LOC Surgery Center Ambulatory Surgery Center Cancer Center Oral Health Center Hickory Hills Radiation Oncology Radiology Department Membership

  3. Opportunity Statement There is an opportunity at LUHS to assure compliance with the 2006 National Patient Safety Goal: Universal Protocol for preventing wrong site, wrong procedure and wrong patient surgery. Project Goal Improve the submission and documentation rates for compliance with proper consents, site verification and time-out procedures.

  4. Most Likely Causes Identified • Knowledge deficit regarding use of tool • Knowledge deficit regarding proper submission of form • Lack of understanding of • Universal Protocol • Which surgeries/procedures are included in protocol • Which surgeries/procedures require site marking • Number of personnel required for a “time-out”

  5. Solutions Implemented • Revision of Operative Procedure Policy Quarter 4 2006 • Revised form implemented 12/2006 • Education sessions for key stakeholders regarding use of tool • Random sampling of verification checklists performed quarterly: 4th quarter 2003 - 4th quarter 2006 • Quarterly reports to clinical departments

  6. Data Analysis • 11 data collection periods since inception • 34 departments submitted forms for audits • 70 sheets per department audited each quarter • Data elements measured: • Consents signed, site marked, time-outcompleted.

  7. Consents Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (#13.0015.6) Data Source: Original data extracted from LUHS Site Verification Sheets by RN and Data Analyst. Analysis: LUHS performance is stable with a mean of 95%.

  8. Site Verification Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (#13.0015.6) Data Source: Original data extracted from LUMC Site Verification Sheets by RN and Data Analyst. Analysis: LUHS performance is stable with a mean of 86%. Results demonstrate significant improvement.

  9. Time Out Definition: Percent of appropriate documentation demonstrating the department is in compliance with the Operative and Invasive Procedure Verification policy. (#13.0015.6) Data Source: Original data extracted from LUMC Site Verification Sheets by RN and Data Analyst. Analysis: LUHS performance is stable with a mean of 96%.

  10. Next Steps • In-service to all key stakeholders: both Inpatient and Ambulatory sites regarding revised form/policy • Monitor departments for compliance • Quarterly reports to clinical departments provide feedback on performance

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