Here are key changes for existing NPSGs
Perioperative team affected
In an effort to clarify the requirements of its Universal Protocol, The Joint Commission has made several revisions and additions, effective Jan. 1, 2009.
"These revisions and additions must be taken seriously by the perioperative team and by any other staff involved anywhere in the facility where procedures are performed," says Kathleen Catalano, RN, JD, director of health care transformation support for Plano, TX-based Perot Systems Corp.
These areas may include the intensive care units, emergency department, patient units, procedure rooms, and radiology. "These departments, in collaboration with the quality department, should work together to develop measures for tracking of these important revisions and additions," says Catalano.
Expect opposition
The revisions may meet with the same opposition as the current requirements of the Universal Protocol, warns Catalano. "That said, it will be imperative for the organization's leadership to truly endorse changes," she says. "At the root of the Universal Protocol is the desire for wrong site, wrong person, wrong procedure surgeries to be a thing of the past."
The verification process now requires a perioperative verification checklist be used to review and ensure availability of relevant documentation, images, diagnostic radiology test results. It should ensure that results are properly labeled and able to be appropriately displayed, and confirm the on-site availability of any required implants, devices, and/or special equipment for the procedure.
Several additions have been made to requirement 1B for marking the operative site. These include specifying the types of cases in which marking is required; requiring the initial marking of the site before the patient is moved to the area in which the procedure will be performed; marking by the licensed independent practitioner who will be involved directly with and present at the time of performing the procedure; use of a marker that is sufficiently permanent to remain visible after completion of the skin prep and sterile draping; final confirmation and verification of the site mark takes place during the "time out" and a defined procedure for patients who refuse site marking or who are unable to be marked.
Requirement 1C, conducting of the final "time out" verification immediately before starting the procedure, also has several revisions and additions. An interactive verbal communication is now required between team members, with the ability for any team member to express concerns about the procedure verification, for instance.
"These changes in the Universal Protocol will make it harder for most organizations to comply, including the portion where you have to document that you have the right patient several times," says Cindy McNeill-McDonald, vice president of quality at FirstHealth of the Carolinas. "We will expand our verification sheet to include all areas, with a sign off for the Universal Protocol."
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