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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

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

department membership
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
opportunity statement

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.

most likely causes identified
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”
solutions implemented
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
data analysis
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.
slide7

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%.

slide8

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.

slide9

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%.

next steps
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