Association for Healthcare Accreditation Professionals

Hello AHAP members,

I thought you might be interested in the following snippet of an article I recently wrote for Briefings on Patient Safety, about the Joint Commission's recently released FAQs, concerning the Universal Protocol.

Heather Comak

managing editor, Briefings on Patient Safety

The Joint Commission released frequently asked questions (FAQ) specifically about the 2009 Universal Protocol in November 2008, clarifying some areas of confusion that were brought about by the release of the 2009 National Patient Safety Goals in June 2008. Traditionally, The Joint Commission does not release FAQs about their standards until the year in which they apply, so this release of FAQs was considerably early.

"The Joint Commission has posted them before January 1 and they need to be applauded for getting them out now," says Elizabeth Di Giacomo-Geffers, RN, MPH CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA.

Originally much of the field thought that although the Joint Commission had added in more detail to the standard, there were still instances in which it was difficult to judge whether completing all or parts of the Universal Protocol was necessary. The FAQs have specifically listed procedures that do and do not require compliance with the Universal Protocol, which is something that will prove helpful to the field.

"I think the most significant changes were that it really did clear up some ambiguity for what was not included,” says Gloria Rawn, RN, MS, JD, healthcare accreditation consultant from Kennebunkport, ME. The FAQs specifically list electroconvulsive therapy, closed reduction, lithotripsy, radiation oncology, and performance of dialysis (excluding insertion of dialysis catheters) as procedures that do not require the Universal Protocol to be carried out.

I just wanted to let everyone know The Joint Commission has released an FAQ on National Patient Safety Goal NPSG.01.01.01. The FAQ looks at whether there are any exceptions for active involvement of the patient or responsible caregiver.

The FAQ specifically looks at sleeping patients and the nurse’s role in identifying non-communicative or confused patients when another healthcare worker uses two patient identifiers.  The Joint Commission states that the purpose behind this is to increase patient safety through such things as medication, diagnostic, and treatment errors. The organization must decide how to assess sleeping/non-communicative/confused patients. The organization must also determine when active involvement is necessary on the part of the responsible nurse or other caregiver.

These decisions must, obviously, be communicated to the staff and be brought about specifically for reasons of patient safety.

The NPSG.01.01.01 FAQ can be found online here.

In case you missed them, we've posted our October 16 and October 28 calls on critical test results. Listen to them now by clicking here

Joining us on the calls was Gayla J. Jackson, RN, BSN. Gayla is a member of the AHAP advisory board and nurse manager at Mount Auburn Hospital in Cambridge, MA. She has 26 years of experience in acute care and was one of the 17 advisory committee participants chosen to work on a three-year federal grant from the Agency for Healthcare Research and Quality (AHRQ). The AHRQ provided funding to The Massachusetts Coalition for the Prevention of Medical Errors along with the Massachusetts Hospital Association for the purpose of identifying, choosing, and implementing two patient safety initiatives, one of which was communicating critical test results.

I hope you all found these calls useful. And look for Gayla at the 3rd annual AHAP conference in May. She will be joining us in Las Vegas for the second year in a row.

Brian Driscoll
AHAP Director