November 21, 2008 | | Comments 0
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Joint Commission releases FAQs for Universal Protocol

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.

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.

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Filed Under: Joint Commission Changes


Heather Comak About the Author: Heather Comak is the Assistant Director of the Association for Healthcare Accreditation Professionals and a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety. Contact Heather by e-mailing her at

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