Procedural Pause/Universal Protocol PQI Project


BACKGROUND: Performance of the procedural pause (a.k.a., universal protocol or "time out") is a national patient safety goal as designated by the Joint Commission. There are three required components to the procedural pause. First, the procedural pause must be conducted in the location where the procedure will be done, just before starting the procedure. Second, the process must involve the entire team using active communication to confirm the correct patient identity, correct side and site, agreement on the procedure to be done, and correct patient position. Availability of correct implants or special equipment is also addressed, as applicable. Finally, this process must be documented, such as in a checklist.

IMPORTANCE: Designation of the procedural pause as a National Patient Safety Goal by the Joint Commission illustrates the importance it has in providing safe and effective patient care. This is directly relevant to clinical practice. Consistent performance of the procedural pause standardizes safe practice performance.

METRIC/BENCHMARK:  The Joint Commission requires 100% compliance. Unpublished benchmark data from a large multicenter academic institution has compliance rates ranging from 69% to 100%.  

GOAL:  100% compliance in performing and documenting the procedural pause.

PROJECT STEPS - Login to and document each competed step

Step 1 (Select project and metric): After selecting the procedural pause project, the diplomat will review requirements of the PQI process and The Joint Commission guidelines regarding the procedural pause. Resources including example procedural pause/universal protocol documentation can be found on The Joint Commission web site:

Step 2 (Collect baseline data): Each institution will determine their optimum data source. Ideally, a search of electronic billing codes or a search of the electronic medical record will be utilized to identify procedures performed in the radiology department. The records of these procedures will be reviewed to assess for accurate documentation of the procedural pause. Chart review can be performed by a member of the allied health staff. The numerator is the number of appropriately documented procedures. The denominator is the total number of procedures. The recommended measurement time frame is one month. During the designated month, the following table should be used to decide the minimum number of occurrences that should be evaluated for compliance.

Number of Cases

Sample Size

< 30

100% cases

30 – 100


101 – 500


> 500


Step 3 (Analyze the data): The collected baseline data will be analyzed and reviewed. Results will be entered into the Radiology Quality database where the results will be stored and the diplomat may compare his or her results to others across the nation. If 100% compliance is achieved and it is felt that there is no need or opportunity for improvement, then the diplomat will discontinue this project and choose another. If there is room for improvement, i.e. compliance rates being less than 100% or need to ensure continued 100% compliance, then the diplomat will proceed to Step 4.

Step 4 (Create improvement plan): The diplomat will make an improvement plan based on the findings of their baseline data acquisition. Three suggested improvement plans are as follows. The first recommended improvement plan is to review and refine the existing procedural pause policy within each institution. Communication of this policy to radiologists performing procedures must be shared via personal or written communication. The next improvement plan option is the development of guidelines defining what constitutes appropriate documentation of the procedural pause. Changes in institutional documentation should be reviewed by the institution's Joint Commission specialist, if one exists. These guidelines should then be implemented. The final recommended improvement plan option involves the direct education of individuals who are failing to comply with the procedural pause. One-on-one discussion with individuals is performed to identify and remove obstructions to their compliance. One of the above suggested improvement plans or a plan developed by the diplomat is documented on the Radiology Quality web site and implemented.

Step 5 (Collect data, compare to initial data, and summarize results): After institution of the improvement plan, the compliance data will then be again collected using the same method the baseline data. This data will be analyzed and summarized. The data will be compared with both the internal baseline data and with other institutions/individuals submitting to the centralized Radiology Quality database.

Step 6 (Control & Close Project): It is of utmost importance to maintain the advances you have achieved. A final report of the project, including the data from the different collection points along with the improvement plan undertaken at each step, should be generated using the Radiology Quality web site. Achieved goals from this project are to be maintained by assigning the continued intermittent collection of data with scheduled review of this data by designated individual(s). After appropriate hand off of this responsibility is performed, the project is closed and a new project is started.