Determining the State of Knowledge for Implementing the Universal Protocol Recommendations: An Integrative Review of the Literature

The purpose of this study was to determine the current state of knowledge concerning the implementation of the Joint Commission's Universal Protocol. We conducted an integrative review of the literature through a systematic search of the National Library of Medicine (ie, PubMed) database to identify empirical and theoretical documents that discussed the implementation process for the Universal Protocol. The current state of knowledge varies from facility to facility, and we noted significant trends, gaps, and areas of concern in the implementation process. Successful implementation of the Universal Protocol has the following elements: a multidisciplinary team approach, active staff/patient participation, supportive hospital administration/leadership, and active communication that promotes a healthy work environment.