The Joint Commission’s Survey Analysis for Evaluating Risk (SAFER) matrix took effect for all healthcare organizations in January 2017. According to TJC, the comprehensive visual (the matrix) is already making an impact in helping organizations understand the severity of findings and how to set priorities.

According to a recent webinar hosted by The Joint Commission, one of the most common questions they have received is about how risk is determined in the new SAFER matrix.

Determining Risk in the SAFER Matrix

As described by The Joint Commission, the factors for determining risk in the SAFER matrix include, but are not limited to, the following:

Operational definitions and anchors

To assist in determining risk in the SAFER matrix, TJC has developed operational definitions and “anchors,” which are in the form of key examples vetted by subject matter experts within the Joint Commission. The examples include where findings were placed on the matrix across all programs, and the rationale for why they were placed in those locations. The Joint Commission has a “library of anchors” that they will build upon as they move forward. Both the operational definitions and anchors are available for customers to access and review.

Surveyor experience and expertise

The Joint Commission is also relying upon surveyor experience and expertise to provide support to determine each finding’s scope and likelihood to harm (the axes used to create the matrix). According to the webinar, extensive surveyor and reviewer education has been conducted, and surveyors have been participating in pilot activities for the past two years to internally get into a common practice while making these designations for every finding during a survey.

Context

Placement of findings in the SAFER matrix is based on the context of the finding itself. The Joint Commission considers it a benefit of the new SAFER matrix and associated survey process to be able to consider the “unique aspects of the finding within each unique organization.”

Survey team discussion

Throughout the course of the survey, the survey team will discuss the placement of findings within the matrix, as well as share the placement decisions with the organization. TJC has received feedback that there is great value for the customer in discussing the placement of findings and the rationale behind the risk determination during survey.

Consistency in Determining Risk

TJC has developed a business intelligence tool that has been collecting surveyor placements. It is intended to ensure, drive, and reinforce consistency by identifying patterns, trends, and anomalies in data. Data from the tool will be used to guide and refine operational definitions and build upon the anchors used in determining risk and placement on the matrix. Additionally, variance can be identified at both the surveyor and standard/EP level.

Additionally, the Joint Commission says they are “formalizing the process” for surveyors to reach out to the Standards Interpretation Group during survey for assistance with questions or in determining placement.

Learn more about the Joint Commission’s SAFER matrix:
Need assistance in preparing for TJC survey?

We have incorporated the elements of scope and likelihood for harm into our TJC mock survey process and reporting to better prepare our clients for this new format. Contact us today to learn more.