In May 2016, The Joint Commission announced its new scoring methodology: the Survey Analysis for Evaluating Risk (SAFER) matrix. The TJC SAFER matrix is intended to better identify and communicate risk levels associated with deficiencies cited during surveys.
According to TJC, the development of the SAFER matrix approach was “driven by the Joint Commission’s focus on providing its accredited and certified organizations with an on-site and post-survey experience that allows the organization to see areas of noncompliance at an aggregate level—one that shows significant components of risk analysis including the likelihood to harm and the scope of a cited deficiency.” This change is intended to simplify how organizations identify areas of risk and establish priorities for improving the safety of care.
How is the scoring methodology changing with the SAFER matrix?
The SAFER matrix replaces the Joint Commission’s current scoring methodology, thereby eliminating Category A and Category C findings, as well as direct and indirect impact Elements of Performance (EPs). The methodology has been confusing to clients, both in identifying critical areas and in defining priorities for follow-up actions.
With SAFER, surveyors will use their experience and expertise to assign levels of risk in the matrix based on 1) the likelihood that a deficiency will cause harm to patients, staff, or visitors, and 2) the scope of the issue – how widespread the issue is within the organization. According to TJC, scoring compliance in this manner focuses greater attention on the context of the findings instead of the EP itself.
The new 3×3 SAFER matrix is color-coded, enhancing the visual impact of the information and helping organizations understand which issues are most critical so they can set their priorities for improvement based on the severity of risk for each finding.
Source: The Joint Commission
Additionally, TJC anticipates that having the aggregate data will allow hospitals and health systems to more easily identify trends and inconsistencies in the provision of safe, quality patient care. Placement of a standard/EP in the upper right hand corner indicates the highest risk of harm, whereas placement in the bottom left corner represents the lowest risk of harm.
With TJC’s SAFER matrix, post-survey follow-up activities will also change. The new SAFER model consolidates the Evidence of Standards Compliance (ESC) process to a single 60-day timeframe for the response and the corrective action plan, which will help organizations focus their efforts on achieving a good action plan to submit to the Joint Commission. Measures of Success (MOS) will not be required, and Opportunities for Improvement (OFIs) will also be eliminated.
When will TJC’s SAFER matrix go into effect?
Psychiatric hospitals that use Joint Commission accreditation to meet CMS deemed status requirements will be provided with a SAFER matrix within their Accreditation of Survey Findings Report beginning June 6, 2016.
All other accreditation and certification programs will begin receiving this matrix in their reports after January 1, 2017.
How should hospitals and health systems prepare for TJC’s SAFER matrix?
At this point, there is not a lot of information available on the SAFER matrix, so we encourage you to read the Joint Commission Perspectives each month to keep abreast of additional information that is released about the process, and share those articles within your organization. We’ll also continue to share what we know.
We also encourage you to network with your colleagues in freestanding psychiatric hospitals who have been surveyed after June 6 for any insights that they can share about the SAFER matrix survey process.
Although understanding the new scoring methodology is important, it’s more important that you stay focused on providing safe, quality care to each and every patient who enters your organization. Continue with your survey readiness efforts including practice tracers and mock surveys.
If you need help in your survey readiness efforts, please contact us, and we can discuss how we can help – whether through mock surveys, focused assessments, or our retainer service for ongoing, on-demand accreditation and compliance support. We believe that ongoing readiness is the best defense against poor survey experiences and the costs in resources for response and recovery, and we can help your organization implement an ongoing readiness program or bolster your current program.