The Joint Commission (TJC) is launching a new matrix for identifying deficiencies cited during surveys, hoping the new format will help hospitals prioritize and focus corrective actions.
TJC will began using the Survey Analysis for Evaluating Risk (SAFER) matrix with psychiatric hospitals in June, and will introduce it to all other accredited programs on January 1, 2017. The SAFER matrix will be part of the facility’s Accreditation of Survey Findings Report. The SAFER matrix replaces the current scoring methodology, which includes Category A and Category C as well as direct and indirect impact elements of performance (EPs), says Carrie Mayer, MBA, certified master black belt in Accreditation and Certification Operations with TJC. The change allows surveyors to perform real-time, on-site evaluations of deficiencies instead of using those predetermined EP categorizations, she says.
“In the current process, we use a lot of predefined categories, predesignating our standards and elements of performance,” Mayer says. “What we found is that what the surveyor actually finds on site and scores under a particular EP could really vary in risk or severity. In our attempt to predefine these categories and predefine the risk, we’ve lost some flexibility for allowing differences in risk from what surveyors see on site.”
The SAFER matrix allows more of a real-time evaluation of risk, Mayer says. The new matrix provides one comprehensive visual representation of survey findings in which all Requirements for Improvement (RFIs) are plotted according to the likelihood of the issue to cause harm to patients, staff or visitors, in addition to how widespread the problem is, based on the surveyor’s observations, Mayer explains.
“A single observation could reveal a widespread problem, such as a general failure to perform recommended high-level disinfection or proper storage of endoscopes,” TJC explains in the post announcing the matrix. “Combined, these characteristics give a more clearly defined sense of the risk of a deficiency. As the risk level of a deficiency increases, the placement of the standard and EP moves from the bottom left corner (lowest risk level) to the upper right (highest risk level).”
A graphic depiction of the matrix and more information on how it used is available online at http://bit.ly/1NNpzk0.
TJC’s description of the matrix includes this example: “A surveyor placed Environment of Care (EC) Standard EC.01.01.01, EP 1, in the row “Moderate,” as it was determined (based on the deficiency observed) that it could occasionally cause harm to a patient, visitor, or staff member, and in the column “Pattern,” as the issue was noted multiple times throughout the survey and could affect a few or some people and/or settings.
Surveyors will follow the same standards and survey process, but under the new system they will also determine how likely the deficiency is to harm the patient, visitor, or staff member, Mayer says. They also will provide an assessment of how large or small in scope the finding is — whether the deficiency was found in an isolated area or throughout the hospital.
“This allows the surveyor to more accurately put the findings in context, as they related to this particular organization,” Mayer says.
The announced change has prompted some anxiety among accredited facilities, but primarily only because it is different from the procedure with which compliance leaders are familiar, Mayer says. The effect on hospitals should be negligible, she says, except that it will provide a more accurate picture of the survey findings. The new matrix is simpler and more relevant, she says.
“I don’t think it’s a huge change. I don’t think it should cause any panic,” she says. “It’s a good change. It simplifies the process where there are so many predesignations, making it one system to classify the risk. This doesn’t change any standards or how the survey works; just how the surveyors communicate what they found.”
TJC is planning to provide blank SAFER matrices to hospitals soon, along with all the definitions and guidance that surveyors will use, to use in mock tracers.
The new matrix will change post-survey follow-up activities, Mayer says. Eliminating the “A” and “C” designations means that Opportunities for Improvement (single observations of noncompliance at Category C EPs) will no longer exist. Instead, all observations of noncompliance will be documented within the matrix. The new approach also eliminates Measures of Success (MOS), the quantifiable measures typically related to an audit determining whether an action is effective and sustained for certain Category C EPs.
“The level of required follow-up will be based on where the findings fall within the matrix,” Mayer says. “Today all of that is predefined, but now the post-survey follow-up will be customized by where the findings fall within the matrix.”
There also will be two new fields in the Evidence of Standards Compliance portion of the survey report. They are related to leadership involvement and preventive analysis, Mayer notes. She suggests studying those two new fields to consider what TJC will expect if there are deficiencies there.
The matrix also should help quality and compliance leaders present survey findings to hospital administration in a more effective way, Mayer says. The matrix will be embedded within the survey report, providing a sort of dashboard report on the survey.
“Right now our accreditation reports can be very lengthy, making it very difficult to pick out what the surveyors found and what is most risky among what they found,” Mayer says. “This matrix is going to put that information up front in a way that should be much easier to understand.”
- Carrie Mayer, MBA, Certified Master Black Belt, Accreditation and Certification Operations, The Joint Commission, Oakbrook Terrace, IL. Telephone: (630) 792-5298. Email: email@example.com.