Infection preventionists should be aware that The Joint Commission (TJC) is using a new accreditation process called the Survey Analysis for Evaluating Risk (SAFER).1
According to TJC, SAFER will help organizations “see areas of noncompliance at an aggregate level.” The new system “replaces the previous scoring methodology, which was based on predetermined categorizations of elements of performance (such as direct and indirect impact).”
Furthermore, with SAFER, surveyors can “perform real-time, on-site evaluations of deficiencies.” Findings will be placed on a matrix “according to the likelihood of the issue to cause harm to patients, staff, or visitors, according to how widespread the problem is, based on the surveyor’s observations.”
TJC says that “performance expectations for determining if a standard is in compliance are included in [SAFER’s] elements of performance (EPs). If an EP is determined to be out of compliance, it will be cited as a Requirement for Improvement (RFI).”
Another important element involves accountability. “All observations of noncompliance will be documented within the SAFER matrix and will require follow-up activity based on surveyors’ observations,” TJC says. “All cited deficiencies will be assigned a single time frame of 60 days for corrective action. For deficiencies of a higher risk level in the matrix, additional information … will be required regarding sustainment of corrective actions.”
REFERENCE
Joint Commission. Facts about the SAFER™ matrix scoring process. April 20, 2017. Available at: https://bit.ly/2zhtDYq.
Financial Disclosure: Peer Reviewer Patrick Joseph, MD, reports that he is a consultant for Genomic Health Reference Laboratory, Siemens Clinical Laboratory, and CareDx Clinical Laboratory. Senior Writer Gary Evans, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Patti Grant, RN, BSN, MS, CIC, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
