| *PR: The SAFER Matrix: A New Scoring Methodology (PDF)[REF: AOM, SC] Perspectives, May 2016, Vol 35, #9, Pg 1 JCp1605_B1
What TJC was calling the ‘Criticality Model’ in January has now been re-named and replaced by the Survey Analysis for Evaluating Risk (SAFER) approach. It is part of the Joint’s larger Project Refresh, a multi-phased process improvement initiative designed to increase simplicity, relevancy, transparency and innovation in selected aspects of the pre-, onsite and post-survey accreditation processes. Ultimately, the point of SAFER is to help organizations better identify and prioritize the risks implicated by their survey findings so they can be more effective in reducing, eliminating and preventing them. The SAFER approach is to reduce confusion, redundancy and facilitate greater effectiveness through clarity and simplicity particularly with regard to categorizing and prioritizing standards. To that end, previous labelings to include direct/indirect, Category A/C, and R or Risk Standards have now been eliminated by the SAFER Matrix approach (SMA).
The SMA is based on two critical factors each having 3 elements forming a 9-block decision grid or matrix with a 10th block for ‘Immediate Threat to Life’ overlaying it all (See below):
1: the likelihood of non-compliance to cause harm (low, moderate or high) to a patient, staff or visitor and
2: the scope or extent of the non-compliance (limited, constituting a pattern or widespread).
A major difference in this approach is that the level of risk for any non-compliant requirement is not pre-defined. Rather, surveyors on site will evaluate the finding against the 2 critical factors and thereby determine its most felicitous placement in the matrix. That placement in turn establishes the degree of risk. Findings at any level will require corrective action due in 60 days. However, those involving higher risk will require additional proof of leadership input and comprehensive systemic analysis (think RCA). These will also be highlighted for surveyors on future surveys.
This new approach will begin June 6th for all Psychiatric Deemed Hospital Surveys. The key changes to keep in mind are:
• No more designation of Direct or Indirect EPs, A or C categories
• No more Opportunities for Improvement (OFIs) or Measures of Success (MOS).
• No more 45-day ESCs
• The “SAFER matrix will be generated and embedded within the survey process and final report”
• Matrix data will be shared with the organization and used to drive the post-survey process
Tip: Familiarize key staff (clinical leaders and mock surveyors) with the operation definitions of the 6 elements supporting the 2 critics factors and begin to incorporate the SAFER approach into your mock survey findings.
See also: TJC summary of SAFER in JConline_May_4,_20161.pdf
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One response to “RTN1605_B1”
The relationship between TJC and an accredited agency is best reflected in the report of findings and the subsequent response of corrective actions.
TJC has continually sought to balance the need for risk reduction with the overall goal of continuous improvement.
This latest TJC revisions take a great step toward simplifying the response process for all state psychiatric hospitals.
While the risk matrix may require some adjustment in thinking about risk, the elimination of the MOS process permits a more efficient resolution.
In addition, the standardization of all corrective actions to a 60 day time period also aids the hospital in establishing internal time frames for response.
For hospital accreditation compliance monitors, these advantages outweigh another benefit of the elimination of 225 standards/elements of performance.
The value to performance and quality will rely on the consistent interpretation of the risk levels and in the hospitals ability to communicate the need for risk reduction to the appropriate staff.