Accreditation

Joint Commission reveals SAFER scoring system for hospital risk

Accreditation Insider, May 3, 2016

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In the May edition of The Joint Commission Perspectives, The Joint Commission announced its new Survey Analysis for Evaluating Risk (SAFER) matrix will be replacing the current scoring methodology, which includes Category A and Category C as well as elements of performance. The SAFER approach is meant to help organizations prioritize and focus their efforts on the direst areas of risk.

Joint Commission accredited psychiatric hospitals will start receiving a SAFER matrix within their Accreditation of Survey Findings Report on June 6, 2016. All other accredited organizations will begin receiving the SAFER matrix after January 1, 2017. The SAFER matrix is a three-by-three grid labeling the level of risk and harm observed for a standard.

The X axis ranks how likely something is to harm someone:
•    Low—Harm could happen, but rare
•    Moderate—Harm could happen occasionally
•    High—Harm could happen at any time

The Y-axis determines the scope of a problem, ranking it as:
•    Limited—A unique occurrence that’s not representative of routine/regular practice
•    Pattern—Multiple occurrences with the potential to impact a few/some patients, visitors, staff, or settings
•    Widespread—Multiple occurrences with potential to impact most/all patients, visitors, staff, or settings

SAFER is expected to give facilities and organizations a clearer sense of the risk of a problem, with all observations of noncompliance will be documented within the matrix. Post-survey follow-up activities have also been changed, with Opportunities for Improvement and Measures of Success eliminated along with “A” and “C” designations.

Submission times for Evidence of Standards Compliance (ESC) will also change, with facilities given 60 days for corrective action for all cited issues. For higher risk level problems, additional information will be required within the ESC on the sustainment of corrective actions.

The Joint Commission warns that Immediate Threats to Life (ITL) will be noted with the SAFER matrix and that the identification and follow-up process for ITLs will not change.
 



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