Update – SAFER™ Having A Positive Impact | Joint Commission
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Update – SAFER™ Having A Positive Impact

Feb 22, 2017 | 2480 Views

By Leslie Wiora
Business Transformation Leader
Division of Accreditation and Certification Operations
The Joint Commission

As 2017 unfolds, so have many of the projects under The Joint Commission’s Project REFRESH multiphase process improvement initiative. The largest being the Survey Analysis for Evaluating Risk™, or SAFER™, matrix. Beginning January 1, 2017, Joint Commission’s survey process began to provide a new, graphical approach for identifying and communicating risk levels associated with deficiencies cited during accreditation surveys via the SAFER matrix.

With the SAFER matrix, if an Element of Performance (EP) is determined to be out of compliance, it will be cited as an RFI (Requirement for Improvement). Each RFI is placed in the SAFER Matrix according to:

  1. Likelihood the RFI will harm an ambulatory care patient, staff, and/or visitor:
    • Low
    • Moderate
    • HIgh
  2. Scope or prevalence, at which the RFI was cited (limited, pattern, widespread)

As the risk level of a finding or observation increases, the placement of the standard and EP moves from bottom left corner (lowest risk level) to upper right corner (highest risk level).  All observations of noncompliance are also documented within the SAFER Matrix – in addition to the preliminary accreditation report – and will require follow-up activity based on surveyors’ observations.

Practicality Beyond the Onsite Survey
But the SAFER Matrix is not solely designed for the onsite survey process. It can also be used as an internal communication tool to involve staff in an ambulatory care organization’s continuous improvement journey.  Michael Sherbun, PhD, RN, MHA, vice president of clinical operations for Signature Healthcare Services, has already undergone two SAFER surveys and noted the new matrix helps drive continuous improvement and strengthen safety culture. He remarked that the visual matrix “makes it real” for employees not only in helping them understand the significance of the risk noted in the survey findings, but also in communicating their own role in making improvements.

The SAFER matrix is also widely utilized in our Home Care Program as a teaching tool. Margherita Labson, executive director of The Joint Commission’s Home Care Program, promoted a colleague’s suggestion to use SAFER as a teaching tool by displaying the information as a wall chart. Find more insights on how the matrix can be used to establish organizational priorities in Margherita’s blog.

Tailored for Ambulatory Organizations
The additional information related to risk provided by the SAFER Matrix helps ambulatory care organizations prioritize and focus corrective actions. The SAFER Matrix allows the organization to see areas of noncompliance at an aggregate level – one that shows significant components of risk analysis and allows surveyors to perform real-time, onsite evaluations of deficiencies.

Moreover, a new SAFER tool is available for ambulatory care organizations to use once the survey report is posted. The new tool, located on your secure Joint Commission Connect® site, allows your organization to filter survey findings to better focus on:

  • Specific standard chapters
  • Ambulatory care sites, or
  • Potential Conditions for Coverage items scored during the survey


This filtering capability allows organizations to interact with the survey data in a more dynamic way, providing an avenue to better analyze the information within the report even after the survey is completed.

The filtering functionality, in addition to the SAFER matrix’s risk communication potential, opens new possibilities for ambulatory care organizations to present compliance information in a more transparent, concise way to staff, leadership and governance throughout your organization. 

For more information on the SAFER matrix, please login to your organization’s secure Joint Commission Connect® site, hover over the Survey Process tab and select the Accreditation SAFER™ Matrix link where additional resources are located.  You may also reach out to your designated Account Executive for more information, or contact: safer@jointcommission.org.

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