Five Ways SAFER Helps Outline Priorities | Joint Commission
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@ Home with The Joint Commission

RSS Feed RSS By: Margherita Labson R.N., M.S., Executive Director Home Care Program, Home Care

A discussion highlighting developments in home health, DMEPOS, hospice, pharmacy and personal care.

Five Ways SAFER Helps Outline Priorities

Feb 16, 2017 | 3496 Views

Between conference travel and family obligations, my longtime group of quality improvement friends has time to get together and catch up only once a year. At our most recent dinner, everyone was most interested to hear about our new Survey Analysis for Evaluating Risk™ (SAFER™) matrix and how it would impact their work.

Historically, Joint Commission survey reports identified areas of deficiency.  The organization then began the job of drilling down to understand and prioritize corrective actions to be done.

You may not have heard the details but the SAFER matrix provides organizations with real-time, on-site evaluations related to the risk of deficiencies to help prioritize and focus corrective actions.

Anyone who has ever been a QA or a performance improvement (PI) will tell you that there is real value in seeing your information graphically, and identifying the true scope and likelihood to harm of compliance issues in your agency before they erupt into a full-blown event. 

Identifying the First Action Item
Leaders of organizations, directors of nursing and hospice administrators always want to know: “What’s most important to do first?”

SAFER offers a way for the PI and team to identify if an issue is an outlier, pattern, or widespread occurrence. For instance, we’re all familiar with the Medicare home health requirement that RNs conduct supervisory visits on aide services every 14 days. With the SAFER matrix, it’s easy to see if the nurse may have temporary competing priorities or if the staff has fallen into a poor practice pattern. While neither situation will itself jeopardize accreditation for a Medicare certified organization, this is a standard deficiency that requires prompt and sustained remediation.

Organizing Priorities
The matrix reporting tool provides a clear illustration to leadership on which operational areas are being impacted. This helps the PI prioritize corrective action. One colleague suggested displaying the matrix information in a wall chart as a teaching tool. It’s an easy way to impart the message that a particular issue isn’t an outlier and is, in fact, a pattern representing process variation. As most of us are working with fixed resources these days and PIs are managing multiple coordinators and branches, the matrix can be used to help assign the work that must be done to achieve a sustained response. 

What I didn’t expect was all the other ways that my colleagues found the tool useful.  I thought I’d share a few of them with you:

  1. Making it a part of a part of a Failure Mode, Effect and Criticality Analysis (FMEA) and Root Cause Analysis (RCA) process.
  2. Using it as part of the process for explaining resource requests and budget allocation to leadership.
  3. Referencing it when reviewing and evaluating contracted service. What appears to be the most cost-efficient item isn’t always the best choice. For instance, a dispensing pharmacy may have historically distributed one large multidose vial of B12 vitamin to cover a patient’s monthly injections rather than dispensing a unit dose monthly, but the preservative is effective for only 28 days—leaving the patient vulnerable to infection. More frequent dispensing is clearly required, resulting in a more frequent dispensing cost.   While the dispensing pattern is economical, it isn’t safe.
  4. Enhancing intra-cycle monitoring self-assessment.
  5. Helping to orient and train staff about why we have standard procedures and performance standards.

If you’re not yet accredited by The Joint Commission and you’d like to know more about our SAFER matrix, don’t hesitate to contact us at 630-792-5070.  With the increasing focus on sustained improvements and performance outcomes in a world of changing regulations and shrinking resources, The Joint Commission can serve as your supportive partner on this journey to zero harm.


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