Project REFRESH Observes First Anniversary | Joint Commission
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This blog shares experiences, case studies and news that add insight and value to the accreditation and certification journey.

Project REFRESH Observes First Anniversary

Jan 17, 2018 | 911 Views

Carrie MayerBy Carrie Mayer

2017 was a big year for Project REFRESH, which is the Joint Commission’s multi-year effort aimed at improving various aspects of the pre-survey, onsite survey and post-survey process. 

Over the last year, I had the opportunity to present Project REFRESH to thousands of different customers across the country. During these presentations, I realized how lucky I was to be in the position of communicating the positive change that REFRESH has brought about. I saw smiles in the audience, heard positive comments and, on a few occasions, even applause. REFRESH has simplified processes, brought transparency to accreditation and increased the relevance of what we do. I would like to highlight a few of the improvements that were recently implemented:

The Review
The Review is a multi-phased effort to modernize and streamline Joint Commission requirements by deleting non-value-added requirements and consolidating redundant requirements.  Throughout 2016 and 2017, almost 300 hospital elements of performance (EPs). Non-hospital program deletions ranged from approximately 50 to 150 depending on the program (e.g., laboratory, ambulatory care, etc.). Subsequent to the deletions, all programs were evaluated for further consolidation of EPs, which began in 2017 and will continue throughout 2018.  

The Survey Analysis for Evaluating Risk™, or SAFER™ matrix, is a transformational approach for identifying and communicating the level of risk of deficiencies found during surveys. The SAFER matrix replaced the old scoring methodology, which depended on pre-determinations of risk, and instead allows surveyors to perform real-time, on-site evaluation of the risk. 

Within SAFER, deficiencies are evaluated for their likelihood to cause harm to patients as well as the scope of the issue. Each deficiency is plotted in the matrix. At the end of the survey, a complete SAFER matrix is provided within the report and organizations can easily visually identify their highest areas of risk (see visual below). Customers have been very positive about the SAFER matrix, saying that they feel it achieved the goal of “now I know exactly where my efforts need to be focused”.  


Evidence of Standards Compliance
An Evidence of Standards Compliance (or ESC) is an organization’s corrective action plan, in which the organization tells us the steps planned to achieve and sustain compliance with Requirements for Improvement (RFIs). In 2017, the ESC was redesigned to encourage organizations to communicate critical aspects of their corrective actions that resolve RFIs, as well as ensure sustainability. Within the improved ESC form, organizations now see:

  • simplified lead-in statements to drive targeted responses

  • enhanced questions to ensure a thorough and comprehensive sustainment plan

  • more comprehensive examples and resources to assist with completion

Accreditation Report
Accreditation reports are one of the most important documents that The Joint Commission provides its customers. The reports serve as the organization’s “road map” for all compliance activities that follow the onsite survey. Successful interpretation of these reports directly influences the organization’s ability to achieve and maintain accreditation. 

In response to customer feedback, The Joint Commission recently redesigned its reports to be more user-friendly, effective January 1, 2018. The new report contains:

  • hyperlinks to sections

  • uses a tabular format that more clearly and succinctly highlights findings and required follow-up activity

  • offers an option to download the findings into Excel for easy sorting and filtering.

Hopefully you can see from above what a fun year it has been for Project REFRESH. While many projects were implemented in 2017, you can expect to see many more improvements coming in 2018… be on the lookout!

Carrie Mayer is a certified Master Black Belt in the Division of Accreditation and Certification Operations at The Joint Commission.  In this role, she is responsible for overseeing strategic and operational excellence activities.

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