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Facts about the SAFER™ Matrix

April 20, 2017

The Survey Analysis for Evaluating Risk™ (SAFER™) is a transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys. The additional information related to risk provided by the SAFER™ Matrix helps 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. It replaces the current scoring methodology, which is based on pre-determined categorizations of elements of performance (such as direct and indirect impact) — instead allowing surveyors to perform real-time, on-site evaluations of deficiencies. These are then placed on the SAFER™ Matrix according to the likelihood of the issue to cause harm to patients, staff or visitors, according to how widespread the problem is, based on the surveyor’s observations.

For psychiatric hospitals: Effective June 6, 2016
For psychiatric hospitals that use Joint Commission accreditation to meet the Centers for Medicare & Medicaid Services (CMS) deemed status requirements, the SAFER™ Matrix will be disseminated in the Accreditation of Survey Findings Report starting June 6, 2016. All other accreditation and certification programs will receive information throughout the year, in anticipation of a Jan. 1, 2017, launch.

Changes to scoring and post-survey processes:

  Change New process

Scoring methodology




Elimination of Category A and C scoring designations, and direct and indirect impact EPs.


Surveyors will perform a real-time, on-site evaluation of deficiencies, placing each one within the SAFER™ Matrix according to the likelihood of the issue to cause harm to patients, staff or visitors, and according to how widespread the problem is, based on surveyors’ observations (that is, scope).

Post-survey, follow-up activities




Opportunities for Improvement (single observations of noncompliance at Category C EPs) will no longer exist.
Also, Measures of Success (MOS) will no longer be required

All observations of noncompliance will be documented within the SAFER™ Matrix and will require follow-up activity based on placement within the matrix. Immediate Threats to Life (ITLs) will be noted with the SAFER™ Matrix, but the identification and follow-up process for ITLs will not change.


Submission time frame for Evidence of Standards Compliance (ESC)

EPs will no longer be identified as direct impact (with 45 days for submission) or indirect impact (with 60 days for submission).

All cited deficiencies will be assigned a single time frame of 60 days for corrective action. For deficiencies of a higher risk level in the matrix, additional information will be required within the ESC regarding sustainment of corrective actions.


The SAFER™ Matrix is part of Project REFRESH, The Joint Commission’s multiphase process improvement project. Various aspects of pre-survey, on-site survey, and post-survey activities are being looked at in an effort to:

  • Simplify them
  • Enhance their relevancy to accredited organizations
  • Increase transparency within the accreditation process
  • Utilize innovative approaches and technology to enrich the customer experience

For more information or questions about the SAFER™ Matrix, contact your organization’s assigned account executive or email safer@jointcommission.org.