Facts about The SAFER Matrix™ scoring process | Joint Commission
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Facts about The SAFER™ Matrix scoring process

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. This new scoring process became effective Jan. 1, 2017 for all accreditation and certification programs. It was first implemented in June 2016 for psychiatric hospitals that use Joint Commission accreditation to meet the Centers for Medicare & Medicaid Services (CMS) deemed status requirements.

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 previous scoring methodology, which was 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.

How the new SAFER™ Matrix scoring process works

The performance expectations for determining if a standard is in compliance are included in its elements of performance (EPs). If an EP is determined to be out of compliance, it will be cited as a Requirement for Improvement (RFI). Each RFI is placed in the SAFER™ Matrix according to how likely it is that the RFI will harm a patient(s), staff, and/or visitor (low, moderate, high) and the scope, or prevalence, at which the RFI was cited (limited, pattern, widespread). As the risk level of a finding or an observation increases, the placement of the standard and EP moves from the bottom left corner (lowest risk level) to the upper right corner (highest risk level).

All observations of noncompliance will be documented within the SAFER™ Matrix and will require follow-up activity based on surveyors’ observations. 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, see the webinar replay and slides on the Joint Commission website, or contact your organization’s assigned account executive or email safer@jointcommission.org.