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SAFER Matrix Scoring Process

  • SAFER® is the Survey Analysis for Evaluating Risk® process, a scoring approach used for surveys and reviews of health care organizations.

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. The SAFER Matrix allows 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 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 require implemented corrective actions that are submitted within the Evidence of Standards Compliance (ESC). The amount of information required within an ESC is reflective of the risk-level and associated SAFER placement of each RFI. For example, deficiencies of a higher risk level in the matrix require additional information within the ESC related to leadership involvement in correcting the deficiency and details of a preventive analysis to identify potential underlying reasons for the deficiency.

For more information or questions about the SAFER Matrix, contact your organization’s assigned account executive.

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