https://www.jointcommission.org/topics/ safer_matrix_resources.aspx.


SAFER Model Immediate Threat to Life


HIGH MODERATE LOW


LIMITED PATTERN WIDE- SPREAD


Scope


SAFER Example— Placement on Matrix


Immediate Threat to Life HIGH MODERATE LOW


LIMITED PATTERN WIDE- SPREAD


While observing process for cleaning instruments after a surgical procedure, observed


tech did not spray used


instruments with enzymatic cleaner prior to transport to decontamination room. Staff indicated that this was not a process in place at this ASC.


The SAFER™ approach attributes risk scoring to the deficiencies allow- ing the organization to see areas of noncompliance at an aggregate level and shows significant components of risk analysis, including the likelihood to harm a patient, staff or visitor and the scope of a cited deficiency. This new approach makes it easier for orga- nizations to understand the surveyors’ findings and make plans to address them. It also helps organizations dis- tribute resources and focus corrective actions on those areas that have the most significant impact on patients.


The SAFER matrix represents a shift from the historical approach of “counting” observations. No longer will organizations need to go through the survey reports and identify the find- ings with the highest risk. Surveyors and reviewers will place each Require- ment for Improvement (RFI) within the matrix according to the likelihood of the issue to cause harm to patients or staff. More importantly, organizations will get reports in real time as surveyors will be using mobile technology to doc- ument findings and place deficiencies into the SAFER™ matrix as the survey is taking place. ASCs will know in real time, via dialogue with surveyors, how the SAFER matrix is evolving. In addition to the new approach to


survey scoring methodology, the Mea- sure of Success (MOS) requirement is no longer required. In the past, organi- zations have had to submit audits four months after a survey to show mea- sured improvement of the corrective


action. The Joint Commission no longer requires the audit, but organizations are encouraged to continue to monitor the effectiveness of their corrective actions.


Continuing the Patient Safety Journey Many elements of Project REFRESH have been implemented, but that does not mean The Joint Commission’s efforts to improve the accreditation and survey process are complete. Cer- tainly, the organization can never be done making improvements to pro- mote patient safety and will continue its journey to achieve zero patient harm. Together with all of its accred- ited and certified organizations, it will continue to innovate and expand knowledge so that all patients experi- ence the safest, highest quality care.


Michael Kulczycki is the executive director of Ambulatory Care Services, The Joint Com- mission in Oakbrook Terrace, Illinois. Write him at MKulczycki@jointcommission.org.


ASC FOCUS SEPTEMBER 2017 |www.ascfocus.org 13 X


Interested in Accreditation? Below are a few helpful hints


Know the standards


To be successful, read and become familiar with the standards manual. The electronic edition of the manual is provided complimentary as part of accreditation, while print copies are available for purchase.


Teamwork is key


It takes an entire office team to suc- cessfully become accredited. Accredi- tation success begins with leadership support, guidance and direction. Do not leave the entire implementation of the accreditation standards up to the assigned accreditation coordina- tor. Parse out work that aligns with team members’ areas of expertise.


Don’t know an answer? Don’t panic.


Remember that surveyors are evaluating processes, not people. It is okay for a staff member to not know the answer to a surveyor query as long as he or she knows which colleague does. Make sure you know who the experts are within your organization.


Likelihood to Harm a Patient/Visitor/Staff


Likelihood to Harm a Patient/Visitor/Staff


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