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    Readiness Rounds Guide To TJC SAFER Matrix

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    Eliana Pedraza

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    © All Rights Reserved
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    Readiness Rounds Guide To TJC SAFER Matrix

    Uploaded by

    Eliana Pedraza
    128 views13 pages

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    Readiness Rounds Guide to TJC SAFER Matrix

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    128 views13 pages

    Readiness Rounds Guide To TJC SAFER Matrix

    Uploaded by

    Eliana Pedraza

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 13

    YOUR COMPLETE GUIDE TO

    THE JOINT COMMISSION'S

    SAFER
    Matrix
    Contents
    INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

    1. THE NEED TO KNOW BASICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

    2. SNAPSHOT OF THE CHANGES . . . . . . . . . . . . . . . . . . . . . . . . . . . 5


    .
    3. SOME THINGS TO KNOW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

    4. THE SAFER MATRIX DETAILS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

    5. MATRIX AXES DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

    6. THE TWO NEW ESC COMPONENTS . . . . . . . . . . . . . . . . . . . . . . . 9

    7. HOW TO PREPARE FOR THE NEW SURVEY . . . . . . . . . . . . . . . . . 10

    All information found in this guide is resourced from The Joint


    Commission's SAFER Webinar and slide deck:
    https://www.jointcommission.org/webinar_replay_slides_safer_matrix/

    Copyright © 2017 Readiness Rounds


    www.readinessrounds.com | (800) 705-3401 | [email protected]
    Introduction

    January 2017 marks the beginning of The Joint Commission's new risk
    scoring method, Survey Analysis for Evaluating Risk, otherwise known as
    SAFER. This new methodology and its scoring will replace the current
    methods to streamline and more accurately conduct surveys and
    findings reports.

    We hope to be a comprehensive TJC SAFER resource for you. This guide


    will outline what the new survey process is all about. We will show you
    what is changing and what will remain the same. The guide will also help
    you to prepare for the new survey method. Most importantly, we will
    walk you through the post-survey process and how to get the best
    outcomes.
    1. The Need to Know Basics

    WHAT TJC SAFER Matrix: a new risk-scoring


    method that is replacing the current
    method. The goal is to “Develop one
    single, comprehensive method of
    categorizing the risk associated with
    standards.” – (TJC)

    WHEN Launching January 2017 

    WHERE Every survey conducted henceforth


    will evaluate risk based on the new
    SAFER Matrix approach. SAFER is
    implemented for all accreditation and
    certification programs.

    WHY To simplify and visually better


    represent the findings for easier
    corrective action post-survey. Current
    scoring utilizes multiple "taggings."
    These can be confusing, even
    contradictory at times, making records
    burdensome to maintain.
    2. Snapshot of the Changes

    CURRENT NEW

    Direct/Indirect Element of Consolidated Evidence of Standards


    Performance (EP) designations Compliance (ESC) into one 60-day
    1 2 3 timeframe

    “A” vs. “C” Scoring Category Replaced by SAFER Matrix

    Measure of Success (MOS) M Replaced by SAFER Matrix

    Opportunities for Improvement Replaced by SAFER Matrix


    (OFIs)

    Documentation Icon D No change

    Risk Icon R No change

    45- and 60-day follow-up post-survey Only 60-day window for all RFIs
    on Requirement for
    Improvements (RFIs)

    Some findings require an ESC All findings will require an ESC

    Current ESC Fields: New ESC Fields:


    WHO WHO
    WHAT WHAT
    WHEN WHEN
    HOW HOW
    Leadership Involvement
    Preventive Analysis
    3. Some Things to Know

    The SAFER Matrix will be: Q: What are the benefits of the SAFER
    Implemented throughout the Matrix?
    entire organization A:     
    A more direct focus on patient
    Built into the survey process
    safety and risk
    and final report
    “The risk analysis takes each
    Matrix data is: finding to the next level --
    Shared with the client the 'so-what?' as to why the
    Used for the post-survey finding is important”
    process Visual representation of the
    survey: More clearly identifies
    Q: How is risk determined with the highest risks
    regard to how EPs will be placed on Aggregates data for standards
    the matrix? refinement
    A:     
    Per operational definitions Post-Survey:    
    Surveyor experience and Follow-ups are customized and
    expertise prioritized according to the
    Based on the context of the placement of the finding in the
    finding SAFER Matrix
    Discussion amongst the All Requirements for
    survey team Improvement (RFIs) are due in a
    60-day ESC
    Higher risk findings will require
    two additional ESC components
    4. SAFER Matrix Details

    What does the SAFER Matrix look like?

    Likelihood to Harm
    Immediate Threat to Life

    High

    Moderate

    Low

    Scope Limited Pattern Widespread

    The Y axis:
    Likelihood to Harm a Patient/Visitor/Staff  --  Low, Moderate, High

    The X axis:
    Scope  --  Limited, Pattern, Widespread
    5. Axes Definitions

    SAFER Matrix

    The Y axis:
    Likelihood to Harm a Patient/Visitor/Staff

    Low Undermines safety/quality or contributes to an unsafe


    environment, but very unlikely to directly contribute to harm.
    = "Rare"

    Moderate Could cause harm directly, but more likely to cause harm as a
    contributing factor in the presence of special circumstances or
    additional failures. = "Possible"

    High Could directly lead to harm without need for other significant
    circumstances or failures. = "Likely"

    The X axis: 
    Scope

    Limited The issue is a “unique occurrence.”


    - Outlier
    - Not representative of routine/regular practice

    Pattern The issue has potential to “impact more than a limited number
    of patients.”
    - Process variation

    Widespread The issue is “pervasive at the organization.”


    - Process failure/systemic failure
    - Majority of patients are/could be impacted
    6. Two New ESC Components

    ESC: Evidence of Standards Compliance

    In addition to the current:


    WHO
    WHAT
    WHEN
    HOW...

    1. Leadership Involvement
    Provide resources (money, staff,
    expertise)
    Champion the change
    Participate on teams
    Motivate employees
    Establish intervals for
    communicating and/or reporting*
    Directly oversee change

    2. Preventive Analysis

    Ensures corrective action is not


    limited to the issue at hand
    Focuses on underlying reasons
    Prevents future occurrences*

    *Readiness Rounds is thrilled to see these two particular components being


    included as core TJC compliance standards. In fact, leadership involvement and
    prevention are foundational strategies we use when working with our clients.
    7. How to Prepare for the New Survey

    How do you prepare for the new SAFER Matrix survey? 

    By being survey-ready. By proactive checking. By performance


    improvement initiatives. This is the foundational strategy of Readiness
    Rounds' platform. We specialize in streamlining checking, allowing for
    proactive checking, and using that data to aggregate performance
    improvement items. This allows a survey to not only go smoothly but to
    come back "empty-handed." 

    Here is a real-life example from one of our clients:

    “We used the Readiness Rounds data to have a finding removed on a


    recent Joint Commission Survey.  We were cited for ceiling tiles.  We sent
    to Joint Commission the Readiness Rounds data showing how often the
    tiles had failed over the last 12 months and combined this with our total
    square footage to contend that the issue did not qualify as a finding.  The
    finding was removed.”

                                - Senior Director, Quality, Performance Improvement

    1. Proactive Checking

    Survey-ready at any time is attainable, eliminating the traditional frantic


    environment of ensuring compliance during the "survey window."

    The true value lies in regular digital rounding in order to gather data to
    analyze for improvement purposes.

    Proactive checking leads to proactive issue resolution, making it more


    difficult for surveyors to find issues.
    2. Performance Improvement Initiatives

    Regular checking allows for analysis on current processes so that areas


    needing improvement can be identified, and resources can be allocated for
    improvement.

    A robust dashboarding tool must aggregate data, making it easier than ever
    to filter out all the noise by showing the top most-failing items backed by
    actual data. Here is where you can get an edge on surveys--by finding and
    fixing issues before TJC does.
    8. Your Post-survey Resource

    How do you respond to findings post-survey? With Readiness Rounds as


    your partner, we specialize in performance improvement with a TJC license.
    Our services extend to all stages of the improvement process. That includes
    assisting in production of requested reports during the survey process as
    well as creating and helping to implement recommendations for
    improvement of findings post-survey.

    During Survey:
    We are available to collaborate with point data to assist with the (now)
    onsite clarification process and available for any data needs you may have.

    After Survey:
    Readiness Rounds will analyze your RFI list and run a report of all EPs with
    questions and related scoring within 2 business days of receipt of RFI list.

    Within 3-5 business days after that, Readiness Rounds will produce the
    Crosswalk with recommended actions.

    Readiness Rounds is committed to


    helping our clients in their quest
    for performance improvement. The
    Joint Commission survey process is
    also a governing force in the quest
    to improve the safety of our
    patients. Even so, survey time can
    be stressful, which is why having a
    partner in the process can
    help make navigating the before,
    during, and after as successfully
    and stress-free as possible. 
    Your TJC Survey Partner
    Stress-free survey? Is that even possible? Yes. With proactive checking
    throughout the year, issues can be found and fixed, ensuring a safe
    environment come survey time. If all of your processes are functioning well
    at all times, survey time will become just another day. Readiness Rounds
    provides the services to make this a possibility. Not only will you be prepared
    for a survey but, more importantly, your patients will be safe and
    their quality of care as exceptional as possible.

    www.readinessrounds.com | (800) 705-3401 | [email protected]

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