TJC’s Survey Analysis for Evaluating Risk (SAFER) Matrix

TJC’s Survey Analysis for Evaluating Risk (SAFER) Matrix

About the SAFER Matrix

The SAFER matrix is a scoring methodology announced by The Joint Commission (TJC) in 2016. According to TJC, the development of the SAFER matrix approach was “driven by the Joint Commission’s focus on providing its accredited and certified organizations with an on-site and post-survey experience that allows the organization to see areas of noncompliance at an aggregate level—one that shows significant components of risk analysis including the likelihood to harm and the scope of a cited deficiency.”

The matrix was introduced with the intent to simplify how organizations identify areas of risk and establish priorities for improving the safety of care. As of January 1, 2017, all accreditation and certification programs are being provided with a SAFER matrix within their Accreditation of Survey Findings Report.

The SAFER matrix replaced the Joint Commission’s previous scoring methodology by eliminating Category A and Category C findings, as well as direct and indirect impact Elements of Performance (EPs). The original methodology was confusing to clients, both in identifying critical areas and in defining priorities for follow-up actions.

With SAFER, surveyors use their experience and expertise to assign levels of risk in the matrix based on:

  • the likelihood that a deficiency will cause harm to patients, staff, or visitors, and
  • the scope of the issue–how widespread the issue is within the organization

According to TJC, scoring compliance in this manner focuses greater attention on the context of the findings instead of the EP itself.

The Matrix

The 3×3 SAFER matrix is color-coded, enhancing the visual impact of the information and helping organizations understand which issues are most critical so they can set their priorities for improvement based on the severity of risk for each finding.

What is the TJC Safer Matrix?

TJC also anticipates that having the aggregate data will allow hospitals and health systems to more quickly identify trends and inconsistencies in the provision of safe, quality patient care. Placement of a standard/EP in the upper right-hand corner indicates the highest risk of harm, whereas placement in the bottom left-hand corner represents the lowest risk of harm.

Impact to Post-Survey Follow-Up Activities

The SAFER model consolidates the Evidence of Standards Compliance (ESC) process to a single 60-day time-frame for the response and the corrective action plan, which will help organizations focus their efforts on achieving a good action plan to submit to The Joint Commission.

Measures of Success (MOS) are no longer required, and Opportunities for Improvement (OFIs) have also be eliminated.

How Should Hospitals and Health Systems Prepare for TJC’s SAFER Matrix?

Understanding the scoring methodology is important, but it’s more important to stay focused on providing safe, quality care to every patient who enters your organization’s care. Continue with survey readiness efforts including practice tracers and mock surveys.

Survey or Readiness Questions?

If you need help in your survey readiness efforts, please contact us. Whether through mock surveys, focused assessments, or our retainer service for ongoing, on-demand accreditation and compliance support, we can help. We believe ongoing readiness is the best defense against poor survey experiences and the costs in resources for response and recovery, and we can help your organization implement an ongoing readiness program or bolster your current program.

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For more information about the SAFER matrix, download the full announcement from The Joint Commission.

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