YOUR COMPLETE GUIDE TO THE JOINT COMMISSION'S SAFER

Transcription

1 YOUR COMPLETE GUIDE TO THE JOINT COMMISSION'S SAFER Matrix

2 Contents INTRODUCTION THE NEED TO KNOW BASICS SNAPSHOT OF THE CHANGES SOME THINGS TO KNOW THE SAFER MATRIX DETAILS MATRIX AXES DEFINITIONS THE TWO NEW ESC COMPONENTS HOW TO PREPARE FOR THE NEW SURVEY All information found in this guide is resourced from The Joint Commission's SAFER Webinar and slide deck: Copyright 2017 Readiness Rounds (800) info@readinessrounds.com

3 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.

4 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.

5 2. Snapshot of the Changes CURRENT NEW Direct/Indirect Element of Performance (EP) designations A vs. C Scoring Category Consolidated Evidence of Standards Compliance (ESC) into one 60-day timeframe Replaced by SAFER Matrix Measure of Success (MOS) M Replaced by SAFER Matrix Opportunities for Improvement (OFIs) Replaced by SAFER Matrix Documentation Icon D No change Risk Icon R No change 45- and 60-day follow-up post-survey on Requirement for Improvements (RFIs) Only 60-day window for all RFIs Some findings require an ESC Current ESC Fields: WHO WHAT WHEN HOW All findings will require an ESC New ESC Fields: WHO WHAT WHEN HOW Leadership Involvement Preventive Analysis

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

7 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

8 5. Axes Definitions SAFER Matrix The Y axis: Likelihood to Harm a Patient/Visitor/Staff Low Moderate High Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm. = "Rare" Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures. = "Possible" Could directly lead to harm without need for other significant circumstances or failures. = "Likely" The X axis: Scope Limited Pattern Widespread The issue is a unique occurrence. - Outlier - Not representative of routine/regular practice The issue has potential to impact more than a limited number of patients. - Process variation The issue is pervasive at the organization. - Process failure/systemic failure - Majority of patients are/could be impacted

9 6. Two New ESC Components ESC: Evidence of Standards Compliance In addition to the current: WHO WHAT WHEN HOW 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.

10 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.

11 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.

12 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.

13 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. (800) info@readinessrounds.com