This single matrix is now used to evaluate risk instead of various criteria that varied by EP. It is a simple 3 level risk evaluation relative to a 3 level scope. The new evaluation has no effect on events that are an immediate threat to life and therefore this is shown above the matrix.
Placement on the matrix is based on surveyor experience, definitions, context and team discussion. "Anchors" are specific examples which have been compared to a pain scale indicating the examples have various levels of severity. We read one report that a "library of anchors" will be produced by TJC over time. (Compass Clinical Consulting, Feb 20, 2017)
If there is an ITL (Immediate Threat to Life), the organization has 72 hours to eliminate the ITL. If it can not be eliminated in that time, an emergency plan that can take up to 23 days (including the 72 hours) to complete.
In all other cases, there are 60 days to show evidence of compliance, including Who, What, When and How.
For non-compliance in the red or dark orange regions, the evidence much also include leadership involvement and preventive analysis. Also these will be consider for special consideration in future surveys through the next full survey.
Leadership involvements looks first at the sustainability of changes and support from the top levels of leadership. Examples give of support are providing resources, speaking out on behalf of the change and establishing plans for period measurement of and reporting on the changes.
Preventive analysis assures that the corrective action is global and not only a solution for the specific case. The analysis reviews underlying reasons. The focus is in preventing future incidents.
The SAFER matrix applies to the entire organization and results will be included in the report as the EC (Environment of Care) rules cited displayed on the matrix. If examples or one EP fit into more than one risk group, it will appear in the most severe group.
Initial evaluation (June 2016) roughly estimated about a fifth of findings were in the widespread and about 2/5ths were limited. The JC Extranet site further defines Likely as harm that can happen at any time without any contributing factors. Moderate likelihood may require other contributing factors or conditions.
(Key Sources: Presentations by George Mills and Caroline Heskett of The Joint Commission 2016-2017)
