Joint Commission Resources Quality & Safety Network (JCRQSN) Resource Guide. Project REFRESH: Improving the Survey Experience

Transcription

1 Quality & Safety Network (JCRQSN) Resource Guide Project REFRESH: Improving the Survey Experience January 26, 2017

2 About Joint Commission Resources Joint Commission Resources (JCR) is a client-focused, expert resource for healthcare organizations. It partners with these organizations, providing consulting services, educational services, and publications to assist in improving the quality, safety, and efficiency of healthcare services, and to assist in meeting the accreditation standards of The Joint Commission. JCR is a subsidiary of The Joint Commission, but provides services independently and confidentially, disclosing no information about its clients to The Joint Commission or others. Visit our web site at: Disclaimers Joint Commission Resources educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of Joint Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The information in this Resource Guide has been compiled for educational purposes only and does not constitute any product, service, or process endorsement by The Joint Commission or organizations collaborating with The Joint Commission in the content of these programs. NOTE: Interactivation Health Networks is the distributor of the Joint Commission Resources Quality & Safety Network series and has no influence on the content of the series Joint Commission Resources. The purchaser of this educational package is granted limited rights to photocopy this Resource Guide for internal educational use only. All other rights reserved. Requests for permission to make copies of this publication for any use not covered by these limited rights should be made in writing to: Department of Education Programs, Joint Commission Resources, One Renaissance Boulevard, Oakbrook Terrace, IL Joint Commission Resources 2 of 56

3 TABLE OF CONTENTS Program Summary...4 Program Outline...5 Continuing Education (CE) Credit...6 SAFER : New scoring methodology helps organizations prioritize, focus corrective actions...7 Joint Commission Online May 4, Excerpts from The Joint Commission Perspectives May The SAFER Matrix: A New Scoring Methodology...9 Project REFRESH and Improving the Survey Experience...10 EP Review Project: The Joint Commission Deletes 225 Hospital Requirements...10 Project REFRESH: Restraint and Seclusion Standards Deletions...21 Project REFRESH: Survey of PC Project REFRESH: Phase II of EP Review Project...24 The SAFER Matrix and Changes to the Post-Survey Process...30 Slides: Project REFRESH and the Survey Analysis For Evaluating Risk (SAFER) Matrix...32 Appendix A: Resources...50 Appendix B: Faculty Biography...51 Appendix C: Continuing Education (CE) Accrediting Bodies...52 Appendix D: Discipline Codes Instructions...53 Appendix E: Post-Test...54 Appendix F: JCRQSN Contact Information Joint Commission Resources 3 of 56

4 Program Summary This page provides an overview of the program content and learning objectives. Please refer to the Table of Contents and Program Outline for a detailed list of the topics covered. The information included in this Resource Guide is intended to support but not duplicate the video presentation content. There may be additional information available online for this topic. Program Description Project REFRESH is a series of interrelated process improvement projects underway at The Joint Commission. These projects look at various aspects of pre-survey, on-site survey, and post-survey activities in an effort to simplify them, enhance their relevancy to accredited organizations, increase transparency within the accreditation process, and utilize innovative approaches and technology to enrich the customer experience. REFRESH projects are being implemented in a phased and coordinated approach, beginning in June 2016 and extending through This new initiative includes a transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys. This Survey Analysis for Evaluating Risk (SAFER) approach provides organizations with additional information related to risk of deficiencies to help prioritize and focus corrective actions. Project REFRESH also includes a project first announced in December 2015, the evaluation of standards and elements of performance (EPs). This project was launched in order to identify EPs that were no longer considered necessary to assess quality and safety. Some of these EPs were no longer needed as they had become a routine part of operations or clinical practice, and others were actually covered under other EPs. This live, 60-minute activity is designed to help organizations better understand Project REFRESH and what to expect in Program Objectives After completing this activity, the participant should be able to: 1. Describe the overall benefit of Project REFRESH. 2. Explain the Survey Analysis for Evaluating Risk (SAFER) approach, and why it was developed. 3. Explain why The Joint Commission deleted a number of EPs from the Comprehensive Accreditation Manual for Hospitals (CAMH). Target Audience This activity is relevant to the entire hospital and medical staff, particularly organization leaders, managers and supervisors, and staff responsible for performance improvement (PI), patient safety, and risk management initiatives Joint Commission Resources 4 of 56

5 Program Outline January 26, 2017 I. Introduction A. Program Content B. Objectives C. Faculty II. An Introduction of Project REFRESH III. The Survey Analysis for Evaluating Risk (SAFER) Approach IV. Project Refresh in the Accreditation Process V. Case Study VI. Conclusion VII. Post-Program Live Question and Answer Session A. Audio only telephone seminar with program faculty for 30 minutes following the program. B. Call ; enter conference code: Or your questions or comments to: Program Broadcast Time Eastern: Central: Mountain: Pacific: 2:00 p.m. to 3:00 p.m. 1:00 p.m. to 2:00 p.m. 12:00 p.m. to 1:00 p.m. 11:00 a.m. to 12:00 p.m. Program Question and Answer Session During the live airing of this program on January 26, 2017, you may be able to talk directly with the faculty when prompted by the program s host. After this date, your message will be forwarded to the appropriate personnel. Immediately following the program, we invite you to join in a live discussion with the program presenters. Call and enter Conference Code: to be included in the teleconference. To submit your question ahead of time or for additional details, please send an to questions@jcrqsn.com. If you submit your questions after this date, your message will be forwarded to the appropriate personnel. You can also receive answers to your questions by calling The Joint Commission s Standards Interpretation Hotline at , option Joint Commission Resources 5 of 56

6 Continuing Education (CE) Credit After viewing the JCR Quality & Safety Network presentation and reading this Resource Guide, please complete the required online CE/CME credit activities (test and evaluation form). The test measures knowledge gained and/or provides a means of self-assessment on a specific topic. The evaluation form provides us with valuable information regarding your thoughts on the activity s quality and effectiveness. Prior to the Program Presentation Day 1. Login to the JCRQSN Learning Management System web site at Select the course for this program, When prompted, choose Access Content to confirm that you would like to access this program. 2. Display and print the desired documents (Resource Guide, etc.). Online Process for CE/CME Credit 1. Read the course materials and view the entire video presentation. 2. Login to the JCRQSN Learning Management System web site at 3. Select from the courses menu block. Note: This assumes you have already been enrolled in the program, as described above. 4. If you did not view the broadcast video presentation, view it online. 5. Complete the online post test (see Appendix E). You have up to three attempts to successfully complete the test with a minimum passing score of 80%. Physicians must take the post test to obtain credit. 6. Complete the program evaluation form. 7. On the top-left corner of the main course page, you will see your completion status in the Status block. 8. Select Get Certificate from within the Status block to print your completion certificate. Note: Certificates for other completed courses can be printed from the My History tab, as well Joint Commission Resources 6 of 56

7 SAFER : New scoring methodology helps organizations prioritize, focus corrective actions Joint Commission Online May 4, 2016 Accreditation SAFER : New scoring methodology helps organizations prioritize, focus corrective actions Project REFRESH, The Joint Commission s multiphase process improvement project, includes a transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys. This Survey Analysis for Evaluating Risk (SAFER ) approach provides organizations with additional information related to risk of deficiencies to help prioritize and focus corrective actions. See the SAFER matrix to the right. This approach 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 a patient, staff or visitor and the scope of a cited deficiency. Beginning June 6, psychiatric hospitals that use Joint Commission accreditation to meet the Centers for Medicare & Medicaid (CMS) deemed status requirements will be provided with a SAFER matrix within their Accreditation of Survey Findings Report. All other accreditation and certification programs will begin receiving this matrix in their reports after Jan. 1, See the table below for the changes related to the implementation of the SAFER matrix.questions may be directed to your organization s assigned account executive, or safer@jointcommission.org. Scoring methodology Post-survey, follow-up activities Submission time frame for Evidence of Standards Compliance (ESC Change Elimination of Category A and C scoring designations, and direct and indirect impact EPs. Opportunities for Improvement (single observations of noncompliance at Category C EPs) will no longer exist. Also, Measures of Success (MOS) will no longer be required. EPs will no longer be identified as direct impact (with 45 days for submission) or indirect impact (with 60 days for submission). New process Surveyors will perform a real-time, on-site evaluation of deficiencies, placing each one within the SAFER matrix according to the likelihood of the issue to cause harm to patients, staff or visitors, and according to how widespread the problem is based on surveyors observations (that is, scope). All observations of noncompliance will be documented within the SAFER matrix. Immediate Threats to Life (ITLs) will be noted with the SAFER matrix, but the identification and follow-up process for ITLs will not change. All cited deficiencies will be assigned a single time frame of 60 days for corrective action. For deficiencies of a higher risk level in the matrix, additional information will be required within the ESC regarding sustainment of corrective actions Joint Commission Resources 7 of 56

8 EP review project eliminates 225 hospital requirements Project REFRESH (see sidebar) includes a project first announced in the Dec. 9, 2015 issue of Joint Commission Online the evaluation of standards and elements of performance (EPs) in order to identify EPs that were no longer considered necessary to assess quality and safety. This effort to modernize and streamline Joint Commission requirements has resulted in the deletion of 225 EPs from the Comprehensive Accreditation Manual for Hospitals (CAMH). The majority of these deletions are effective July 1. The other 94 deleted EPs, which relate to duplicative restraint and seclusion standards, become effective in January None of the deletions are connected to Medicare Conditions of Participation. The deleted restraint and seclusion standards were only applicable to organizations that do not use accreditation for About Project REFRESH Project REFRESH is a series of interrelated process improvement projects underway at The Joint Commission. The projects look at various aspects of pre-survey, on-site survey, and post-survey activities in an effort to: Simplify them Enhance their relevancy to accredited organizations Increase transparency within the accreditation process Utilize innovative approaches and technology to enrich the customer experience REFRESH projects will be implemented in a phased and coordinated approach, beginning in June 2016 and extending through Medicare reimbursement purposes. The deleted standards were very similar to other restraint and seclusion requirements (standards PC through PC ) that address the Conditions of Participation (CoPs). For simplicity and clarity, The Joint Commission decided to use the restraint and seclusion standards that address the CoPs for all organizations, regardless of deemed status. The deletion of Standards PC through PC will go into effect in January Read the prepublication standards for more information. (Contact: Maureen Carr, mcarr@jointcommission.org) Joint Commission Resources 8 of 56

9 Excerpts from The Joint Commission Perspectives May 2016 The SAFER Matrix: A New Scoring Methodology Project REFRESH (see related articles on page 10), the Joint Commission s multiphase process improvement project, includes a transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys. This Survey Analysis for Evaluating Risk (SAFER) approach provides organizations with additional information related to risk of deficiencies to help prioritize and focus corrective actions. The development of this 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. Beginning June 6, 2016, psychiatric hospitals that use Joint Commission accreditation to meet the Centers for Medicare & Medicaid (CMS) deemed status requirements will be provided with a SAFER matrix (shown on the right) within their Accreditation of Survey Findings Report. All other accreditation and certification programs will begin receiving this matrix in their reports after January 1, Likelihood to Harm and Scope of Cited Deficiencies The SAFER matrix replaces the current scoring methodology, which includes Category A and Category C as well as direct and indirect impact elements of performance (EPs). In place of using those predetermined EP categorizations, surveyors will perform a real-time, on-site evaluation of deficiencies, placing each one within the SAFER matrix according to the likelihood of the issue to cause harm to patients, staff, or visitors and according to how widespread the problem is based on surveyors observations (that is, the scope). A single observation could reveal a widespread problem, such as a general failure to perform recommended high-level disinfection or proper storage of endoscopes. Combined, these characteristics give a more clearly defined sense of the risk of a deficiency. As the risk level of a deficiency increases, the placement of the standard and EP moves from the bottom left corner (lowest risk level) to the upper right (highest risk level). The SAFER matrix shown below demonstrates the placement of an EP at the intersection of the likelihood to harm a patient, staff, and/or visitor and the scope of the deficiency. In this example, a surveyor placed Environment of Care (EC) Standard EC , EP 1, in the row Moderate, as it was determined (based on the deficiency observed) that it could occasionally cause harm to a patient, visitor, or staff member, and in the column Pattern, as the issue was noted multiple times throughout the survey and could impact a few or some people and/or settings. Impact on Scoring and Post-Survey Follow-up Replacing the scoring model will also result in changes to post-survey follow-up activities. As a result of the elimination of the A and C designations, Opportunities for Improvement (single observations of noncompliance at Category C EPs) will no longer exist. All observations of noncompliance will be documented within the matrix. In addition, Measures of Success (MOS), quantifiable measures typically related to an audit determining whether an action is effective and sustained for certain Category C EPs, will no longer be required. The submission time frame for Evidence of Standards Compliance (ESC) will also change because EPs will no longer be identified as direct impact (with 45 days 2017 Joint Commission Resources 9 of 56

10 for submission) or indirect impact (with 60 days for submission). Instead, all cited deficiencies will be assigned a single time frame of 60 days for corrective action. For deficiencies of a higher risk level in the matrix, additional information will be required within the ESC regarding sustainment of corrective actions. The higher risk deficiencies also will be provided to surveyors for possible review or on-site validation on subsequent surveys. Please note that, while Immediate Threats to Life (ITLs) will be noted with the SAFER matrix, the identification and follow-up process for ITLs will not change. The Joint Commission will provide additional targeted, specific information to psychiatric deemed hospitals in preparation for the June 6, 2016, launch of the SAFER matrix. All other accreditation and certification programs will receive information throughout the remainder of the year in preparation for their January 1, 2017, launch. Questions may be directed to your organization s assigned Account Executive. Project REFRESH and Improving the Survey Experience Project REFRESH is a series of interrelated process improvement projects underway at The Joint Commission. The projects look at various aspects of pre-survey, on-site survey, and post-survey activities in an effort to simplify them, enhance their relevancy to accredited organizations, increase transparency within the accreditation process, and utilize innovative approaches and technology to enrich the customer experience. REFRESH projects will be implemented in a phased and coordinated approach, beginning in June 2016 and extending through Please see the articles in this issue on the SAFER matrix (page 9) and EP review (page 5) for key project updates. The PR icon accompanying these and future articles identifies their content as part of Project REFRESH. EP Review Project: The Joint Commission Deletes 225 Hospital Requirements Project REFRESH (see related articles on page 9 and above) includes a project first announced in the December 2015 Perspectives: the evaluation of standards and elements of performance (EPs) in order to identify EPs that were no longer considered necessary to assess quality and safety. Some of these were no longer needed because they had become a routine part of operations or clinical practice. Others were actually covered under other EPs. This effort to modernize and streamline Joint Commission requirements resulted in the deletion of 225 EPs from the Comprehensive Accreditation Manual for Hospitals (CAMH). The majority of these deletions 131 are effective July 1, The other 94 deleted EPs, which relate to duplicative restraint and seclusion standards, become effective in January 2017 and are discussed below. None of the deletions are connected to Medicare Conditions of Participation. The Joint Commission deleted requirements from 13 of the CAMH s 18 standards chapters. The following chapters were excluded from review: Accreditation Process Requirements (APR), Life Safety (LS), Medical Staff (MS), and National Patient Safety Goals (NPSG). Potential deletions from the Emergency Management (EM) chapter will not be implemented until comparisons can be made to the Center for Medicare & Medicaid s (CMS) final rule on emergency management (which should be available in the first part of 2016). Restraint and Seclusion Deletions Many of the deletions in the Provision of Care (PC) chapter 94 EPs were restraint and seclusion standards, and these require more explanation. The 2017 Joint Commission Resources 10 of 56

11 deleted restraint and seclusion standards were only applicable to organizations that do not use accreditation for Medicare reimbursement purposes. The deleted standards were very similar to other restraint and seclusion requirements (Standards PC through PC ) that address the Conditions of Participation (CoPs). For simplicity and clarity, The Joint Commission decided to use the restraint and seclusion standards that address the CoPs for all organizations, regardless of deemed status. These restraint standards deletions (Standards PC through PC ) will go into effect in January 2017, six months later than the others. Additional information about this change will be included in a future Perspectives article. Rationale for Deletions The deletion of these requirements is not expected to change current patient care processes or to affect quality and safety. The review project was initiated, in part, as a response to customer feedback regarding the complexity of Joint Commission standards. The Joint Commission also recognizes that the concepts of some standards, considered groundbreaking when they were introduced years ago, have now become part of organizations routine operations. Therefore, while it is important to continue following the practices that hospitals find to be useful, it is no longer necessary to include them in standards. Removing such requirements allows a greater focus on the most important contemporary quality and safety issues. For the most part, the deletions fall into one or more of the following categories: Are duplicative of, or implicit in, other existing EPs Address issues that, having been covered by standards for many years and are now a routine part of operations or clinical care processes, no longer need to be addressed in standards. Some of them no longer address contemporary quality and safety concerns, and how they are managed can be left to the discretion of the organization. Are adequately addressed by law and regulation or other external requirements, so separate Joint Commission requirements are not needed The deleted requirements listed in the table beginning on page 12 will be posted on The Joint Commission website at standards_information/prepublication_standards.aspx; they are no longer part of the manual as of the spring E-dition and the 2016 Update 1. Next Steps In the next phase of the project, The Joint Commission will continue to evaluate EPs for possible deletion or consolidation in anticipation of a second phase of deletions for January During this time, The Joint Commission will also closely monitor feedback from the field for comments on the first phase of deletions. The complexity of federal and state regulations makes any changes in EPs challenging, and The Joint Commission is prepared to make further modifications to the EPs to improve standards and safeguard patients. Questions may be directed to Maureen Carr, MBA, project director, Department of Standards and Survey Methods, The Joint Commission, at mcarr@jointcommission.org. The Joint Commission Perspectives May Joint Commission Resources 11 of 56

12 EP Review Project: The Joint Commission Deletes 225 Hospital Requirements (continued) Continued from page 5 Standard Deleted EP Topic EC EP 2 Identifying who will intervene in threatening environmental conditions EC EP 4 Designating physically separate smoking areas EC EP 2 Minimizing fire risk if patients are permitted to smoke EC EP 1 Soliciting input on medical equipment from those who operate and service it EC EP 9 Implementing protective measures during repairs/ corrections if emergency power system test fails EC EP 10 Performing retest after repairing/correcting emergency power system EC EP 3 Recommending priorities for improving environment of care EC EP 3 Reporting performance improvement results for analysis HR EP 7 Orienting external law enforcement and security personnel HR EP 5 Staff education and training specific to patient population HR EP 6 Staff education and training on communication, collaboration, coordination HR EP 7 Staff education and training on reporting unanticipated adverse events HR EP 8 Staff education and training on fall reduction activities HR EP 2 Using assessment methods to determine competence HR EP 15 Taking action when competence does not meet expectations Duplicative of (or implicit in) EP shown EC , EP 1 EC , EP 1 EC , EP 1 Other EPs in this standard HR , EPs 1 and 4 HR , EPs 1 and 4; reporting requirements in LD chapter Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements 6 The Joint Commission Perspectives May

13 Standard Deleted EP Topic IC EP 3 Including written description of process for evaluating infection prevention and control plan IC EP 7 Communicating responsibilities for preventing/controlling infection IC EP 1 Identifying resources about infections that could cause influx of potentially infectious patients IC EP 5 Describing methods for managing influx of potentially infectious patients IC EP 6 Activating response to influx of potentially infectious patients IM EP 1 Identifying internal and external information needed to provide care IM EP 3 Using identified information in developing processes for managing information IM EP 4 Assessing, selecting, integrating, and using information management systems IM EP 5 Testing plan for managing interruptions to information processes IM EP 6 Implementing plan for managing interruptions to information processes IM EP 5 Monitoring compliance with policy on health information privacy IM EP 8 Monitoring compliance with policies on health information security and integrity Duplicative of (or implicit in) EP shown IC , EP 7 IC , EP 2 IC , EP 4 IC , EP 4 LD , EP 1 LD , EP 1 LD , EP 1 EC utilities management and EM emergency management requirements EC utilities management and EM emergency management requirements IM , EP 2 Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements Continued on page 8 May 2016 The Joint Commission Perspectives 7

14 EP Review Project: The Joint Commission Deletes 225 Hospital Requirements (continued) Continued from page 7 Standard Deleted EP Topic IM EP 1 Using uniform data sets to standardize data collection IM EP 2 Making cooperative or contractual arrangements for knowledge-based information resources LD EP 2 Making decisions when a leadership group fails LD EP 7 Providing a system for resolving conflicts LD EP 11 Designating someone to perform duties of an absent chief executive LD (entire standard) EPs 1 3 Making sure that leaders have the knowledge or seek guidance for their roles LD EP 2 Approving process for managing conflict among leadership groups LD EP 4 Making sure conflict management process includes certain steps LD EP 3 Providing opportunities to participate in safety and quality initiatives LD EP 6 Providing education on safety and quality for all individuals LD EP 7 Establishing team approach among staff at all levels LD EP 8 Making sure all staff can openly discuss issues of safety and quality LD EP 9 Making patient safety literature and advisories available to all staff LD EP 10 Defining how patients can help identify/manage safety/quality issues LD EP 5 Monitoring implementation of budget and long-term capital expenditure plan Duplicative of (or implicit in) EP shown IM , EP 1 LD , EP 1 Also addressed at LD and LD Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements 8 The Joint Commission Perspectives May

15 Standard Deleted EP Topic LD EP 4 Making sure that marketing materials accurately represent hospital as well as care, treatment, and services LD EP 6 Making sure that care, treatment, and services are not negatively affected when staff are excused from responsibilities LD EP 2 Making sure that safety and quality do not depend on patient s ability to pay LD EP 2 Making sure that care, treatment, services are consistent with mission, vision, goals LD EP 6 Testing/analyzing design of new/modified services/processes and determining whether design is improvement LD EP 7 Involving staff/patients in design of new/modified services/processes MM EP 3 Informing prescriber and patient if medications that are brought in are not permitted MM EP 4 Reviewing literature and other external sources for new technologies and best practices NR EP 4 Considering education and experience required for peer leadership positions when appointing nurse executive NR EP 5 Considering hospital s scope of services/ complexity and position s authority/responsibility when appointing nurse executive Duplicative of (or implicit in) EP shown MM , EPs 1 and 2 NR , EP 3 Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements Continued on page 10 May 2016 The Joint Commission Perspectives 9

16 EP Review Project: The Joint Commission Deletes 225 Hospital Requirements (continued) Continued from page 9 Standard Deleted EP Topic NR EP 6 Considering scope/ complexity of nursing care needs of patient population when appointing nurse executive NR EP 7 Considering availability of staff and services needed when appointing nurse executive NR EP 5 Writing standards to measure, assess, and improve patient outcomes PC EP 4 Including certain information in initial patient assessment PC EP 23 Gathering required data and information during patient assessments and reassessments PC EP 7 Completing a nutritional screening within 24 hours of admission PC EP 8 Completing a functional screening within 24 hours of admission PC EP 5 Assessing (or referring for assessment) patients who meet criteria for possible abuse or neglect PC EP 1 Performing testing and procedures as ordered PC EP 3 Providing information to interpret results when test report requires clinical interpretation PC EP 5 Making sure that group contingencies are based on collective group outcomes PC EP 7 Using education and positive reinforcement in behavior management PC EP 9 Protecting patient s physical safety during behavior management Duplicative of (or implicit in) EP shown Other EPs in standard; PI duties of leaders in LD and PI chapters PC , EPs 1 and 2 PC , EP 1 Other EPs in this standard Other EPs in this standard Other EPs in this standard Other EPs in this standard Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements 10 The Joint Commission Perspectives May

17 Standard Deleted EP Topic PC EP 3 Locating resuscitation equipment strategically throughout hospital PC EP 3 Seeking additional assistance when staff have concerns about patient s condition PC EP 4 Informing patient and family how to seek assistance when there are concerns about patient s condition PC EP 1 Assigning responsibility for safe/accurate provision of food/nutrition products PC (entire standard) PC (entire standard) PC (entire standard) EP 1 EP 1 EPs 3, 4, 6, and 7 Arranging for academic education for children and youth Providing access to the outdoors to patients with long lengths of stay Maintaining personal hygiene of patients in hospitals with behavioral health units PC EP 1 Making sure of the qualifications and credentials of those administering moderate or deep sedation and anesthesia PC EP 2 Making sure sufficient number of qualified staff are present during procedures involving moderate or deep sedation and anesthesia PC EP 2 Assessing patient s anticipated needs for care after operative/ high-risk procedures or those involving moderate or deep sedation and anesthesia Duplicative of (or implicit in) EP shown PC , EP 2 Other EPs in this standard Other EPs in this standard PC , EP 6 PC , EP 1 HR , EP 1; HR , EP 3; HR , EPs 1 and 2; HR , EP 1; LD , EP 3; MS , EP 6; PC , EP 10 HR , EP 1; LD , EP 3; MS , EP 6; PC , EP 10 Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements Continued on page 12 May 2016 The Joint Commission Perspectives 11

18 EP Review Project: The Joint Commission Deletes 225 Hospital Requirements (continued) Continued from page 11 Standard Deleted EP Topic PC EP 3 Providing the patient with treatment and services before operative/highrisk procedures or those involving moderate or deep sedation and anesthesia PC EP 7 Making sure that an LIP plans or concurs with the plan for sedation or anesthesia before it is administered PC EP 6 Discharging outpatients who have received sedation or anesthesia in the company of a person who accepts responsibility for the patient PC (entire standard) EPs 1 3 Making sure of safe use of surgical treatments for emotional, mental, or behavioral disorders PC EP 8 Providing written discharge instructions that the patient/family/ caregiver can understand PI EP 38 Evaluating effectiveness of fall reduction activities PI EP 39 Collecting data on efficacy of response to changes in patient s condition PI (entire standard) EPs 1 10 Using data from clinical/ service screening indicators and human resource screening indicators to assess/ improve staffing effectiveness RC EP 4 Making sure that medical record contains information unique to patient RC EP 13 Making sure that medical record has all information required to provide care, treatment, and services Duplicative of (or implicit in) EP shown PC , EP 1 RI , EP 1 Standard is not in effect at this time. RC , EPs 1 and 2 Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements 12 The Joint Commission Perspectives May

19 Standard Deleted EP Topic RC EP 3 Measuring medical record delinquency rate no less regularly than every three months RC EP 4 Making sure that medical record delinquency rates are no greater than 50% of the average monthly discharge rate RC (entire standard) EPs 1 4 Making sure that medical record contains summary list for each patient receiving continued ambulatory care RI EP 12 Discussing circumstances in which patient information must be disclosed/reported RI EPs 2 8 Honoring patient s right to give or withhold informed consent regarding external use of recordings, films, or other images RI EP 1 Reviewing all research protocols and weighing risks/benefits to research participant RI EP 9 Keeping all information given to subjects in the medical record or research file RI EP 2 Basing number of patients in a room on age, development, condition, diagnosis needs, and hospital goals RI EP 17 Determining restrictions on communication with patient s and/or family s participation RI EP 18 Documenting restrictions on communication in the medical record RI EP 19 Evaluating restrictions on communication for therapeutic effectiveness Duplicative of (or implicit in) EP shown RC , EP 2 EP 1: RC , EP 13 EP 2: RC , EP 2, and RC , EP 1 Other EPs in this standard Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements Continued on page 14 May 2016 The Joint Commission Perspectives 13

20 EP Review Project: The Joint Commission Deletes 225 Hospital Requirements (continued) Continued from page 13 Standard Deleted EP Topic RI EP 10 Allowing patients to freely and safely voice complaints and recommend changes RI EP 2 Maintaining a list of patient advocacy groups and their contact information RI EP 3 Giving list of patient advocacy groups to patient TS EP 2 Identifying affiliated organ procurement organization in written policies and procedures TS EP 4 Coordinating tissue acquisition, receipt, storage, and issuance TS EP 11 Complying with state and/ or federal regulations as a tissue supplier WT EP 5 Making sure current and complete policies and procedures are available to person doing waived test WT EP 6 Following written policies, procedures, and manufacturer s instructions for waived testing WT EP 7 Following specified criteria for confirmatory testing WT EP 8 Making sure that the clinical use of results is consistent with hospital policies and manufacturer s recommendations Duplicative of (or implicit in) EP shown RI , EP 1 RI , EP 1 TS , EP 1 TS , EP 2 WT , EPs 1 and 2 WT , EPs 1 and 2 WT , EPs 1 and 2 WT , EPs 1 and 2 Reason for Deletion Addresses routine part of operations or clinical care processes Adequately addressed by external requirements 14 The Joint Commission Perspectives May

21 Project REFRESH: Restraint and Seclusion Standards Deletions Excerpts from The Joint Commission Perspectives July 2016 As previously announced (see May 2016 Perspectives, page 5 (page 10 in this document, and the related article below), The Joint Commission is conducting a multiphase review project to streamline the accreditation requirements for hospitals. This initiative examines standards and elements of performance (EPs) to identify those that were considered necessary to evaluate on survey when they were introduced years ago but that have now become part of routine hospital practice. The first phase of this project resulted in the deletion of 225 EPs. A majority of these deletions 131 are effective July 1, The remaining 94 EPs address restraint and seclusion and are scheduled for deletion, as discussed below, because they are duplicative of other standards; these deletions become effective January 1, Streamlining from Two Sets to One The Joint Commission currently has two sets of standards that address restraint and seclusion: 1. Non-Deemed Standards The Joint Commission s original restraint and seclusion standards, these currently apply only to hospitals that are not seeking accreditation for deemed status purposes. These requirements comprise Provision of Care, Treatment, and Services (PC) Standards PC through PC Deemed Standards These standards, which align with Centers for Medicare & Medicaid Services (CMS) requirements, must be followed by hospitals seeking accreditation for deemed status and are covered in Standards PC through PC Because these two sets of restraint and seclusion standards are largely duplicative of each other, The Joint Commission decided to delete the first set and use only the second set. Therefore, as of January 1, 2017, all hospitals regardless of whether or not they seek accreditation for deemed status purposes will be required to follow Standards PC through PC Similarities and Differences There are similarities and differences between what is required by the two sets of standards. Both sets of standards require, for example, that hospitals do the following: Clinically justify the use of restraints Use physician orders for restraints Limit the use of restraints to situations when they are needed to protect the patient and others Limit the amount of time patients are kept in restraint; discontinue restraints as soon as possible Monitor patients in restraints Make sure staff are competent to use restraints Use the least restrictive method of restraint that is possible Follow policies on the use of restraints Among the several differences between the two sets of standards, one is that while Standards PC through PC (those being deleted effective January 1, 2017) require hospitals to determine whether the need for restraints is for behavioral or medical reasons, Standards PC through PC (those aligned with CMS requirements) do not specify that hospitals are required to make this distinction. In addition, while the deleted standards require the debriefing of individuals who have been placed in restraints, this is not specified in the CMS-related requirements. Despite these differences, hospitals are free to continue to follow the processes in Standards PC through PC even though they are not required within Standards PC through PC For more information regarding the multiphase EP review project, please contact Maureen Carr, MBA, project director, Department of Standards and Survey Methods, The Joint Commission, at mcarr@jointcommission.org Joint Commission Resources 21 of 56

22 Correction The May 2016 issue of Perspectives includes a table listing the 131 EPs deleted as of July 1, Please note the following error regarding Record of Care, Treatment, and Services (RC) Standard RC on page 13 of the table (page 19 in this document). The reason for the deletion of EP 1 of this standard should not be that it is duplicative of Standard RC , EP 13, as that requirement has also been deleted. EP 1 was deleted because it addresses routine parts of operations or clinical care processes. The table also neglects to show that EPs 3 and 4 were deleted for the same reason. However, the reason for the deletion of EP 2 is correct as noted in the table: EP 2 is duplicative of Standards RC , EP 2, and RC , EP 1. The Joint Commission regrets any confusion that this may have caused Joint Commission Resources 22 of 56

23 Project REFRESH: Survey of PC As part of the EP review project component of Project REFRESH (see the May 2016 issue of Perspectives), The Joint Commission deleted Provision of Care, Treatment, and Services (PC) Standard PC , Element of Performance (EP) 23, effective July 1, Standard PC addresses the need for hospitals to define the scope and content of screening, assessment, and reassessment; the deleted EP 23 addressed the implementation component of the standard. To retain the implementation component as part of this standard, the language of Standard PC , EP 1, has been modified effective immediately to include the underlined text below: EP 1: The hospital defines, in writing, the scope and content of screening, assessment, and reassessment information it collects. Patient information is collected according to these requirements. (See also RC , EP 2) Note 1: In defining the scope and content of the information it collects, the organization may want to consider information that it can obtain, with the patient s consent, from the patient s family and the patient s other care providers, as well as information conveyed on any medical jewelry. Note 2: Assessment and reassessment information includes the patient s perception of the effectiveness of, and any side effects related to, his or her medication(s). This revision will not appear online in E-dition or in print in the Comprehensive Accreditation Manual for Hospitals until the accreditation products are updated in late fall In the interim, noncompliance related to screening, assessment, and reassessment as defined by the hospital will be cited at Standard PC , EP 1. Questions about this requirement and others related to the multiphase EP review project may be directed to Maureen Carr, MBA, project director, Department of Standards and Survey Methods, The Joint Commission at mcarr@jointcommission.org. Joint Commission Perspectives, August 2016, Volume 36, Issue 8 Copyright 2016 The Joint Commission 2017 Joint Commission Resources 23 of 56

24 Project REFRESH: Phase II of EP Review Project The Joint Commission recently completed the second phase of its EP Review Project, resulting in the deletion of 51 additional elements of performance (EPs) for hospitals. These deletions are effective January 1, The EP Review Project is a multiphased component of Project REFRESH, a series of interrelated process improvement initiatives The Joint Commission is conducting throughout 2016 and Phase I of the EP Review Project (see May 2016 Perspectives, page 5 [page 10 in this document]) resulted in the deletion of 225 hospital EPs. A majority of these deletions 131 became effective July 1, 2016; the deletion of the remaining 94 EPs (see July 2016 Perspectives, page 5 [page 21 in this document]) will become effective January 1, As with the Phase I deletions, deleting the 51 Phase II EPs is not expected to change hospitals current patient care processes or to affect quality and safety. The Phase II deletions are a result of further evaluation of the current requirements; for the most part, the deletions fall into one or more of the categories established during Phase I: Are similar to, implicit in, or duplicative of other existing EPs Address issues that, having been covered by standards for many years and are now a routine part of operations or clinical care processes, no longer need to be addressed in standards. Some of them no longer address contemporary quality and safety concerns, and how they are managed can be left to the discretion of the organization. Are adequately addressed by law and regulation or other external requirements, so separate Joint Commission requirements are not needed The deleted requirements (and reasons for each deletion) are listed in the table that begins on page 3 and posted on The Joint Commission website at n/prepublication_ standards.aspx. These requirements will be removed from the fall E-dition update as well as from 2016 Update 2 and the 2017 Comprehensive Accreditation Manual for Hospitals. NET STEPS The third phase of the EP Review Project will include EP deletions from the accreditation programs for ambulatory care, behavioral health care, critical access hospitals, home care, laboratories, and nursing care centers. These EP deletions will become effective in July The next stage will involve consolidations of existing requirements across accreditation programs. Questions may be directed to Maureen Carr, MBA, project director, Department of Standards and Survey Methods, The Joint Commission, at mcarr@jointcommission.org. Joint Commission Perspectives, November 2016 Copyright 2016 The Joint Commission 2017 Joint Commission Resources 24 of 56

25 Reason for Deletion Standard Deleted EP Topic EC EP 8 Monitoring and reporting incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual EC EP 12 Having procedures that address how to obtain emergency repair services EC EP 23 Providing emergency access to all locked and occupied spaces EC EP 1 Making sure staff and LIPs can de-scribe or demonstrate methods for eliminating and minimizing physical risks in the environment of care EC EP3 Making sure staff and licensed independent practitioners can de-scribe or demonstrate how to report environment of care risks EC EP 12 Conducting environmental tours every six months in patient care areas to evaluate the effectiveness of previously implemented activities EC EP 13 Conducting annual environmental tours in nonpatient care areas to evaluate the effectiveness of previously implemented activities EC EP 14 Using tours to identify environ-mental deficiencies, hazards, and unsafe practices EC EP 1 Making sure representatives from clinical, administrative, and support services participate in environment of care data analysis EC EP 2 Determining whether changes re-solved environmental safety issues Duplicative of (or implicit in) EP shown EC , EP 1 Addresses routine part of operations or clinical care processes Adequately addressed by external requirements 2017 Joint Commission Resources 25 of 56

26 Reason for Deletion Standard Deleted EP Topic Duplicative of (or implicit in) EP shown Addresses routine part of operations or clinical care processes Adequately addressed by external requirements HR EP 6 Uses information from HR , EPs 1 5, to make decisions about various staff job responsibilities HR EP 17 Making sure social workers have certain education qualifications and experience (for orgs with deemed status and swing beds) Moving to Glossary HR EP 13 Providing education and training on how to identify early warning signs of a change in a patient s condition and how to respond to a deteriorating patient PC IC EP 8 Identifying methods for reporting infection surveillance and control in-formation to external organizations IC , EP 9 IM EP 1 Having written policies addressing data capture, display, transmission, and retention IM EP 1 Having processes to check health information accuracy RC , EP1 LD EP 2 Making sure chief executive provides for staff recruitment and retention LD , EP 3 LD EP 3 Making sure medical staff structure conforms to its guiding principles MS introduction; MS LD EP 5 Making sure organized medical staff oversees quality of care, treatment and services provided by individuals with clinical privileges MS LD EP 1 Discussing various issues (such as performance improvement, safety and quality issues) that affect the hospital and its population(s) LD LD EP 2 Establishing time frames for discussing issues that affect the hospital and its population(s) 2017 Joint Commission Resources 26 of 56

27 Reason for Deletion Standard Deleted EP Topic LD EP 6 Making sure independent public accountant conducts annual audit of hospital s finances LD EP 1 Making sure leaders of program, service, site, or department oversee operations LD EP 2 Using arrangement and allocation of space to support care, treatment, and services LD EP 3 Following ethical practices for marketing and billing LD EP 7 Giving patients information about charges they are responsible for LD EP 1 Considering the use of clinical practice guidelines when designing or improving processes MM EP 10 Making sure medications in patient care areas are available in the most ready-to-administer forms commercially available or in unit doses re-packaged by pharmacy or licensed repackager NR EP 2 Giving nurse executive same authority to speak on behalf of nursing that other leaders have for their disciplines, departments, or service lines NR EP 4 Making sure nurse executive participates in defined and established meetings of hospital s corporate (and other senior clinical and managerial) leaders NR EP 1 Establishing process for selecting, electing, or appointing a qualified nurse as the nurse executive NR EP1 Making sure nurse executive coordinates development of hospital-wide plans to provide nursing care, treatment, and services Duplicative of (or implicit in) EP shown LD , EPs 2 5 LD , EP 3 MM NR , EP1 NR , EP 5 NR , EP 4 Addresses routine part of operations or clinical care processes not surveyable Adequately addressed by external requirements 2017 Joint Commission Resources 27 of 56

28 Reason for Deletion Standard Deleted EP Topic PC EP 8 Accommodates a patient s special diet and altered diet schedule PC EP 10 Offering substitutes of equal nutritional value when a patient refuses food PC EP 4 Providing education and training to patients based on assessed needs PC EP 8 Having resuscitation equipment available for operative or other high-risk procedures PC EP 3 Describing mechanisms for external transfer of patient PC EP 4 Making sure hospital and receiving organization agree about their roles in keeping patients safe during transfer PC EP 3 Providing patients with information about why they are being discharged or transferred PC EP 5 Providing patients with information about any alternatives to a transfer PI EP 12 Collecting data on behavior management and treatment PI EP 30 Considering data collection on staff opinions and needs, perceptions of risk to individuals, suggestions for improving patient safety, and willingness to report adverse events Duplicative of (or implicit in) EP shown PC , EP 7 PC , EP 7 PC , EP 10 PC , EP 2 PC , EP 2 PC , EP 2 Other EPs in standard Other EPs in standard Addresses routine part of operations or clinical care processes PI EP 1 Compiling data in usable formats Adequately addressed by external requirements PI EP 2 Identifying data analysis frequency PI EP 5 Comparing data with available external sources PI EP 1 Prioritizing identified improvement opportunities 2017 Joint Commission Resources 28 of 56

29 Reason for Deletion Standard Deleted EP Topic Duplicative of (or implicit in) EP shown Addresses routine part of operations or clinical care processes Adequately addressed by external requirements PI EP 3 Evaluating actions to confirm they resulted in improvements PI , EPs 2 and 4 RC EP 9 Using standardized formats to document the care, treatment, and services it provides RC EP 12 Tracking the location of all components of the medical record RI EP 15 Offering patients telephone and mail service (based on setting and population) RI EP 16 Providing access to telephones for patients who desire conversations in a private space, based on setting and population 2017 Joint Commission Resources 29 of 56

30 The SAFER Matrix and Changes to the Post-Survey Process As announced in the May 2016 Perspectives, The Joint Commission is conducting a series of interrelated process improvement projects known as Project REFRESH. This multiphase undertaking includes the Survey Analysis for Evaluating Risk (SAFER ) matrix, a transformative approach for identifying and communicating risk levels associated with deficiencies cited during accreditation surveys and certification reviews. As a reminder, all accreditation and certification programs will begin receiving the SAFER matrix in their reports as of January 1, The SAFER matrix (see Figure 1 on page 31) will replace the current scoring methodology based on predetermined categorizations (Category A or Category C; direct or indirect impact) of elements of performance (EPs), allowing surveyors and reviewers to perform real-time, on-site evaluations of deficiencies and their associated risk. Surveyors and reviewers will place each Requirement for Improvement (RFI) within the matrix according to the likelihood of the issue to cause harm to patients, staff, or visitors and according to the scope of a cited deficiency. This approach provides one comprehensive visual representation of the survey or review findings and is designed to help organizations prioritize and focus corrective actions. Figure 2 on page 31 explains how RFI placement on the matrix drives the organization s post-survey follow-up process. As shown, the submission time frame for Evidence of Compliance (ESC) for all findings placed within the matrix is 60 days (the 45-day submission required for EPs formerly cited as direct impact will be eliminated). Findings identified as high risk (those placed in the dark orange and red boxes) will require additional information within the ESC to demonstrate that an organization will sustain the corrective actions. These findings will also be proactively shared with surveyors and reviewers for potential review on subsequent on-site surveys up to and including the next full survey event. With the move to the SAFER matrix, the current 10-day post-survey clarification opportunity will remain. The clarification process will continue to serve as an opportunity to submit clarifying evidence if an organization was in compliance with a particular standard at the time of survey. However, the clarification process is not intended to be an opportunity to challenge the professional judgment of the surveyors and reviewers or to dispute the placement of findings on the SAFER matrix. Some aspects of the post-survey process will not remain. In addition to eliminating the Category A, Category C, and direct and indirect impact designations, the SAFER approach will eliminate the use of Measures of Success (MOS). The sidebar at right provides details on how the MOS requirement will be eliminated. In addition, because Category C EP designations will be eliminated, Opportunities for Improvement (single observations of noncompliance at Category C EPs) will also be eliminated. The SAFER matrix is meant to be utilized as a tool in the survey process to illustrate potential risk areas at the organization. It will not be used in isolation to drive or determine if certain decision rules will be applied. The SAFER matrix also will not impact the process used on site to determine a Condition Level Deficiency or the declaration of an Immediate Threat to Health and Safety. For more information, please contact your organization s assigned Account Executive or review the resource documents located on the extranet site under the Survey Process tab. Joint Commission Perspectives, October 2016, Volume 36, Issue 10 Copyright 2016 The Joint Commission Removal of MOS Measures of Success (MOS), quantifiable measures typically related to an audit determining whether an action is effective and sustained for certain Category C EPs, will be eliminated for all accreditation and certification organizations effective January 1, Organizations that have an MOS due in 2016 are still required to submit the MOS. However, organizations that have an MOS that is due on or after January 1, 2017, are not required to submit it. If these organizations wish to enter or print the data for their own internal improvement efforts, the MOS tool will stay open on their extranet site through the end of Although the MOS tool will close as of January 1, 2017, organizations are encouraged to continue to monitor the effectiveness of their corrective actions through future measurement as they find value in doing so Joint Commission Resources 30 of 56

31 Figure 1. SAFER Matrix Note: If an Immediate Threat to Health and Safety, also known as Immediate Threat to Life (ITL), is discovered during a survey, the organization immediately receives a Preliminary Denial of Accreditation (PDA) and, within 72 hours, must either entirely eliminate the ITL or implement emergency interventions to abate the risk to patients (with a maximum of 23 days to totally eliminate the ITL). Please see The Accreditation Process (ACC) chapter within the Comprehensive Accreditation Manual for more information. Figure 2. Placement of RFI on SAFER Matrix and Follow-Up Activity 2017 Joint Commission Resources 31 of 56

32 Slides: Project REFRESH and the Survey Analysis For Evaluating Risk (SAFER) Matrix Leslie Wiora, MS, PMP Business Transformation Leader Accreditation & Certification Operations The Joint Commission Copyright 2016 by Joint Commission Resources, Inc. All rights reserved What is Project Refresh? A series of process improvement initiatives underway at The Joint Commission Guiding principles: Simplification, Relevancy, Innovation, Transparency REFRESH projects will be implemented in a phased and coordinated approach, beginning in June 2016 and extending through 2017 Project Refresh in the Accreditation Process Outcomes of REFRESH Projects Real-time information gathering between surveyors and Standards Interpretation Group during survey Enhanced mobile technology Fewer standards Revised criticality models for standards Easier & less complex decision process Streamlined post-survey process Higher consistency in interpretation of standards 2017 Joint Commission Resources 32 of 56

33 Initiatives you will be hearing about today The Review Survey Analysis for Evaluating Risk (SAFER) Matrix Post-survey Follow-up Project Refresh in the Accreditation Process The Review An effort to modernize and streamline Joint Commission requirements Initially focused on Hospital standards/elements of performance (EPs) Criteria for removal: Duplicative Routine part of operations/practices Adequately addressed by external requirements No longer addressed contemporary issue 2017 Joint Commission Resources 33 of 56

34 Phase EP deletions effective July 1, 2016 An additional 94 EPs (related to duplicative restraint and seclusion standards) were identified for deletion, however become effective January 2017 Communicated to field in May Perspectives Reason for Deletion Standard Deleted EP Topic Duplicative of (or implicit in) EP shown Addresses routine part of operations or clinical care processes Adequately addressed by external requirements EC EP 2 Identifying ho will intervene in threatening environmental conditions. EC , EP 1 Phase 2 Includes additional deletions Includes consolidations of similar concepts to streamline volume of requirements Customer engagement occurred with majority positive feedback Approval, implementation plan and timeline pending Project Refresh in the Accreditation Process 2017 Joint Commission Resources 34 of 56

35 SAFER Matrix Survey Analysis for Evaluating Risk (SAFER) A transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys Helps organizations prioritize and focus corrective actions Provides one, comprehensive visual representation of survey findings Replaces current scoring methodology Implementation: January 2017 Was implemented June 6, 2016 for deemed Psychiatric Hospitals only Current State Multiple different taggings Attempt to pre-determine risk through: Direct versus Indirect, A category vs. C category, Measure of Success (MOS) sometimes required Risk Icon sometimes applied Problem Require extensive upkeep Can be confusing to customers At times are contradictory Creates a one size fits all approach Solution Develop one single, comprehensive method of categorizing the risk associated with standards 2017 Joint Commission Resources 35 of 56

36 A New SAFER Concept Likelihood to Harm a Patient Increasing Risk Scope What Is SAFER? The Survey Analysis for Evaluating Risk (SAFER ) is a transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys. The additional information related to risk provided by the SAFER Matrix helps organizations prioritize and focus corrective actions. The SAFER Matrix provides one, comprehensive visual representation of survey findings in which all Requirements for Improvement (RFIs) are plotted on the SAFER matrix according to the likelihood of the issue to cause harm to patients, staff or visitors, in addition to how widespread the problem is, based on the surveyor s observations. The SAFER Matrix replaces the current scoring methodology, which is based on pre-determined categorizations of elements of performance (such as direct and indirect impact) instead allowing surveyors to perform real-time, on-site evaluations of deficiencies. Placement of RFIs within the matrix will determine the level of detail required within each RFI s Evidence of Standards Compliance follow-up Joint Commission Resources 36 of 56

37 The Joint Commission s Survey Analysis for Evaluating Risk (SAFER) Matrix You can type findings in each applicable box, e.g., IC , EP1 A New SAFER Model Immediate Threat to Life (follows current ITL processes) 2017 Joint Commission Resources 37 of 56

38 IC The hospital implements infection prevention and control activities when doing the following: IC , EP 4 Storing medical equipment, devices, and supplies. A colonoscope used for the operating room was stored in an operating room cabinet with the tip of the colonoscope touching supplies stored in the bottom of the cabinet. During an upper endoscopy procedure, a GI technician entered the endoscopy suite from the adjoining endoscope reprocessing room in order to place a processed endoscope into storage. This practice posed an unacceptable risk of cross-contamination. During an endoscopy procedure, the GI technician opened the endoscope storage closet to retrieve a CLOtest kit. This action had the potential to expose the stored endoscopes to aerosolized particles in the endoscopy suite. During a tour of the Endoscopy Department, note was made of the endoscope storage cabinets with the doors wide open with scopes stored in the cabinets. Staff explained that it was the practice in the department to leave the doors open during the work day. This resulted in an opportunity for air borne contaminants to deposit on the cleaned/stored scopes In the supply room was an opened and partially used bottle of 0.9% normal saline used for dental irrigation. The bottle was not labeled with the open date, and the instructions on the bottle stated 'discard unused portion'. During the building tour in the pediatric area, the intake room and two examination rooms were observed. Located under the sinks in all three areas were multiple boxes of gloves at risk of damage from water. During the building tour it was noted that in the radiology area there were several cardboard boxes on the floor that appeared to be water logged. In addition, throughout this entire facility there were other cardboard boxes stored directly on the floor at risk for water damage. How Is Risk Determined? Operational definitions and anchors Surveyor experience and expertise will provide the support to determine the scope and likelihood to harm for the finding Based on the context of the finding Discussion amongst the survey team Example #1 Immediate Threat to Life (follows current ITL processes) It was observed that there was an entry in the record which had not been authenticated and/or dated and timed. The Intake assessment had been signed by the author but the entry was not dated and timed Joint Commission Resources 38 of 56

39 Example #2 Immediate Threat to Life (follows current ITL processes) An open electrical junction box with exposed wiring was observed above the ceiling in the 2nd floor corridor by patient room An open electrical junction box with exposed wire connections was observed on the wall behind the dry sprinkler valve in the basement mechanical room. Two (2) open electrical junction boxes with exposed wire connections were observed under the ceiling beam in the elevator equipment area in the penthouse. Example #3 Immediate Threat to Life (follows current ITL processes) Patient's diet had been changed on 3/14, but his treatment plan had not been updated as of the afternoon of 3/15; patient was on Aspiration Precautions due to his swallowing difficulties with his cerebral palsy, so diet played a major part in his treatment Joint Commission Resources 39 of 56

40 Example #4 Immediate Threat to Life (follows current ITL processes) It was observed that the grab bars posed a ligature risk because they were not continuous with the wall. The handicap grab bars were located on both sides of the hallways on all units currently in use. The organization reported that all of the handicap grab bars in hallways were similar to this. Example #5 Immediate Threat to Life (follows current ITL processes) While observing the process for cleaning instruments after a surgical procedure it was observed that the tech did not spray the used instruments with an enzymatic cleaner prior to transporting them to the decontamination room. Staff indicated that this was not a process in place at this facility Joint Commission Resources 40 of 56

41 A Picture Is Worth a 1,000 Words... Immediate Threat to Life MM , EP 8 MM , EP7 MS , EP5 PC , EP4 PC , EP6 PC , EP1 PC , EP5 MIM , EP3 MS EP1 MS , EP3 IC , EP2 IC , EP4 RC , EP19 RC , EP4 Benefits of the SAFER Matrix Focus on patient safety/risk to patients Risk analysis Takes each finding to the next level the so-what? as to why the finding is important Visual representation of survey Indicates severity of findings to organizations for prioritization More clearly identifies the highest risks Aggregate data for standards refinement, improving consistency, etc Joint Commission Resources 41 of 56

42 Sample Report NOTE: This is a sample report and the findings and placement of standards and elements of performance within the SAFER matrix do not represent findings or placement within the SAFER matrix for any future onsite events. Where Will SAFER Be in the Report? Report Contents page SAFER Matrix Description page Survey Analysis for Evaluating Risk (SAFER) Matrix Likelihood to Harm and Scope designations for each EP Report Contents Page 2017 Joint Commission Resources 42 of 56

43 SAFER Matrix Description Page 2017 Joint Commission Resources 43 of 56

44 SAFER Matrix Element of Performance Likelihood to Harm and Scope Designations 2017 Joint Commission Resources 44 of 56

45 Post Survey Follow-up Follow-up Actions Follow-up customized and prioritized according to placement within SAFER Matrix Prioritized Follow-up Action ESC Changes All Requirements for Improvement (RFIs) due in a 60 day ESC 45 day ESC no longer applicable All findings will require an ESC OFI section of the report no longer applicable Findings of higher risk will require 2 additional ESC fields Current ESC Fields WHO WHAT WHEN HOW *These are required for all RFIs cited during the survey 2017 Joint Commission Resources 45 of 56

46 New ESC Fields Only for findings cited within the higher risk areas (dark orange and red areas of SAFER matrix) Includes 2 new fields: 1. Leadership Involvement 2. Preventive Analysis Leadership Involvement The measure of the success of change is in its sustainability within organizations Success and sustainability are highly influenced by support from the top level of leadership Types of Leadership Involvement Providing resources (e.g. staff, money, expertise) Serving as a champion of the change Direct participation on teams Motivating employees Establishing intervals for communication and/or reporting Direct oversight of change *This list provides examples of leadership involvement. It is not an exhaustive or prescriptive list as to how organizations should incorporate leadership involvement into the corrective action plan Joint Commission Resources 46 of 56

47 Leadership Involvement ESC Preventive Analysis Ensures the corrective action does not simply fix the issue at hand Focuses on identifying and addressing underlying reasons that caused the issue Efforts also focused on preventing future occurrences of the high risk issue Preventive Analysis Questions What went wrong? Why did this happen? What process(es) failed? What is the underlying reason why this went wrong? *This list provides examples of questions surrounding Preventive Analysis. It is not an exhaustive or prescriptive list as to what questions organizations should incorporate within their analysis Joint Commission Resources 47 of 56

48 Preventive Analysis - ESC What Does This Mean? Beginning January 2017 SAFER implemented for all accreditation and certification programs No more Direct and Indirect EP designations Consolidated ESC into one 60-day timeframe No more A or C categories No more Opportunities for Improvement (OFIs) No more Measures of Success (MOS) For all surveys: The SAFER matrix will be implemented for the organization as a whole (including tailored programs) The SAFER matrix will be generated and embedded within the survey process and the final report Matrix data will be shared with the customer Matrix data will drive the updated post-survey process Resources Available Extranet Site: 2017 Joint Commission Resources 48 of 56