Survey Analysis for Evaluating Risk (SAFER ) Insights July 13, 2017 Caroline Heskett, MPH The Joint Commission, Accreditation & Certification Operations Project Manager, Business Transformation
Objectives Review SAFER Matrix concept Review the application of SAFER onsite (including operational definitions) Discuss two anchor examples Provide information on Post Survey Follow-up Share Ambulatory specific SAFER data Review FAQs SAFER slide 2
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 SAFER slide 3
Previous 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 SAFER slide 4
Problems Require extensive upkeep Can be confusing to customers At times are contradictory Creates a one size fits all approach SAFER slide 5
Solution Develop one single, comprehensive method of categorizing the risk associated with standards SAFER slide 6
A New SAFER Model Immediate Threat to Life (follows current ITL processes) HIGH Likelihood to Harm a Patient/Visitor/Staff MODERATE LOW LIMITED PATTERN Scope WIDESPREAD
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 Data from the BI tool SAFER slide 8
Operational Definitions Applied at the organization level Looks at the scope of patients impacted (or potentially impacted) by an issue of noncompliance Shift from historical approach of counting observations Now we want to assess the patient impact, or potential impact, of an issue(s) SAFER slide 9
Scope Category Definition Further Guidance LIMITED PATTERN WIDESPREAD Unique occurrence that is not representative of routine/regular practice, and has the potential to impact only one or a very limited number of patients, visitors, staff Multiple occurrences of the deficiency, or a single occurrence that has the potential to impact more than a limited number of patients, visitors, staff Deficiency is pervasive in the facility, or represents systemic failure, or has the potential to impact most/all patients, visitors, staff An outlier. Scope is isolated when one or a very limited number of patients are affected and/or one or a very limited number of staff are involved, and/or the deficiency occurs in a very limited number of locations. Process Variation. Scope is pattern when more than a very limited number of patients are affected, and/or more than a very limited number of staff are involved, and/or the situation has occurred in several locations, and/or the same patient(s) have been affected by repeated occurrences of the same deficient practice. Process Failure. Scope is widespread when the deficiency affects most/all patients, is pervasive in the facility or represents systemic failure. Widespread scope refers to the entire organization, not just a subset of patients or one unit. SAFER slide 10
Likelihood to Harm Category Definition Further Guidance LOW MODERATE HIGH Harm could happen, but would be rare Harm could happen occasionally Harm could happen at any time Undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm. It would be rare for any actual patient harm to occur as a result of the deficiency. Could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures. If the deficiency continues, it would be possible that harm could occur but only in certain situations and/or patients. Could directly lead to harm without the need for other significant circumstances or failures. If the deficiency continues, it would be likely that harm could happen at any time to any patient (or did actually happen) SAFER slide 11
Example SAFER Matrix Immediate Threat to Life HIGH MM.03.01.01, EP8 MM.03.01.01, EP7 Likelihood to Harm a Patient/Visitor/Staff MODERATE MS.01.01.01, EP5 PC.01.02.01, EP4 PC.01.02.03, EP6 PC.01.03.01, EP1 PC.01.03.01, EP5 IM.02.02.01, EP3 MS.08.01.01. EP1 MS.08.01.03, EP3 IC.02.01.01, EP2 IC.02.02.01, EP4 LOW RC.01.01.01, EP19 RC.02.03.07, EP4 LIMITED PATTERN Scope WIDESPREAD
SAFER Matrix Tool: Will show all RFIs from the final report for event selected with observations underneath the matrix SAFER slide 13
Filters: Tool allows organizations to filter RFIs Provides more dynamic interaction with the survey/review information Filter categories include: Program Standards Chapter Condition of Participation (or Condition for Coverage for ASC) Site CLIA number SAFER slide 14
Anchor Examples
Example #1 - AHC EC.02.06.01, EP1 The surveyor noted that in 1 of 3 of the Post-Surgical Recovery Area patient restrooms, the nurse call button was not functioning. Because patients using this restroom are recovering from surgery and anesthesia, they may become unsteady and at risk of falling and would be unable to access immediate assistance if needed. Staff indicated they were not aware of the one call button in the Post- Surgical Recovery Area not functioning. SAFER slide 16
Rationale Patients using this restroom are recovering from surgery & may become unsteady as a result of anesthetic medications administered for surgery These patients are at high risk of harm if they experience dizziness or feel unsteady & require immediate assistance; therefore, High likelihood to harm One nurse call button was found to be nonfunctional. This appears to be an isolated issue & is not a widespread problem; therefore, Limited in scope SAFER slide 17
Example #2 AHC PC.03.01.03, EP6 For 3 of 8 patients, History and Physical examinations (H&P) were performed more than 30 days prior to the patient's surgery with no updated assessment prior to the procedure. For the first patient, the H&P was dated October 16 and the procedure was performed on January 4th. For the second patient, the H&P was dated November 30th and the procedure was performed on January 8th. For the third patient, the H&P was dated October 26th and the procedure was performed December 14th. Policy states that a new H&P must be performed if the original examination is dated more than 30 days before the procedure is to be performed. SAFER slide 18
Rationale It is important to ensure that no changes in the health/medical status of patients has occurred to help prevent issues or complications that could result during surgery. If a change had occurred in medical/health status this could place a patient at Moderate risk of harm, especially in the presence of other circumstances or additional failures For several patients (3 of 8), history & physicals were not performed within 30 days of scheduled elective surgical procedures with no updated assessments prior to the procedure. In the majority of cases H&Ps were completed appropriately. As a result, this issue appears to be a pattern of performance variation, but doesn t represent a pervasive or systemic problem & Pattern in scope SAFER slide 19
Additional Anchor Examples Located on organization s Extranet site Created for each program (including Certification) Provides observation, placement on SAFER matrix and rationale for placement Currently available SAFER slide 20
Post Survey Follow-up
Follow-up Actions Follow-up customized and prioritized according to placement within SAFER Matrix SAFER slide 22
Prioritized Follow-up Action SAFER Matrix Placement Required Follow-Up Activity HIGH/LIMITED, HIGH/PATTERN, HIGH/WIDESPREAD 60 day Evidence of Standards Compliance (ESC) ESC will also include two additional areas surrounding Leadership Involvement and Preventive Analysis MODERATE / PATTERN, MODERATE/WIDESPR EAD Finding will be highlighted for potential review by surveyors on subsequent onsite surveys up to and including the next full survey or review MODERATE / LIMITED, LOW / PATTERN, LOW / WIDESPREAD LOW/LIMITED 60 day Evidence of Standards Compliance (ESC) SAFER slide 23
ESC Changes All Requirements for Improvement (RFIs) due in a 60 day ESC 45 day ESC no longer applicable All findings require an ESC OFI section of the report no longer applicable Findings of higher risk require 2 additional ESC fields *No more Measures of Success (MOS) *Note: This does not apply to Sentinel Events where a MOS is required. At this time, the submittal of a MOS for Sentinel Events is still required. SAFER slide 24
Leadership Involvement Success of change is dependent on its sustainability within organizations Success and sustainability are highly influenced by support from the top level of leadership SAFER slide 25
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 SAFER slide 26
Additional Items to Note
What is NOT Changing? 1. Adverse decision determination during survey 2. Immediate Threat to Life process 3. Determination of Condition Level Deficiency (CLD) process (applies to those using TJC for deeming purposes) 4. Onsite survey activities utilized during survey (i.e. Tracer Methodology, Record Review, etc.) SAFER slide 28
How do I prepare? Preparing for a SAFER survey is the same as preparing for a survey today: 1. Ensure full understanding of requirements 2. Continue conducting self-assessments of compliance 3. Review SAFER information located on your organization s secure Extranet site SAFER slide 29
What s Next
Feedback Implemented January 2017 for all accreditation and certification programs Voice of Customer Surveyor feedback Organization feedback SAFER slide 31
Data Analysis Business Intelligence tool Collecting SAFER placement across all programs Looking for statistically significant trends for: Standard placement EP placement Variation across programs Data will help identify areas for improvement SAFER slide 32
Data Analysis: SAFER Benchmarking Proportion of SAFER Category Scores for AHC 2.53% Likelihood to Harm a Patient/Staff/Visitor HIGH 1.83% 2.83% 2.65% 7.31% MODERATE 14.58% 16.62% 10.25% 41.44% LOW 26.44% 13.47% 11.32% 51.24% 42.85% 32.92% 24.23% LIMITED PATTERN WIDESPREAD Scope *Data as of 6/30/2017
Most Frequently Cited AHC Standards For Full and Initial Ambulatory surveys from 1/1/17 through 6/30/17 SAFER slide 34
Frequently Asked Questions
Will the ICM/FSA/AMP tools be updated with SAFER? Yes, all tools have been updated with the new SAFER process Have the option to identify Likelihood to Harm and Scope designations Not required Optional for organizations to use SAFER matrix will be created within tool SAFER slide 36
Which surveys/reviews does SAFER apply to? SAFER applies to all accreditation surveys and certification reviews Includes: Initial surveys/reviews Full resurveys/reviews Follow up surveys/reviews Intracycle surveys/reviews (i.e. Extension Survey) SAFER slide 37
How does SAFER play into the final decision for an organization? Final SAFER matrix visual will not drive the final accreditation/certification decisions Final accreditation/certification decisions will be made through the same decision process used historically SAFER slide 38
Will the Clarification Process be impacted by SAFER? Overall clarification process still remains Have 10 business days (starting day final report received) to complete/submit What s changed with clarifications: 1. Required Documents are not eligible for Clarification (checklist under development) 2. Audits are no longer an option for Clarifications (removal of C EPs) 3. Clerical Errors are not eligible for Clarification (but will be corrected) SAFER slide 39
Resources SAFER slide 40
Resources Available Extranet Site: SAFER slide 41
Internet Available to All www.jointcommission.org/safer SAFER slide 42
Questions? safer@jointcommission.org SAFER slide 43
The Joint Commission Disclaimer These slides are current as of 6/1/2017. The Joint Commission reserves the right to change the content of the information, as appropriate. These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides. These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission. SAFER slide 44