Can TJC Cure Your Survey Blues?

Do Joint Commission surveys make your staff sick? Higher levels of stress and a visit from The Joint Commission (TJC) correlate, and occupational stress is a major contributing factor to employee illness. Beginning January 1, 2017, TJC hopes to make surveys easier for everyone. In a self-improvement initiative, TJC developed the new Survey Analysis for Evaluating Risk (SAFER) matrix to create a more simplified, clear, and relevant process for scoring surveys. If you haven’t explored the implications of the new methodology, we suggest you read this post and examine how your organization may be affected.

COMMON COMPLAINTS OF THE PREVIOUS METHOD

PROBLEM: Organizations were frustrated by repeated citations for essentially the same standard.
SOLUTION: TJC removed a number of requirements from the Elements of Performance (EPs) that were deemed redundant, a routine part of policies and procedures, and already covered by external requirements.

PROBLEM: Organizations were confused by multiple labels for EPs that sometimes even resulted in contradictory findings.
SOLUTION: TJC eliminated Category A and Category C findings, Direct and Indirect Impact of EPs, Measures of Success (MOS) and the Risk Icons. Additionally, Opportunities for Improvement no longer apply because all observations of noncompliance are documented on the SAFER matrix.

PROBLEM: Organizations were frustrated and confused by different due dates for Direct and Indirect Impact citations.
SOLUTION: TJC changed the Evidence of Standards Compliance (ESCs) due date to a single timeframe—within 60 days. Note: Immediate Threats to Life findings did not change and will follow the same process as 2016.

SAFER MATRIX CHANGES AND POSSIBLE IMPLICATIONS

CHANGE: Plotting the degree of likelihood to harm a patient, visitor or staff on one axis against the range of its scope on the other axis, the SAFER matrix uses a color-coded chart to comprehensively depict the organization’s overall compliance.
IMPLICATIONS: With all infractions listed on the same matrix, it should be easier to identify widespread compliance issues. Furthermore, the severity of risk will be more obvious, allowing the organization to better prioritize corrective action.

CHANGE: All findings require ESCs within 60 days, and high-risk findings will require two additional fields to demonstrate how an organization will sustain the corrective actions. Observations falling in all dark orange and red boxes of the SAFER matrix will require new sections on the ESC for Leadership Involvement and Preventive Analysis in addition to Who, What, When and How. And these findings will be flagged for possible review in subsequent surveys.
IMPLICATIONS: With TJC emphasizing leadership’s enhanced culpability for creating and sustaining changes within the organization, surveys may create even more top-down stress for the staff, and more detailed ESCs may make it tougher to meet a 60-day deadline.

CHANGE: There will no longer be Opportunities for Improvement (these second-chance suggestions weren’t required to be addressed in an ESC). All surveyor observations will be plotted, and you either comply, or you don’t. Even if the finding presents low danger and is a one-time event, an ESC is required.
IMPLICATIONS: The potential number of required ESCs could dramatically increase. Note: During on-site ESCs for observations related to established processes, the surveyor may annotate the finding to reduce subsequent ESCs, but Requirements for Improvement (RFIs) will still be issued.

CHANGE:If all documents are not available for inspection at the time of survey, the organization is noncompliant. A RFI will be placed on the SAFER matrix regardless of whether the organization can later prove there was compliance at the time of survey since documents will not be eligible for the clarification process.
IMPLICATIONS: The need to closely monitor external vendors and staff for documentation compliance will be an added task to an already busy schedule for those in charge of maintaining compliance.

CHANGE:The surveyor will explain and point out RFIs during the survey and make it clear by stating the RFIs will appear on the survey report.
IMPLICATIONS: If the surveyor is citing an incorrect standard or misinterprets a standard, the organization’s healthcare survey team will have the opportunity to clear up the error.

CONCLUSION

As with any change, you have to take the bad with the good. The SAFER matrix eliminates redundant standards, highlights high-risk compliance issues and clarifies scoring consequences. Meanwhile, there is a potential for more paperwork, increased leadership responsibility and heavier staff/vendor oversight. The only sure way to reduce your stress is to be prepared. Knowing the standards for your organization and completing mock tracers using TJC’s SAFER matrix will ensure that you are taking steps towards continuous improvement. Providing this level of attention to your quality of care just might make it all worth it.

Let it out! What do you think the implications will be for your organization? What have you done to get ready for the change? Join us on social media, and join in on the conversation!