Joint Commission: Insight into the Top Cited Elements of Performance and SAFER Scoring


pic_connors_bryan150x180Bryan Connors

Environmental Health & Engineering, Inc.

Bryan Connors, Practice Director, Healthcare, provides technical expertise for hospitals in support of Joint Commission, Hospital Pharmacy USP, OSHA and EPA compliance, infection prevention, industrial hygiene, and hazardous materials management.

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Joint Commission: Insight into the Top Cited Elements of Performance and SAFER Scoring

Sweeping changes have been made to the Joint Commission standards and survey process. From the new “See it Cite it”, which ends decades long scoring protection from the Statement of Conditions (SOC) process, to a renewed focus on ligature risks in behavioral health setting, significant change has come to the Joint Commission. Annually the Joint Commission releases a ranking of the top 10 most cited standards. Many appear on the list year after year, with the Environment of Care (EC) and Life Safety (LS) standards still the most prevalent, typically comprising five or more of the top standards. What is missing from the list – and what would be most helpful to facility managers – is specifically what the issue was at the Element of Performance level. This session will shed light on the specific deficiencies behind the most commonly cited standards within the EC and LS, and where they are typically scored on the new SAFER matrix.

Data from nearly 50 EC and LS mock surveys and a half dozen Joint Commission surveys in 2017, under the SAFER matrix methodology, provides valuable insight into the specific issues behind the commonly cited standards and Elements of Performance. EH&E has access to this unique data set by conducting mock surveys and participating in Joint Commission surveys for hospitals across the northeast. The findings of our analysis will be shared to help facility managers better focus their resources for greater compliance and safety at their institution. The findings will be mapped to the Joint Commission’s SAFER matrix to clearly illustrate the risk and severity. This information is a useful, visual tool in communicating with hospital leadership to establish priorities and allocate the necessary time to resolve the more challenging deficiencies.

The changes present some good news for facility managers. Under the new scoring system the risk level is ranked by the specific finding – not the standard. This provides the institution with a much more realistic picture of critical vulnerabilities than the previous scoring method. Early analysis of the data illustrates this improvement in scoring. For example, missed deadlines and grace periods by vendors for testing of fire safety equipment are still prevalent in hospitals and are still cited during surveys. However, now the scoring for these types of deficiencies is ranked more appropriately when compared to completely missing the test, or relative to improper pressurization and ligature risks that present a more severe risk to patient safety.

Effective strategies and best practices for resolving the deficiencies that present the greatest risk to patients and the hospital will be discussed. Additionally, this session will review the key components of the SAFER methodology and provide participants with a picture of what they may expect during their next survey.