Created in 2008, the Joint Commission Center for Transforming Healthcare aims to solve health care’s most critical safety and quality problems. The Center’s participants–some of the nation’s leading hospitals and health systems – use a systematic approach to analyze specific breakdowns in care and discover their underlying causes to develop targeted solutions that solve these complex problems. In keeping with its objective to transform health care into a high reliability industry, The Joint Commission shares these proven effective solutions with the nearly 21,000 health care organizations it accredits and certifies. Hospitals have made significant advances in quality–even better results are now achievable. Hospitals and The Joint Commission are working together to improve systems and processes of care.
The Element of Performance, or EP Review Project is a multi-phased component of Project REFRESH, which, as you know is a series of interrelated process improvement initiatives The Joint Commission is conducting throughout 2016 and 2017. The Joint Commission recently completed the second phase of its EP Review Project, resulting in the deletion of 51 additional EPs for hospitals. These deletions are effective January 1, 2017.
Also effective January 1, 2017, The Joint Commission will implement three changes to the clarification process. During the survey, the surveyors and the organization will work together to identify, and correct any clerical errors in the report. If clerical errors are identified post survey, The Joint Commission will work with the organization to make the needed corrections. Secondly, the audit option will no longer be a part of the clarification process. Clarification audits involved Category C elements of performance, which will be eliminated with the upcoming implementation of the Survey Analysis for Evaluating Risk, or SAFER Matrix. Finally, Findings of “lack of required documentation at the time of survey” will no longer be eligible for the clarification process. When an organization does not have required documentation available at the time of survey, the organization can expect that the surveyor will give the organization a reasonable amount of time to produce missing documents.
These changes will apply to all accredited organizations and certified programs.
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, 2017. The SAFER matrix 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.