This May 2017 edition of Joint Commission Perspectives is full of important information about changes coming in 2017. The lead article is about an entirely new scoring methodology that will eliminate the A and C elements of performance as well as the direct and indirect categorization of elements of performance. Consultants and some quality staff may shed a tear at the loss of the C elements of performance. If you really understood how to conduct audits, these made for good clarification opportunities and elimination of findings. But farewell to the C elements, it was a good decade. In addition to eliminating the C elements, this also means the Opportunities for Improvement section, or OFI’s will also be gone. Next year any one observation against what used to be a C element of performance will now result in a finding that must be addressed in the ESC.
Replacing the existing scoring methodology will be a totally new logic developed by TJC called their SAFER Matrix. It basically is a risk assessment method, looking at the significance of a finding and how widespread the finding is. For example, a failure to time a paper medical record entry in one location, one chart would probably end up as low significance and limited scope within the hospital, thus using the SAFER methodology it would be deemed a low harm finding. This would contrast with a failure to pre-clean surgical instruments being returned to central sterile supply noted in all OR’s and all outpatient locations. This would likely be a high-risk issue with widespread application, thus in the red zone on the safer scoring method.
So what will it mean to be scored in the red zone? TJC indicates that a yet to be defined requirement will be created to add detail in the ESC on how the corrective action is going to be implemented and sustained. More practically, as senior leaders examine the report, those findings in the red zone should earn their attention, while those in the yellow area of the matrix might be considered minutiae, subject to more routine attention. TJC also hints that findings in the red zone might be subjected to an on-site validation. The article does not mention how the red zone scoring logic will play into the current method for identification of non-compliant COP’s. Given that CMS and TJC have historically used a “manner and degree” logic, it would seem likely that high risk issues/widespread issues will also be COP issues.
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