For clinical engineers, maintaining CMS compliance and keeping a hospital ready for Joint Commission inspection surveys means a continual education on constantly-evolving requirements. At the seventh annual Clinical Engineering Association of Illinois (CEAI) conference, George Mills, director of the Engineering Department and the Accreditation Organizations Department at The Joint Commission (TJC) addressed the crowd on some recent updates to certification policies and processes.

Key elements of the latest initiatives, according to Mills, are the implementation of the new SAFER matrix for accreditation surveys, the release of a new Physical Environment Portal, and a strong emphasis on hand hygiene among all health care workers in the interest of reducing hospital-acquired infections (HAIs).

Preparing for the SAFER Matrix
Mills related that TJC has improved its survey process by deploying the Survey Analysis for Evaluating Risk (SAFER) system. SAFER is a graphic method to communicate risk levels associated with standards non-compliance cited during surveys. The new scoring methodology was developed, according to Mills, to clarify the system of multiple “taggings” that TJC uses for Elements of Performance (EPs).

The SAFER Matrix replaces the current scoring methodology, which includes “A” category and “C” category EPs, Measures of Success (MOS) and the criticality model. Its goals are to more easily identify higher risk Requirements for Improvements (RFIs), better organize findings according to potential on patients, and present a single visual representation of survey findings.

Psychiatric hospitals that use TJC to meet CMS requirements have been getting accredited under the SAFER matrix since June and all other accreditation and certification programs will begin receiving it in their reports next year. Additional details on the SAFER approach to the survey and accreditation process can be found at the Joint Commission website.

Utilizing the physical environment portal
Along with other specific recommendations for preparing for surveys, Mills highlighted the new Joint Commissions Physical Environment Portal (JCPEP).

This resource is intended to provide guidance and education that will help reduce instances of non-compliance for the eight EC/LS standards that were most frequently identified in the 2014 survey. Provided at no cost, it will be updated with articles, videos and pictures to illustrate compliance, surveyor insights, including “fireside chats” for each of the eight standards, and recommended customer strategies.

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