Infection Control and Prevention Affected by Joint Commission Survey Process Changes

By on 4:33 AM

The Joint Commission survey process has undergone some changes for 2017 that affect infection control and prevention and should be of interest to hospitals, ambulatory surgery centers (ASCs) and other provider organizations.

New Scoring Methodology

The Joint Commission is using a new scoring methodology called SAFER (Survey Analysis for Evaluating Risk). It is described as "a transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys."

Part of The Joint Commission's multiphase process improvement project dubbed "Project REFRESH,"  this new scoring process became effective Jan. 1, 2017, for all accreditation and certification programs. Note: It was first implemented in June 2016 for psychiatric hospitals that use Joint Commission accreditation to meet the Centers for Medicare & Medicaid Services (CMS) deemed status requirements.

The SAFER methodology incorporates the use of the SAFER Matrix. The SAFER Matrix replaces the previous scoring methodology based on predetermined categorizations of elements of performance.

Rather, the SAFER Matrix allows "surveyors to perform real-time, on-site evaluations of deficiencies. These are then placed on the SAFER Matrix according to the likelihood of the issue to cause harm to patients, staff or visitors, according to how widespread the problem is, based on the surveyor's observations."

The Joint Commission says use of the matrix will allow organizations "to see areas of noncompliance at an aggregate level, showing significant components of risk analysis."

As an article from APIC about the new scoring methodology notes provides an example of how different infection prevention- and control-related findings might be placed in the matrix.

Use of the new scoring model also result in changes to post-survey follow-up activities.

Extra On-Site Surveyor for ASCs

In 2017, roughly two-thirds of Joint Commission-accredited ASCs using the Medicare-deemed option may have an extra on-site surveyor and need to allocate a larger time commitment from leaders and staff, according to a report from Michael Kulczycki, The Joint Commission's executive director of ambulatory health care.

Kulczycki notes that one of the reasons for the additional surveyor is the completion of "CMS mandated patient tracers, medical records, credentialing files and an 82-question infection control worksheet."

While the second surveyor will likely lead to increased scrutiny of an ASC's practices and compliance with standards and regulations, it will also, as Kulczycki states, help deliver a "meaningful, consultative survey experience."

Infection Control Consulting Services (ICCS) is a national provider of hospital infection prevention and ambulatory surgery infection prevention consulting services. These services include accreditation survey preparation, utilizing standards set forth by CMS and The Joint Commission; assistance with plans of correction related to survey deficiencies; mock surveys; and on-site or remote educational programs. Contact ICCS to learn how its team of expert consultants can assist your organization.

Phenelle Segal, RN, CIC, FAPIC

Phenelle Segal, RN, CIC, FAPIC, is the founder and president of Infection Control Consulting Services LLC (ICCS). Phenelle has more than 30 years' experience providing customized comprehensive infection control and prevention services to healthcare facilities nationwide. Her services focus on assisting hospitals, ambulatory surgery centers, dental office and oral surgery practices, doctor's offices, nursing homes and other organizations with implementing and maintaining an infection control program that: complies with The Joint Commission, AAAHC, Centers for Medicaid and Medicare Services (CMS) and other regulatory agencies; respond to situations of noncompliance; and improve the processes for reducing risk.