After this session you’ll be able to:

1. Explain the SAFER Matrix used by The Joint Commission (TJC).
2. Discuss how to assess risk using mitigation strategies for compliance to the SAFER Matrix.
3. Identify tools for creating and implementing required corrective action plans.

Why this is important:

The SAFER Matrix has been introduced to all hospitals that have TJC accreditation to better identify and communicate risk levels associated with deficiencies cited during accreditation surveys. The findings could be widespread or a one-time deficiency using the new matrix.

With this new initiative, findings that could cause harm to patients, staff, or visitors will be cited, and expectations are that each standard cited will be addressed by an action plan following the Evidence of Standards compliance. Learn how to complete an action plan using the Evidence of Standards for corrective action tools and how to write mitigation and risk plans to meet compliance within a 30- to 45-day revisit of TJC for TJC matrix findings. The work continues as the Road to Zero is achieved!