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TJC’s SAFER matrix has been around since January 2017. Feedback from the field has been very positive. At the same time, clients often ask just how surveyors make decisions about scoring on the matrix. So, let’s take a closer look at that.

SAFER Matrix Decisions

TJC has guidelines for scoring the SAFER matrix. Yet, there’s admittedly a degree of subjectivity involved.

On team surveys, there are occasionally robust discussions about where to place a finding on the matrix. As a result, surveyors sometimes contact TJC Central Office to make a final decision.

At the recent annual Behavioral Health Care Conference in Chicago, TJC shared insights about how surveyors make these decisions so we’ll take a look at those. We’re also sharing examples of the various categories of SAFER matrix findings directly from our clients’ recent surveys.

SAFER Matrix Operational Definitions

Surveyors evaluate each Requirement for Improvement (RFI) and Element of Performance (EP) against two key factors when placing it on the matrix. The first is the Likelihood of Harm to patients.  The second is the Scope of the noncompliance.

Likelihood of Harm

Surveyors score the Likelihood of Harm as Low, Moderate, or High. Seems like this could be a tough thing to predict. So, let’s review the guidelines they use.

Low Likelihood of Harm means harm to a patient could happen but would be rare. This is typically a safety or quality issue that’s not best practice but unlikely to directly harm a patient.

Moderate Likelihood of Harm means harm could occasionally happen. The surveyors think if the deficiency continues, harm could possibly occur but only in certain situations and/or for certain patients.

High Likelihood of Harm means harm could happen at any time. Surveyors think if the deficiency continues, it’s likely that harm could occur at any time to any patient (or actually did happen.)

Scope of Noncompliance

Surveyors score the Scope of Noncompliance as Limited, Pattern, or Widespread. So, what are the guidelines for that?

Limited Scope means surveyors see the noncompliance as not representative of the organization’s routine practice. The deficiency affects a limited number of patients or it occurs in a limited number of locations. Essentially, it’s an outlier.

Pattern Scope means surveyors have seen multiple occurrences of the deficiency. It affects more than a limited number of patients and/or it occurs in several locations.

Widespread Scope means surveyors have observed the deficiency as pervasive throughout the organization. They see it as representing a systemic failure.

SAFER Matrix: Examples of Scoring

The following are some real-life examples of recent TJC survey findings and their scoring on the SAFER matrix.

Low Likelihood of Harm and Limited Scope

PC.01.02.13 EP 3: “In one of five patient records reviewed, the record lacked a psychosocial assessment.”

Low Likelihood of Harm and Pattern Scope

PC.01.03.01 EP 1: “Seizures listed on treatment plan but not on problem list. CVA (cerebrovascular accident) listed on problem list but not in treatment plan. Parkinsonism not addressed on treatment plan.”

Low Likelihood of Harm and Widespread Scope

LD.04.03.09 EP 4: “Contracts for direct patient care vendors did not include any quality metrics to describe the organization’s expectations of the vendor providing these services. The CFO assisting the surveyor with contract review confirmed this.”

Moderate Likelihood of Harm and Limited Scope

MM.03.01.05 EP 2: “The medication cart contained multiple medications brought into the facility by residents. There was no documentation that reflects the medications were verified by identity and that the medications were examined for integrity.”

Moderate Likelihood of Harm and Pattern Scope

HRM.01.02.01 EP 1: “The organization had not verified through the primary source the Medical Director’s DEA registration. In addition, a case manager and technician’s alcohol and drug registration had expired. The organization did not have documentation at the time of expiration that the primary source was queried to ensure active licensure.”

Moderate Likelihood of Harm and Widespread Scope

MM.04.01.01 EP 1: “The organization did not have a policy or process to ensure the standing order given by the Medical Director for over-the-counter medications provided instructions to staff members monitoring self-administration of medication of when to give these medications to clients.”

High Likelihood of Harm and Limited Scope

PC.01.02.08 EP 2: “One of the hospital’s identified interventions to reduce falls was to activate the bed alarm for patients assessed as high fall risk. It was noted that for a patient identified as a high fall risk, the bed alarm was not functioning due to bed not being plugged into outlet. This was confirmed by the Director of Social Services.”

High Likelihood of Harm and Pattern Scope

NPSG. EP 1: “During a tour of the Intake and Assessment area, it was observed that patients awaiting intake/admission can access the bathroom in the hallway. The fixtures inside the bathroom are ligature resistant. However, the door hinging and door knobs are traditional and allow for loop capability. Video monitoring only allows for monitoring inside the waiting room area.”

High Likelihood of Harm and Widespread Scope

NPSG. EP 3: “In 6 of 6 patient records reviewed, Hospital policy states that patients on suicide precautions are required to have a nursing suicide assessment daily. The nursing progress note is completed twice a day and the nurse identifies per a checklist the status of suicidal behavior. This is completed for all patients. There is not a separate suicide assessment for patients identified as increased risk for self-harm. The checklist does not document a thorough review of patient’s risk factors on each shift. In addition, the nursing progress notes did not indicate a risk factor or plan for providing for patient’s safety.”

Post Survey: Evidence of Standards Compliance

Remember, there are certain categories of higher risk SAFER matrix findings that require additional detail when you submit your Evidence of Standards Compliance after your survey. These include the following:

  • Any findings in the High Likelihood of Harm category
  • Findings in the Moderate Likelihood of Harm category rated as either a Pattern scope or a Widespread scope.

In these cases, you must answer questions about leadership involvement in implementing the corrective action. Specifically: “Which members of the leadership team will support future compliance?”

Likewise, you must also describe how you conducted preventive analysis. Specifically: “What analysis was completed to ensure not only the noncompliant issue was corrected (surface/high level resolution) but also any underlying reasons for the failure were addressed as well?


For additional info on how the SAFER matrix impacts your organization, see our earlier post SAFER Matrix: Update for Psychiatric Hospitals and BH Organizations.

Also, see TJC’s Fact Sheet on the SAFER Matrix Scoring Process and their SAFER Matrix Extranet Tool Video Demo.

Barrins & Associates

When we conduct our Mock Surveys, we always include a SAFER matrix display of your findings – just like TJC. Clients tell us it really helps their leadership teams zero in on the top priorities. And also helps support their continuous readiness – the key to survey success!