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The Joint Commission’s Accreditation 360 represents the most significant restructuring of hospital accreditation in years. Launching January 1, 2026, Accreditation 360 is designed to simplify and align standards with CMS Conditions of Participation (CoPs), reducing redundancy and clarifying expectations. The following comparison, based on insights from Field Director Jim Grana and official Joint Commission resources, highlights what’s changing—and what’s staying the same.
Key Differences: Old Process vs. Accreditation 360
|
Aspect |
Old Process (Pre‑2026) |
Accreditation 360 (2026+) |
|
Structure of Standards |
Separate chapters for Environment of Care (EC) and Life Safety (LS), with overlapping EPs across related chapters. |
Consolidated Physical Environment (PE) chapter replaces EC and LS; some requirements move to National Performance Goals (NPG). Over 700 requirements removed. |
|
Number & Redundancy |
Many standards and EPs with overlap and duplication between EC/LS and other chapters. |
Fewer standards and EPs; reduced duplication and streamlined structure. |
|
Survey Tools & Process Flow |
Used Survey Activity Guide, document review, building tours, and tracer tools tied to EC/LS. |
Same tools and tracers, now organized under PE/NPG; survey process remains unchanged. |
|
How Findings Are Reported |
Findings cited under EC/LS numbering (e.g., EC.02.03.05). |
Findings will use new PE/NPG identifiers (e.g., PE.03.11 EP3). Structure changes, not substance. |
|
Continuous Engagement & Support |
Traditional 3-year survey cycle with limited recognition of exceptional practices. |
Accreditation 360 introduces continuous engagement and the SAFEST framework to recognize strengths as well as deficiencies. |
|
Transparency & Public Access |
Limited public access to crosswalks and disposition reports. |
Disposition reports, crosswalks, and standards are publicly available online through Joint Commission resources. |
|
Alignment with CMS & CoPs |
EC/LS sometimes included additional requirements beyond CMS CoPs. |
Accreditation 360 fully aligns Joint Commission standards with CMS CoPs, reducing conflicting interpretations. |
What Doesn’t Change Under Accreditation 360
- The survey process, agenda, and tools remain identical.
- Criteria, codes, and expectations are unchanged.
- The SAFER matrix continues to determine finding severity (risk × pervasiveness).
- NFPA 101/99 (2012 editions) remain in effect; no new codes adopted.
- Requirements are reduced, not added.
Insights from Jim Grana and Joint Commission Resources
- Surveyor tools such as the Document Review Tool, Building Survey Tool, and Kitchen Tracer remain — only the nomenclature changes.
- Jim Grana emphasized 'no scope creep' — the standards have new labels, not new expectations.
- Findings are now classified under PE and NPG identifiers.
- Accreditation 360 introduces SAFEST (Survey Analysis For Evaluating Strengths), recognizing exceptional practices in addition to noncompliance.
- The new model reduces overlap, aligns with CMS, and enhances clarity for hospitals.
Practical Implications for Facilities Leadership
- Rename, don’t reinvent — existing compliance programs remain relevant under new titles.
- Update references and training materials to match PE/NPG terminology.
- Use disposition and crosswalk reports to map your EC/LS content to new standards.
- Prepare for SAFEST recognition by highlighting your department’s strengths.
- Ensure ongoing alignment with CMS CoPs to avoid contradictory interpretations.
Bottom Line
Accreditation 360 is a reorganization, not a reinvention. The standards are cleaner and more aligned, but the survey process remains familiar. For facilities leaders, the path forward is clear: update terminology, review documentation, and stay engaged with new Joint Commission resources. If your team was survey-ready before, you’ll be ready again in 2026 — only with a better playbook.
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