How to Prepare for Accreditation 360

January 1, 2026 marks the official start of the Joint Commission’s Accreditation 360 — a complete overhaul of how hospital standards are organized and written. The goal isn’t to make accreditation harder; it’s to make it clearer, simpler, and more aligned with the CMS Conditions of Participation (CoPs).

But simplification doesn’t mean “set it and forget it.” Hospitals still need to do some focused prep work to ensure a smooth transition.

As Jim Grana, Field Director at the Joint Commission, explains: “The standards are changing; the survey process is not. If you were survey-ready before, you’ll be ready again — as long as your documentation matches the new format.”

Step 1: Understand What’s Changing (and What’s Not)

The survey process itself will look familiar — same tracers, same SAFER matrix, same survey complement. What’s changing is how standards are structured and labeled.

• Environment of Care (EC) and Life Safety (LS) chapters are being consolidated into Physical Environment (PE).
• Some requirements move into the new National Performance Goals (NPG) chapter.
• The total number of standards and elements of performance (EPs) drops by roughly 50–75 percent.

It’s a reshuffle, not a rewrite. The codes, expectations, and survey methods remain the same.

Step 2: Start with the Joint Commission’s Free Resources

The Joint Commission has released a set of pre-publication tools that are open to everyone. The most useful for facilities teams include:

1. PE and NPG Webinars – 25–30 minute overviews explaining how the old EC/LS standards map to the new structure.
2. Survey Process Guide (2025 edition) – the updated version of the Survey Activity Guide, complete with tracer tools.
3. Disposition Report – your crosswalk showing exactly where each standard and EP landed: deleted, moved, or revised.
4. Crosswalk Compare Report – aligns CoPs with both the old and new standards.
5. Accreditation 360 FAQ – updated regularly with real questions from the field.

Step 3: Map Your Current Program to the New Structure

Run a crosswalk exercise inside your own hospital.

• Take your EC/LS documentation and map each item to its new home in PE or NPG.
• Highlight gaps where your current references, policies, or training materials still use the old terminology.
• Update binders, electronic files, and intranet pages to match the new labels — it will prevent confusion during survey prep.

If your organization has a shared drive or compliance portal, make sure the new “PE” and “NPG” folders are clearly labeled and populated.

Step 4: Conduct a Mock Survey Using the New Tools

The Survey Process Guide contains updated versions of the surveyor tools you already know — document review, building tour, kitchen tracer, emergency management tool, etc. Use them to perform a mock survey between now and the end of 2025.

• Walk the building with the updated checklists.
• Log findings and classify them using the SAFER Matrix (risk × pervasiveness).
• Review documentation the same way surveyors will — to the new PE and NPG references.

Think of it as an open-book test; all the answers are in the Survey Process Guide.

Step 5: Tighten Competency and Job Description Documentation

Under NPG, competency and training expectations remain, but they’ll be reviewed more closely. Ensure every facilities role has:

• A current job description that reflects what the person actually does.
• Evidence (degrees, licenses, certifications) that matches the job description.
• Documented competency assessments showing periodic skill validation.

Surveyors will verify that your documentation supports your stated expectations — not prescribe new ones.

Step 6: Communicate Across Leadership and Clinical Partners

Don’t keep Accreditation 360 in the facilities silo. Brief nursing, quality, safety, and leadership teams on what’s changing. Make sure everyone understands that:

• The process is the same.
• The standards are reorganized.
• The surveyors are trained and ready.

This helps reduce anxiety and ensures consistent messaging when surveyors arrive.

Step 7: Stay Connected and Keep Learning

Between now and the rollout, new FAQs, interpretations, and examples will continue to appear in Perspectives and EC News. Set aside 15 minutes a month to review updates and adjust your internal references. If possible, attend a Base Camp or Accreditation 360 overview session from the Joint Commission to see how other organizations are preparing.

The Bottom Line

Preparing for Accreditation 360 isn’t about learning a new system — it’s about making sure your documentation, terminology, and training match the new structure.

Focus on:

• Mapping EC/LS → PE/NPG
• Verifying documentation
• Refreshing competency and training files
• Communicating clearly across departments

Do that, and your 2026 survey will look and feel just like your last successful one — only cleaner, clearer, and more streamlined.

Accreditation 360 isn’t a new game. It’s the same game with a better rulebook.

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