Why Competency Matters More Than Ever in Healthcare Facilities Management

As hospitals prepare for Accreditation 360 to go live on January 1, 2026, one topic is rising above all others: competency.

Not new — but newly important.

The Joint Commission’s revised structure replaces EC and LS with PE (Physical Environment) and NPG (National Performance Goals). While the survey process isn’t changing, the focus on how hospitals define, document, and demonstrate competency is sharpening.

“Organizations set their own expectations for individuals coming into these roles,” says Jim Grana, Field Director at the Joint Commission. “We simply validate that those expectations are being met.”

The Core Idea

Competency isn’t a certificate on a wall. It’s proof that people can do the work safely, effectively, and consistently — that facilities teams can operate systems supporting patient care without introducing risk.

The Joint Commission isn’t dictating what your job descriptions say. It’s ensuring your organization lives up to what it has written.

If your job description says a CHFM and a degree are required, surveyors will expect to see both. If it says five years of experience, there should be documentation validating that. That’s the standard: alignment and evidence.

Why This Matters Now

Hospitals everywhere are hiring from outside healthcare — from manufacturing, commercial real estate, and the military. The result? Teams with great technical skill but limited hospital-specific context.

That reality makes the definition of “competent” even more critical. Facilities leaders must clearly outline:

• What’s required for each role
• How competency is measured
• How performance is validated over time

Without that structure, organizations risk two outcomes: compliance findings and, more importantly, a slow erosion of institutional knowledge.

How to Get Ready

Here’s a simple tune-up checklist to run before your next survey:

1. Audit job descriptions – make sure they’re current and realistic for today’s workforce.
2. Match documentation to requirements – degrees, certifications, licenses, training logs.
3. Update competency assessments – evaluate performance, not just attendance.
4. Create a competency matrix – list key systems and who’s qualified for each.
5. Integrate into IDPs and onboarding – turn competency into a development tool, not just a compliance task.

Bottom Line

Competency connects everything: compliance, safety, workforce development, and succession planning. It’s not just about passing a survey — it’s about protecting patient safety and preserving knowledge as a generation of facility leaders retires.

When staff see that leadership invests in defining and tracking competency, they see a profession — not just a job.

The survey process isn’t changing — your documentation and alignment are. You define the expectations; the Joint Commission validates them. Competency is your strongest defense against both findings and turnover.

If you’re leading a facilities team, now’s the time to revisit your competency framework. Define it. Document it. Demonstrate it. That’s not just good survey prep — it’s smart leadership.

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