Healthcare Facilities Network
The Healthcare Facilities Network podcast highlights the essential role of facilities
management in delivering high-quality patient care. Hosted by Peter Martin, this show brings you expert insights on the issues, trends, and solutions shaping the future of healthcare spaces. Learn from industry leaders and discover ways to drive positive change in your facility.
Healthcare Facilities Network
Joint Commission: New Rules for Hospital Safety and Standards
Joint Commission is rolling out Accreditation 360, a major update to hospital standards that takes effect January 1, 2026. In this episode of Healthcare Facilities Network, Jim Grana, Life Safety Code Field Director at Joint Commission, walks us through what these changes mean for hospitals and healthcare teams across the U.S.
Jim explains how the standards are being restructured, including a nearly 50% reduction in Elements of Performance for some hospitals, and offers practical guidance on how organizations can prepare. From understanding the new numbering system to identifying what’s critical for compliance, this episode makes Accreditation 360 clear and actionable.
Whether you’re directly involved in hospital compliance or just curious about how these updates impact healthcare operations, Jim provides insight, strategies, and perspective to help teams stay ahead of the changes.
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In terms of what happens, like the agenda is going to be the same. Um, as we talked about, the tools are all the same, the servers will be working off those tools and providing them to the organizations. It's just a change of the existing process, right? Because we're still doing the survey process, you know, we're still evaluating all of our life safety features and the uh physical environment features of the buildings, and we'll be scoring the same things, but they're just gonna go into a new location now.
SPEAKER_01:There's a major crisis facing healthcare facilities management. We have aging employees, aging buildings, and aging infrastructure. We've created the healthcare facilities network, a content network designed specifically to help solve for these three pressing issues in healthcare facilities management. We bring on thought leaders and experts from across healthcare facilities management, all the way from the C-suite to the technician level. Because at the end of the day, we're all invested in solving the aging issue. Thanks for tuning in. Look at our videos, you will find that is a theme across our content. This is the Healthcare Facilities Network. I'm your host, Peter Martin. For those of you who do not know, Jim is field director in the Division of Accreditation and Certification Operations at the Joint Commission. No, at Joint Commission, right, Jim? The is gone. Correct. At joint commission. That'll be uh that'll be a while. I mean, if you think about it, people are still saying Jaco after how many years, so that the is gonna hang around for a while. Probably. But, anyways, if you take anything from this, uh get rid of the the. In Jim's role, though, he manages and supports Joint Commission life safety code surveyors, implements and evaluates the accreditation survey process and performance, and serves as a faculty for educational programs throughout the United States. Jim, what else did I miss?
SPEAKER_00:Yeah, so a quick background on my healthcare experience. So um I worked for about a decade um in the Midwest here. I worked for an organization called Advocate Health, which has kind of changed names a few times since uh they've gone through some mergers and joiners. But uh I'm located out here in the Chicagoland suburbs area. Um, I started out in healthcare as a facilities mechanic where I got to experience all the life safety features and do all the inspection testing maintenance that we now, that I now get to survey to. Um, I worked my way up through that system, uh, got into safety management where I was an environmental care committee chair, uh, also was on our quality management oversight committee. And then I moved my way up to manage one of those sites that I was overseeing from the safety perspective as uh in the facilities management team at a we'll say a medium-sized hospital. Uh it wasn't small, but it also wasn't big. So uh that's my experience before then coming over to the joint commission where I started off in the standards interpretation group. Uh, and then this year I jumped in to join the field director team. Awesome, Jim.
SPEAKER_01:So people may have seen Jim before. He's been on our millennial roundtable group. But you know it's funny, as you were talking, Jim, I was thinking, I think we met in 2014 and you were literally still a technician. Correct. Kind of starting out, and now what, coming up on 12 years later? It's it's really kind of a testament to obviously your work ethic, your ability, but also kind of this healthcare career where there's you're passionate about what you do, where there's opportunity if you are passionate and want to make move up and make a difference. It's it's a tremendous, it's a tremendous path.
SPEAKER_00:There's also some great networking and tools and resources out there. You know, a shout out to all the local and regional Ashy um societies out there, which I now have the pleasure to go talk at. Um, but you know, I was a part of of Hesney, the the uh Northern Illinois uh engineering society, which had wonderful resources and was a great networking group, um, and a lot of individual individuals there that I keep in touch with to today. Um, you know, those things I can't shout their praises enough in terms of providing courses, education, opportunities to go survey hospitals or I should say uh audit hospitals and look at processes. So, you know, I tried to use as many of those as as possible to help um provide me with resources along the way. And yes, also just being kind of motivated to also get into it and being very passionate about life safety.
SPEAKER_01:Yeah, no, we certainly are. And so that brings us to so the topic for today's conversation is accreditation 360. So why don't we just start right there, Jim? What is accreditation 360?
SPEAKER_00:Accreditation 360 is Joint Commission's new accreditation process where we are revamping all of our standards, or as we usually call it, the accreditation manuals that apply to the hospital and the critical access hospital programs. And we have a lot of others, but these are the two that we're rolling this out for in 2026. Uh, it's a new consolidated, simplified accreditation manual, with the goal being to align the joint commission standards with CMS's state operations manual and the conditions of participation that accredited organizations that receive reimbursement from the centers for Medicare and Medicaid services provide. So that is in a nutshell what it is. So you mentioned conditions of participation. Are conditions of participation changing? The COPs or conditions of participation of participation are not changing. Okay.
SPEAKER_01:And when does accreditation 360 go into effect? January 1st, 2026. January 1st, 2026.
SPEAKER_00:So the hospital and critical access hospital program specifically.
SPEAKER_01:Yeah, very important, right? Hospitals and critical access hospitals.
SPEAKER_00:Correct.
SPEAKER_01:So is the survey process changing, Jim?
SPEAKER_00:No. So that is the critical part of all this. So for organizations who might have some anxiety about an upcoming survey, let's say they've got one coming up in 2026. Um, what we'd like to emphasize to you is the survey process you went through, let's say three years ago, um with our all of our survey activity guide, which is turning into the survey process guide, which we might get a chance to talk about later on in this call. The tools that we provided, like the document review tool, the buildings uh survey tour tool, uh the kitchen tracer tool. There's probably some others I'm forgetting, but all these tools that we have used and shared with organizations over the years to provide the survey process or the survey scope, uh, none of that is changing with this. For the life safety code survey or survey process, what's changing is really the nomenclature and the standards that we're using to then score items that we might find out of compliance during the survey process.
SPEAKER_01:What's the goal of A3 or accreditation 360? Or I think you guys are calling it what, A360? Yeah, A360, yeah.
SPEAKER_00:Yeah. So the the goal is really it is a consolidation and a unification with the COPs. So if you looked at our, for example, if you looked at the current accreditation manual, the way it's listed is it has the COPs, and then you have all the standards underneath them that you'd have to follow. Now, there are, when we say standards, it's probably pretty important for me to flush out the different types of standards out there. Like CMS has their standards, which they call KTAGs, uh, which there's 130 some odd K tags, which are all based on life safety and healthcare facilities code and the state operations manual. Then you have joint commission. We have our standards, which we call the standards and elements performance or EPs. And so there's a lot of what you would say, I call it like overlapping of interpretation on requirements. And what we're doing with accreditation 360 is we're trying to simplify the joint commission standards so they're better aligned with what CMS's requirements are. So instead of having all these different layers of interpretation on what's required, we're trying to simp uh simplify and unify it and align it with what those requirements are from CMS. Because at the end of the day, that's what we're accredited organizations are required to follow is CMS's conditions of participation.
SPEAKER_01:One of the big headlines out of A360 is the reduction in standards and the reduction in EPs. And I just, you know, we'll we'll roll these numbers by you. So currently, so current state, life safety, 23 standards, 260 EPs on the EC side, 21 standards, roughly 190 plus EPs. In the future state, beginning January 1st, 2026, that becomes that's under we're calling it the PE, correct? Yeah, physical environment standard, yes. So the physical environment standard, so the LS, the EC, they go away, it's the physical environment standard, comes down to is reduced to 12 total standards and just about 67 EPs. So a significant reduction in both standards and EPs into this one thing which we're calling the PE.
SPEAKER_00:Yeah, if if you go through one of our A360 presentations, they'll talk about for the hospital program, I think they say it's a 48% total reduction of all standards and EPs and 46 for critical access. But for life safety, it's actually closer to like 75%. Um, so we definitely had a more of an alignment than some of the other chapters of our standards.
SPEAKER_01:So, what's like the practical implication of this reduction?
SPEAKER_00:Well, I'm gonna speak from that specifically from the life safety code perspective, because that's obviously where my wheelhouse is. Uh the scope isn't really changing at all. And then that's why, you know, at the outset of this, we kind of talked about the survey process isn't changing. And then the reason for that is because if you think about what organizations are required to follow, the codes, which for us is National Uh, the National Fire Protection Association, NFPA, uh 101 and 99, the Life Safety Code and Healthcare Facilities Code, respectively, are required to be followed per the conditions of participation of CMS. That's not changing. The codes haven't changed. The adopted version, which we follow 2020, 2012 right now, because that's what's been adopted by the federal register. It's actually in federal law, uh, it requires an act of Congress to actually enact a new version of and adopt a new version of a code. Um, and that's and that is not happening as of this time. So that's why, from a survey scope and the expectations for life safety compliance, there's really no change because the code's not changing, the COPs aren't changing. There are some small tweaks happening to this uh the state operations manual, um, but it's really more of a, I would say, other detail-oriented changes to try and provide better understandings of the scope. Um and Joint Commission is looking into those uh and how they're how they might apply. And I know that's kind of like uh on the front of everyone's mind right now, but uh I've done a rough overview of them and we'll see if there's gonna be changes that come. But as of right now, because everything that we're doing here with accreditation 360 is was reviewed and approved by CMS, um, there's gonna be no changes to what we're actually evaluating.
SPEAKER_01:With the reduction in standards and the reduction in EPs, folks are worried that kind of the the guardrails are gone, right? Sometimes if you have more proscriptive, it's just easier to know and prepare for. With those removed, I've heard some folks out in the field, and again, obviously it's not based, it's based on their experience as opposed to what they're experiencing, because it's not taking place yet, but they're a little bit more concerned that theoretically there could be more high-risk um findings under the new under the new um survey prove process, but under the P, let's just call it the PE, the physical environment.
SPEAKER_00:Because the the requirements aren't changing, really, and we aren't re-educating surveyors on changing our process, right? Because I already talked about how the process isn't changing. So the only thing that's like the tools, um, if you go onto our website right now, you can actually look at the survey process guide, which is our new reformatted version of our survey activity guide, which hopefully our organizations are familiar with that you have access to now. Um, anyone can actually go onto our website right now and download the survey process guide, which is our updated manual. Uh, it it goes into step-by-step detail of what the expectations of the survey process are. And from this from the life safety code perspective, all we have done is essentially use the existing formats of our tools and our survey guidance. And we've changed the nomenclature to reflect the new standards. But if you look like the document review tool is probably, I think, the best example because everyone's probably very familiar with it. We provide it on survey, the surveyors use it as their tool to complete the survey process. Um, I've been teaching Base Camps for years, and I always show examples of it and how you can use it. Literally, the order of the document is staying exactly the same. The only thing that's changing is instead of EC235, it says PE311EP3. Um, so it's just the nomenclature and standards that are changing. But what we're doing, what we're evaluating, none of that's changing. So there shouldn't be any, and I'll try to use a term I think is applicable to all of our facilities people, no scope creep uh that's happening with this, right? And and we're still, and and and uh, I'm one of the people who's responsible for training the surveyors. We are not changing our survey process. You know, we we make tweaks, you know, as things get clarified, as we get maybe advice from CMS, or maybe if there's updates to interpretation on things. Of course, there's micro changes, they happen all the time. And we try to communicate those out to the field via our periodicals that we provide, like perspectives and EC News. But in terms of substantial changes of survey process, none of that is happening with accreditation 360. And so, to the second part of your question about is it going to make findings look higher risk or change the way they're evaluated? No. Um, we use the safer matrix to try and determine the scope, we call it the manner and degree of a finding. That is, we evaluate two things. What's the risk? Is it low, moderate, or high, which is based on the likelihood that this non-compliant issue could cause harm to a patient, staff, or a visitor. And then we have the manner. The manner is the quantification of the finding. Is it is this something that's happening pervasively across the organization? Have we identified the same issue in various areas? Uh, to give you some context, you know, if you're evaluating smoke compartments and we find issues with smoke barriers, you know, if we find it in once one smoke barrier in one compartment in a building that has 20 compartments, well, that's a limited scope because it's only impacting a very small part of the hospital. Now, if we find there's penetrations in every single smoke barrier throughout every single smoke compartment, well, now you've got what we call a widespread issue because it's pervasive across the campus. And that is what we use to drive the risk levels of findings. So the way we evaluate findings is not changing either. We still use the manner and degree based on the risk and the pervasiveness of the issue to determine how high risk or or where something's placed on the safer matrix.
SPEAKER_01:From a facilities perspective, um what should organizations be doing now? I know you talked about the I know you have a lot of tools on the Joint Commission website, so certainly on the joint commission website, so certainly touch on that. But what else if somebody is if they're expecting that they're within the first six months of 2026, what would you suggest they do?
SPEAKER_00:So a few things. First of all, uh we have a number of documents that we have provided as resources for uh uh for accreditation 360. And again, these are available to everybody that's that is able to access our website. Um, you don't have to be logged in or anything like that, or even be a customer. You can activate these uh these resources. So um, and we also have some new resources that we've been releasing along with this. So I'll try to touch on these. Let's go in order of what I think is most helpful. First of all, in September, we started releasing webinars for all the new standards, chapters, standard chapters, um, for accreditation 360. And PE, which we've talked about, physical environment, and national performance goals, NPG, which is another one of our new standards, that does have some of our old EC standards rolled into it. Um, there are webinars that specifically cover those chapters, what those chapters involve, and how they were crosswalked from our old stuff. And I'm talking more about the PE webinar for for right now. So these webinars are free. All you have to do is go to our website, go to browse webinars, and it'll give you a list of all the ones. There are more coming, but really the two for our facilities people are gonna be the PE and the MPG, are the ones I'd encourage. They're not too long. I think they're about 25-30 minutes uh in length. Um, I've gone through them recently. I've gone through them a couple times. They're I think they're very helpful. So that's the where I'd start is watch those webinars that are free and accessible to uh to everybody out in the public. And then we have our what we call pre-publication resources. These are five guides that have been released in uh they came out at on July 1st when we announced uh accreditation 360, or sorry, I think it was July, yeah, it was July 1st. Uh came out at 360. We've been updating them um as we've gotten some constructive feedback or if we've found any errors. These documents are very long. I want to preface that. Um, like for example, the survey process guide, which I already talked about, is 600 semi-pages long. Um, so these are hefty documents. Um, and there's a lot to them. And I want to stress that all of them are PDF documents that you can use control F and search. And I highly encourage doing that that way to be efficient. Uh so you don't if you go in, you want to know, well, what are the physical environment requirements in the survey process guide? Well, go in, control F, search physical environment, and away you go. I do think the survey process guide is probably the I'm gonna put it in third place after the webinar. Um, a document that I think everyone should be looking at, um, specifically because I want people to be aware of the survey guidance tools that we have in there, which are at the end of the document. But there's a there's a table of contents that you can search at the beginning so you know which pages, and or you can search them using control F, as I just mentioned. But the the document review, the document review tool, the building survey tool, the kitchen tracer tool, the emergency management tool, these are all things that are there I think people should be looking at. They're there, they look exactly the same as they used to, with the exception of they have the new standards on them. Um, so I would anyone ask me if like what's what do you do for survey readiness? Right there, look at that survey process guide, look at what falls under PE requirements and NPG, and be prepared for that. It's an open book test. For those looking for more specific accreditation 360 guidance on how the standards are changing from EC DLS, I would recommend they look at the disposition report, which is the second most important document, I'd say, of the three the three I've talked about so far. Uh, this document shows you uh it's in alphabetical order of the standards. And what it does is it shows you a list of the existing standards as of 2025. So again, you could search EC or LS and you'd you get the list, and they are in order, so you don't have to like it's not jumping around. You'd you'll show you what the standard was, what the EP text was for it, and then it'll tell you what the disposition of it was, which is what happened to it in accreditation 360. And you'll see it was either deleted, it was moved, it was split, or it was revised. And sometimes you might have more than one of those applying. Um, if it was deleted, that was what we most likely determined is it was it was either redundant, maybe that was covered by another EP. I can tell you in EC and LS there were redundant standards in EPs where that you could easily say that they were for more than one topic could have fallen underneath them uh that had another location that would have been just as appropriate. Um I know that because of my time in SIG. Um, and then uh it also might not be considered a requirement that joint commission determined is something that we aren't going to keep inside of scope. Um, so if it wasn't required by code or if it wasn't required by the state operations manual or the COPs, and we determined that we didn't want to make that a necessary a necessary requirement, it might have been deleted. Alternatively, most of them probably got moved or split because they were probably consolidated. Um, as we as we saw, we did quite a bit of reduction. Um, some of them were revised, which means um, like for example, some of the moved and revised applies to a lot of our interim life safety measure or the ILSMs. Those existed, those exist right now at LS121, and then there's 15 EPs. Those are gonna be now under PE, well, I think it's 321, I think is all the ILSM requirements. And the EPs are still there, it's still 15 EPs, but they did clarify the language a little bit and revised it. So those say moved and revised, for example. And then you've got some that got split where maybe they had a leadership implication, but maybe they had another implication, so it got split into two standards. And I'll tell you, most of the ones that that happened to did have either an EM portion or a leadership portion, so it kind of got split into two other different standards.
SPEAKER_01:So these are my words, not yours. You know, as you were so the disposition report, like if there's a director out there or just somebody out there who wants to see where everything went, I don't like you, you know, you're talking about the guides, the 600 pages, but if they want to look at Cliff Notes, dive into that part before they get into the meat and potatoes. It almost seems like the disposition report is kind of that map for you, and then you dive into it and dig if you want to know where things went.
SPEAKER_00:Yes. I I think if you're someone who's familiar with the process, has a relatively good comfort with the standards, and you just want to know what what are the new standards, disposition report is is my starting point for you. Yes.
SPEAKER_01:So that's like a nice cheat sheet.
SPEAKER_00:If yeah, and it's only 300 pages. That's better than that. Yes, remember, we have a so there's a lot of standards. I mean, of those 300 pages, probably if I had to take a rough estimate, 40 or 50 are for PE and MPG, which are the new from our old ECLS standards. So I mean, remember, there were what 20, there were 44 ECLS standards. Um, so you got 44 pages, you know, 44 items to cover. I think that's about 40 pages uh of items that have to get covered for ECLS showing how they're being transposed into physical environment and NPG.
SPEAKER_01:So I've heard you and um your colleague, your field director colleague Tim Mark and John. I don't envy the two of you as we approach as you approach January 1st. We talk a lot about kind of crosswalks between the old and the new. Is the disposition report one of those crosswalks?
SPEAKER_00:Yes, I I would call it a crosswalk because it shows you old and it shows you or existing and it shows you new, new state. We also have two crosswalk tools that you can use as well. Um, again, I think the disposition shows it better than any of the pages, but there's also one that's called the crosswalk compare report. Compare. Yeah. Um, it's it's on that pub pre-publication website tool. So it's it's with the disposition report and the accreditation manual and the survey process guides that are available to everyone online. Uh, it shows you a list of the COPs, the conditions of participation. Uh so it's in order of the COPs, and then shows you what what are the existing standards that fall under those COPs, what were the EPs under them, and then it shows you what are the new standards that would then fall under the COPs. Um, so I think that one's a little bit clunkier to use, but it's still I think very important. That's it's a I mean, I'll be honest, I keep all these documents open all the time, so I'm referring to them constantly. Um, just like I when I was in SIG, I was always referring to Edition, which has all the current standards and things like that. So, you know, we we try to provide more almost more resources than you might be able to possibly use, but they but I do think they have very specific uses that they can be very helpful for. So it's probably a good idea just glance over all of them, see which one helps represent the information best to you.
SPEAKER_01:If you like this video, please like and subscribe to the network. And more importantly, share it with your colleagues in the healthcare industry. Together, we can solve the aging crisis that's impacting all of us. The national performance goals. Can you talk a little uh you know you hear a lot about the new PE standards, right? But the NPG is a little bit less. What are the national performance goals?
SPEAKER_00:What are the elements? So there's quite a few. Um, and I'll I'm gonna be honest, I'm I'm gonna pull up a cheat sheet here to help me with NPG because it's got it's got a lot of scope. It's a very big chapter. So uh kind of a summation is if you were for if you're looking at our current standards, you'll see that we have the national performance or national patient safety goals, NPSG. That standard is actually going away, and it had a lot of clinical elements built into it about patients' rights, patient safety, and things like that. Um, when we revamped the physical environment or the ECLS standards into the physical environment, we realized there are some things that are not required by code, also not required by conditions of participation. Some of them have requirements by state and local authorities uh or some federal requirements like uh OSHA, for example, or uh maybe the EPA. Uh so for those where they don't necessarily have a code or a COP direct requirement, moved and revised and put into the National Performance Goal chapter, which you can kind of think of it as a joint commission specific requirement chapter.
SPEAKER_02:Huh.
SPEAKER_00:Yeah, that that's how I I try to think about it. But it has a lot of elements built into it.
SPEAKER_01:So if you say a joint commission specific, that would mean uh well something that perhaps the DNV doesn't have. It's it's unique to the joint commission.
SPEAKER_00:I can't comment on what uh what other organizations' requirements are because I'll be honest, I don't know all of them off the top of my head.
SPEAKER_01:Sure.
SPEAKER_00:Um but they are uh they are yes, joint commission specific because maybe they aren't required by other AHJs, for example, which you know, HJs is a authorities having jurisdiction, which um there's lots of layers of that that goes into play too for a lot of organizations. So uh the kind of the scope is um for national performance goals is it covers culture safety, covers there's emergency management portions. So um I and I want to mention that to say that we still have the EM chapter, the environment, the emergency management chapter that was revised about three years ago. Um, it still is remaining, however, some parts have been plucked out, usually because they have some sort of leadership involvement or a committee involvement and got put into national performance goals. Uh, there's also health care equities covered here. There's some infection prevention control requirements, pain management. These are obviously clinically based. Uh patient rights, I mentioned before, is here. There's also our suicide risk reduction requirements. So this was built into our national patient safety goals previously and has been transposed over into physical environment. That does have a life safety codes element to it because we do evaluate the environmental risk assessments if organizations have dedicated behavioral health departments or units. So we would evaluate their environmental risk assessment uh if they have high-risk patients that they're overseeing and make sure that they're following what their mitigation strategies are in place for those areas. Wave testing, workplace uh and patient safety is here. So our old EC211 security and safety requirements now fall under NPG, which I you know, I think does make sense if you think about it. Those aren't required by code per se. Those are kind of things that are above and beyond. There are some authorities having jurisdiction that might have requirements uh regarding that, but uh that's where that lives now. Uh workplace violence is is covered under this as well. That's a CMS requirement, yes, um, but does follow international performance goals. Uh staffing requirements are covered here. And finally, imaging safety and medication management. Now, obviously, imaging safety does have some life safety code server uh implications because we evaluate the uh mitigation strategies and policies procedures for radiation safety and uh nuclear medicine safety, for example. So um MRIs as well, right? We have to have um policies and control measures in place for our MRI machines due to the serious safety risks that can be involved with those.
SPEAKER_01:That's kind of an overview of what MPG So there's some familiar elements within NPG. It shouldn't be completely new to folks.
SPEAKER_00:Right. Because again, the the process isn't changing. So the things that we review, the things that we evaluate, uh none of that's changing. It's just been moved. It's been kind of put into a new living spot for how we're gonna score it and not evaluate it, but just how we're gonna score it.
SPEAKER_01:So you said um, I think staffing levels within it. And as you know, I mean, kind of like staffing levels, recruitment, competency, it's all near and dear to you know, to me and what I do and what we continue to do across. Is there anything, Jim? Those competency assessments that you folks do, is there any are are they I and I should probably should have looked. Are they included in the MPG or what about staffing levels is in there?
SPEAKER_00:Uh competency and training is what was covered under there. So yes, that would that would fall under under that purview there. So yes, we're still gonna be doing the same process of evaluating the facilities leadership teams, making sure that they have uh the organizations have a job description uh and that they've they have uh the people that are in place for those positions meet the requirements that the organization has uh determined they want to have for those individuals.
SPEAKER_01:You know, I used to, like I said, I used to do the recruiting. I would see, and I wonder, you know, as we go forward bringing more people in who don't necessarily have healthcare experience. I mean, it's just a fact. You guys don't control it, I don't control it. Organizations are bringing folks in who do not have healthcare experience. It's probably important, and again, I know you can't tell hospitals what to do, so this is probably just me talking, but that job description becomes very important because that's what you're measuring the organization against, right? You're not telling them what that job description is, they're telling you and you're ensuring that they're hitting that. Is that accurate?
SPEAKER_00:That is accurate, yes. So organizations kind of set their own expectations for individuals that are coming into those roles, and then we evaluate that those individuals are meeting that criteria. So we we ask the organizations, you know, provide the documentation to validate that if you said that this individual is going to have a certified health care facilities management certificate uh and have a college degree because your job description says those are required, then we'd evaluate we'd want to see documentation that shows that that individual in that role has those requirements in place. Let's talk about ASCs.
SPEAKER_01:We talked about um hospitals, critical act uh acute care hospitals, critical access. What if where do ASCs fall within the new survey process? And and are there different, not differentiators, but how do we define different ASCs, I guess?
SPEAKER_00:Yeah, so the way we do it, it's actually up to the organizations, right? So organizations get licensing for their or for their their hospital and then for their associated facilities there providing health care. And so what what the joint commission does is we survey a hospital and it's I'll call it a pertinent facilities based on if they fall under the CCN or the CMS licensing number or uh um certification number of the hospital. So a lot of like organizations I worked at, for example, we'd have a hospital and then all the local or regional, if it was ambulatory surgical center or a sleep center or a pain clinic, you know, if it if it kind of reported to the hospital, it then had a requisite CCN number that fell under the hospital. So those would all be considered to be in scope for the Joint Commission to survey those organizations. So if you're a hospital and you have an ASC that falls under your CCN, we would survey it and it would be surveyed under the same accreditation 360 standards in 2026 that the hospital would. But of course, from a life safety code perspective, we evaluate the buildings based on their occupancy. So if it is an ASC, uh most likely it's gonna be an ambulatory occupancy per NFPA 101, and we would evaluate it based on chapters 20 and 21 of the life safety code based on that occupancy.
SPEAKER_01:So if it's an ASC that is not under the CNN, what's the situation with that?
SPEAKER_00:Yeah, so for ASCs that don't fall under the CCN of the hospital, or they might be standalone facilities. Um, so we have a different program for those that's called the ambulatory health care program, uh, or or the ambulatory health care certification uh uh for accreditation. And so when we'd survey a site like that in 2026, that program is not changing. So they would still have the EC and LS standards and all the other clinical standards applicable to them until that chapter and program is updated as well. And I'm not gonna ask you the question, when do you expect that chapter to become?
SPEAKER_01:Please don't. You get enough. And and it's it's the headline out of that is if if you're kind of that standalone, not under the hospital license, CCN, you are you continue business as business is done until such time you hear otherwise.
SPEAKER_00:Yeah, which of course there'll be you know an announcement, an update similar to how we did with help with uh uh hospitals and with critical access hospitals.
SPEAKER_01:So, Jim, what is it? I I kind of you know, as you're talking, like I'm just thinking it's it's a huge you alluded to it earlier, I think. You know, it's like a huge project management. You forget what you're doing, it's just a huge project management task on the point of the joint commission. Can you talk a little bit about a little part of that? The train, like the instructor training, you guys must be rolling your surveyors through now, just getting them up and training. Well, like what should a hospital who's being surveyed early on, what should they expect out of the surveyor? And when I say that, I guess I mean it's it's not changing, right? And you've made that very clear, but yet your guys, there's still a is it a nomenclature change?
SPEAKER_00:Is it uh yes, I I the survey process of what like let's if you went through a surveyor in in in 2020 uh 2023 and you're gonna go through one 2026, in terms of what happens, like the agenda is gonna be the same. Um, as we talked about, the tools are all the same, the surveyors be working off those tools and providing them to the organizations. Like, that's really gonna look very, very different the same. Really, the only thing that's gonna be different for the organizations is what the report looks like. Like, to be honest, that's that's really the difference, is the survey report. So, what we need to do from a training perspective is obviously teaching everyone what the new standards are, um showing them what how this stuff all crosswalks. Um, and then we need to we we're working on training the surveyors on how to write the new stand observations in the new standards. And again, it's a lot of this is it's just a change of of the existing process, right? Because we're still doing the survey process, you know, we're still evaluating all of our life safety features and the uh physical environment features of the buildings, and we'll be scoring the same things, but they're just gonna go into a new location now. Um, so there's just a kind of a change management trainings that has to occur, if you will.
SPEAKER_01:The normal time it took to survey your hospital, there's no additional time added on.
SPEAKER_00:It's the same, it's the same time commitment. Same time commitment, same, same. We call it the survey complement. That's the number of surveyors and the number of days they're on site. Um, as we've discussed, uh and people have probably heard me talk about this a lot. If I've come to your your regional uh meetings, is we we have had changes at the Joint Commission to the survey process for off-sites and for hospice. And I talked about these at the Ashley conference, and Tim and I are talking about these as we go along. Um, and there's been memorandums released about this. And so there's there have been some changes that have occurred um prior to accreditation 360 coming out that have impacted the survey complement. So, for example, if you have an uh inpatient hospice building that's uh located remotely from your hospital, you'd probably have an extra life safety code surveyor on site for one day to evaluate that building uh as per our new hospice process for evaluating those inpatient deemed facilities. And then we have our off-site survey process that went live back in um in July, where we are now evaluating the off-site locations that our clinical surveyors are evaluating. So that has created some changes to our survey complements. But accreditation 360 is not going to impact any of those things at all.
SPEAKER_01:Okay. Can I go back to I I I wanted to ask, just going back to the competency assessments, you guys are not required, or you like the organization does not have to uh demonstrate that an that the hypothetical facility director meets the job description. They just have to document that they meet the job description. Can you give me an example? So, like, okay, uh CHFM certification, five years experience, and college degree required. So yeah, and say so you know, sometimes, especially at these smaller critical access hospitals, those job descriptions can be like jack of all trades where they're throwing everything in there, you know, requiring a license. Say it's a licensed electrician. They don't have to like they don't have to quantify, they just have to, they just have to show that their director has five plus years, they have their CHFM, they've got their licensure, and they have five plus years experience. They don't have to document that they do those things in a um looking for, in a competent fashion. They don't have to demonstrate their work. Now, I guess you you could say you'd probably see that in the survey process. So maybe I just answered my question.
SPEAKER_00:So yeah, so I guess kind of break that down into two pieces. So we what we would look what we look at as a surveyor is we would ask for the job description, evaluate what it says is required versus what's recommended or what's excluded entirely. We'll ask for documentation that shows. So if it says they have a college degree, then what I'd expect to see is either their resume or maybe they have a diploma in the their personnel file that shows that they have that degree. If it says they have they have to have a CHFM, for example, we'd have to see the license or at least the license number so we can look it up. Um, so we'd have to validate those things. Um, in terms of like evaluating, it sounds like you're getting more towards like evaluating the competency, like in person. Yes. Yeah, that that's kind of going to be done based on how compliant the organization functions and and and getting an assessment of the involvement and oversight that that facilities leader is demonstrating at the organization.
SPEAKER_01:Yeah. It's very it's it's just such an interesting environment. Um, I know that you guys are tracking questions, and I know that you want questions, especially during these early periods. Can you talk about that? What you are not seeking, but what you know, if people have questions, what would you like them to do? How do they do it? How do they see the answers? Explain that process, please.
SPEAKER_00:Sure. Yeah. So I did forget to mention something when I was talking about the uh pre-publication documents, is one of the other resources we recently re released, and I'd say recently, but it's probably been about a month now, is we have a frequently asked questions that's specifically dedicated to accreditation 360. So when accreditation 360 went live, uh there was a link to submit questions specifically about accreditation 360, which is still up. So if you have any, feel again, go to our website, go to accreditation 360 page. And I believe there's a there's several links on different locations that say, Do you have a question? Here's how you can submit one. Um, there's also, um, I think if you go to the pre-pre-publication page, uh, there's a survey you can take, which will also ask, you know, are these resources helpful? And you can give feedback on that as well. And we're using those questions, the feedback, everything that we're getting to build that FAQ that's out. So uh please take a look at if you have a question. Um, and we've had many, which is great. We've had a lot of feedback that we've used constructively, so we appreciate that and welcome it. Um, we've used that FAQ to respond to a lot of those questions. So uh please take a look at that and uh because more than likely than not, if you have a question, it's probably been asked and then hopefully it's been answered.
SPEAKER_01:Are there opportunities to collaborate with the joint with joint commission as A360 gets rolled out or input, or is that the question and answer that opportunity?
SPEAKER_00:Uh I'd say that's the best one right now. Um, you know, I I do know that of course surveyors are on site and organizations try to ask them questions. And yeah, you know, the the thing you got to keep in mind is the surveyors do have a day job that they need to focus on. Um and we're cognizant of that. We're trying not to overload them with too much information, you know, right now as they're trying to maintain their current work process with the current standards, right?
unknown:Right.
SPEAKER_00:So, you know, we're trying to we're trying to stage the rollout of this process so it it makes sense to both the organizations and to the surveyors. So that's one of the things I might caution organizations is don't ask questions about A360 to the surveyors, because they might not be the best resource because we we there's a lot of information that's out there, and they um we that's why we put all these resources online is that's like your source of truth to try and get to what's going on. Because like any company, we have a lot of different departments and the surveyors are doing their day job, and then we've got a whole department that's dedicated to managing the new standards as they come out.
SPEAKER_01:It's like anything. I mean, there's refinements. You know, we you try to do your best, and it's like a construction project. You know, you open for operations, you find things that, oh shoot, we missed it. It's probably very similar. It's a project management.
SPEAKER_00:Yeah, and the other thing I'd mentioned, you know, and I I think Tim and I, we try to we try to focus on the collaborative survey process is very important to us. You know, at the end of the day, we're trying to make sure these healthcare organizations are providing the safest environment possible, but we're also trying to be a resource to organizations towards that. Um and providing lots of of education and understanding and and kind of the why, why things are out of compliance, why things have to be the way they are. Um, you know, I know that's one of the reasons a lot of our surveyors do this job is they like to have that collaborative element with organizations. Um and so we we are of course looking for opportunities on that. So if there are ways that organizations think we can be uh more collaborative on this accreditation 360 process, um, you know, we're working towards that. I think we've done a, in my humble opinion, I think we've done a really good job of trying to provide a lot of resources in this time frame over the six months before the rollout's gone live with the webinar. Like the webinars are great. Um there's a base camp that's coming out in a month that I'm teaching along with one of my SIG colleagues uh that's gonna cover A360 and the new standards. Um there's I'm sure there'll be more other like, you know, uh periodicals, perspectives, EC News that's coming out. Um, I actually I know for a fact there are some that are coming out about that. Uh they'll be talking about PE. So we really are trying to focus on getting as much messaging out as we can about it in hopes that it reaches as many people as possible uh from our accredit organizations.
SPEAKER_01:Yeah, you can't really ever over-communicate, right? No matter what you're doing. No matter how much you communicate, there's always gonna be somebody who should have communicated more. So, yeah, absolutely. Um, two quick questions, Jim. I know we're up against it. The first question was is there anything that I didn't touch on that we didn't touch on that I didn't ask about that you think is important to just get out there?
SPEAKER_00:I I don't think so, but I I think I'll just reiterate like the the big takeaway here is there's the standards are changing, the survey process is not. So if you had a successful survey, you know, in your last triennial cycle and you've maintained your evidence of standards compliance and you're doing your rounding and you're staying on top of the code requirements and what was required historically, you should expect to have a successful survey again in 2026 because the overall process is not changing. And that's I think the biggest and most important message I want to make sure that everyone has.
SPEAKER_01:Yeah, no, that's great. And for a person like me who's always looking to kind of shortcut the the learning parses, I really like that disposition report that you get. I mean, that's a that's a sounds like it'd be a great tool. And my second question, the hardest question of all, are you taking a vacation between now and January 1st?
SPEAKER_00:Uh I'm going to try to in November, but we'll see. Um we shall see. There's there's a lot there's it. I mean, it sounds like a lot of time between now and Chris and Christmas and New Year's, but in reality, I don't think so. Yeah, no, it's really not. Yeah, and I've I'm gonna keep looking at my calendar and it just keeps filling up as we get into the year, but you know, I'll try to take a little bit of time to to relax. Um, it's you know, but I will say though, it's been uh a great collaborative effort on this end as well. Uh working with the surveyors, working with my fellow field directors, and working with the standards interpretation team where I came from. And so it's it's it's been a positive environment where we're working together to get this all worked out with everybody.
SPEAKER_01:So you know, I'm sure you have lots of meetings to begin with. This must be like meetings on steroids, especially as you get closer to that date. I can't imagine what that's like.
SPEAKER_00:Yeah, it's it's a lot of touch points between a lot of different departments uh because there are a lot of pieces moving. But uh I do think it's uh it's a testament to this organization that we're making it work, um, that the people are are are putting the time in and collaborating so well um with all the different pieces that are moving. So in some ways it's it's kind of impressive, um, as well as it is daunting, I guess, you know, when you're rolling out new stuff like this. But that's it's seriously, it's it's it's impressive to see it all happen, and it's a great group of people that I work with. So I'm very proud of this team. That's awesome.
SPEAKER_01:So, Jim Grana, field director, joint commission. As always, I appreciate your time. I I wish you and your colleague Tim Markijon and everybody at the Joint Commission the best as you guys roll this out. January 1st, 2026 is that date. Yes, sir. Thank you so much, Pete. It was great talking to you. Jim, always great. Thank you so much. This is Peter Martin for the Healthcare Facilities Network. Thanks for watching. We'll be back with another episode very soon. If you want to be a guest on a future episode of the Healthcare Facilities Network, go to healthcarefacilitiesnetwork.com and let us know who you are and what you want to talk about. Because together, we can solve this critical aging issue.