Healthcare Facilities Network

Accreditation 360: Latest Insights From the Field

• Peter

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The Joint Commission’s new Accreditation 360 update is reshaping the Healthcare Facilities Management standard, but what are early 2026 surveys revealing in practice?

In this episode, we unpack real stories and firsthand observations from some of the first surveys conducted under the updated Accreditation 360 framework. From emerging survey trends to on-the-ground challenges, this conversation offers insight into how organizations are responding to the new expectations.

We explore “Bucket Fear,” how it influences behavior during surveys, and what leaders can do to manage it effectively. The discussion also examines the role of leadership presence and why “manner and degree” continue to significantly impact survey outcomes under the new standards.

This is not a theory. It is perspective from the field. If you are responsible for compliance, accreditation readiness, or facilities operations, this episode delivers timely insight to help you reduce risk, strengthen performance, and approach your next survey with confidence.

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👥 Connect with Larry F. Ruben: https://www.linkedin.com/in/larryfrubin/
👥 Connect with Taylor Vaughn: https://www.linkedin.com/in/taylor-vaughn-chfm-sashe-ba1443147/
👥 Connect with Edward Browne: https://www.linkedin.com/in/edwardbrowne/

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Opening And Early Survey Reports

SPEAKER_01

I have not been involved in a January survey yet. I'd love to see some. I know the couple out I talked to the people that actually were surveyed and how it went. And uh some went good and uh some went not so good. I guess there was one surveyor that expected the uh this hospital to have to start using the correct document and review sheet showing the PE's. And in the annual training, we thought the surveyors learned, hey, give them some time. It's even Jim said the same thing. We're not gonna go after that right away. Give them, you know, three, six months, give it some time. Well, that didn't turn out to be uh everybody on the same and that's that's common, by the way. There's so many different people involved, things change.

SPEAKER_04

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.

Panel Intros And Roles

SPEAKER_05

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. Very happy to be joined today by an esteemed group of panelists. And what I like about the panelists, so we're here to talk about Joint Commission's new accreditation 360 program, which rolled out January 1st of 2026. We have a nice mix of folks who have been in the role and now have transitioned to consultant, with now a person who's still in the hot seat working in a hospital every day. And so we got our consultant, we have our healthcare professional still in the role, and I appreciate them joining us. And before, why don't we just ask each of them to introduce themselves a little bit of background, who you are, what you're doing, and I'm sure many of these faces are recognizable. Larry, we'll start with you because you're to my left on my screen.

What Accreditation 360 Really Changes

SPEAKER_01

Okay, thank you. Uh welcome to all. Uh, name's Larry Rubin. I'm a uh former Joint Commission surveyor, um, also former with uh Cleveland Clinic and had worldwide operations with them maintenance. And now I run uh Rubin Healthcare Compliance, uh semi-retired and having some fun. So this is uh this is gonna be interesting. Next couple of months are gonna be very interesting. A lot of changes coming, as you probably already know.

Field View From A Recent Survey

SPEAKER_05

A lot of changes. Now I would say that, Larry, it's the stuff that we don't tape. Before we started taping, we were talking about iguanas dropping out of trees because Larry is down there in St. Petersburg, Florida. You got your fire going on your your virtual. Are you warm enough, Larry? I'm gonna add another log in a minute. No, we're gonna be able to do that. We tape on February 5th. So uh pretty chilly all over the country. Larry, thank you. Taylor, how about you?

SPEAKER_00

Hi, um, my name is Taylor Vaughn. I live in Dallas, Texas. I am a facility manager at Children's Health. I oversee regulatory compliance for facilities as well as project management. And I just hit 10 years there, so getting a little time under my belt.

SPEAKER_05

Congratulations, Taylor. And Taylor, you're also president of CAFM, correct?

SPEAKER_00

I am. I'm uh president of the Texas chapter of um of Ashie, so Texas Association of Healthcare Facilities Management. Very proud of that organization and all the work we're doing to provide education to facilities managers in Texas.

SPEAKER_05

And you have your show uh April, April, early April.

Grace Period Confusion And Documentation

SPEAKER_00

Yep. Uh last few days of March into April, we'll have our annual conference. Um we got a really cool lineup of speakers. So if you're able to come down, it's in Allen, which is just a little bit north of Dallas. So um really easy to get to. So come on out if you're able.

SPEAKER_03

Excellent. Taylor, thank you. Hello, everyone. Um, my name is Ed Brown. Um, I have been in the healthcare facilities management and support services world for over 40 years, everything from community-based hospitals to tertiary care hospitals, mostly in the New England area. Um I semi-retired to use Larry's term, um uh a few years back. And I do consulting through various agencies, but primarily Joint Commission Resources. I do mock surveys with them and I do a lot of education. Um, and in fact, coming up, I've already been booked to do a couple of uh big seminars for them. So there's a lot of need for new education around these new standards, which we're going to be talking about. And then um, I'm also a member of the New England Healthcare Engineers since we're talking about society societies. And when you're an old retired guy like me, they they make you a parliamentarian. So, you know, I I have to keep an updated copy of Robert's Rules of Order at my at the ready all the time. So you know what?

Persistent Findings And Hot Topics

SPEAKER_05

It's funny you bring that up. I have wanted to do a show on kind of Robert's rules and meetings because healthcare and probably most things are so overrun with inefficient meetings and we all deal with them. I'm gonna put that on. I've got to do it. Um, it's been on the list, but I forgot about it. So thanks for bringing that show down to that book. Happy to help with that one.

SPEAKER_03

It's a lot of fun. It's it's a way out. Why can't we do that, Robert's rules? Absolutely. And the moon goes quiet. It's like I make it up as I go along, but we have a book.

SPEAKER_05

Well, if you like if you got the book and you sound authoritarian in your declaration, you've got that credibility, and they're gonna move along with you.

SPEAKER_03

Yeah, well, I'm not I'm not good at authoritarianism, but we'll see.

Buckets, Safer Matrix, And Risk

Manner And Degree Explained

SPEAKER_05

You know, that's really actually a kind of a nice transition, authoritarianism into the joint commission survey process, but we're not talking about that today. We're talking about accreditation 360. Just if you were wondering, I am actually out in Milwaukee taping in a hotel room, not a virtual background. Um, visiting my son at Marquette tonight on Thursday, and then heading to basketball games over the weekend. So very excited. It's cold, but there's no other place I'd rather be. So that's my virtual background. Thank you all for tuning in. Let's start. Just a quick thing on A360, and then I put it over to the experts. Um if you are not up to speed on accreditation 360, we on the Healthcare Facilities Network released an interview with Jim Grana, field director for the Joint Commission back in November now. You can find that in our archives. Jim does a great job explaining everything. We talked for about an hour. Jim is a smart guy, great guy, collaborative guy. I would highly uh suggest you watch that interview because it's Jim himself talking about it, answering questions. And then we at Cref released a webinar. It's free in December with my colleagues Tom Grice, Sharon Tyrrell. They talk about accreditation 360. There's a lot of accreditation 360 information you can find out there, even on the Joint Commission or Joint Commission website, right? No longer the Joint Commission, it's joint commission. But what we wanted to do is just convene these experts together. It rolled out January 1st. So really the four weeks. We're four weeks in so far. Um, if you don't know the details, you know, the elimination of the EOC and life safety and the new physical environment chapter and the rollout of national performance goals. We're not going to go over that here. There's a lot, like I said, go to gyms, there's lots of places you can find the nuts and bolts of it. So I just asked our folks to convene uh four weeks in or so, just to get their thoughts, you know, what they may be seeing so far, what they're hearing, what they're doing, how they're preparing for it. And I want to do, I want to start with Taylor, because Taylor, you're in the field now. You had your successful Joint Commission survey back in August. So you're through the window. But let me just ask you, you know, from your perspective, your thoughts, ramifications of A360, how you view it, how your organization views it.

Leadership’s Role And Funding Reality

SPEAKER_00

Yeah, so we had our survey in August, so we kind of hit the sweet spot of like we've got plenty of time to prepare. Um, so pretty happy about that. I think it's really interesting. Um, you know, not a lot changed. We didn't, there wasn't anything that we went through and decided we weren't gonna do any more resource processes or or inspections, obviously. Um we did go in and update some of our policies and our our paperwork, so that's all completed. Um I think we're a little worried about having less standards, means possibly higher level findings because there's just not places to put findings. There's only a couple buckets now. Um and I I know a lot of people in the industry are a little worried about that too, and I I guess we'll just gonna have to see how that plays out and step up our game during survey. Um so probably worried about that, but as far as the survey process, you know, none of that changed. So that was that was nice to hear. It's just business as usual. We updated our documentation and that's kind of it.

SPEAKER_05

So you're rolling along in your typical three-year cycle. Kind of watch what's going around, watch what happen what's happening.

SPEAKER_00

I know a couple people who have already been through survey and they said that you know, surveyors are are working with them because not everybody has time to update their their um their stuff yet, and just kind of going through fully and and you know, not sighting anybody for having it completely transitioned over yet, which is very understandable. Um so I've heard that from a couple of people that surveyors are being you know are willing to work with them on it.

CMS Alignment And Tags

SPEAKER_01

That's good news. I have not been involved in a January survey yet. I'd love to see some. I know the couple out I talked to the people that actually were surveyed and how it went. And uh some went good and uh some went not so good. I guess there was one surveyor that expected the uh this hospital to have to start using the correct document and review sheet showing the PEs. And in the annual training, we thought the surveyors learned, hey, give them some time. It's even Jim said the same thing. We're not gonna go after that right away. Give them you know three, six months, give it some time. Well, that didn't turn out to be uh everybody on the same and that's that's common by the way. There's so many different people involved, things change, and so uh one of the things that I'm working on right now, and uh you know, being a I'm a former school teacher, I BS Masters before engineering was in education, and I'm putting together my cheat sheet. And this cheat sheet is uh what we normally use. I have six pages of normal findings that Ed and Taylor probably already have now. Your normal findings all the time. I took this, I'm taking the six pages of my normal findings and now putting them to the new PE. It's gonna be interesting. So we've got some time. I think things are gonna change, and I've seen a lot of surveys now that have actually I have the copies of the actual surveys that they've done at some of the hospitals, and they're strange. I'm I'm seeing some strange things that I and I'll go over that a little bit later with everybody. So I'll let Ed tell his little stories and see what happens.

Fire Drill Rules And Randomization

SPEAKER_05

You you kind of laid the uh you laid the table out and then you said, See ya, you're turning.

SPEAKER_01

I I I throw a hand grenade all the time. That's it's normal.

Lithium Batteries And Reportable Events

SPEAKER_03

You know, and and you talk about your your six pages of normal findings. Well, we all you know, when I do go out and do mock surveys or when I'm doing a presentation for a large group, we talk about those. Um, and we say, you know, it hasn't changed, and it's probably not gonna change. And you know, if you if you you know, we always like to refer our clients back to good documentation that's out there published by the joint commission, and one of those things is perspectives, right? And if you look at which by the way, perspectives is going away. The February edition is the last one. And in classic joint commission form, they're gonna replace it with something else. It has it's like joint commission information magazine or something. It's got a very bland name, but perspectives itself is going away. Um, but in the January edition of Perspectives, um, you can see that those from 2025, those findings have not changed. They talk about the physical environment improvement opportunities is what I guess we're going to start hearing the word opportunities a lot more than findings. Hazards are around, you know, sharps, hazards around cleanliness, hazards around incorrect pressure relationships, temperatures and humidities, all those things, uh clean and odor-free environments, those are all still there as hot topics or uh big opportunities during 2025 and are going to remain there through 2026 and beyond because it's one of those needles that we just can't seem to move in many organizations, except for Taylor's. Taylor's is perfect, I understand.

SPEAKER_00

We like to think it is.

SPEAKER_03

Well, it's Texas. I get it.

Using The Survey Process Guide Wisely

SPEAKER_05

Let me ask, um, if the findings, right? If the findings really don't change year to year, right? You gotta you're finding consistency in what they are.

unknown

Right.

SPEAKER_05

What is changing then with this? And what should uh hospitals and organizations like Taylor's group or Taylor people in it, if the findings are gonna stay the same, okay, what's the ramification?

Safest Matrix And Best Practices

SPEAKER_03

So Taylor, I think, hit the nail on the head. As since there are less standards and less EPs, and the algorithm that fills up the safer matrix doesn't change, then you're gonna end up with more high and widespread findings. Those eyewashed innovation findings that might have been in the middle of the grid or down low and to the left were gonna are gonna get pushed up high and to the right. With that said, I have heard during the first three to four weeks of survey, and it comes from a very reputable source, that that has not happened. But three weeks out of 52 is not a big sample. So um I think we need to pay close attention to it. The only other um parallel we can look at is when they did the changes to the infection control manual. What's that now, two years ago, where or more, where they took a whole heck of a lot of standards and condensed them down to three, four standards with associated EPs, everyone said, hey, that's gonna happen. We're gonna have everything high and widespread. And it didn't.

SPEAKER_05

Why didn't it?

SPEAKER_03

It seems that the surveyors were however they however the findings worked, um, didn't push them up to high and widespread. Now there's an algorithm behind it too, which I I wonder whether there was some and you know, what do you call it, coding engineering that behind that, but I don't know.

Preparing Executives For New Optics

SPEAKER_01

Yeah, I still want to think that you know all the changes that you're seeing really you're taking your findings, just putting them to a different bucket. And really that's all that's happening. And I can see the widespread if you have something low and it's not widespread, it's uh and it starts going up to white, it still stays low. It doesn't, it won't go high unless it happens to be uh an issue, such as here it comes, manner and degree. So we knew that was gonna come out eventually. So I know Ed is an expert on manner and degree.

SPEAKER_05

What is manner and degree? And again, so here's the for people who are watching, we are this is uh just kind of a conversation. We're not a news organization here. There's no ill intent. This is for people who need information or want information, just to kind of get a feel from folks in the field. So I would just always say that we never try to put people on the spot. Listen, at the end of the day, it's all about patient safety. Everybody in this Zoom and everybody who watches this has the same goal, right? Now, this is one of those, this is one maybe one of those challenges that gets you to those goals, but it's kind of a blanket statement. So within manner and degree, there is no from our perspective. We're not trying to throw anybody, anything, anyone under the bus. But what is it, Larry? Just what's manner and what do we or Ed or whomever?

SPEAKER_01

Well, Ed's that expert, I can tell.

Reports By Severity Not Alphabet

National Performance Goals And Leadership

SPEAKER_03

But let's let's let's talk about there's two examples that I like to use. Um, one is what during a survey there might be problems found with a few fire doors that they're not latching, or there's some damage to them, or something. And so they they rate a finding. And maybe there's ten doors that have a problem, but maybe you're a big organization that has a thousand doors. Well, the manner is the damage to the fire doors, and the degree is a mathematical calculation in a in a way. So, where should that land on the on the safer matrix? Should they look at all thousand fire doors? Well, that's not possible. Should should they, if they find five, should they, wait a minute, I better go look at 25, or maybe I should go look at 50. Maybe I should spend half a day looking just at fire doors because I found a few early on. And again, first impressions are so important. You know, if they find those early on, they're gonna keep digging. So there's one example of manager degree. The other example I like to give is hallway clutter, right? So surveyors go out, again, first impressions, they see hallway the life safety guys seeing some hallway clutter, seeing some exits uh obstructed. Wait a minute, how many exits do you have? How many times is it found? But wait, you have a survey team, you have a complement of surveyors who are out there, physicians and nurses, who are also going to look at and potentially find hallway clutter, and they're all able on their systems to put in that finding. And all of a sudden the degree increases because now you've got findings from four surveyors, not just one, and it pushes it up high and to the right. So that's those are the kinds of things that from a man or degree perspective can start to catch uh uh an organization flat-footed a bit. Um, it's not just the life safety guy that's looking, it's all of them at some of these things.

Challenges For New Facility Leaders

SPEAKER_01

So it's the intensity of whatever you're finding. So that's going to be the key to this whole thing. If you're seeing it all the time and it's pretty serious, there's your manner and degree.

SPEAKER_05

So it seems like uh the degree, you know, the manner is one thing you you find it, but the degree is you want to kind of control the degree. Yeah, density. Yeah. And and as we talk about buckets, because everybody talks about buckets, right? Taylor, it was one of the first things you mentioned, Larry and Ed, you agreed. People you talk to, everybody's kind of worried about these buckets. They took a lot of buckets away. There's fewer buckets. Does the manner and degree, I'm imagining the manner and degree translates into those buckets that folks are fearful of filling up? Is that correct? And does that all does that kind of intensify the bucket the bucket fear?

Training, Media Signals, And Final Takeaways

SPEAKER_03

I think it could if bucket fear is a real, you know, I think there's a whole presentation that could be done around. I was just thinking that we should trademark that. We should, yeah. Bucket fear. Um that BF. Um you invited me. Um that's how I felt.

SPEAKER_05

But it's a real thing, right? It is a it is not I and I think and Taylor, maybe you don't have, but I I would imagine from like your perspective and from the folks in the field working with C level leadership with the people you report to, that's what I mean. Again, you're here to create a safe environment, but along with that, there's that fear, okay, if I have too many in this bucket and they're too high, what is my management gonna say to me about what we are doing in our program?

SPEAKER_00

Definitely. So, you know, making sure our leaders know that, hey, these standards are changing. The safer matrix may look a little bit different. Even if we have the same findings we did three years ago, they may be plotted differently and just making sure they they know that. Um but kind of going back to the the manner and degree thing, the the fire door example is a great example, but kind of from my perspective, maybe we started off the survey with obviously with documentation, you looked at my fire door annual inspection and we had failures, we got them all repaired, we had ILSMs, everything was great. And then you went out in the field and you found ten fire doors. Hopefully, you'll give me the benefit of the doubt and say, I know you, I know you did your inspection, I know you got all these repairs done. Maybe somebody hit this door with a car yesterday. In the past, we've been given that that you know, that level of of trust that this is a functioning hospital. Things break within 10 minutes. And I would hope that that would continue with this new standard and that would go into the manager's degree. Like, I know this was a Finding. It's gonna be a finding. But they did their inspection, they did what they were supposed to do. Stuff happens. I'm gonna try to keep as low as possible because I know they're trying to do the right thing, and I would hope that that would continue with his new standards.

SPEAKER_05

Sorry, Annette, to you on the consultant side, because it wouldn't be fair to ask Taylor, I don't think. She can chime in, of course, if she wants. But um do you feel or do you think I hate the word field? Do you think that um from the surveyor perspective, on the surveyor side, does the the new standards does it give latitude's probably not the best word, but does it does it kind of remove some of those guardrails and allow the surveyor maybe to go into areas as Taylor was just saying, you know, we we want the bet hopefully we get the benefit of the doubt because we've shown you we've done all our fire doors, we've been consistent. But are some of those guardrails gone and do potentially, potentially, let's use that surveyors have more latitude, and within that latitude can they veer into areas that are uncomfortable?

SPEAKER_01

Well, you know, as a surveyor, uh even as a consultant, uh, you always want to help the team. And the biggest change in A360 is the fact that leadership is finally getting involved, the CEO or the COO or the CFO is finally getting involved with you. That's so critical because when you start having these problems and and and issues that maybe the the support's not really hasn't been there. Obviously, we all say the same thing. Hey, the MRI is a lot more sexier than replacing the chiller, but uh you're now at the table with them now. So hopefully that this will make a big change. And I think that the there's gonna be some good things happening with that kind of action. So uh and the surveyor always wants to sort of help a little bit if they see a problem like that and they say, look, the funding is not coming your way, and that's gonna be part of the final report. So you know, maybe you need to put more money into your uh ITM to take care of your equipment, and it's not happening. You're seeing all these issues, 10 fire doors, what out of a thousand, whatever it happens to be, maybe there's some help there. And that's what I that's what I'm hoping. I think we're all saying the same thing, the heads are shaking. I'm hoping that happens. But it's uh that's been a long time happening. And I think CMS saw that. So I'm hoping that uh there'll be a change in the attitude.

SPEAKER_03

I think one thing that or concept that we all can't lose track of is all of this, and you mentioned CMS, it's all based on the conditions of participation. It always really has been. And I think Joint Commission did get a little outside the guardrails of conditions of participation with some of the standards, and they went, wait a minute, we're not gonna example would be nowhere in the codes does it say you can't have carpet underneath a hand sanitizer, alcohol-based hand sanitizer. So that one went away a few years ago because it was never in a code, never in a COP. And there's hundreds of examples like that. And now with the new standards, they're really in line with the conditions of participation. And wait, the K tags and the A tags, because those tags, remember if any of us have, we've all experienced a CMS look behind survey validation survey, even though they're doing it different in the past two or three years. But when those 16 surveyors show up on a Monday morning and say, hey, we're here to see if Junk Commission did their job right, they're looking at conditions of participation and they're giving you a report based on the tags. And you go into the new SPG and you'll see that it's aligned with um the tags. And so that's what I work as I work with my clients. It's like, wait a minute, what's old is new again, and it's always been there, and I get facility managers who go, Tags? What tags? Okay, let's take it right back to the beginning. So um the the guardrails have been there, um, and I think now we're getting back inside them just in a different way.

SPEAKER_04

If you like this video, please like and subscribe to the network. And more importantly, share it with your colleagues in the healthcare industry.

SPEAKER_05

Together, we can solve the aging crisis that's impacting all of us. There are changes to fire drill uh policy procedure. Anybody want to chime in on what those changes are? And and I it seems like they're well, I'm not gonna say positive, but anyways, what are the other changes to fire drill? Anyone want to take that one?

SPEAKER_03

So the grid's the same. The grid is the same. You go into the SPG, it's the same grid with the same mistake on the top line that talks about ambulatory health care. And I don't know how many times I'm gonna bring that up. But um, but the only change I have heard of is the one hour rule is not based in code, it's not based in a COP. So if you have a drill that's within that one hour issue, you know, one month, one quarter to the next, they won't cite that anymore.

SPEAKER_01

But you have to watch out, and we're still gonna see this on the survey. Um, I I'll watch up walk up to the uh nurse nursery station and say, hey, there's a problem in room, whatever it happens to be. Tell me, how often do you have your fire drills? Oh, it's always on a Thursday at three o'clock. Uh, that's the problem. So the complacency, we want to make sure that doesn't happen again. So even though the it's changed now and it's it's relaxing a lot, and that's great for everybody, but the surveyors will go around and say, hey, see how often do you have those? And when is it? So and and I've got the answer so many times. Oh, yeah, don't worry, it's always on a Thursday at three o'clock change to shift. It's perfect. No. What would you recommend? Well, hopefully, uh, whoever's running this, the uh Taylor's probably doing it right now, making sure that the the the time is off by more than an hour or so. Don't don't become commonplace. That's that's kind of key.

SPEAKER_00

Yeah, I'm I'm fortunate to not have to deal with with fire drills. Our safety team does that. But I think it's just gonna make it more it's it's gonna take away that I have to meet this very specific guideline and just make it easier to make it random. That's make it random, people don't expect it. That's the only thing you're trying to do, and you don't have to work within that confines of the one hour. So I I think it's a great change.

SPEAKER_03

That's why you're here, Taylor, the voice of the field. I like to have I like to recommend to my clients don't you have like real fires, don't you have real people stations? Every day what you know, you have you know, popcorn, I know it happens, right? So much so why not use those? Why not respond to them and keep the records like you do a drill? If you do that, at least maybe 50% of them are real. Boy, I'll tell you, you won't have any problems with with the one hour issue.

SPEAKER_05

You know, that made me think, Ed, when you said don't you have real fires, um, back in December, we did an episode with Donna Geringer from um Metro Health, and she's their safety person. And it was it was talking about lithium batteries and just kind of the the issues with lithium batteries. So as soon as you said don't you have fires, my mind immediately went to Donna's great episode. So if you want to hear about lithium batteries and putting policies and procedures in place, I would recommend Donna um from December. I think that's gonna be a huge issue going, right? These these things are everywhere. It's gonna give you a nightmare, I'd imagine.

SPEAKER_03

So there's something that just came out in the past couple of weeks about significant reportable events. Um, and then as of January 2027, Joint Commission and the NQF are joining their lists of reportable events. And the new one, what there's a bunch of new ones, but two of the new ones have to do with fires, have are now equipment fires. And it's a very broad definition of what equipment is, and that's what they're looking for. They're looking for the battery issues as well as anything else, because there have been some pretty significant hospital fires around lithium batteries, and um, there are surveyors that go out and investigate those.

SPEAKER_05

Yeah, it was interesting to me. I mean, Donna's really well versed on it. She's done a lot of research on it. She has some personal experience, so not to hijack it, but it made me think of it. Um I want to get back to um something, Larry, that you brought up like really in your kind of when you first started talking. Um the you mentioned that um Jim, and you know, Jim said this on the podcast we did. There's gonna be a grace period, right? Three months, six months, there there's gonna be a transition period. There has to be. But some of the surveyors citing that the hospital's not using the new standards. If you're that director, I'm not asking you whether they're right or wrong to do that. I'm asking you how would you how do you respond to that appropriately without crossing bonds if you find yourself in that scenario where hey, you're using the new standards, I didn't need them yet. How would you reply to that or respond to that?

SPEAKER_01

The uh survey process guide has fantastic information and it really does. And if you just take that information out and start using it, there's so many, everything's there. Everything that you need from a building tour to the kitchen, uh, everything is in there. If you just take the time, start printing it out now and start using it, you'll be up to date and you won't get caught. But I some of the surveyors are actually expecting you to be start using that stuff, especially the document review. It's it's in the survey process guide, it's there for you to use. Print it out and start using it. And so many hospitals have added things to it, which I think is great. They've uh turned it to electronic and they've actually added to that the process of uh whenever they have an interim life safety measure, and they also put all the repairs. So another column is the ILSM, and then what did you fix? What failed? And this the fixed is right there attached to it. So people see that and they're now using it because it is a it's an easier bucket to put in, I guess. There's not as many, but it is all in one area. You're starting to see the 411s and the 311s uh really be pretty heavy, makes it a little easier, but it's gonna be what where we're going, so we might as well start using it that way. And it's okay. Survey process guide is is is in there. There's so much training on the uh joint commission site right now. You should be taking advantage of it. There's some great webinars. I mean, if you just watch some of the stuff, it's great. And there's a lot of new material out. Uh, there's the crosswalks, there's everything that you can possibly. I'm using right now, I'm doing the exact same thing using the crosswalk and dispositions and everything, and trying to put my my uh cheat sheet together of common findings, make sure that I'm correct, and I'm doing it through finding all the information from these survey process guides and the dispositions. So it's there. Uh it just takes some more time to get it done, but it's uh it's where we're going.

SPEAKER_03

So uh it can be intimidating because when you open it up for the first time, there's seven this morning when I opened it up was 702 pages or something. It's like, whoa, I'm not looking at that. But if you really look, if you really dig in, there's only like 50 pages or 45 pages that have to do with our world if we want to put a wall around it. And then I think as Jim Grana pointed out in your previous interview with him, control F is your friend. You know, it works and it works. Um, and I just did it for for for giggles. I I control F and I put the word document in. It came up with 23 pages with the word document in it, and it it was like four clicks, and I ended up on the document list for facilities.

SPEAKER_05

You know, the disposition reports, the crosswalks, there's really so much to get to. We don't have a lot of time. And I would just say if people like there's lots of resources out there, the joint commission has put a lot of resources on their website. Go to it. Hopefully, you've heard of the disposition reports and crosswalks, but I want to talk about um, as I said, we've got to finish with leadership, but the safest matrix and the sharing of best practices, and that can be a bit of a game changer on the good side. Can you talk a little bit about that? Kind of what they're what they're doing and and how we share best practices. What's a little bit new for this accreditation 360 rollout?

SPEAKER_01

Well, I think we've always had that. It's it's just hasn't been called Faceless Before Safest. And I think it's fantastic. That is something great to share with everybody. Whether they put it in the EC News. And now, Ed, is the EC News going away as well, or just perspectives?

SPEAKER_03

I I only saw the announcement for perspectives, but you know, strap in, who knows?

SPEAKER_01

Yeah. But I think it's it's they're great. Let's let's share it among the community. Uh so they're all doing the right things, and and boy, it's gonna help us. Maybe the top 10 life safety, the top tape 10 uh ELC will go away. Maybe it'll be the top 10 PE someday. But if we have all these great ideas of from the Safest program, that should help a lot, you would think.

SPEAKER_03

And I and I'd love to see a safest review that's facility or physical environment focused. I think what I'm starting to see now is safest items that are more clinically focused. One of my colleagues was talking about something that, you know, on the women and baby side, you know, some you know, neat stuff from a healthcare and and patient care, but I think, you know, it's going to be up to us and our colleagues to say, hey, surveyor, this is something really cool that we do. And and make sure you're putting it out there during the survey, saying, I I I would love to have you consider this from a from a safest perspective. Two reasons. One, it probably is really cool and you should get credit for it. And two, it uses up an hour of the survey. So oh boy.

SPEAKER_05

What what did I say? Nothing. Okay. Well, it's like you it's like back when you're in college. You ask a question to get your prof off the you know, you have 50 minutes to kill if you can kill 10 out of 50. That's great. They all got a flight to catch. That's what I keep reminding of. So I'm I'm glad you clarified that. So the the burden, not the burden, but the onus is on the facility to bring these things to attention and get it decided to publicize.

SPEAKER_03

That's my way of looking at it. So, yes. Um, will the nurse surveyor and the CNO collaborate a little bit and look at some clinical issue and say, wow, this is cool. Let's make let's get it onto the safest matrix. You bet they're doing that. So the facility leaders and the safety leaders kind of need to do the same thing. Hey, we're doing this really cool thing down in the kitchen or in uh in uh hyperbarracks or something. Um, can you look at this and and see if if you this you know rings your bell from a safest perspective?

SPEAKER_01

And don't forget the the life safety survey has been around to a lot of hospitals, so they know what really is top-notch. So I think that's gonna help too.

unknown

Yep.

SPEAKER_05

You mentioned uh, so you know, one of the things uh like in the webinar that Tom Grice of of our company did, and and Taylor, you alluded to it, was you know, with all these changes that it's incumbent on directors of FM, just folks in FM, and again, that's what we focus on on leadership, Taylor. You and your role to to be able to articulate to C level leadership, that word again, that hey, there's gonna there may be some changes, kind of lay the groundwork for that. That kind of ties along with the leadership perspective. Can we talk about that a bit? Taylor, can you talk to like the importance of doing that for your leadership or really any leader, you know, whomever you report to? How does A360 suck in leadership? Or how like how should it uh how should it operate? Now we know how it operates in reality most of the times, but how should it operate where leadership becomes more engaged? So maybe on the smaller level, Taylor, how you do that with your leadership, and then broadly, what's A360 seeking to do by bringing in leadership to the process?

SPEAKER_00

Right. So we we actually started working on this, gosh, as soon as it first came out, which was last summer, we made our own crosswalk. Um, and then joint commission came out with one. So we fact-checked ours against theirs. And um we also updated, like I said, all of our policies and documentation. So I put together a PowerPoint and presented it to our facilities leadership, saying that we did all those things and also preparing them that things are gonna look different on the safer matrix. Um so just having that, making sure that they know that is definitely key because the last thing you want to do is have them learn it during a survey when they get the safer matrix and it looks drastically different. Um and just you know, watching those webinars on joint commission, I've watched them all. I've downloaded all the the resources they put out. The standards are free now and available to the public, which is awesome. Um, so just taking advantage of all those free things is just really helpful. But as far as you know, what is leadership or what what is A360 gonna do for leadership, I think the safest matrix or safest what it's practice or whatever it was called is gonna be a really cool thing. And I from two perspectives, one, I hope I can get some of my stuff in there, but also not having to reinvent the wheel on things that I need to work on. What is the best hospital doing? I wanna do that, and I can go grab it from the website and not have to come up with my own thing. Um, but how cool would it be to get acknowledged for that during a survey that hey, we're gonna put this process that the facilities is doing into the safer practice. Um and the C-suite's gonna see that, they're gonna see that final report. That's gonna be awesome for facilities. So I think that is gonna be the best thing to do from a facilities perspective with this new process.

SPEAKER_03

Leadership got a different lens on survey reports last year, right? We at one point, the when a final report came out, it was uh findings were alphabetical. How bizarre was that, right? So EC was always top of mind when that when that first page was opened. Here's all the here's all the EC stuff. It's like, wait a minute. And you and my phone would ring when back when I was sitting in Taylor's role. And they, well, you know, what's going on with all the environment stuff? It's like, well, wait a minute, look down the list a little bit, you'll see the infection control stuff. Now it's by severity. That report comes out by severe. Where does it land on that safer matrix? So everything in the high and to the right is going to be first on that report. And not to pick on my infection control colleagues, but that's where a lot of that stuff now ends up. And so leadership has got a different, I think, a better lens on what the accreditation process is finally producing. And the not to minimize it, but the little stuff, which was a lot of the EC stuff, is down all down low and to the left. Um, yeah, it all has to get taken care of, but it's not the big issue that some made it out to be four years ago, three years ago.

SPEAKER_01

I'm just hoping that that I'm that we're gonna see leadership get involved. It's not just the environment of care and all that PE, are they gonna be at these meetings? Is there gonna be more involvement, more funding, more attention to detail for uh facilities? That's gonna be key.

SPEAKER_05

So did I hear you correctly? Do you think that this is one way that from the outside CMS Drink Commission trying to create more of a leadership involvement in the process? Do you think that's perhaps one of the goals secondarily?

SPEAKER_01

This has been going on for a long time. Uh we went out surveying that we have the environmental care meetings, and we say, well, who's there from this from the leadership team? Is the CEO there or the COO or the CFO anybody? None, nobody. So we said, gee, you're really it was kind of our requirement, you need to have somebody involved from the C-suite, somebody, and using it's the COO. And I did that for the uh Cleveland Clinic. I made sure that all our hospitals had the COO in those meetings. And if you get the CFO, even better, because that's your funding, that's where you really get your money from. So I I think you've seen that now. Everywhere it was was it from CMS? I I don't think so, but it was joint commission. So uh unless Edis sees something different, I didn't see it any place in the COPs. So it's uh basically it was joint commission doing that, which made sense. Leadership needs to be involved, and I think now with the A360, leadership needs to be involved, they're going to be involved in these meetings now.

SPEAKER_05

So what happens if leadership's not involved?

SPEAKER_03

Well uh priorities won't be correct. So what I was about to say was before they uh they created NPG standards, you'd look for workplace violence standards in four different areas and you'd have to build a program and make sure you grabbed all the HR, the leadership, the EC standards, and create your program. Well, CMS doesn't drive. That necessarily, but now the NPG standards have it all in one place. Everything to do with workplace violence. Leadership must be involved. And you'll look through several of those NPG standards, and they've got leadership front and center in the way they wrote those up, whether it's workplace violence or water management. Leadership has to have their foot in the bucket, so to speak.

SPEAKER_05

Getting back to the safest program, whatever they're terming it, and your example there, Taylor, I think potentially I always worry about those critical access hospitals, smaller community hospitals that don't have the time, the resources, people, the money to put in some of these cool things that everybody talks about. And hopefully that gets in some way they can utilize that to save them time and money because they simply don't have the resources. And Ed, NPGs, we didn't talk about the national performance goals. It's a whole nother level there. Simply didn't have the time. But if you're not familiar with the NPGs, there's a lot of information. National performance goals. Ed, you just touched on it a little bit there. So dive into that. And there's so many different topics we could cover. But I do want to thank Larry, Taylor, Ed. And actually, last word to you folks. Is there anything you think is important that I didn't ask you about or that we didn't cover, or any final thoughts?

SPEAKER_00

The standards are much less prescriptive now, which we've talked about. They're trying to be more in line with CMS. You know, they took away some of those extra requirements they had. And that's good. But also, if you were a new facility manager or a new director, um now you have to go dig through code to find out what you have to do, which is a lot more challenging and very intimidating. Um so you know, there's good things and bad things. I would say if you're new to this industry and you're trying to learn what to do for joint commission, um, maybe look at the past standards. Look what look what was required before. Look at other accrediting organizations like DHQ or even D and V, see what they're requiring, because those are all coming from code. And it's really, really intimidating to try to dig through NFPA 99 101 and see what you have to do. Um, whereas before you could just re-joint commission standards. So one kind of negative thing is just it's a lot harder to find out what you have to do.

SPEAKER_05

That's a great one, which actually could lead to yet another episode where as we're bringing in people without that experience, that can be a real risk. And you talk about leadership getting them involved, that's a risk they may not know that they have. I'll shut up. Larry or Ed, you're next, please.

SPEAKER_01

Just uh last little comment that I have is that there is more training out there. And I think Taylor brought up a very good point, but also CMS has great training and it's free. And you can it's called surveyor training. All of the joint commission surveyors had to take it, and it's like uh it's a like a week or two, two weeks of work to get it done. It's a lot, but it's uh you've got to you go through all the COPs, you go through everything. So uh and it gets you into the code, which like Taylor said, it can be very confusing. Yeah, we you go from 25 to 10 to 101, but you go all over the place, but it's uh it's what you have to do.

SPEAKER_03

Pay attention to what's out there in the media as well. If things are happening at other healthcare institutions, whether it's a fire or a bad event in a hyperbaric suite or or some security event, we're hearing so much more about workplace violence, especially if you listen to the media coming out of the nursing strikes in New York City these days. Um there's a lot that the survey side of the world, the joint commissions, the DNVs, whoever, are they listen to that. And when they come out and do survey, their lens may be in a direction that maybe you weren't expecting. Um, so that media um lens that you should keep on uh yourself and your organization is so important. So important.

SPEAKER_05

Great one. So Larry Rubin, Taylor Vaughan, Ed Brown, I really appreciate it. I had a lot of this was a great episode. I really enjoyed it. You guys were fantastic, and maybe we reconvene in two months, down the line. We got another two months of data just to check back in. If you guys are willing, the iguanas won't be falling falling out of the trees, Larry. Taylor Dallas won't be encased in ice. And Ed, maybe you'll be sailing out in Boston Harbor, but it'll probably be still pretty chilly in May this year.

SPEAKER_03

Uh-huh. I'm hoping to get in early. We'll see.

SPEAKER_05

Good luck. So, this is Peter Martin from the Healthcare Facilities Network. As always, thank you for watching, and we'll be back with another episode. If you want to be a guest on a future episode of the Healthcare Facilities Network, go to healthcarefacilities network.com and let us know who you are and what you want to talk about. Because together, we can solve this critical aging issue.