Healthcare Facilities Network

Joint Commission A360 Compliance Check In

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Earlier this year, Joint Commission rolled out its most significant change to hospital compliance in more than 60 years: Accreditation 360. In this recorded webinar, Tom Grice and Sharon Tyrrell guide facilities leaders through the essential updates and what organizations need to know to prepare for the new framework.

The session explains how standards have been streamlined, chapters consolidated, and National Performance Goals updated, highlighting the practical steps teams can take to build sustainable systems and maintain readiness. Tom and Sharon offer guidance on aligning compliance efforts with high-quality patient care while navigating this major regulatory shift.

This is not a theory. It is actionable insight from experts who understand the realities of healthcare facilities management. If you are responsible for compliance, survey preparedness, or facilities operations, this webinar provides clear, practical strategies to approach Accreditation 360 with confidence.

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👥 Connect with Sharon Tyrrell: https://www.linkedin.com/in/sharon-tyrrell-chfm-chsp-31684921/

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What Accreditation 360 Changes

SPEAKER_03

If you're in the healthcare industry, I'm sure you've heard about the big changes coming January 1st, 2026. Accreditation 360.

SPEAKER_02

Accreditation 360 is Joint Commission's new accreditation process. 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.

SPEAKER_04

Again, there's there's a lot of questions. But we're going to try to you know explain what we think is going to be happening, how how things are going to be moving forward. I'm Tom Grice, Vice President of Regulatory and Facilities for KREF.

SPEAKER_00

I'm Sharon Tyrell. I'm the National Director for Regulatory and Facilities.

SPEAKER_04

Thank you, Sharon. Again, welcome everyone. So today, hopefully, what you're going to learn is some early insights on the accreditation 360, the biggest shifts, how to align your team for success under the new model. And then hopefully some practical guidance from our experience that would that we're starting to see in the field. And then we're going to talk a little bit about what to start doing now to prepare for 2026, January 1st. So accreditation 360 goes into effect January 1, 2026. There's two new chapters, and that will shape joint commission on how uh hospitals are evaluated. Um the new chapters are physical environment and national performance goals. So the the shift to accreditation 360, you know, what what what joint commission is saying is it's going to streamline the standards, which we are seeing that. Um it's going to be outcome focused. Um and and and it does, which which is near and dear to our heart. It it does um uh set up organizations for a continued readiness program. We have a program that's called constant state of readiness. So um again, it it's it's it's more so that hospitals and and organizations can be um uh always ready. You know, I I I I hate when, you know, as I was in in your shoes, you know, every three years we just reinvented ourselves. And and as soon as Joint Commission would walk out the door, everyone would breathe. And then two and a half years later, we spend all this money and we try to get get ready again. And and and this is going to be a a constant state of readiness. Um, there's gonna be an elevated life safety and environment of care emphasis. However, it does align better with the CMS conditions of participation, and we deal with DNV a lot. Um, it it is more like DNV. DNV comes on an annual basis, they have very general standards and so forth, um, just like what um accreditation 360 is.

The New Physical Environment Chapter

SPEAKER_00

So, what's staying the same? So really everything is staying the same, right? There it there's been no changes as far as the the requirements themselves. Um, there's been no changes with it the adoption of NFPA 101 and 99, the 2012 edition, and and and then of course all the other um reference publications um that um CMS has adopted through 101 and 99. So just a reminder um for all the subsequent are the reference publications. If you're not sure what edition those are, you can find that in chapter two of um NFPA 101. And the the again the and we'll say this time and time again through this presentation. What how the the survey process hasn't changed, how they they come in and conduct the survey, and the requirements have not changed. The only thing that's changed is basically the standards, right? So the standard labels, they they decrease the amount of elements of performance and whatnot. But it keep doing everything that you're doing. If you're compliant now, you will remain compliant moving forward. So again, so the current environmental care and life safety chapters now become one chapter. It's called the physical environment. So we'll refer to it as the PE chapter. And currently there are 40 um plus standards and about 450 EPs that are within the current life safety chapter and the environmental care chapter. So now they become 12 standards and 67 EP. So you can see what a reduction, about 75% reduction that has been with the new uh physical environment chapter.

Plain Language And New Tools

SPEAKER_04

So this is a long slide, and and I'll go through each one. So um the key differences old process versus the um A360 is what we call it. Um so to start off, you know, the the structure of the standards, you know, currently chapters of the environment of care, there's separate chapters for life safety, and many of the EPs um overlap, right? So um the new accreditation 360 uh it consolidates everything into the physical environment chapter, it replaces environmental care and life safety, and some requirements, however, do move over to national um uh performance goals. There was over 700 EPs that have been removed. Um, that's good, that's bad, we'll get into that in a little bit. But um number and redundancy, so many of the standards and EPs with overlap and duplication currently, um, you know, they duplicate each other, and I'm sure you all have seen that happen in your organizations. So now, you know, the new A360, uh, there's fewer standards, fewer EPs. They've reduced the duplication and streamlined the structure. Um survey tools and process flow basically stays the same. It it it does it stays the same. Um how findings are reported right now scored under ECLS. In the future, they're gonna be scored under PE and um national uh um performance goals. Um, and additionally, probably more leadership um will be involved, and and we'll get into that later. Um, so continuous engagement and support. Right now it's a three-year survey cycle. But the A360 does introduce a continuous engagement and safest framework, and and that we we've tried to dig into that safest because it looks like it's it's it's uh it's capitalized for a reason, like the safer matrix. We don't have much details on what that looks like at this point. Um, however, what we're hearing is that that's going to help organizations be in a constant state of readiness. Um, you know, uh transparency and public access. Before you could not get the the CamH or anything else unless you were actually accredited by the Joint Commission. All of the I don't know about the CMH, but the crosswalks and everything else that that that they're publishing are available to the public for download. So I invite you to go out to the Joint Commission website, download some of those crosswalks, um, and and you know start working towards uh uh conversion to the A360. So everyone should be able to get it for free. Um just go to the go to joint commission website um and and be able and and you can download those. It does better align um with CMS and the conditions of participation, you know, in the past or or currently, you know, uh some DNV is really good for this, but but joint commission, there are some standards that go above and beyond the conditions of participation. Um this actually kind of ratchets that back a little bit.

SPEAKER_00

So and Tom, I just want to add a just a couple of things. So I with Joint Commission, if you're a joint commission accredited, you you see the the current standards, how they are pretty prescriptive, if you will, in what you need to do, how often you need to do it. In my opinion, the unfortunate part uh with the new A360 and and D and V sites are are probably used to this, right? Is that we're no longer gonna have that prescription, right? Or description or that detail of how often do you have to do something. You know, you're you're not gonna have the the fire alarm and fire suppression system, you know, those 28 standards that are in the 02, 03, 05 standard right now, EPs 1 through 28, those are all now gonna be scored under one standard and one EP. So you're not gonna have, you know, you're gonna do your your quarterly supervisory signals and you know, semi-annual water flows and all that. So recommendation um for you guys is print a copy of the current standards right now, right? Use those as a guide. Um, they will help you maintain compliance into the coming year. So, with all the tools that joint commission, the crosswalks are are are wonderful, they've got despis dispositions out there. So there's all kinds of tools that joint commission has made available for you guys.

SPEAKER_04

Thank you, Sharon.

SPEAKER_00

So again, um don't reinvent reinvent existing compliance, right? So like I told you, we're gonna we're gonna try to shove this down your throat as much as we possibly can about, you know, don't change anything. So if you're maintaining compliance now, you'll continue to maintain compliance in the coming years. So um update your references and your training materials to match the new um PE and MPG terminology. We recommend that you go to a more of a plain language. Yep. We have been hearing um with some of the um surveyors and and colleagues and whatnot that um more than likely that's how, especially in the building tour portion of things, right? So again, we had 91 EPs in the life safety chapter that are now gonna go over to a to one standard and one element of performance. And so I'm asking, you know, surveyors, what is the what is the safer matrix going to look like? Is there gonna be any kind of reference to a K tag or or something like that? And they all keep telling or saying that it's all gonna go to plain language. So um I would stay away from referencing any kind of you know standard and and and whatnot. So again, use the disposition in the crosswalk reports to um map your your content um to the new standards. Um consider process maps. I know CREF, we have um created process maps from the from the old to the new, and it really helps us, you know, kind of you know maintain that flow and and requirements and whatnot. So really recommend you try to do something like that. And then again, um ensure ongoing alignment with the the COPs to avoid um any kind of um interpretations or or contradictory um interpretations.

SPEAKER_04

So again, I I I really think this will be better during document review, uh especially for your state agencies or a CMS survey, because uh I don't know about you guys, but you know, when I was a director, my books were set up, you know, every every element of performance had a tab, and and I would have CMS show up and they're like, show me your sprinkler report. And I'd be like, shit, where's my sprinkler report? Sorry, that that sorry. Um uh I apologize. Um but but yeah, it it you know it you fumble when CMS or state comes in with binders set up for the joint commission. But if they're all in plain language and I can go right to my sprinkler reports, that's that's perfect. Absolutely. I agree with that.

SPEAKER_00

Um, so the new P numbering structure really hasn't changed. They're still going to do the you know, 010101. It's just gonna have PE in front of it instead of the EC or the LS or an MPG. So um the SPG, which is now known or which is the survey process guide, um, is replacing the survey activity guide. Um, the crosswalk for the um um EC and LS documentation to the new PE structures out there. And listen, guys, that survey um process guide has lots of tools at the end of it. So it gives you um some explanation of some of the standards that have been you know removed or now put into the MPG chapter and whatnot. But at the end of that thing, you will find building tour guidance, you'll find kitchen tracers um um tool, you'll find a document review tool, um, all sorts of things at the at the end of that um or at the last few pages of that survey um uh process guide. So again, update, start thinking about your policies, all your maintenance logs, your matrix matrices, um, your readiness tools. Highly recommend um you know, updating them to the new standards using the plain language. All right, Tom.

National Performance Goals Explained

SPEAKER_04

All right. So national performance goals, you know, they draw existing topics from previous previous chapters, such as patient safety, emergency preparedness, and and and workforce readiness. A360 is gonna unify that into a single framework. And you see it here culture of safety, EM alignment. So it's really getting the organizations aligned as opposed to just being chapter and verse on we meet this, we meet this, we meet this. Uh so you know it it it just unifies the the organization in a better in a better um manner.

Off Site Locations And Life Safety

SPEAKER_00

And also national performance goals are those standards that that joint commission, when Tom spoke earlier about um, you know, there are some standards that go above and beyond the conditions of participation. And the national performance goals is is basically what that is. So those are are are yes, they're standards, and yes, you will be cited for them, but they go above and beyond the the uh CMS's conditions of participation. Correct. So life safety drawings. So I think everyone kind of had a heart attack um besides all the new changes, but everybody got a little squirmy. Um now they're you know, they're gonna um start going into your off-site locations, right? The life safety surveyor. Um, you know, before we've experienced where it was just the clinical surveyor would go to your your licensed off-site. So it's not every off-site that you have, it's only the license, licensed off-sites that are part of your accreditation, right? Or your hospital license. So um, so expect the life safety code surveyors to go over there. And you've got to have your your documentation for those buildings, right? So you've got to, you know, you've got fire doors, if you've got fire extinguishers, exit signs, all that fun stuff, your generators, all that wonderful fun stuff over there. They could be asking for that documentation. Um, don't provide it unless they ask it, ask for it, but make sure that you're doing your testing and whatnot over there. So um again, you know, a lot of these bee occupancies may not have life safety drawings. And in the beginning of all this, they were telling us, oh, well, you know, you've got to have all the same requirements and do all the same things at your um bee occupancies as you do for your hospital. Well, SIG spoke out, and so no, you do not have to have life safety drawings. That's one component you don't have to have, um, but um starting in January. So don't get squirmy about it. Um, but again, make sure that you're doing all your testing and and all your maintenance and stuff over at your bee occupancies.

Biggest Risks And Surveyor Discretion

How Surveys May Look Different

SPEAKER_04

And and for the bee occupancy, if it's a lease space, in other words, if you lease from someone else, just make sure you have their documentation because the common areas are still surveyable, right? So if they do fire alarm testing, generator testing, and all of that, and it's it's it's not up to you. You still need to be able to provide that documentation to the surveyors. All right. So so concerns we hear from the field. So multiple interpretations. How many people this is a change. In our opinion, it's not that big of a change, but you know, change is hard for many people. So, you know, there's multiple interpretations. Um, you know, there's multiple interpretations become a single scoring in documentation. So there's some issues with that, right? So the guardrails are now eliminated. Individual survey just surveyor discretion potentially is gonna increase findings, and we'll talk about this in a little bit, but but uh just because there's low the there's there's less standards, there's gonna be more findings in a single standard. So we think that's going to potentially roll up and roll over, right? On the safer matrix. So just just keep that in mind. So our take is the scope is more widespread. Again, leaving and leave leaving it up to surveyor dependent, and we all we all see that. Um higher risk due to the number of findings that could be scored under a single standard, you know, as we see it now. You know, if you get three you know findings under a particular standard, it potentially can roll up. Um we we we think there's gonna be more leadership involvement. In other words, I there's there's gonna be scoring under leadership more than it was before or than it is now, right? So easy life safety, et cetera. Um, and then potential, especially this the beginning of the year, probably up until June, there's gonna be inconsistencies because you know, as we talk to surveyors that we know they're still not totally uh aware of of how this is gonna look. I think there's gonna be some inconsistency, just like back in 2016, when you know the safe safer matrix uh and and uh see it cited came out and we adopted uh the the uh 2012 uh life safety code. So there's gonna be some inconsistencies, I think, is what we're we're anticipating. So um so the procedural changes that we're thinking is is gonna be happening is there's gonna be more field time. So what we're hearing is they want to they want to focus about two hours on document review. What does that mean? So they get out into the facility for a lot longer. I mean, I I've been in document reviews sometimes that took a day and a half, right? Um, you just you you you never know. So, you know, our message to you is get your documents in order and make sure that they are complete. Audit them, audit them on a regular basis. You know, we we come and audit our clients on a quarterly basis. You know, we we look at anything that's and and then we come back next next quarter, we look at anything that was missing to see if it was fixed, and then we look at anything that that that came due and make sure that all those documents are there, additionally, that any deficiencies have been have have been uh rectified. Wider staff engagement. Life safety surveyors are gonna start talking to staff a lot more, a lot more. Um, you know, typically once we get on building tour, you know, depending on the surveyor, they may talk to a couple of staff, ask them how to how to find a an you know uh a uh MSCS sheet or or whatever. Um, and then they're gonna actually focus on repeat issues, right? So they're gonna look at, they're gonna have your your previous survey and they're going to look for that being a trend, right? And then they're gonna they're gonna it so it it becomes kind of more like a tracer. Um, and then more focus on non clinical competencies. You know, in the past, we we they didn't really focus on our competencies a lot, but they're gonna pull a job description for, you know, as an example, materials management, you know. If they see an electric uh pallet jack, it's probably in the job description that they're going to have to operate that pallet jack. So they're going to want to see that there's a competency that that person knows how to do it. So keep that in mind. They're going to start focusing more on non-clinical competencies.

SPEAKER_00

And I just want to add one thing. So Tom's talking about the the documentation, and it is very important that you have your documentation in order, right? So and there's there's no particular way that you have to set up your binders that that's what you do. You know, a joint commission doesn't have a required method in how you um provide your testing documentation. It can be electronic, it can be paper, and that you know, I'm an old school girl, I like the paper stuff. Um, but please also pay attention when when um you're having your document review session, and um let's say that you're missing a piece of or a document that the surveyor is requesting, and you have one chance for an IOU, right? So he's gonna ask you one time, he or she is gonna ask you one time um as an IOU. Make sure you write it down, you you get that document and you provide it to the surveyor. That surveyor will not ask you for that document again. So it's very important um to take some notes and ask for something that you you know, make sure that you provide it to the surveyor.

SPEAKER_04

So great point, Sharon.

SPEAKER_00

So immediate steps to prepare. Um, so risk assessments. You know, Joint Commission has always focused on on risk assessments, you know, and we see a lot. I mean, we basically have a risk assessment, if you will, the interim life safety is risk assessment when you um are not able to fix a life safety component um in your hospital, right? So, but there's other risk assessments to take into consideration. Your behavioral health risk assessments, your you know, a risk assessment if your temperature and humidity are out of range, air pressure, all those types of things. Make sure you have your risk assessments um out there and and documented and whatnot. And it's a good time to go out and do risk assessments to see if you do have any risk and and whatnot. Um, validate your regulatory documentation. Like Tom said, do a monthly, quarterly review of your documentation to make sure that you are completing that circle. Yes, I've got my testing. We see a lot of times where you know you'll get your your report, you shove it in a book and then you know, call it a day and check that box. Yep, it's there. But you know, pay attention to your deficiencies that have been identified. Make sure you have work orders um to show that you corrected that deficiency. And if you didn't immediately remember, you know, if you if you have a life safety code deficiency and it can't be um repaired immediately, then you need to do an ILSM risk assessment, at least the assessment part, and it needs to be documented. So make sure you're closing that loop on on all of your um inspection testing and maintenance documentation. There's gonna be um get your cross-department alignment, especially in the in the areas of like radiology and whatnot. You know, they're in the in um the environment and care um portion of uh our standard or our whatnot. Um, you know, there was a lot of radiology stuff. You know, you're gonna, you know, do the physicist is gonna do this report and have to do all these fun little things, and make sure you understand those processes. And I know you're not responsible for them, but a surveyor could be kind of talking to you and and whatnot. So understand all the requirements, even though you may not be directly responsible for them. Um, again, competency-based training, like Tom said, make sure that you have all your competencies for your folks and and um in their areas of work. Continue all your inspection testing and maintenance that you are doing today. Again, none of that has changed, right? So all the NFPA requirements remain the same, so nothing has changed. Again, download that survey process guide and review it. Again, lots of tools in there, and then you utilize the available crosswalks. It will really help you start to understand how things are today and what they're gonna look like next year in the years coming.

SPEAKER_04

So thank you, Sharon. All right, so immediate steps to prepare. Um, you know, do some mock surveys. Do do do uh, you know, I I know they're not required anymore, but you know, do your your your your rounding, your EOC rounding or safety rounds or how well whatever you call it, and and and just just do that on a on a regular basis, right? And and or you know, hire hire a third party to come in, craft or someone else, and and we'll do a mock survey for you, right? So um just just be aware, right? Um and then review your your deficiencies from last year and or from the the last triannual and the previous triannual because it's still if it if you skipped a year a one cycle, it's still a repeat, right? So just just make sure that you've hardwired whatever the whatever the findings were at that time. Validate your CMMS data. You know, that that in my opinion is important. Make sure, make I could go on for hours about CMMS, but just just make sure that you've you've you you've done the the assessment on, you know, is it is it high risk, is it, you know, confession control, is it low risk or what have you. Make sure you have that that that document available. You know, as a side note, make sure everyone does the OR wet location risk assessment because we see that a lot. That's that's missing. Even though you have line isolation panels and those those types of things, CMS still requires for you to do a um an OR wet location uh risk assessment, just as a side note. Um update your standard operating procedures and then you know conduct license offset off-site assessments. A lot of times your offsites, you know, they're out of sight, out of mind. Um so you know, get over there and do some tours and and and make sure that that things are compliant there as well.

Ongoing Readiness Without Checklists

SPEAKER_00

Okay. Ongoing readiness. So um the impact. So again, we're we're thinking that there's gonna be increased risk expectations. Um, there's gonna be some collaboration is gonna be emphasized. Um start thinking about you know, daily compliance, you know, reviewing uh the work orders or your PMs and stuff on a daily on a daily basis, and then you know, try to start thinking about maintaining that constant state of readiness. Anything to add there, Tom?

SPEAKER_04

No, I think you you you covered it. I think I think we've driven home the constant state of readiness already, so I think we're good there. Yeah.

SPEAKER_01

Go ahead.

SPEAKER_04

Um, so field test of strategies to prepare. You know, again, see here here again. We tell you constant state of readiness, right? Um, and then you know, rapid communication. Just make sure what when you find things out there in the field or if there if there's issues, that that the communication channel remains open, you know, cross-department, up to leadership. You know, there's you know a lot of times we need we need funds or or what have you to fix things. So just make sure that that that you're communicating your needs um for for your house, right? Um and then cross-disciplinary tracers. And and uh I uh this is Tom Grice speaking, not anyone else. People ask me all the time do you have an environment of care checklist that we can go out and do our um our safety rounds? I'm a believer that if you have the right people doing rounds and it's cross-disciplinary, everyone knows what they need to look for. If you use a checklist, I think you lose sight of everything. This is Tom Grice, this isn't anything else, but I think you lose sight of a lot of things. If Tom Grice comes in and does the facilities, and I have the housekeeping supervisor doing you know, infection control and cleanliness, and I have dietary, you know, looking at the are are are they are are they foaming in and out of the rooms, those types of things, it's it's it's much it you you you have a much better program when when you're going out and and and doing these surveys. And then again, can't stress it enough competency validation. Um, you gotta make sure if it's in the job description, there's a competency in their file that shows that they're competent to do whatever it is.

Key Insights And Final Recommendations

SPEAKER_00

New tools and resources again. So um Joint Commission has um uh developed and distributed um webinars on all new chapters um within the joint commission now. So there is a webinar on the uh physical environment and the NPG. Highly recommend that you um take a listen to those. They're I believe they're available for a little while longer. I know that there's a a cutoff point for that. Um, so it you know, recommend that again your survey process guide. Um, they came out with a um an update to the survey process guide, and they had um updated it to include um a building tour guidance um template form, if you will. So um again, that survey process guide is is is is is valuable. So your disposition report, it's a crosswalk showing exactly where each current EP and what the new where it goes into the future, right? So it will tell you if it's been deleted, if it's been um if there's a new standard associated with it now, if it's been rewritten. It gives you all the fun things about it. So um, and then the um accreditation 360 um frequently asked questions is an involving library of real questions from the field. So take a look at those. You may have several questions that could have already been answered from them. So highly recommend you visit the joint commission website. Again, all of these tools are out there for you, and um, and there's some good stuff out there. Go ahead.

SPEAKER_04

So Tom and Sharon's key insight. That's scary. That title is scary. Yeah, um, all right. So, first of all, joint commission, as you've i haven't said the yet today. I've I've I've been watching myself, but joint commission is the new name to refer to joint commission, um, no longer the joint commission or Jacob. And you know that they actually made a point on in that in several different um presentations that they did. So just keep in mind, you know, surveyors they may cite it, I don't know, but uh again, it is now the joint commission. Um we feel that as I said earlier, potentially there's going to be more findings and condition level roll-ups due to more findings in the broader. So just keep that in mind. Let your let your executive leadership know.

SPEAKER_01

That's exactly what I'm saying.

SPEAKER_04

You know, because you know, for for some reason, all the surveys I go through, it's it's it's how many findings? How many findings? It's like they're keeping score. So they need to be aware that there's probably going to be a lot more findings.

SPEAKER_00

Uh, so and they're gonna shift over to the widespread things, and they're gonna shift. So, yeah, yeah.

SPEAKER_04

So good good point.

SPEAKER_00

Yeah.

SPEAKER_04

Um, plain language, you know, it that that um that allows for more alignment with CMS and state requirements. I think that is the best part of this, is that we can have, you know, I've been in organizations where they have a binder for CMS, they've got a binder for their state, they've got a binder for joint commission, and they have to every every report they get, they have to copy it three times. This you you can have one binder system and be aligned with all the requirements. So I think that's that that is a a positive of the change. Um, and always the requirements haven't changed. It's just where they're scored. It's you still have to, you know, do everything. Um if you're compliant now, you're gonna remain compliant. Period.

SPEAKER_00

Can't stress that enough. Yeah, keep doing what you're doing.

SPEAKER_04

Don't change it.

SPEAKER_00

Don't change it.

SPEAKER_04

Yep.

SPEAKER_00

Okay. Final recommendations, again, start now. We've only have a few weeks, and I, you know, I hate it for the folks. I guess someone has to be a guinea pig at the first of the year, but you know, I feel sorry for you guys who are due joint commission in January. I've got a hospital that I that I help, and I know they are stressing big time. So um, but start now. So um your documentation in line in in order and organized. Focus on on your people and your processes, you know, bring in, you know, start educating your staff on on these changes in in the new processes or the process. So um keep your documentation simple. Again, only provide documentation to your surveyor if they request it. Only answer the question that is asked. Don't vomit at the mouth, don't just hang on your binder and just give them all your things. So, and um, and then of course, collaboration, you know, with all your departments, with executive leadership, senior leadership, department directors, all the way down to you know, the housekeepers and whatnot. And um, you know, it it it's a change, but it's not really a change, it's only changing the standards and how they're scored, and that is it. Continue doing what you're doing, and you'll be great.

SPEAKER_04

So again, we can support you with readiness assessments, um, um, you know, physical environment strengthening mock surveys, training programs, education. We can even do competency gap analysis, provide process maps for you. Um, you know, if I'm sure most of you have these programs already within your hospital, but it if you don't, you know, feel free to reach out. We have all of it. Um, we've been creating it since uh um the the the uh the announcement was made that we're moving to A360. So so just you know, if you are struggling, we are here to help. Just reach out. Yep.

SPEAKER_00

Thank you, Tom. And here's our contact information. So, Peter, any questions? Anything? So, again, my name is Sharon Tyrell. Here's my my email address, and Mr. Tom Grice, his email address. Again, if we can help in any way, please do not hesitate in reaching out to us.

Q And A Management Plans

SPEAKER_03

Thank you. Yes. Before you leave, can I there's a couple of questions that came in? Can do you mind if I fire them to you? Oh, sure. But you know what's really interesting? Um, and this hit me when I was listening to you guys speak. So and your messaging is ran with doing, I mean, Jim Grant has been on the healthcare facilities work, not big changes. But I always look at like I'm not a technical person, I'm more like a uh well, I mean, I was a recruiter in business development, I was a project manager, I'm not what you guys, but you know, it hit me that if I'm listening to that, everything's perception in the world, right? So if and your key point, I think the biggest takeaway when you said to tell your executive leadership the changes, if I'm a director and I know that my C level doesn't necessarily understand what I do or sometimes even care what I do, I just gotta keep things running. And now these guardrails are eliminated. They only see the leadership only sees we're getting dinged more now. That's on you.

SPEAKER_00

What are this is probably higher and wider, and it's going up the food chain, if you will. That will put it in.

SPEAKER_04

And we saw that in 2016 with See It Cite It. Yep. You know, and I was right in front of my leadership saying, you don't understand. If they see something, you know, look in the past, they would just walk by it if they only saw it once. Now they're gonna cite it. Yeah, and uh I was I was in front of my senior leadership at that time.

SPEAKER_00

Yeah, we know the days of you know, two or three findings here and there is is out the window and has been for quite some time. You know, they're gonna find something, they're they're gonna do it. So um, you know, give them the low-hanging fruit stuff, you know, give them that stuff that that easy thick stuff, you know. Um, yep. So go ahead.

SPEAKER_03

Yeah, uh that was great advice to start now, right? Because you have to start now to dedicate, because it's gonna take a while to it's like planting a seed, it doesn't just pop, it just takes constant reinforcement, which uh you guys talk about quite a bit. Yes. All right. So first question what are your thoughts about maintaining the management plans? Thank you, Skip.

SPEAKER_04

Yes, so maintaining your management plans, you know, again, plain language. Um and and again, this isn't a sales call, but you know, we do have standard management plans for adjusting to the new A360 standards, but maintaining your your management plans shouldn't change really much at all.

SPEAKER_00

Um they do not have a uh standard associated with them now. So everybody's thinking, oh, they've been deleted, we don't have to do them and whatnot. But if you look through that survey process guide, it does talk about your management plans, your annual evaluations, your environment and care committee or physical environment committee, safety committee, whatever you would like to call it. Um so those things are still talked about in the survey process guide. So don't go away from doing your management plans and annual evals and your your safety committee and whatnot. So correct. Um but yeah, like Tom said, use plain language, get away from referencing any kind of standard um or K tag or A tag or anything like that.

SPEAKER_04

Just use plain language, even in your policies, don't put standards, ECs, people's names in your policies, right? You you just keep it simple, keep it plain language. Then you don't, then when changes happen in the future, you don't have to you don't have to go back. But uh so many policies we see that at the end they have a reference to you know ECF, whatever it is. So keep that out.

SPEAKER_03

Just keep it plain language. Excellent. Can I ask a question? I'm gonna get back to we have a couple more here, but the SPG, the survey process guide that you guys were talking about, and there's one slide on there where it's 600 plus pages. Now, this question I'm gonna ask, it's not meant as a as a as a sales question at all, because I know that obviously we can help. There are other organizations that can help, but let's say that's a massive, that's that's a massive amount of pages. And some of the feedback I've heard from the field is it's daunting. Like where if you're a smaller hospital, you don't have a lot of funds to help, you're up early in 2026, you're on your own. How do you start to just chip away? How do you start and not be daunted?

SPEAKER_04

So so, first of all, remember, whatever you're doing now, keep doing it.

SPEAKER_01

Right. Okay.

SPEAKER_04

That don't change anything from that aspect. You know, I I don't think over this first year you're gonna be deaned because you you you called something an EC or an LS or whatever. And and 600, keep in mind, 600 pages is everything in the hospital. We got to focus on the PE, right? So it's it's in the MPG, thank you. So it's it's much smaller. Yeah, you're right. 600 pages is daunting, but it's much smaller than that. And if you don't have time to read through the PE section and the the MPG section, just don't stop doing what you're doing. That that's that's the key. Don't don't stop.

SPEAKER_00

And and also the survey process guide, you know, I I agree with Tom. Um, you know, our the standards in our world have have have decreased by tremendously. But at the at the end of that survey process guide, there is that document review tool that's a great tool that you know at least it will give you a quick assessment, you know, if you're compliant or not compliant with all your testing documentation. They also have the um um the building tour guidance. They just updated the survey process guide to to include that. So it's a good tool for you to walk around your hospital to do a quick little assessment to see if you're maintaining compliance. And don't forget your off-site locations.

SPEAKER_03

Exactly.

SPEAKER_00

Very important.

SPEAKER_03

Thank you, sure.

SPEAKER_00

Yeah, very important.

SPEAKER_03

So excellent. Uh Don, yes, the oh, the slide deck sent to attendees. Uh email me directly on that. Let me think. We hadn't planned on it, but we can. Um and then Noe, thank you for that comment. I think that's all we have for questions. Can I ask you one last one? And if anybody else wants to get on before we close it up, Tom, you were talking about the um, you know, the FM competencies, uh, how they're going to be looking at the non-clinical staff a little a little bit more. Um not hard, but a little bit more. Uh what are your thoughts on, and we talk about this a lot again on the healthcare facilities network, but and you see it out, what do you see out in the field as we're bringing in more people who maybe don't have the experience that you two did or that many of the people on this call did? How is an organ like if you're looking at job, what should somebody do to make sure that the job descriptions aren't gonna mess them up on these uh surveys? Like if you know you have somebody in there who doesn't maybe have that experience, how do you manage that?

SPEAKER_04

So that that that's uh that's a double-edged sword, Peter. Um so first of all.

SPEAKER_03

You're not a director anymore, though.

SPEAKER_04

You're you're you're a consultant, so you can answer if I have someone that is using you know a piece of equipment or whatever, it's in the best interest of the organization to make sure they're competent, right? Because you don't want someone getting hurt. I was at a survey last week, and I walked out in their dock area and they had a forklift. And of course, what does Tom Grice say? Who who uses it? Oh, we all do. Okay. Are you are do you have a competency? Are you certified? Do you have it safety checked? All of those types of things. So I asked the question, then of course, you know, yep, yep, yep. So then I got back into the conference room and I said, could I see the certifications for all the maintenance staff that you said use? They brought them in and they expired in 2022. They were certified at one time, yeah, but not now. So just again, it it protects the organization more than the the ding of not having a competency. So focus on the competency. Don't don't exclude it from the job description because you want to make sure that people know what they're doing and how to do what they're doing and what they're is expected of their position. Does that answer your question, Peter?

SPEAKER_03

It does. So the cynic in me, Tom, the cynic in me. Well, you were answering that. Honest to God, I was thinking you're absolutely correct, but you know, and I know, just because you talk to enough people, that not all organizations we cut corners, we it maybe there's no no ill intent, but like the reality is it doesn't always occur.

SPEAKER_04

It doesn't.

SPEAKER_03

Sorry to say.

SPEAKER_04

We have these driving floor machines. And you know, I'm sure that many people on the call have had to patch many walls because of them driving into, you know, or you know, other fire doors now, you know, they're they're they got a 60% failure rate on the fire doors because you know the floor machine hits them and the guy just keeps going. So again, it it competencies are meant to protect everyone involved. Yeah, yeah.

SPEAKER_03

Excellent. Well, I think that's it for the QA part. Tom and Sharon, thank you for uh thank you for joining us today. Appreciate it.

SPEAKER_04

Again, reach out if you anyone has any problem or any questions. If you just want to ask us any questions after this, you see our emails here, please reach out. We're always here to help. Healthcare is our life.

SPEAKER_01

Yep.

SPEAKER_03

That's why you're on Tom and Sharon. And if you do want a presentation, we can email. If you reach out to us, we can email it to you, I assume. So just connect with if you don't want to bother Tom and Sharon about it, you can always email me, pmartin at craft.com. We will send it to you. We'll put the webinar up there, we will record it. So thank you for attending.

SPEAKER_04

And oh, you can hit print screen right now, and you'd have this to be able to come back to you. So just on your computer, hit print screen, and you'll have our contact information.

SPEAKER_03

Thank you everybody for attending. Good luck.

SPEAKER_01

Thank you. Bye bye.

SPEAKER_03

All right, see you all.