Joint Commission’s Physical Environment Survey Process and Accreditation 360: What it Means for Hospital Facility Managers

Joint Commission’s (JC) survey process is an essential and often complex part of a hospital’s operations. Staying ahead of changes is key to maintaining accreditation and ensuring a safe environment for patients and staff. With recent updates to the survey process in 2025 and the launch of Accreditation 360, hospital facility managers need to be prepared.

This post breaks down the key changes facility managers need to know about—from the latest Life Safety Survey requirements to the comprehensive restructuring of standards under the new Physical Environment chapter.

2025 Survey Process Updates

The Joint Commission took the first steps to streamlining with updates to the survey process that went into effect earlier this year.

• NEW! Life Safety Surveys – As of July 1, 2025, Life Safety Surveyors are required to visit offsite business occupancy locations. If a Clinical Surveyor visits a healthcare facility, the Life Safety Surveyor will too (though not necessarily at the same time). This could result in additional Life Safety Surveyor days.
• Redesigned Survey Report: The report is now ordered using SAFER Matrix placement (instead of alphabetical listing), allowing for the findings that should be treated as the highest priority for the organization to be listed first. This can be a positive change for facility management teams, as alphabetically, Environment of Care (EC) findings come first, often causing a misleading initial impression that there are significant issues within the EC, when in reality, other areas may need more attention. Requirements for Improvement (RFIs) that score towards the top right of the SAFER Matrix are now prioritized within the report, simplifying the identification of key issues.
• SAFER Matrix: Descriptors or “short names” have been added for each Element of Performance (EP) to help organizations better understand the matrix at a glance.
• SAFER Peer Benchmarking Tool: This new tool allows hospitals to compare their survey performance against similar organizations based on size, services, and demographics.
• Document Upload Capability: Hospitals can now upload survey-related documents to their Joint Commission Connect® extranet site during any survey type, allowing for all surveyors to see the uploaded documents, and minimizing the chance of multiple requests for the same document. While we have seen some initial technical issues in recent surveys, this feature promises increased efficiency once fully implemented.

Accreditation 360: The New Standard

On June 30, 2025, Joint Commission (JC) announced the launch of Accreditation 360: The New Standard. Accreditation 360 goes into effect January 1, 2026, and will impact all hospital groups.

Accreditation 360 is designed to streamline and simplify processes and better align JC standards with the Centers for Medicare and Medicaid (CMS) Conditions of Participation (CoPs). The consolidation (not elimination) of standards into broader categories resulted in a 50% reduction in the total number of standards.

While the standard numbers and organization have changed, the core substance and intent of the standards and survey process remains largely intact. The most notable change for facility management teams is the replacement of the Environment of Care and Life Safety chapters with the new Physical Environment (PE) chapter and selected standards in the new National Performance Goals (NPG) chapter.

What’s New in Accreditation 360

• To create better alignment with the CMS CoPs, the Environment of Care and Life Safety chapters were replaced by the new Physical Environment chapter and selected standards in the new National Performance Goals (NPG) chapter.
• The new NPG chapter replaces the previous National Patient Safety Goals (NPSG) chapter, and aims to address critical issues, including those that affect the safety of the physical environment. Most standards in the NPG chapter are “above and beyond” what is required by CMS but are issues that JC has identified as priorities for high-reliability organizations.
• Emergency Management and Infection Control remain stand-alone chapters, but some standards and EPs have been moved to the new NPG chapter.
• Combined, the PE and NPG chapters have 63 EPs related to previous EC and LS standards, in comparison to the previous EC and LS chapters which had 195 and 269 EPs, respectively.
• In a move towards greater transparency, starting in July, the Joint Commission standards will be available online and searchable by the public.

Notably Unchanged in Accreditation 360

• Interim Life Safety Measures (ILSM) – Requirements remain unchanged, other than standard numbers (PE.03.02.01 + PE.03.01.01.08).
• Workplace Violence Prevention – The standard is retained and now consolidated under NPG (NPG.02.04.01).
• Water Management – The requirements remain unchanged (PE.04.01.05).
• Emergency Management (EM) – Though the substance of all EPs remains unchanged, some requirements have been moved to the NPG chapter. Facilities teams should verify if any EM standards they are responsible for are now in the NPG chapter.
• The survey process – JC has indicated that, though the revisions to the standards are “substantial, no new concepts have been introduced”. While the standards have undergone significant changes, the underlying codes that they are based on (primarily the 2012 Life Safety Code and 2012 Healthcare Facilities Code) remain unchanged.  Hospitals should expect to be surveyed to the same requirements to which they have previously been held.

What Facility Managers Can Expect

• While the standard numbers and organization are changing, the core substance of the standards remains largely intact.
• Consolidating EPs into fewer standards has pros and cons. The previous 195 EC and 269 LS EPs were a significant burden. Aligning with the fewer, broader CMS CoPs is a positive change. The downside is that unless the Joint Commission changes the scoring process, the large reduction in the number of standards will likely lead to multiple issues being grouped under a single Element of Performance. This will potentially move organizations further to the right on the SAFER Matrix, indicating more widespread issues.
• The revised Hospital Physical Environment Document Review tool suggests that JC expects facilities to maintain the same documentation in the same order as it’s currently maintained—for now! In the immediate future, facility compliance managers should keep their compliance binders set up as they are currently and simply update the standard and EP references. For facilities that are expecting survey around the first of the year, JC has indicated that it understands there will be a learning curve and that it will not cite health care facilities for references to the old standards as long as the requirement is being met—at least for the first month or so! That said, healthcare organizations are advised to take steps now to ensure they are prepared for the revised structure.

Navigate accreditation changes with confidence—contact us today to ensure your facility is survey ready.

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