The Joint Commission Physical Environment Survey Process – 2025 and Beyond

The Joint Commission is streamlining its accreditation process, with some changes already in effect for 2025 and a more significant shift expected in 2026. This update summarizes the changes related to the Environment of Care (EC) and Life Safety (LS) chapters and their potential impact on hospital facility management groups.

2025 Survey Process Updates

A few enhancements were implemented in 2025:

• 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, EC findings come first, causing an often 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.

Looking Ahead: 2026 and the Physical Environment Chapter

The anticipated merger of the Environment of Care and Life Safety chapters into a new Physical Environment chapter has been pushed back to at least 2026. A specific effective date is yet to be announced, but The Joint Commission typically provides a six-month window for compliance with new requirements.

Key Future Updates:

• Physical Environment EPs will better align with the CMS Conditions of Participation (CoPs).
• The number of EPs will be significantly reduced; approximately three EPs will exist for each CoP.
• Some existing standards that are not required by CMS, such as Workplace Violence and Water Management, are expected to be retained.
• Other EPs not required by CMS, like Management Plans and Annual Assessments of Management Plans, are likely to be removed.

Proposed Changes Brings a Mix of Upsides and Downsides

Pros:

• Reduced Complexity: Consolidating EPs into fewer standards simplifies compliance. The current 195 Environment of Care and 206 Life Safety EPs are a significant burden. Aligning with the fewer, broader CMS CoPs is a positive change.
• Continuity: There are no anticipated major changes to expectations for compliance. Hospitals will likely continue their current practices to maintain and demonstrate compliance (EC tours, documentation, inspections).

Cons:

• Potential for Higher-Severity Citations: Reducing the number of standards may lead to multiple issues being grouped under a single EP, potentially moving organizations further to the right on the SAFER Matrix, indicating more widespread issues.
• Documentation Reorganization: Hospitals will need to reorganize their documentation to align with the new Physical Environment chapter structure, repeating a process they have already undertaken for the EC and LS chapters.

 

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

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