Readiness Rounds - Blog , Accreditation & Regulatory Compliance

The Joint Commission’s 2026 Accreditation 360 Overhaul: Key Changes for Hospitals

Thu, 06 Nov 2025 12:42:58 -0600

Hospitals across the country are preparing for one of the largest regulatory transitions in recent memory. Joint Commission’s 2026 standards overhaul will reshape the framework hospitals use to guide compliance, accreditation, and performance improvement.

While the changes aim to simplify and modernize the accreditation process, the scale of restructuring is significant. Hundreds of standards have been renumbered, merged, or rewritten. For most hospitals, it represents months of work to update policies, crosswalk documentation, and retrain staff on the new structure.

What’s Changing in 2026

According to The Joint Commission’s June 30, 2025 announcement, the organization will remove more than 700 requirements from its accreditation manuals as part of its new Accreditation 360 initiative (The Joint Commission, June 2025). The goal is to streamline standards, reduce redundancy, and make compliance more transparent.

Key structural changes include:

Consolidation and reduction: More than 700 standards removed or merged, reducing the total number of hospital standards by nearly half.
New organization: Chapters such as Environment of Care and Life Safety are now merged into a single Physical Environment (PE) section.
New National Performance Goals (NPGs): Replacing the National Patient Safety Goals (NPSGs), these emphasize measurable outcomes and continuous improvement (Joint Commission, NPGs page).
Clearer mapping to CMS Conditions of Participation (CoPs): Each standard now explicitly identifies whether it is based on a federal requirement or exceeds it (HFMMagazine).

The new standards take effect January 1, 2026. Joint Commission has indicated a short grace period for hospitals to update internal documentation and crosswalks.

Why This Matters

The 2026 update is more than a renumbering exercise. It reshapes how hospitals organize, document, and demonstrate compliance. Key challenges include:

Crosswalking legacy standards to the new framework
Updating policy and procedure references
Training leaders and staff on the new numbering and expectations
Maintaining survey readiness throughout the transition

Even for hospitals with strong regulatory teams, reconciling hundreds of changes manually can take months.

Automation and AI: A Smarter Way Forward

To address the scale of change, Readiness Rounds has launched an AI-assisted Regulatory Dashboard designed to automate much of this work.

The platform:

Maintains live access to both Joint Commission and DNV standards
Automatically maps 2025 to 2026 standards as updates are released
Highlights changes and identifies affected policies and departments
Provides real-time readiness summaries for hospital leadership

For hospitals, that means no separate logins, no manual tracking, and no lag between what is published and what internal teams see. The result is continuous regulatory alignment without the clerical burden.

How You Can Prepare Today

Confirm accreditation path: Know whether your organization follows Joint Commission or DNV and centralize standards access.
Audit policy references: Identify where old numbering or chapter references appear in your policies.
Implement automated mapping early: Avoid the late-2025 scramble by deploying AI-assisted tools that auto-update as new standards release.
Educate leaders: Help department heads understand what is changing and why it matters.
Focus on continuous readiness: The new National Performance Goals emphasize sustained reliability, not just survey preparation.

Looking Ahead

The 2026 Joint Commission overhaul is ambitious. It is designed to simplify accreditation while raising the bar for performance improvement. Hospitals that adopt automation and begin aligning early will navigate the transition smoothly and stay survey-ready with less disruption.

Readiness Rounds supports hospitals nationwide in maintaining high reliability and compliance readiness.

To see how AI-assisted compliance can simplify your 2026 transition, you can use the calendar below to select a meeting time convenient for your schedule.

Book a 15-minute demo ↓

Further Reading

Digitization and Consolidation of Quality Observation Data

Mon, 21 Apr 2025 23:50:37 -0600

Co-authored by David Chou

David Chou is a CIO, health IT thought leader, a “Top CIO to follow on Twitter," and keynote speaker. David is a regular contributor to Health Standards and frequently shares his views on health care technology in his Twitter feed.

Originally published on Health Standards blog (link no longer available).

Current status: Archaic tools and an over-reliance on EHRs for quality data

The typical hospital is making approximately 400,000 quality observations a year. It’s important to note that I am referring to data that is not pulled from the electronic health record (EHR). The EHR is unable to effectively collect and aggregate data such as observations of safety and compliance of the physical environment, evaluation of staff knowledge on hospital policy/emergency response, the gathering of patient feedback relating to their experience while they are still within the continuum of care, or measurements of evidence-based guideline adherence during the performance of routine hospital procedures.

The 400,000 quality observations I mentioned above are happening (or should be if they are not) in many different areas of the hospital, among various departments and disciplines. The Pharmacy is checking the compliance of the storage of medication; the Environment of Care team is making sure the physical environment is compliant and safe; Leadership is rounding for patient experience purposes; the Quality department is conducting tracers; Infection Control is examining processes around CAUTI, CLABSI, High Level Disinfection etc.; and Nurse Managers are conducting Open Medical Record reviews. With only these few examples, you can see that most hospitals are amassing an incredible amount of potential performance improvement (PI) data!

But, the common theme throughout is “data rich, information poor” as the data is oftentimes not available for review and discussion. More often than not, this is due to:

Manual data collection

Paper checklist and manual follow up. This process has proven to be inefficient and leaves an incredible amount of room for mistakes due to inter-reviewer reliability and the probability of leaving issues unresolved.

Data manually aggregated

Like the manual data collection, the manual aggregation of data is inefficient, open to human error, and substantially difficult in consistently showing the data for PI. Hospital staff, including those at the director-level, are spending hours upon hours developing and inputting data into spreadsheets every month.

Data viewed in a silo

All the aforementioned departments that are collecting this data are only seeing quality from their perspective. It is difficult, if not impossible, for executive leadership to have a concise global summary of quality and accreditation data.a

Not used for PI or data is not usable for PI

Oftentimes, rounds are done just for documentation and finding issues and by using archaic means of collecting and aggregating the data, hospitals are finding that their reports are not very usable for PI efforts. While documentation and finding issues are critical, hospitals are missing a gigantic learning opportunity.

Most hospitals don’t proactively check as much or as thoroughly as they should on a routine basis unless TJC, CMS, etc., is expected. Reasons often heard include being understaffed, lack of efficiency tools, confusion surrounding accountability and responsibility, and a lack of leadership support.

Example: Pharmacy thinks storage of medication outside of the pharmacy is nursing’s responsibility, nursing thinks its pharmacy. Rounds aren’t conducted and patients are exposed to potential medication safety risks, leaving the hospital open to negative regulatory findings and liability risk.

Executive Leadership rounds are not done by the C-Suite consistently and are done on the back of a napkin. This is a missed opportunity to collect crucial PI data, as they wait for the hospital’s HCAHPS score to see what they should have known and taken action on months before.

Front-line staff only sees executive leadership on their units when something is wrong (Hawthorn Effect), which demonstrates a lack of executive support and involvement and overall prolongs the transition to a culture of safety.

Why do hospitals need to upgrade to digitally-based tools for quality observation data collection?

As many other industries have already determined, moving past archaic and inefficient processes and becoming a digital enterprise has numerous benefits.

Specifically switching to a single digital High Reliability rounding platform to collect all of your organization’s quality observations offers numerous benefits:

Streamlines effort to collect and aggregate data

Takes the noise out of prioritizing PI projects and leadership can quickly determine if PI projects are having the desired effect

Creates capacity (less time spent by staff on rounding and creating reports), reduces likelihood of human error in closing the loop on issues and manual report creation.

“What are our challenges as a health system? As a hospital? On each unit? What TJC/CMS regulations do we struggle with the most?”

“Did that education initiative we started four months ago fix our poor hand hygiene performance?” All of these questions can be answered with the implementation and proper use of the right tool.

When used for PI, digitally-based tools allow for regulatory compliance to become a byproduct of proactive checking

Your hospital will continuously be survey ready!

High reliability actually becomes feasible

A robust, enterprise wide, digital high reliability-focused rounding platform allows you to measure quality and safety data, allowing leadership to continually improve and sustain performance in real time. Waiting for old, reactive, less relevant data from the Leapfrog Group or HCAHPS will become a thing of the past.

A worthy evaluation

A hospital wanting to improve the safety and care of its patients, eliminate inefficient and wasteful processes, mitigate risk, and improve patient experience would be well-served to explore options to move to a platform as described. Enterprise health systems have hundreds or thousands of applications that work together or, in the worst case, don’t work together. As we progress down the path of having data and information everywhere, how can we use the data to provide the best quality of care for the patient? This is the challenge that we are all facing. What is your solution to this problem?

Your facility is currently doing the best it can, but I bet there are a few things you'd still like to improve. That's where we excel - bringing all the pieces together. Leave us a message below or contact us to see where your facility is at.

TJC SAFER Matrix - Definitions & Examples

Thu, 17 Apr 2025 05:46:14 -0600

January 2017 marks the official launch of The Joint Commission's new risk scoring method program. All accreditation and certification programs will receive this matrix in their 2017 reports.

We will be your complete TJC SAFER Matrix resource in the next few weeks with a new article each week outlining all the major changes and new updates, alongside a comprehensive TJC SAFER Matrix eBook.

What is the SAFER Matrix?

It is a new risk scoring method for observations found during a TJC survey.

We begin today by discussing the definitions found in this new scoring method. Then we'll show you two separate examples of how it is utilized.

Y-Axis Definition

First, the y-axis is titled "Likelihood to Harm a Patient/Staff/Visitor". Defined as: the likelihood that a patient would be harmed from this incident. There are three levels of likelihood along the y-axis on the matrix.

High: The observation made "could directly lead to harm without need for other significant circumstances or failures." (1) In other words, harm is likely.

Moderate: The observation made "could cause harm directly, but more likely to cause harm as a contributing factor in the presence of special circumstances or additional failures." (1) The key word here is possible.

Low: The observation made "undermines safety/quality or contributes to an unsafe environment, but very unlikely to directly contribute to harm." (1) It would be rare for patient harm to occur.

x-Axis definition

Secondly, the x-axis is titled "Scope". Defined as: the analysis of how widespread the problem is. Again, there are three levels of scope along the x-axis on the matrix.

Widespread: The "issue is pervasive at the organizational level; it is a process or systemic failure. In other words, a majority of patients could be impacted." (1)

Pattern: The "issue has potential to 'impact more than a limited number of patients'" (1); it is a process variation.

Limited: The "issue is a unique occurrence" (1); it is not representative of routine/regular practice.

When an issue is discovered during the survey, the Likelihood to Harm and the Scope will both be determined and the issue will then be placed in the appropriate box on the SAFER Matrix (shown below).

We've created an eBook that has these definitions plus many more need-to-know basics.

Let’s look at a couple of examples:

Example 1

While reviewing pain management for hip replacement patients, it was discovered that nurses were administering higher doses of pain medication than needed, according to the patient’s description of pain using the pain scale rating. It was agreed that nurses need to administer pain administration as prescribed and that doctors should not order ranges in the medication dosage. (2)

This issue would be placed in the Moderate/Pattern box (see below) because, for several records, the administration of pain medication is not consistent with provider orders. The medication type and dose were not in keeping with the severity of pain reported by patients. This appears to be a pattern of performance variation but doesn’t represent a pervasive or systemic problem in this program. It is possible that a patient could be overmedicated thus placing them at a moderate risk of harm.

Example 2

While reviewing rounding checklists, it was discovered that critical lab results were not called into the physician within the required timeframe. That timeframe was set by the lab policy and hospital procedures for critical result reporting. The facility had written definitions of critical results, the timeframe for notifying providers, and expectations of who should report the results and to whom they should be reported. Therefore, the organization’s policies and procedures were not followed. (3)

This issue would be placed in the High/Limited box (see below) because the critical test results were not called into the provider for one patient making the limited column appropriate. The organization has a clearly defined written policy and procedure for how critical values should be handled. This policy states the provider should be notified within an hour of result confirmation. The technician did not follow the policy. This appears to be an isolated issue and does not appear to be a systemic or widespread problem. Because of the nature of the tests and the critical results, the fact that the provider was not notified immediately placed the patient at immediate risk of harm, making the high likelihood to harm designation appropriate for this finding.

In the next couple weeks we will discuss more in-depth ways in which the Matrix will impact you, how you can prepare, as well as the way it has been designed to help you post-survey.

We've put together an eBook for an all-in-one guide to the new changes, new matrix details including the two new components, and how to prepare for the new survey.

Sources

1) Webinar Replay and Slides: SAFER Matrix. (2016, October 26). Retrieved from https://www.jointcommission.org/webinar_replay_slides_safer_matrix/ (no longer a live link)

2) Heskett, C. (2016, November 15). Survey Analysis for Evaluating Risk™ (SAFER™) Matrix. Slide No.15. Retrieved from https://www.jointcommission.org/assets/1/6/SAFER_Webinar_11-15-16.pdf (no longer a live link)

3) Heskett, C. (2016, November 15). Survey Analysis for Evaluating Risk™ (SAFER™) Matrix. Slide No. 16. Retrieved from https://www.jointcommission.org/assets/1/6/SAFER_Webinar_11-15-16.pdf (no longer a live link)

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Medication Storage Safety

Fri, 04 Apr 2025 22:01:00 -0600

During annual Joint Commission (TJC) surveys, the same Medication Management Standards turn up as the highest in non-compliance. (1) This chapter of standards contains several elements covering a wide range of issues, leaving the difficult task of drilling down to the heart of the problem. Are your medications properly stored in secure locations? Are medication orders written and reviewed properly? Is everything labeled correctly?

Medication management is just as important to patient safety and health as any other measure in the hospital environment. Patients and families expect to receive safe treatment and care while at the hospital. A patient receiving the wrong medication or dose can cause irreparable harm and stain your facility’s reputation.

Consistently topping the list of trouble spots for Medication Management is:

1. Storage and Security of Medications at a non-compliance rate of 34.7% in 2013, an increase over 2012 for the same standard. Ouch!

2. Medication Orders at 22.4%

3. Medication Order Review at 15.7% non-compliance. (2)

Why are so many organizations struggling with meeting these important Medication Management standards?

What can your facility do to identify issues and improve your compliance rates?

Monthly checklists offer several valuable benefits:

Proactive rounding spots and corrects problems immediately addressing potential patient safety issues. Are Pyxis locked and secured? Are medication rooms accessible to non-qualified personnel? Find out sooner rather than later.
Monthly rounds maintain readiness for Joint Commission visits, allowing you peace of mind that your house is in order. (3)
Correct and monitor any infraction immediately and use the opportunity to improve performance. . Don’t let a lack of education be a detriment to the safety of your patients.
Visit areas you don’t normally see. Expand your reach to ensure that everyone everywhere in your facility is up to standard. Enlist your staff of technicians to make the rounds and empower them to address the patient safety issues.
See a clear and concise visual of the results of rounds on a monthly basis. With standardized graphs, you can easily spot your organization’s most problematic standards and units, allowing you to focus on process improvement both with individuals and hospital-wide.
Use the results to engage department staff for improvement ideas and open lines of communication. Engagement is a key to success in any endeavor.

Take charge of your Medication Management compliance.

Gather data from monthly rounds and use the data to construct a solid plan for performance improvement. Consider the safety of your patients.

Credits:

1) Pharmacy Practice News Article http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Policy&d_id=51&i=September+2012&i_id=884&a_id=21566#sthash.I4BUyrDs.dpuf (link no longer available)

2) Link or image of Table 1 – Medication Management Standards/NPSGs with the Highest Rates of Noncompliance Among Hospitals

3) Pharmacy Practice News Article http://www.pharmacypracticenews.com/ViewArticle.aspx?d=Policy&d_id=51&i=August+2015&i_id=1213&a_id=33285 (link no longer available)