Joint Commission Standards Receive Significant Updates

Joint Commission (JC) announced on June 30, 2025, that it is making significant updates to its standards used by hospitals and critical access hospitals to guide compliance with JC accreditation requirements and the Centers for Medicare & Medicaid Services’ (CMS) Conditions of Participation.  

The change, which consolidates and rewrites JC’s Life Safety and Environment of Care standards to improve alignment with the Conditions of Participation, will require careful review by health care facilities managers working to remain compliant with JC accreditation requirements.  

ASHE is committed to supporting health care facilities professionals as they implement this change and is updating several resources and education courses to help the field understand and reference the updated JC standards. Read below for a summary of the JC standard modifications, the impact on the field, and what ASHE tools and resources are available to help facilities professionals through this change.    

Key Changes in Structure  

The accreditation restructuring, titled “Accreditation 360: The New Standard,” includes a complete overhaul of the standards numbering system and elements of performance, making prior versions of the standards vastly different from the newly published standards.

For example, one of the most notable changes for facilities managers is the restructuring of the Environment of Care (EC) and Life Safety (LS) chapters into a single, unified chapter titled “Physical Environment.” Additionally, the total number of standards and elements of performance have been significantly reduced, simplifying compliance requirements. Previously, the EC and LS chapters contained 44 standards with 396 elements of performance. Under the new JC structure, these have been consolidated and the number of elements of performance have been reduced by 46% for critical access hospitals and 48% for hospitals.  

In total, JC said it is removing 714 requirements from the hospital accreditation program. And in a move towards greater transparency, starting in July, Joint Commission standards will be available online and will be searchable by the public.

Full details on the standards update are available on Joint Commission’s website here, including accreditation requirements, crosswalks, survey process guides, disposition reports and more.

What This Means for Compliance  

At first glance, it may seem that JC has reduced compliance requirements. However, these requirements have been consolidated, not eliminated, into broader standard categories, ensuring greater alignment with CMS’ Conditions of Participation as well as K-Tags and A-Tags from CMS’s Survey Operations Manual.  

While the standard numbers and organization are changing, the core substance of the standards remains largely intact. JC has been approved as a national accrediting organization by CMS and must ensure that its accreditation standards are in alignment with the Conditions of Participation, which incorporate the NFPA 99, Health Care Facilities Code, and NFPA 101^®, Life Safety Code^®, along with additional referenced codes.  

The updated standards will take effect on January 1, 2026, though JC has noted that it understands there will be a learning curve in the field and that they will not cite hospitals for references to the old standards as long as the requirement is still being met. ASHE advises that health care organizations take steps now to ensure they are prepared for the revised structure if participating in JC’s accreditation program.  

Impact on CMS, JC Accreditation and the Field  

CMS has approved Joint Commission as a national accrediting organization, meaning that JC is permitted to act as an agent of CMS to determine whether a health care organization meets CMS’ Conditions of Participation. National accreditation organizations must get renewed periodically, and as part of its review process, CMS evaluates JC surveys for disparities with CMS’ own requirements.  Because the CMS Tags and JC’s standards are currently similar, but not the same, it has made the process of determining these disparities difficult. This consolidation is expected to simplify that comparison, thereby creating greater transparency on how JC standards align with federal requirements.  

For the health care facilities field, this shift presents a positive development. The increased consistency between JC standards and the Conditions of Participation will help organizations gain a clearer understanding of their origins and intent, and highlight areas where JC standards exceed CMS’ minimum participation requirements.  

It's important to remember that JC does not have the authority to waive or modify the Conditions of Participation. For JC to maintain its status with CMS, the organization must cite and enforce all CoP requirements during surveys. The only entity that can grant waivers for individual requirements is CMS.  

This consolidation marks a significant step toward enhancing transparency and consistency in health care facility compliance. Health care organizations should take a proactive approach in adapting to these revisions to maintain consistency.  

While most of JC’s requirements align directly with the CMS Conditions of Participation, it’s important to note that some JC accreditation standards do go beyond those baseline requirements. This is a natural aspect of the accreditation process. All accrediting organizations include additional standards that reflect their unique mission and priorities.

These added requirements are not simply about regulatory compliance — they’re designed to promote the highest levels of quality and patient safety, in alignment with the values of the accrediting body.

Stay Prepared with ASHE Education Programs and Tools

To help organizations get up to speed on these changes and be able to speak the same accreditation language, ASHE’s Physical Environment Survey Readiness Program has been fully updated to reflect the new JC consolidated standards. This program ensures compliance with JC and other accrediting organizations, helping health care facilities stay completely survey ready. ASHE members have an exclusive look at this program and the JC standards on July 10 and July 11. To register, click here.  

Additional tools and resources are currently being developed and will be made available to ASHE members to help with this transition soon.

JC representatives will also be discussing these standard changes and answering questions during a concurrent session at ASHE’s Health Care Facilities Innovation Conference, taking place July 27 to July 30 in Columbus, Ohio. A post conference session add on for attendees that want to get more details about the consolidation is also being held with JC. Ahead of these presentations, JC officials are collecting questions from ASHE members on the standards change that they can answer during the Health Care Facilities Innovation Conference sessions. To submit a question, click here, and for more information on the Health Care Facilities Innovation Conference and JC’s presentations, click here.