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 revises JC’s Life Safety and Environment of Care standards to enhance alignment with the Conditions of Participation, will necessitate careful review by EVS leaders as they strive to maintain compliance with JC accreditation requirements.

Key Changes in Structure and What it Means for Compliance

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.

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.

For example, the total number of standards and elements of performance has been significantly reduced from 1,551 to 774 standards, simplifying compliance requirements. In a move toward greater transparency, starting in July, Joint Commission standards will be available online and 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.

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 it will not cite health care facilities for references to the old standards as long as the requirement is still being met. AHE advises that health care organizations take steps now to ensure they are prepared for the revised structure if they participate in JC’s accreditation program.

Impact on CMS, JC Accreditation and the Field

CMS has approved the 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.

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.

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.

Recommended Next Steps for EVS Leaders

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

AHE recommends that the EVS leaders take the next six months to review the JC crosswalk to understand the changes and the new elements. While it may seem that the new standards have been reduced, they have not. The JC consolidated its existing standards to align with the Condition of Participation requirements but has not added any new requirements. In preparation for the following year's survey, EVS leaders should review their current documentation and align it with the new standards. Although the updated standards will take effect on January 1, 2026, AHE recommends taking proactive action to ensure alignment and consistency.

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