VPC is ready to help with a slew of documentation requirements and standards citation changes
To align with updated CMS standards, the Joint Commission has reduced its total standards from about 1,551 to about 774. The JC is calling this “Accreditation 360: The New Standard” and rolling out a public, searchable standards database.
This nearly 50% reduction sounds dramatic, and it is. Over 700 existing standards are “streamlined” into a framework more closely aligned with CMS Conditions of Participation (CoPs). But the requirements aren’t dramatically different from before. The total number of standards is lower, but each standard is also longer or broader.
The result is a significant update to documentation requirements.
The JC has created “prepublication standards, crosswalks, disposition “crosswalk compare” reports, and survey process guides to help organizations map old EPs to new ones.” For most organizations, this is likely to result in significant short-term headaches and time-consuming administrative work.
VPC can help you update your documentation and prepare for the new changes. We’ve developed in-depth knowledge of these changes and are already helping healthcare facilities of all sizes with these changes.
New National Performance Goals (NPGs)
The former National Patient Safety Goals (NPSGs) are now 14 “outcome-focused” National Performance Goals. The intent is largely the same, but NPGs combine regulatory CoP issues and performance requirements, such as staffing to meet patient needs or suicide risk reduction.
The new standards seek to clarify each standard as either:
- “Derived from CMS CoPs” or
- “Exceeds CoPs and is elevated to NPG”
Other important Joint Commission standard changes
For example, the former Environment of Care (EC) and Life Safety (LS) standards are now rolled together in a Physical Environment standard. What was a list of various medical equipment tests that needed to be conducted is summarized into a single item, like “The hospital maintains essential equipment in safe operating condition.”
Nurse staffing and suicide risk now an NPG, with a purported emphasis on outcome and performance. Formerly, these measures were part of multiple regulations.
Volume thresholds have changed or are reduced, such as PCI-case volume requirements for various cardiac certifications (PHAC, CHAC, CCC) and reducing aneurysmal subarachnoid hemorrhage cases from 20/year to 10/year for stroke certification.
Other changes and updates for Accreditation 360
Critical Access Hospitals are subject to the same restructuring and other JC-accredited programs are set to transition in 2026 or very soon. These include:
- Psychiatric hospitals
- Ambulatory surgical centers
- Home care
- Nursing facilities
- LTC facilities
Looking for help before a survey or with documentation? VPC is ready
We’ll review your training and documentation to map old standards to the new framework.
We’ll assist with continuous engagement and ongoing performance metric evaluation requirements.
Separate mandatory CMS CoPs from Joint Commission standards reorganized into NPGs.
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