The Monroe File


  • Director of engineering in the standards interpretation group at the Joint Commission
  • Registered professional engineer, Certified Healthcare Constructor and project management professional
  • Member of the American Society for Healthcare Engineering faculty and teaches project management at the graduate-school level


  • Has more than 25 years of experience in health care facilities and project management
  • Has directed all sides of health care facilities, including planning, design, construction and operations
  • Implemented the facility master plan for a 305-bed hospital, and was a facility director for a 1.3-million-square-foot health care facility


  • Master of business administration from Northwestern University’s Kellogg School of Management, Chicago
  • Bachelor of science in mechanical engineering from Northwestern University’s McCormick School of Engineering, Chicago

After starting out as an associate project director in the Joint Commission’s department of standards and survey methods, Ken Monroe last year was named director of the standards interpretation group’s department of engineering. This month, he talks about the Joint Commission’s role in improving the health care physical environment.

What was your health care background prior to joining the Joint Commission?

I have more than 25 years of health care experience in directing all sides of facilities, including planning, design, construction and operations. I have been a facility manager, project manager, project director, design team leader and general contractor. My largest project was a 305-bed, $450 million replacement hospital and the largest facility I’ve managed was a 1.3 million-square-foot teaching facility.

What are the Joint Commission’s departments and how do they function?

The Joint Commission has three operating groups that must work together to be successful. The department of standards and survey methods (DSSM) writes standards and survey methods, the department of accreditation and certification operations conducts on-site surveys, and the standards interpretation group (SIG) interprets standards for surveyors, customers and other public entities.

No one department can stand without the support of the other two as the activities of all three are intertwined. I arrived at DSSM just before the Centers for Medicare & Medicaid Services’ (CMS) Final Rule in May 2016, which moved health care organizations to the 2012 National Fire Protection Association’s Life Safety (LS) Code and Health Care Facilities Code. From this, I learned firsthand about the effort required to re-create the Joint Commission’s LS and Environment of Care (EC) chapters. Now, as the director of engineering in SIG, I have the responsibility of interpreting the standards we write.

What is the SAFER Matrix and how does it help to address key issues with the “see-it/cite-it” survey scoring methodology?

The Survey Analysis for Evaluating Risk (SAFER) approach provides health care organizations with additional information related to risk of deficiencies to help prioritize and focus corrective actions. The development of this approach was driven by the Joint Commission’s focus on providing its accredited and certified organizations with an on-site and post-survey experience that allows an organization to see areas of noncompliance at an aggregate level — one that shows significant components of risk analysis including the likelihood to harm and the scope of a cited deficiency.

The SAFER matrix replaces our old scoring methodology. In place of using predetermined elements of performance (EP) categorization, surveyors now perform a real-time, on-site evaluation of deficiencies, placing each one within the SAFER matrix according to the likelihood of the issue to cause harm to patients, staff or visitors and according to how widespread the problem is based on surveyor observations — that is, the scope.

With our SAFER Matrix, it is easier for organizations to understand the areas that need immediate attention and which areas can be remedied at a less frenetic pace. What we have seen in the see-it/cite-it climate is that more observations are scored.

The Joint Commission recently rewrote its Emergency Management chapter in accordance with new CMS standards. Why is this issue increasing in importance?

As we experience more climate change and violence, health care organizations must take stronger steps to provide a safe haven not only for patients, but also for staff and visitors. As recent hurricanes in Louisiana and Florida have proven, health care organizations are expected to be a safe haven or place of refuge for displaced people. Therefore, having plans to keep the lights on regardless of the conditions outside is a community expectation.

To address this, we updated our emergency-management requirements last November. The updated standards will help organizations to more effectively plan for disasters and coordinate with federal, state, tribal, regional and local emergency preparedness systems. They apply to deemed status surveys for hospital, critical access hospital, ambulatory, home health and hospice settings.

Several new EPs — statements that detail the specific performance expectations, structures or processes that must be in place for an organization to comply with standards — were part of the emergency-management update. The EPs address key areas in planning and response. Many of these requirements provide more specificity to expectations that organizations were already meeting.

Are there other physical environment issues that the Joint Commission is addressing or planning to address?

Over the past year, ligature issues have come under closer scrutiny. The Joint Commission has mounted a tracking system to help our accredited health care organizations track and monitor their way to ligature-resistant environments.

In addition, the Joint Commission has convened an expert panel with representation from provider organizations, experts in suicide prevention and design of behavioral health care facilities, Joint Commission surveyors and staff, and other key stakeholders to discuss ligature issues and formulate directions to aid organizations in creating ligature-resistant environments.

We hope to be able to reduce health care-associated infections through better facility planning, design, construction and operations. We also would like to find a way to assist our accredited health care organizations in the area of energy management, as well as to help facility directors focus on capital planning for their equipment.

What is the Joint Commission’s Leading the Way to Zero initiative? 

Imagine a day of zero complications of care, missed opportunities, overuse, lost revenue and harm events of any kind. While accreditation is an important step in the process, it’s just the start of what we can accomplish. Leading the Way to Zero begins with high reliability, incorporating interrelated components of leadership, safety culture and robust process improvement. High reliability helps organizations to stay safe through a culture characterized by a collective mindfulness in which all workers look for and report small problems or unsafe conditions before they pose a substantial risk and when they are easy to fix. By combining our knowledge, tools and trusted solutions, we will work with health care organizations by identifying and addressing the quality and safety problems.

What is the best way for health care organizations to get clarifications for survey and/or day-to-day facility issues?

The Joint Commission’s SIG posts frequently asked standards interpretation questions on our website. In addition, Joint Commission-accredited health care organizations may contact SIG directly by completing an online submission form.

To stay up-to-date on the latest Joint Commission news, the free Joint Commission Online and the subscription-based Environment of Care News publications also may be useful.