As part of its efforts to review and potentially eliminate accreditation requirements not also required by the Conditions of Participation for the Centers for Medicare & Medicaid Services, The Joint Commission has announced another series of changes, some of which will affect facilities managers working for critical access hospitals (CAHs).

The first of the changes made in this effort was announced in January 2023. At that time, there were 56 standards deleted from the hospital accreditation program as well as four standards revised. Additionally, the CAH accreditation program had 37 standards deleted and four revised. Two of the retired standards were from the Environment of Care (EC) and Life Safety (LS) chapters. The Joint Commission indicated at that time that further changes would be forthcoming.

Those changes are now here with the second round of revisions recently announced. The changes affect six different accreditation programs, but the ones most impacting facilities managers are revisions and deletions in the EC chapter for CAHs.

Revised standards

The Joint Commission revised the following standards for CAHs:

Requirements for preconstruction risk assessments

Standard EC.02.05.05 states: “The critical access hospital inspects, tests, and maintains utility systems. Note: At times, maintenance is performed by an external service. In these cases, critical access hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.”

Standard EC.02.06.05 states: “The critical access hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.”

  • The revised elements of performance

Standards EC.02.05.05, Element of Performance (EP) 1 and EC.02.06.05 EP 2 were consolidated into the new EC.02.06.05 EP2, which reads:

“When planning for demolition, construction, renovation, or general maintenance, the critical access hospital conducts a preconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services and mitigates the identified risks. Note: See LS.01.02.01 for information on fire safety procedures to implement during construction or renovation.”

Requirements for monitoring, reporting and investigating

Standard EC.04.01.01 states:  “The critical access hospital collects information to monitor conditions in the environment.”

  • The revised element of performance 

Standard EC.04.01.01 EP1 now reads:

“The critical access hospital develops and implements a process(es) for continually monitoring, internally reporting, and investigating the following:

  • Injuries to patients or others within the critical access hospital's facilities and grounds;
  • Occupational illnesses and staff injuries;
  • Incidents of damage to its property or the property of others;
  • Safety and security incidents involving patients, staff, or others within its facilities, including those related to workplace violence;
  • Hazardous materials and waste spills and exposures;
  • Fire safety management problems, deficiencies, and failures;
  • Medical or laboratory equipment management problems, failures, and use errors;
  • Utility systems management problems, failures, or use errors; and
  • Based on the results of the data analysis, the lab identifies opportunities for improvement and resolves any environmental safety issues.

Note 1: All the incidents and issues listed above may be reported to staff in quality assessment, improvement, or other functions. A summary of such incidents may also be shared with the person designated to coordinate safety management activities.

Note 2: Review of incident reports often requires that legal processes be followed to preserve confidentiality. Opportunities to improve care, treatment, and services, or to prevent similar incidents, are not lost as a result of following the legal process. (See also EC.02.01.01, EP 17.)”

Deleted elements of performance 

The Joint Commission deleted the following EPs for CAHs.

Standard EC.04.01.01 EPs 3-6 and 8-11 were deleted. Previously, these EPs required hospitals to report and investigate incidents such as:

  • Occupational illnesses and staff injuries;
  • Incidents of damage to its property or the property of others;
  • Safety and security incidents involving patients, staff or others within its facilities, including those related to workplace violence;
  • Hazardous materials, and waste spills and exposures;
  • Fire safety management problems, deficiencies and failures;
  • Medical/laboratory equipment management problems, failures and use errors; and
  • Utility systems management problems, failures or use errors. 

The Joint Commission explains that the changes were made to streamline the accreditation requirements.

"The Joint Commission wants to focus on code and regulatory issues that are most impactful in evaluating features in the physical environment that promote a healing environment and support to patient care," says Herman A. McKenzie, director in The Joint Commission's Standards Interpretation Group.

He added that further changes are not expected. "While we are always evaluating our requirements there are no specific changes planned for our physical environment standards."