The 2011 Joint Commission standards in the Environment of Care (EC), Emergency Management (EM) and Life Safety (LS) chapters of the accreditation manual contain almost no changes in language or requirements from the 2010 edition. But lest health facilities professionals get too comfortable with their present level of compliance, there are changes in schedules, surveyor time on-site, decision rules and interpretations that may impact their surveys.

Many changes are a result of the oversight that must be maintained by the Centers for Medicare & Medicaid Services (CMS) for the Joint Commission's deemed status in the accreditation process. The Joint Commission has been working closely with CMS to be sure that their standards are aligned with CMS's conditions of participation and that surveys under the auspices of both organizations have similar outcomes.

The survey schedule

Once the Joint Commission got into full swing with unannounced surveys, they were scheduled so surveyors could appear at a health care facility anytime between 18 and 39 months following the previous triennial survey, with the average time interval remaining at 36 months.

Based on requirements from CMS, the maximum Joint Commission survey interval will return to 36 months in 2011. Although this is only a three-month reduction in the survey window, organi­zations now will know that their on-site survey will be completed by the triennial anniversary of their previous survey date, and many health care organizations seem more comfortable with this slightly shorter time frame.

Life safety surveyors first came upon the scene in 2004, with one day on-site for hospitals of 200 or more beds. Since then, the assignment of these surveyors has increased to include hospitals of all sizes, with larger hospitals getting a second day of the surveyor's time.

For 2011, all hospitals, including critical access hospitals, will have a life safety surveyor for at least two days, and those of more than 1.5 million square feet will have a third day. Yet an additional day will be added for every three buildings classified as health care occupancy. The additional on-site time will serve to alleviate much of the pressure felt in surveying the mid-size to larger hospitals, and also will afford some time for education of the organization's staff.

Very small hospitals, however, likely will receive an extremely thorough building assessment for Life Safety Code® compliance, given the time available to do so. The scope of responsibility of the life safety surveyors officially will not change, but it would not be unreasonable to expect the Joint Commission survey team to take advantage of their expertise while they are on-site.

Again, to better align themselves with CMS, the Joint Commission is changing some of its accreditation decision designations, which are defined fully in the 2011 accreditation manuals.

The first two decisions essentially are unchanged:

Preliminary accreditation. An organization is compliant with selected standards for early survey, prior to an organization's initial opening.

Accredited. An organization is compliant with all standards during the on-site survey, or has appropriately addressed any recommendations for improvement via evidence of standards compliance.

The following Joint Commission accreditation decisions are slightly changed in title and/or definition:

Accreditation with follow-up survey. An organization is not compliant with selected standards that require a follow-up survey in 45 or 60 days (accreditation decision rules) and has successfully addressed problem areas via evidence of standards compliance.

Contingent accreditation. An organization has failed to address identified problems resulting from an accreditation with follow-up survey or does not have a required license (or similar issue) at the time of the survey. This decision usually warrants a follow-up survey in 30 days.

Preliminary denial of accreditation. This means a health care organization has one of the following situations:

  • An immediate threat to health or safety (In the EC, EM and LS chapters, this typically is based on a failure of the fire pump, fire alarm, generator, medical gas alarm or an exiting problem.); or
  • Failure to resolve identified problems for accreditation with follow-up survey (twice); or
  • Failure to resolve requirements of contingent accreditation; or
  • Significant noncompliance with Joint Commission standards.

This decision is subject to review and appeal.

The last accreditation decision is unchanged:

Denial of accreditation. This is issued when all appeals have been exhausted.

These revised accreditation decisions also resulted in renaming and renumbering the accreditation decision rules.

There is only one of these rules that affects the LS chapter (none impact EC or EM). It is now rule AFS13 (Accreditation with Follow-Up Survey), and reads, as always, "The organization has failed to implement or make sufficient progress toward the corrective actions described in a Statement of Conditions, Part 4, Plan for Improvement, which was previously accepted by the Joint Commission, or has failed to implement or enforce applicable interim life safety measures." This rule applies at standards LS.01.01.01, EP 3 and LS 01.02.01, EP 3.

Further evidence of the CMS influence on the Joint Commission is that any "condition level deficiency" found during the survey will receive a recommendation in the leadership chapter of the Joint Commission accreditation manual.

A condition level deficiency means that a health care organization is found to be out of compliance with one of the CMS conditions of participation, or with several standards under one condition, or has one severe or critical health or safety breach. Under these circumstances, in ad­dition to scoring the relevant standard(s) for the particular offense, the organization's leadership also will be cited.

Further changes

In mid-2010, four elements of performance were omitted from EC.02.06.01, "The hospital establishes and maintains a safe, functional environment." While not brand-new information, they bear noting in this review of 2011 requirements.

The elements of performance (EPs) that have been omitted are:

  • EP 4: Space for recreation and social interaction;
  • EP 5: Storage space to meet patient needs;
  • EP 6: When length of stay exceeds 30 days, outside areas for patient use; and
  • EP 18: Interior space to accommodate use of equipment.

One change that was made to the 2011 standards is found in EC.02.06.05, EP 1. "When planning for new, altered or renovated space," hospitals have looked to the 2001 edition of the Guidelines for Design and Construction of Hospitals and Health Care Facilities, which then was published by the American Institute of Architects, as one of several acceptable references. Starting this year, the reference is to the 2010 edition of the Guidelines for Design and Construction of Health Care Facilities, which now is administered by the Facility Guidelines Institute and published by the American Hospital Association's American Society for Healthcare Engineering.

The Guidelines apply to new construction and renovation only; they are not retroactive. Moreover, EC.02.05.01, EP 6, which addresses airborne contaminants, still references the 2001 edition, though the 2010 edition also may be used for this purpose.

Medical equipment

While there have been no written changes to the standards for medical equipment (EC.02.04.01 and EC.02.04.03), there are some changes in focus and interpretation by the surveyors that will be forthcoming in 2011.

For many years, the Joint Commission has allowed a risk-ranked inventory of medical equipment with preventive maintenance frequencies that are not necessarily based on manufacturers' recommendations. Meanwhile, CMS has required hospitals to adhere to those manufacturers' recommendations without deviation based on organizational experience or other factors.

CMS recently has altered its stance, seeing the merit to the Joint Commission's approach, but maintaining oversight of the process. Accordingly, if a Joint Commission-accredited organization has adjusted medical equipment preventive-maintenance frequencies to something different from manufacturers' recommendations, it must be prepared to justify that change to the surveyor based on relevant data.

Endoscopes have been found by the nonprofit ECRI Institute, Plymouth Meeting, Pa., to be the No. 1 cause of health care-associated infections that are related to technology, and this has not gone unnoticed by the Joint Commission. To increase oversight of the cleaning and processing of scopes, hospitals are asked to place the endoscopes on their medical equipment inventory. This can be done in aggregate by listing the total number of scopes rather than identifying each one.

The expectation is that the clinical engineering department periodically will review the cleaning process to be sure that it is being performed appropriately, and does not imply that clinical engineering directly performs the cleaning process or any preventive maintenance.

This is similar to the expectation for oversight of sterilizers and dialysis that has been included in the medical equipment standards for some time, and yet clinical engineering typically does not perform these functions either. The difference is that this expectation for endoscopes is not in the written standards.

Survey process impact

The changes to the standards are few and predominantly impact survey process more than compliance activities. But, especially in the area of medical equipment, the interpretation may make all the difference. Expect surveyors to look closely at these areas.

Susan B. McLaughlin, FASHE, CHFM, CHSP, is managing director of MSL Healthcare Consulting Inc., Barrington, Ill., and a former associate director, standards interpretation, at the Joint Commission. She can be reached at


For more information

The Joint Commission's website at offers a number of resources to help hospitals stay up-to-date on Joint Commission regulations and survey protocols.

Additionally, the organization's Joint Commission Resources, whose website is at, offers subscriptions to such newsletters as Environment of Care News and The Joint Commission Perspectives that offer regulatory news and advice.