In June 2025, the Joint Commission (JC) announced sweeping changes in their national accreditation standards. The changes are described as aligning existing JC requirements with the Conditions of Participation (CoPs) from the Centers for Medicare & Medicaid Services (CMS), identifying those items JC requires that are above and beyond the CoPs, and to reduce the burden of accreditation for JC customers. But does the redesign accomplish the intended goals, what are the impacts to the service organizations who use JC for accreditation, and how should healthcare HFM and HTM teams prepare for changes in January 2026?
Overview of Changes: What You Need to Know
When we look at the redesign, we find that the major changes can be grouped into Chapter and Element of Performance (EP) changes. The most noticeable change in chapters is moving the Environment of Care (EC) and Life Safety (LS) chapters to the new Physical Environment (PE) chapter. This new alignment places most regulatory checks involving the structures, systems, and assets (SSAs) of an organization into one location as an attempt to both make it easier to review those applicable items and to get closer alignment with CMS CoPs. However, since the alignment between current JC EPs and new EPs is not comprehensive, it can be difficult to get a clear picture of how the old and new align and to ensure proper documentation of activities.
But the biggest change, and the one creating the most anxiety, is the realignment of EPs to CoPs. Organizations have long used the EPs to create checklists used to increase compliance readiness. What used to be hundreds of individual requirements across multiple chapters, each with detailed individual explanations, has become a single chapter with a dozen or so requirements. As an example: what is currently EC.02.03.05 with 23 EPs is now PE.04.01.01 EP3. Many of the other EP requirements have been moved into the National Performance Goals (NPGs) and continue to be used in accreditation surveys as beyond CMS requirements. Ultimately this makes it more difficult to align old and new documentation practices and introduces risk into the survey process.
The Impact on Operations: Minor, Yet Major
Ultimately the JC documentation changes shouldn’t impact the daily operations of healthcare service organizations or how they maintain their SSAs. Healthcare service organizations will continue to achieve compliance with all related regulations as they’ve done in the past. For example, JC’s EC.02.03.05 EP18 involves ensuring proper operation of smoke and fire dampers one year after installation, then at least every 6 years after that. These checks must be documented and provided to surveyors or AHJs during inspections. The JC EC and EPs reference multiple NFPA regulations (NFPA 90A-2012: 5.4.8; NFPA 80-2010: 19.4; NFPA 105-2010: 6.5) as the source for this survey requirement. Beginning in 2026, these checks will continue to be required and verified during JC surveys, but will be covered under PE.04.01.01, any applicable NPGs, and the Survey Process Guide (SPG).
So, although what is getting done (ITMS, PMs, CBM) won’t change, the tracking, documenting, and reporting of those activities will be greatly impacted. Defining how the old (EC.02.03.05 EP18) aligns with the new (PE.04.01.01) will take effort and patience, should be started sooner rather than later, and will likely affect any CMMS and many of the reporting mechanisms currently in use. One area that will likely need updated documentation is to reference the regulatory code onto the work performed; in other words, ensure the code (NFPA 25-2012 Table 5:12) is specifically annotated on the Work Order to ensure compliance and survey readiness.
However, JC’s move from specific checklist-type surveys to an open-book style does expose the possibility for new documentation needs. For example, EC.02.03.05 EP3 only requires documentation of annual manual pull station tests. However, NFPA 72:2022 14.3 (Table 14.3.1.17(5)) requires a semi-annual visual inspection verifying location and condition as well as the annual manual test. The new 2026 JC reference PE.04.01.01 EP2 references the NFPA 72 table, indicating a surveyor will likely want documentation on both the semi-annual and annual ITM activities. If you’ve not included this second item in your survey documentation, there’s potential for a non-compliant finding. Following through with this, it would be a good idea to review your ITM procedures to ensure all relevant code-required checks are being documented within your CMMS.
Next Steps: What Should Our Team Focus on to Prepare for the Switch?
It’s probably a good idea to make the very first decision to be where and how to draw the line between old and new. You must decide to either update existing records, effectively eliminating all previous references to the old values, or to create new records and draw a line in the sand. Both have dramatic repercussions that must be weighed. If you choose the former, it is likely all references in historical records will be changed to the new values. This would eliminate the ability to produce future reports and analytics based on those original code references. But, it’s also the choice with the least amount of effort involved.
If you choose the latter, it will retain all historical records and preserve reporting and analytic capabilities but would have the most effort since it would require the creation of all new records. However, a capable CMMS would have the tools and support that make this process as efficient as possible through duplication or data service tools.
The next choice involves the old adage “How do you eat an elephant?”. The answer: one bite at a time. Breaking the effort into smaller, more manageable parts greatly improves the chances of completion while also allowing you to report “wins” when each step is complete. The project may have steps like:
- Define all codes/values needing to be migrated (include volume of records affected, risk, criticality, etc.)
- Identify reporting and other analytics using those codes/values.
- Prioritize the list, ensuring all items are covered.
- Identify the required documentation within referenced regulations NOT specifically called out by JC but required by those regulatory agencies.
- Establish due dates for each item on the list.
- Get started!
Since healthcare is a risk-adverse industry you might want to jump on the codes/values affecting the most critical or highest-risk SSAs. However, starting with a low-risk, small number of affected records would allow the team to work out the kinks before moving on to other items.
Most activity surrounding compliance by service departments is captured within a CMMS, and updates to Procedures are usually where most effort is expended. You’ll need to locate and any reference to the old code/value (EC, LS) then either update to the new (PE) or duplicate them into new Procedures containing the new code/values. Review all ITM schedules and update them to ensure the new Procedures are properly scheduled and will not create any gaps in performance (leading to possible compliance infractions). A next logical step is to create new versions of any reports/analytics using the old codes/values/records and point them to the new code/values/records.
Once the first batch of new records are generated, use the new reports and analytics to ensure you are capturing the documentation and can provide the results to a surveyor/inspector/AHJ in a consumable format. When you are confident the process has worked, then aggressively move on to the other items in the list, repeating the do/check/act process to ensure compliance is always proven.
Although there is not a lot of time left, most organizations should be able to complete the migration to the new code/values before January 2026, ensuring a smooth transition to the new compliance structure of the JC. As healthcare’s leading CMMS, FSI has already started preparations to help streamline compliance for healthcare facilities and HTM teams. Our Joint Commission Update Solution is designed to simplify and strengthen your compliance workflows across multiple regulatory bodies – with Joint Commission being the initial focus.
Interested in learning more about how FSI can support your compliance needs during this transition? Contact our team today: mzimmer@fsiservices.com