Workshop: Mastering The Joint Commission standards and CMS regulations

Editor's Note

Hospitals that succeed in surveys are those that “hardwire safety so you’re not ramping up and down,” said John R. Rosing, MHA, FACHE, executive vice president and principal of Patton Healthcare Consulting. Speaking at the OR Manager Conference, Rosing reminded perioperative leaders, “If we’re really about providing quality care, we want these processes in place, functioning day in and day out.”

He started by urging leaders to see accreditation as more than a regulatory hurdle. “It allows you to go for Medicare and Medicaid,” which he said often represents “50% of your patient revenue.” The aim, he added, is to sustain compliance between surveys, not “let things slide and ramp up” when the next visit looms. While accreditation remains voluntary, “if you’re not accredited, you fall under state survey,” which tends to be “not as friendly or flexible,” he cautioned. He also described survey variation as inevitable because some surveyors are full-time The Joint Commission staff, while others “do 4 or 5 weeks of survey activity throughout the year,” which can result in inconsistent findings. “It can be frustrating,” he said, “and they work on it all the time to build consistency.”

The presentation outlined how infection prevention remains the most common cause of “immediate threat to health and safety” findings, particularly in sterilization and disinfection. “These areas, by their nature, are high risk,” Rosing said. He explained that “55% of condition-level findings” stem from sterilization or high-level disinfection errors—issues that must be corrected “within 45 days” and are often re-surveyed.

A major 2026 shift will reshape the accreditation landscape. The Joint Commission’s Comprehensive Accreditation Manual for Hospitals will shrink from 496 to 146 pages, with “700 EPs removed,” while the Survey Process Guide will expand to 696 pages containing “many tracer tools.” The new National Performance Goals (NPGs, formerly National Patient Safety Goals) will bundle policies and requirements across patient identification, time-outs, infection prevention, alarm safety, workplace violence, and medication management. “Do not assume deletion means no requirement,” Rosing cautioned, urging teams to update policies to reflect new numbering and “educate leaders on expanded NPGs and bundled requirements.”

From there, he delved into OR “hot spots” that most often trip up teams. On medication management, he displayed photos of unlabeled syringes. Multidose vials “are not permitted to be in patient care areas,” and anesthesia carts “must be locked or under supervision.” Rosing recommended adding language to policy that explicitly authorizes support staff access to storage areas “to perform tasks outlined in their job description” to avoid security citations. He also addressed warming cabinets, reminding leaders The Joint Commission “requires a beyond-use date, not the date placed,” and to inspect daily for expired products. Malignant hyperthermia carts, he said, should be sealed, logged daily, and treated “just as you would a code cart.”

The most common NPG citations, Rosing noted, involve lapses in two patient identifiers, critical result reporting, incomplete handoffs, unlabeled solutions, and flawed time-outs. “If anyone in the room is doing something else during the time-out—adjusting the airway or the back table—that’s a finding,” he warned. He also stressed electronic documentation competency as an emerging risk: “Surveyors will ask staff on the floor to find the H&P or consent. Many don’t know where to look.” Leaders should run tracer drills to ensure teams can locate key documents such as the post-procedure note and post-anesthesia assessment.

On tissue management, Rosing urged vigilance: “No record of the fluid used to thaw the tissue or the lot numbers of those fluids” is a frequent citation. He emphasized bidirectional traceability “back to the manufacturer, in receipt and storage, to the patient,” adding that “if you expect multiple departments to do this correctly, you’re making it more difficult.”

In central sterile processing, he said surveyors are now “very comfortable being in the OR or central sterile,” and they are increasingly detailed. He advised daily environmental checks: verify negative pressure in decontam, clean ceiling vents, and “act on what you record.” Seemingly small oversights—like dirty vents, missing ceiling tiles, or standing water—“get noticed,” he said. Staff must also be ready to answer “How do you know the instruments are clean?” and demonstrate adherence to AAMI ST79 standards for biological testing, IUSS use, and documentation.

Per Rosing, the goal is not to survive a visit but to embed sustainable excellence. “Be curious,” he said. “Use your surveyor eyes.” His guidance summed up the workshop’s theme: readiness depends on continuous practice, including tight documentation, disciplined reprocessing, clear labeling, and a culture where every nurse can prove compliance at any moment.