Surgical Solutions Insights

Accreditation 360: A New Era of Joint Commission Healthcare Accreditation

Written by Surgical Solutions Team | Jul 8, 2025 8:15:00 PM

It’s Here. Are You Ready?

When The Joint Commission calls something “the most sweeping rewrite since 1965,” it’s worth paying attention.

On June 30, 2025, The Joint Commission (TJC) introduced Accreditation 360: The New Standard, a major overhaul of healthcare accreditation as we know it. Backed by data analytics, performance benchmarking and outcome-based measures, Accreditation 360 is so much more than a reduction of documentation or reshuffling manuals. This is now a fundamental shift in how healthcare organizations prove they are providing safe, high-quality care. And with it, there are higher expectations with clear paths of accountability aimed at showcasing better outcomes for patients, rather than long policies.

This shift in Joint Commission accreditation represents more than a policy update. It marks a response to evolving healthcare laws and the increasing demand for quality improvement in healthcare.

Why Accreditation 360? Why Now?

Hospital accreditation has always been central to healthcare quality and safety. Now, with Accreditation 360, the Joint Commission is redefining how healthcare industry regulations and TJC accreditation standards align with outcomes-focused care.

We can all agree that healthcare has undergone significant changes in the last decade. Some may argue that, in the post-COVID era, the healthcare industry has responded with a range of adjustments. This is true, but also consider the rising patient acuity, chronic staffing changes and challenges plus overall regulatory fatigue are stretching teams thin. The traditional accreditation model was built for a different era. Accreditation 360 is the Joint Commission’s answer to that reality: a smarter, more modern approach designed to support how care is and should be delivered today.

What’s Changing in Healthcare Compliance and Accreditation?

Here’s a summary of what Accreditation 360 introduces:

  • There are 714 more standards removed: On top of 400 eliminated in 2023.
  • Updated Accreditation Manual: Clearly separates CMS Conditions of Participation (CoPs) from new National Performance Goals (NPGs) which now integrate with the previous National Patient Safety Goals (NPSGs). 
  • 14 NPGs Introduced: Simplifies safety practices into measurable, shared goals. These NPGs merge existing requirements, CMS Conditions of Participation, and former National Patient Safety Goals into a new structure focused on measurable outcomes.
  • Outcome-Focused Certifications: Starting with Maternity, Orthopedic, Spine, and Cardiovascular procedural care.
  • New Continuous Engagement Model: Supports ongoing readiness and performance, not simply ready for survey week.
  • SAFEST Benchmarking Database: A tool to capture and share leading practices across organizations.

And for the first time ever, Joint Commission standards will be publicly searchable online.

This Is More Than an Accreditation Update. It’s a Culture Shift.

Let’s be clear: this isn’t about easing up on expectations. It’s about removing redundancy and focusing squarely on consistency, accountability and outcomes. The days of simply pointing to a policy are fading. Surveyors want to know if your team follows it and why.

One of our team members, Rebecca Lauber, captured it perfectly in a recent LinkedIn post:

“It’s no longer enough to point to a policy. Now we have to prove we follow it and explain why. When documentation is simplified, outcomes become the loudest evidence in the room.”

 

Exactly, Rebecca. The number of standards might be lower, but the scrutiny is higher.

And most critically: If your frontline teams can’t walk a surveyor through key processes without management stepping in, that’s not simplification, that’s exposure.

That’s the essence of Accreditation 360.

What Accreditation 360 Means for Hospital Accreditation and Healthcare Compliance

For compliance teams, Accreditation 360 doesn’t reduce the need for vigilance, it raises the bar. As healthcare compliance becomes more outcomes-driven, departments like Sterile Processing (SPD) and Infection Prevention (IP) and OR teams, this new shift brings heightened scrutiny. The good news: it also brings a greater opportunity to lead.

Here’s where that pressure (and opportunity) will show up most clearly:

  • Increased focus on core SPD processes like instrument tracking, water quality and BI failure management.
  • Emphasis on real-time readiness, not just cleaning up for survey week
  • Frontline knowledge matters: staff must be able to speak confidently about their processes and rationale
  • Benchmarking tools will surface variation across departments and highlight gaps

If your SPD team isn’t aligned to current AAMI standards, or your infection prevention practices vary by shift, this new model could reveal those cracks.

The Bottom Line: "Less Is More" (Only If You're Ready)

Accreditation 360 isn’t just a rebranding. It’s a call to action.

It challenges every healthcare organization to move beyond the superficial polish of compliance week and embrace a year-round readiness mindset. It raises the bar but not by adding more hoops to jump through, more so by demanding meaningful, demonstrable outcomes.

Here is the question we’re asking ourselves, and encouraging our clients to consider, too:

If a surveyor walked in today, could your staff explain your most critical processes without missing a beat?

If the answer is no, or even “I’m not sure,” it might be time for a new kind of preparation.

 

Quick Readiness Check:

Can Your Team…

  • Explain your water monitoring process, including frequency, parameters, and rationale?
  • Walk a surveyor through your most recent BI failure response?
  • Articulate how your practice aligns with national performance goals?
  • Describe how recent TJC changes have impacted your workflows or training?

If any of these gave you pause, you’re not alone. That’s precisely the point of Accreditation 360: to help organizations refocus on what matters most, not just what’s written.

 

What Should Healthcare Leaders Do Next?

Whether you’re in a leadership, compliance or education role, here’s how to lead your teams through this change:

  1. Educate Teams at All Levels. Share the “why” behind Accreditation 360. Empower staff to speak to process decisions, not simply recite policy.
  2. Audit Your Readiness. Run internal mock surveys focused on frontline engagement, not just documentation.
  3. Modernize Your Tools. Use SAFEST and other benchmarking platforms to assess performance and share best practices across units.
  4. Shift to Continuous Readiness. Consider adopting the Continuous Engagement Model to move from “survey prep” to ongoing improvement.
  5. Invest in Competency-Based Training. Especially in SPD and clinical departments. It’s no longer enough for top leaders to know the standards. Your staff has to live them.

Final Thought: Will “Less” Expose More?

Accreditation 360 removes hundreds of requirements. But in doing so, it shines a brighter light on what remains. There’s less noise now, which means the gaps will be easier to spot.

If your organization is committed to safety, quality, and transparency, this model can serve as a launchpad for true excellence. But if your strategy relied on policies alone, consider this your wake-up call.

Need help preparing for Accreditation 360?

Whether you're developing a training plan, running a mock survey, or trying to interpret the latest healthcare industry regulations, our experts can help. We offer:

  • Training & Readiness Support
  • Fresh Look with Mock Surveys
  • Custom Gap Assessments
  • Leadership Briefings on NPGs & Surveyor Focus
  • Staff Competency Planning

Let’s talk about how to turn this shift into your strategic advantage. 

Begin by contacting us to walk you through the next steps.

 

Join Our Next Roundtable: “Real Talk, Real Impact”

We’re launching our second invite-only roundtable for surgical leaders, sterile processing professionals and perioperative teams who want to be part of the solution.

This is your chance to:

  • Share real-world insights on survey prep, SPD challenges, and OR operations
  • Help shape new tools and resources
  • Connect with peers navigating the same changes you are
  • Be part of the conversation influencing what comes next

This is not a webinar. It’s a candid, facilitated discussion through a Zoom link with leaders who want to make change happen.

Spots are limited. Sign Up for Your Invite.

 

Ready to Learn More?

We’ll be rolling out new resources, webinars, and toolkits to help teams navigate Accreditation 360 with confidence. Stay tuned for our upcoming readiness series and interactive quizzes launching this fall.

In the meantime:

  • Sign up for our Webinar to discuss these changes in real time.
  • Download the Accreditation 360 Readiness Checklist.
  • Schedule a 15-minute call [MEETING LINK] with our Solutions Experts to help you understand these changes and what they mean for your facility.
  • Check out the official Joint Commission Accreditation 360 resource page:
    Joint Commission Accreditation 360

 

 

Sources:

The Joint Commission – Official Press Release

The Joint Commission - Accreditation 360: The New Standard

The Joint Commission – Learn the Process: The Accreditation Standards

The Joint Commission – National Patient Safety Goals (NPSGs)

National Quality Forum (NQF) Joint Commission Launches a Transformative Approach to Healthcare Accreditation

Becker’s Hospital Review – Joint Commission Cuts Standards by 50% in Sweeping Overhaul