Transition to Accreditation 360

We’ve all experienced the frustration of a “moving target.” Whether it’s evolving clinical protocols or the increased workloads caused by staffing shortages, moving targets make our jobs more complicated. That may also seem to be the case as you transition to Accreditation 360. When new documents like “NPG 1, Right Patient, Right Care” seem to blur multiple requirements together, how do you manage the compliance implications?

Our advice is to move beyond just surface-level compliance. Instead, healthcare leaders must distinguish between high-level public summaries and the technical roadmap required for a successful, zero-finding survey. Here are two key examples:

Decoding NPG-1

Upon closer inspection, “NPG 1” attempts to synthesize a broad range of standards, specifically NPG.01.01.01 through NPG.01.06.03, rather than focusing on a single goal. While these briefs are helpful high-level summaries for the media or public audiences, they lack the granular detail necessary for rigorous internal preparation.

2) The Survey Process Guide

In addition, the most critical and informative resource to ensure full compliance remains the 700 plus page Survey Process Guide. Unlike the high-level briefs, this guide provides a comprehensive look at both the standards and their specific Elements of Performance (EPs). More importantly, it pulls back the curtain on the actual techniques surveyors use to evaluate compliance. This includes everything from:

• Direct Observation of Care Processes
• Staff Interviews
• Audits of Medical Records
• Meeting Minutes, Logs and Performance Improvement Data

Understanding these specific evaluation methods is the key to moving beyond surface-level readiness.

Bridging the Gap Between Theory and Practice

To further bridge the gap between theory and practice, we also recommend reviewing the recent webinars produced by the Joint Commission, which are highlighted in the December 2025 Issue of Perspectives. These sessions offer valuable context on the new standards format across different chapters. If you haven’t viewed these yet, they are an essential supplement to the Survey Process Guide. Relying on the right documentation is the first step in turning a complex survey process into a manageable and successful accreditation journey.

Do You Need Help Navigating Accreditation 360?

Patton Healthcare Consulting helps hospitals nationwide master the transition to Accreditation 360 and remain compliant in this evolving landscape. Request a meeting today to review your specific compliance challenges with our experts.