March 2026
Inside This Issue
Survey Process Simplifications:
Well, the first issue of the new replacement for Perspectives is out. The first two articles discuss simplification of some aspects of the survey process.
The first simplification we had given readers a heads up about in the last paragraph of our February Patton Post newsletter is the elimination of JC’s requirement that subsequent fire drills must be conducted at least one hour or more from the prior drill. The second aspect of this simplification indicates that quarterly fire drills no longer need to be conducted at least 10 days or more from the prior drill. In other words, if you are late in scheduling in one quarter and early in scheduling in the next quarter, that is acceptable.
JC is also simplifying its evaluation of waived testing procedures, requiring adherence to the manufacturer’s instructions for use, however any published “advisory guidance” in the package insert is optional, subject to your own policies and procedures. In other words, you can choose to incorporate advisory guidance, but JC does not mandate implementation of what is considered advisory.
A third deregulation we recently noticed is that the maternal safety standards implemented by JC in 2021 under PC.06.01.01 and PC.06.03.01 have not be moved into the 2026 hospital manual. In 2024 CMS had published maternal safety regulations, but as yet has not published the complete interpretive guidance for these regulations. The disposition document JC had published indicating where content moved between the 2025 and 2026 manuals indicates that the maternal safety elements of performance will be replaced with “more direct EPs with CMS approval.”
Unfortunately, the leadership role JC had taken in developing these new requirements has been put on hold, pending CMS finalization of interpretive guidance and then approval of JC’s elements of performance. We would assume that most leaders would likely want to continue their existing application of maternal safety expectations during this period of regulatory alignment, however lapses in compliance with hospital policies can lead to potential findings, not specifically addressed in an element of performance. The potential for patient safety would seem to outweigh the risk of a noncompliance with policy finding.
NQF Serious Reportable Events (SRE):
Probably the most important news in the new Joint Commission News publication is that effective January 2027, JC will be adopting the National Quality Forum’s (NQF) serious reportable event list as part of its Sentinel Event list. A link has been provided in JC News to an extensive 162-page NQF/JC joint publication that discusses this change in significant detail. A crosswalk comparing the 28 NQF serious reportable events (SRE) to existing sentinel event definitions has been included in their document.
The 28 NQF SREs have been categorized into 4 sections including:
- Procedural events
- Product or device events
- Patient protection events
- Care provision events
In each of the above categories, JC has identified what this means for the definition of what constitutes a sentinel event. JC has identified two planned actions for each of the 28 SREs.
The first planned action is a simple alignment of two similar definitions. For example, SRE 1 and SRE 2 which are “wrong site, wrong patient, wrong procedure” and “unintended retention of a foreign object,” both of which correlate closely with existing JC definitions, will need some minor definitional and terminology alignment. The second planned action definition is that the SRE will be added to the existing JC sentinel events list. We noted that 16 of the SREs will require addition to the JC sentinel event list. These 16 will require some planning, preparation and hospital policy modification in anticipation of 2027.
In addition, after January 2027 these may involve a workload burden to conduct the intensive analysis needed to identify potential root causes, action plans and measurement strategies. For example, SRE 19, “patient harm associated with a medication error” and SRE 23, “patient harm resulting in failure to act on clinically significant laboratory, pathology and radiology test results” may both have a higher frequency than anticipated and be subject to definitional arguments.
We anticipate there will be much more to come regarding guidance and educational material from JC on this complex issue. In addition, the existing Sentinel Event chapter in the accreditation manual will need to be rewritten to incorporate these new definitions and provide details on compliance with JC’s sentinel events policy. For the present, we encourage readers to download the alignment document and begin to analyze its potential implications for current policies and workloads.
PE Serious Reportable Events:
This month’s issue of EC News has a companion article to the one we already discussed in their new newsletter called Joint Commission News. This is also about serious reportable events, or SREs, but it focuses on just those related to the physical environment. Surprisingly, there are actually 10 of the 28 SREs that are linked to the physical environment.
In these SREs, the causation may be related to the environment, or sometimes the way in which staff and patients function in the environment. In either situation it is appropriate to examine the physical design to determine if redesign of the environment or process could lessen the chance for the SRE.
The environmental SREs are as follows:
SRE 5: Introduction of unapproved, unscreened or inappropriately approved device, implant or object in MRI zone IV, regardless of outcome.
SRE 6: MRI thermal injury, patient harmed.
SRE 8: Patient harm associated with contaminated drugs, devices or biologics.
SRE 9: Medical device malfunction, patient harmed.
SRE 10: Medical gas systems: Patient harm occurring when systems designed to deliver a specific medical gas, deliver the wrong gas or no gas, or are contaminated by some toxic substance.
SRE 11: Fire, flame or unanticipated smoke, heat or flashes occurring during direct patient care caused by equipment in the healthcare setting, regardless of outcome.
SRE 13: Patient elopement, patient harmed. NOTE: Some states may have a definition that does not require the patient to have been harmed, as does today’s JC sentinel event definition.
SRE 14: Patient suicide or attempted suicide after presentation for care or within 7 days of discharge.
SRE 17: Falls. Patient harm associated with a fall.
SRE 18: Burns. Patient harm associated with an unintended burn from any source.
As you prepare the application of these 2027 SRE definitions it would be advisable to proactively examine design of the environment and the work processes related to these SREs.
Fire Extinguisher Inspections:
In the past few months, EC News has had several articles reminding readers of the multiple, detailed NFPA requirements for mounting and inspecting fire extinguishers. As consultants we have had concerns about the deletion of those details from the standards, however it appears that the contributors to EC News must have similar concerns given the number of articles reminding readers of this change.
The March issue of EC News has one more reminder article, however this one looks really useful because they have created another of those JCR inspection tools, this time for portable fire extinguishers, and the tool includes all the detailed, multiple expectations, that used to be in the standards, in a checklist format. Follow the link in EC News to download this document.
Case Study: Mass Casualty Chemical Spill:
JC published its latest edition of EM Leader in mid-February. The lead article has been prepared by White Plains Hospital in New York. They discuss a community drill they conducted simulating a mass casualty event involving a chemical spill. This gave them an opportunity to test their triage processes prior to and after decontamination in the parking lot, as well as their response to a chemical incident. They did find one important vulnerability to analyze, where some of their portable air purifying respirator batteries were drained and needed to be charged. Your EM team will find this to be informative and may want to initiate a similar drill to test their readiness for a chemical spill with mass casualties.
EM Training:
The second article provides suggestions on EM training for staff, detailing requirements in each training related element of performance. JC also provides 10 suggested training tips. Tip #8 was interesting in suggesting to not just store EM equipment, but rather to deploy it during drills and allow staff to practice setting it up and using it. This certainly sounds like sound advice and, thinking of the drained batteries mentioned above, we would also suggest keeping this equipment on your equipment checklists and testing either batteries or identifying a recharging interval and process for all stored emergency equipment.
High Consequence Infectious Disease:
EM Leader has a refresher article on the high consequence infectious disease aspect of emergency management that provides a wealth of information with links to resources from Federal Agencies and other authoritative sources. Your EM Team and infection prevention teams will find this to be a great source for ideas to strengthen this aspect of your EM plan.
DNV:
Their monthly healthcare update was posted to their LinkedIn site in late February. It focuses on their stroke certification programs and collaboration with the American Heart Association. There are multiple links within the update to guidance documents and their stroke certification standards. The starting point to review these materials is on their February 2026 Edition LinkedIn newsletter.
DNV had posted their advisory notice with their updated 2026 standards in August 2025. Given our earlier discussion about maternal safety standards, we looked to see what they said and noted that they do have current maternal safety standards on pages 158-162 of their 2026 standards manual. If you would like to review their standards you can view their Publication to obtain a copy.
DNV has also posted information about an educational program they call the DNV University. This is basically multiple training programs for different audiences taking place simultaneously. The first one coming up is in Nashville, TN April 21-23 and a second program scheduled for Denver, CO July 21-23.
CIHQ:
They are holding their Accreditation and Regulatory Summit in Council Bluffs, IA on October 6-8. They are also planning a preconference on Oct. 5th regarding their certification programs.
Their 2026 Hospital, Critical Access Hospital, and Psychiatric Hospital standards are also available for download on their website.
Following that same thread, we took a look to see what they had published relative to maternal safety standards, and they have standard OB-1 that details their maternal safety expectations. One element, E discusses training based on QAPI and current clinical practice guidelines that is effective 1/1/27, although the remainder of their maternal safety standards are applicable 1/1/26.
ACHC:
ACHC has an inventory of previously conducted webinars that you can view or download from their website. They held two for hospital providers in January, one on Just Culture and a second on Designing Better Systems. These can be obtained by visiting their Webinar homepage.
ACHC’s hospital and other program standards and updates for 2026 are also available for downloading on their website, although you will have to provide them your contact information for likely marketing calls.
They do have new standards effective 1/1/26 for obstetric services, available as a separate download using the previously mentioned link and they too have the training requirements effective 1/1/27.
CMS did not publish any new QSO memos or expire any existing memos during the past month.
CONSULTANT CORNER
Dear Readers,
Looking to strengthen staff readiness for accreditation and regulatory expectations? Our Customized Education and Training programs deliver practical, targeted education tailored to your organization’s needs.
We support a wide range of healthcare settings, and our team partners with organizations to navigate today’s evolving regulatory landscape. Contact us to learn more.
Thank You!
Julia Finken, RN, BSN, MBA, CPHQ, CLSSMBB
Julia.finken@hbsinc.com
Jen Cowel, RN, MHSA
jencowel@pattonhc.com
Yvonne Rockwood, MBA, MHA, CPHQ
yvonnerockwood@hbsinc.com