By K Richard Douglas
The Joint Commission’s Accreditation 360 (A360) initiative began reshaping hospital regulations in January of this year, streamlining a number of requirements to better align with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COPs). The initial changes updated the manuals for hospitals and critical access hospitals.
Most of the changes are related to nomenclature along with a large number of reductions in requirements.
What Is Accreditation 360 (A360)?
The Joint Commission says that Accreditation 360 (A360) removes “more than 700 (714) requirements from the hospital accreditation program, which builds on the reduction of 400 requirements announced in 2023.”
Approximately 82 percent of U.S. hospitals are accredited by the Joint Commission. If the organization discovers deficiencies during an inspection, it will take a collaborative approach with the facility to implement a corrective action plan.
Compliance is a big deal and a big cost for healthcare facilities with annual costs for personnel and compliance activities accounting for millions of dollars annually. In some areas, such as infection prevention, many hospitals still fall short. A360 seeks sustained performance in all areas that are evaluated.
A360 was first announced by the Joint Commission in June of 2025. The organization states that A360 “focuses on outcome measures for certification, provides better support and more efficiently shares leading practices across the healthcare ecosystem.” It is the Joint Commission’s first major evolution to the accreditation process in 61 years.
The primary goal of the new approach is that it “aims to reduce burden on clinicians and health systems while maintaining rigor and sharpening the focus on quality and safety areas that matter, all in service of delivering better patient care,” according to the Joint Commission.
A New Survey Process Guide
Another component of A360 is an updated Survey Process Guide (SPG). The new guide replaces the existing Survey Activity Guide (SAG) and aligns with the Medicare State Operations Manual. The new guide is the same guide that will be used by surveyors, according to the organization.
The chapter entitled “Environment of Care” has been eliminated and replaced by “Physical Environment.” New regulations focus on “continuous improvement and competencies.”
The process for a hospital to become accredited and certified is not just a one-time event or even limited to an annual review. It is an ongoing process of improvement to quality of care and safety that is the foundation of A360 as it attempts to streamline and simplify the process.
Joint Commission certifications have shifted to a focus on outcome measures with a special emphasis on maternity care, cardiovascular procedural care, hip and knee procedural care and spine procedural care.
What A360 Means for HTM
For the HTM department, there is little impact from the Joint Commission’s changes, but the evolution of the accreditation process and associated expectations is instructive for all members of healthcare.
When an HTM professional considers the changes that were instituted beginning this year, the important thing to consider is that preparation for a visit by a surveyor remains useful knowledge. Leveraging the existing technology that is available in the HTM department can facilitate this preparation.
“The most important thing to know is that no HTM requirements whatsoever have been eliminated. Keep doing what you’ve been doing,” says Matthew F. Baretich, PE, Ph.D., president of Baretich Engineering in Colorado.
He says that what the Joint Commission has done concerning HTM is to remove from its standards any language that is not explicitly in the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COPs). However, all requirements that have been “removed” have simply been moved elsewhere.
National Performance Goals Replace Patient Safety Goals
The Joint Commission has a set of standards that provide goals for hospitals to improve safety, quality and outcomes. These National Performance Goals (NPGs) provide a measurable framework for hospitals.
The organization describes these goals as “14 high-priority topics that are measurable, actionable and organized to make it easier for hospitals to track progress and improve outcomes on key areas of patient safety and quality care.” The goal remains patient safety and quality of care.
Beginning January 1, 2026, the Joint Commission’s NPG chapter for hospitals and critical access hospitals replaced the former National Patient Safety Goals (NPSG) chapter.
The goals include a culture of safety, prioritizing infection prevention and control, reducing the risk of suicide, a medication management program and an emergency management program.
Where HTM Can Find the Relocated Requirements
With the shuffling of the regulations, requirements and focus, what resources can HTM reference for guidance and what should be done with any current equipment management plan?
Baretich says to see how the requirements have been relocated, go to the Joint Commission website (www.jointcommission.org) and search for “Critical Access Hospital and Hospital Requirements Streamlined to Reduce Burden.”
“There you’ll find a set of lengthy documents (which cover all hospital requirements, not just HTM). Download the documents to see how things have been restructured. You might try AI tools to help sort things out,” he suggests.
He says that one of the files available for download is the Survey Process Guide (SPG). It describes how the accreditation survey will be conducted. Biomeds can search that document for HTM-related terms.
“I’m often asked by clients if HTM programs should drop the Medical Equipment Management Plan (MEMP) because there is technically no longer a requirement to have one. My advice is to keep what you’ve got for now. If you really want to, you could update the numbering for standards and elements of performance, but my suggestion is simply to add a note to your existing MEMP saying that you are temporarily retaining the old numbering system. That will show you’re aware of the A360 changes,” Baretich suggests.
How HTM Can Prepare for a Joint Commission Survey
A presentation at the November 2025 MD Expo in Dallas provided a comprehensive overview of how an HTM department can assess and ensure its readiness for inspection.
In the presentation, Damion Schinnerer, MBA, MM, MA, director of purchased services and capital for CHC Supply Trust, covered several strategies to help an HTM department prepare for a surveyor visit.
Joint Commission-accredited inspections are performed routinely and are unannounced, so preparation and organization can be the difference between panic and a smooth interaction with the surveyor.
Schinnerer believes that compliance can benefit from proper use of a CMMS. He says that technology allows easier preparation for surveys.
“I believe the most crucial part of maintaining compliance is the proper and effective use of PCR codes. They are generally overlooked or misused, creating chaos and confusion in your CMMS and regulatory reporting,” he says.
Schinnerer says that PCR codes are crucial because they provide the CMMS with a consistent way to document, track and verify maintenance actions associated with an alternative equipment maintenance (AEM) program.
“In healthcare, that documentation is often what shows auditors that your AEM decisions are risk-based, followed as written, and supported by maintenance history rather than guesswork,” he says.
Schinnerer adds that a well-structured PCR code system helps maintenance teams do three things at once: standardize work orders; verify inspection and testing completion; and create a defensible compliance record.
“When equipment is managed under AEM, the facility must maintain policies, procedures and documentation supporting the program, and it must follow the activities and frequencies it sets for itself. PCR codes make that evidence easier to capture inside the CMMS instead of scattering it across paper forms, emails or technician notes,” Schinnerer says.
He says that they also help confirm that the AEM is being applied correctly to the right assets.
“That matters because not every device should qualify for AEM treatment, and some categories, such as equipment governed by other rules or new assets without enough maintenance history, may require stricter manufacturer-based maintenance. By tying a PCR code to each corrective and preventive maintenance task, your CMMS can show whether the work was performed in accordance with standard manufacturer guidance or an approved AEM pathway,” Schinnerer says.
He says that for compliance, the biggest value is traceability.
“If surveyors ask how a specific device was maintained, the CMMS should be able to show the asset history, the assigned maintenance method, the completed work, and the date and frequency of service. CMS guidance emphasizes that hospitals electing AEM must support the program with documentation and adhere strictly to the maintenance activities they establish. PCR coding strengthens that trail by making every action searchable and auditable,” Schinnerer explains.
Driving the point home, Schinnerer says that PCR codes also improve operational consistency.
“They reduce variation between technicians, help supervisors spot missed tasks, and make reporting easier for quality, safety and accreditation reviews. In practice, that means fewer compliance gaps, faster audits and better confidence that the equipment is safe and maintained as intended,” he says.
Schinnerer says that, in short, PCR codes are not just administrative labels. They are the backbone of a CMMS-driven AEM program because they connect maintenance execution, compliance proof and equipment safety in one reliable record.
He says that it is wise to be prepared and have information in a format that allows for quick access and availability. He says the quick availability of the information that the inspector is asking about will help them to move on to the next topic and hasten that particular item. This also can prevent opening a can of worms or bringing up a concern that forces the inspector to go down a rabbit hole, according to Schinnerer.
In addition to PCR codes, Schinnerer says that cable management is one example of the merging of IT and biomed and the focus of a surveyor might land on cabling that brings up a concern. It is better to get the right-length cables because if it looks right, it works right, the inspector will simply move on.
When preparing for an inspection, Schinnerer says that it helps when techs make work orders look the same. This can be done through standardized checklists and canned nomenclature; the process can be streamlined. If everyone has the same orientation, an inspector will see concise and consistent text. This streamlines processes even when it doesn’t involve an inspection.
Examples are label placement, with the label door-facing, or PM stickers being bigger on beds and stretchers, so clinicians are needed to assist. He says that the ability to scan a barcode to determine service history is a big plus. There are also simple things like avoiding residue build-up from old stickers and keeping surfaces clean.
Organization is important. Schinnerer says that when an inspector asks for a piece of material, many biomeds will run back to the biomed department and start a two-hour search looking for the requested information when some preparation would allow much quicker access.
What’s Missing From A360: MEMP, AEM and Imaging
It is important to be aware of what is included and what changed in A360. However, there are some items missing from the new regs.
One of the things lacking is a requirement to have a MEMP, according to Samantha Jacques, Ph.D., FACHE, AAMIF, FACCE, vice president of clinical engineering at McLaren Health in Michigan.
Jacques also says AEM is not mentioned, although it is still asked about in the Survey Guide. She also says there are no “specific requirements around equipment such as sterilizers, quality testing of imaging equipment, etc.”
An exception that may bear attention is in the area of staffing.
“Most HTM groups don’t do the competency assessments upon hiring. Some do it every three years, but overall, the competency assessment pieces are new pieces most programs need to put in place,” Jacques says.
The Bottom Line for HTM: Outcomes Over Process
It is a good practice for employees to be aware of any changes that are enacted by the Joint Commission since most healthcare facilities are accredited by the organization.
“While the HTM requirements have not fundamentally changed, requirements for other hospital functions certainly have. The Joint Commission is working to break down silos and focus hospital leadership on outcomes rather than structures and processes,” Baretich says.
For all the scale of Accreditation 360 — more than 700 requirements retired, a decades-old chapter renamed and an entirely new survey guide — the message for HTM professionals is steadying rather than alarming. The requirements that govern medical equipment management have not disappeared; they have moved, and the disciplines that have always marked a well-run department still carry the day: a maintained MEMP, a well-structured CMMS, defensible AEM documentation and readiness for an unannounced surveyor. The one genuinely new expectation worth acting on now is competency assessment. Beyond that, knowing where the requirements went — and being able to show a surveyor exactly how a given device was maintained — remains the surest path through any inspection.
