What The Joint Commission’s SOC process changes means for facility managers

Even if you weren’t at the annual American Society for Healthcare Engineering (ASHE) meeting in Denver last month, you’ve probably heard that The Joint Commission (TJC) has made changes to its Statement of Conditions (SOC) requirements. The SOC was first created in 1995 to help healthcare organizations develop Plans for Improvement (PFIs) to correct deficiencies in the National Fire Protection Association’s (NFPA) Life Safety Code. Health facilities use PFIs to outline action items and track their progress against deadlines.

Not familiar with the changes? Here’s an overview (all changes became effective August 1):

  • Deficiencies are no longer documented through an organization’s SOC. Instead, the deficiencies will be outlined in the Requirements For Improvement (RFIs) managed by an external surveyor.
  • Organizations will have 60 days to correct deficiencies. No extensions will be permitted unless previously approved by the Centers for Medicare Services (CMS) regional office.
  • There will no longer be a six-month automatic extension.
  • TJC will not review open PFIs or include them in final reports. Only equivalency requests related to survey events will be reviewed.

These changes present many implications for facility managers. Here are five:

Tighter deadlines.

Given that a 60-day grace period is no longer allowed, it’s critical that facilities stay organized so they can meet deadlines. In the event a facility cannot meet the deadline, they can request a Time Limited Waiver (TLW). However, it’s important to note that the TLW request has to be submitted within 45 days of the last day of the TJC survey.

External reporting.

Facilities will no longer be in charge of formally documenting self-reported deficiencies. Instead, the organization will provide the deficiencies to a surveyor, who handles the documentation. This means facility managers need to be very clear about the deficiencies they’ve identified so there is no miscommunication between them and the surveyor.


After a survey, the facility has the opportunity to submit “Clarifying” ESC (Evidence of Standards Compliance) if they were in compliance with a particular standard at the time of survey (65 percent of Clarifications result from a lack of documentation).

SAFER matrix.

TJC is considering a simplified matrix to quickly and visually identify and prioritize the RFI’s for follow up activity. The new matrix identifies low-level and high-level risks and wide spread deficiencies for both surveyors and hospital staff.

Incentive to evaluate safety measures.

According to the ECRI Institute, there are an estimated 600 surgery fires in the U.S. each year. While some fires don’t cause injury, others are devastating and may cause severe third-degree burns or even death. TJC’s changes offer an opportunity for facility managers to take a good look at what measures are being implemented to prevent fires from occurring.

If you have questions about these changes, please give us a call at (215) 499-0808.

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