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The past few years have been busy ones for Joint Commission. In addition to yet another name change (they have scrapped “the” from their appellation, and are now known only as Joint Commission), the organization has revised their survey process to better align with CMS mandates including the removal of the “blackout date” process, stricter notification practices for healthcare organizations when surveyors present for unannounced surveys, and streamlining of the SAFER matrix (the “report card” that healthcare organizations receive from surveyors that lists necessary corrective actions needed to remain in compliance). If that weren’t enough, even more significant changes are in store for 2026.

January 2026 marks the inauguration of Accreditation 360: a series of significant changes designed to improve the survey process for both healthcare facilities and for Joint Commission surveyors. Some of the changes include consolidation of 2 chapters (Life Safety and Environment of Care) into one chapter called “Physical Environment.” The organization is also retooling the current National Patient Safety Goals chapter (originally designed to supplement the CMS Conditions of Participation and target high-risk practices like medication labeling and care for patients at risk for suicide) into a new chapter called “National Performance Goals.” While many of the current goals will remain in place under this new format, the National Performance Goals chapter will have more emphasis on leadership accountability and sustainability.

While these revisions primarily impact acute care and critical access hospitals, the stated intent of Joint Commission leadership is to eventually implement a similar model for other accreditation and certification programs. However, during a recent webinar a consultant reiterated the key takeaway from a Joint Commission leader who was asked about the Accreditation 360 process at a recent conference: “fundamentally, the survey process is not changing.”

This is understandably taken as whiplash by hospital regulatory leaders who are anxious about what these changes mean on a practical and logistical level. Indeed, many of the revisions taking place with respect to Joint Commission standards do not change the nature of what surveyors are looking for. For example, 2 current standards that concern utility systems for “critical” areas (e.g. rooms where sterile procedures are performed) and “non-critical” areas (e.g. standard patient rooms) will be combined into 1 standard that assesses whether utility systems are working as intended.

What contributes to anxiety, however, is whether or not this type of consolidation will make it easier for hospitals to receive “condition-level” findings (i.e. findings that impact the CMS Conditions of Participation) which are more serious and require more effort from healthcare facilities to correct. Additionally, these condition-level findings also involve a 45-day follow-up survey from local agencies, which only increases the stress regulatory leaders face to get back into compliance.

Ultimately, it will not be entirely clear- either to healthcare facilities or Joint Commission surveyors themselves- how these changes will work in action. With huge impacts to federal funding and administrative oversight in Washington D.C. looming over every corner of healthcare, morale is not exactly high. One regulatory leader I spoke to summarized this unease when discussing Accreditation 360: “it’s a fitting name, because we will likely go full circle on this and be back to where we started in no time.”   

Emily, a certified Nurse Aide, witnessed a patient's struggle to swallow during mealtime. She saw the panic, the desperation, the silent scream for help. In that instant, Emily's Sensitivity to Operations kicked in –She was aware of the patient's needs and responded promptly.

The Power of Vigilance

With swift action, Emily alerted the team, and they sprang into motion. The patient's airway was cleared, and oxygen flowed freely once more. Sensitivity to Operations had saved the day, turning a potential tragedy into a triumphant tale of teamwork and quick thinking.

The HRO Difference

Emily's actions embodied the High-Reliability Organization (HRO) values of Duty to Speak Up, Respect for People and Commit to Zero Harm.  These values bolster the HRO principle of Sensitivity to Operations.  The healthcare team implemented changes to prevent similar incidents. They enhanced training on dysphagia and aspiration precautions; they adopted standardized assessment tools for identifying choking risks and increased their supervision and support for vulnerable patients at mealtimes.

The Lasting Impact

Emily's moment of vigilance had a ripple effect, transforming the way her team approached patient care. Sensitivity to Operations became the guiding principle, ensuring that every patient received the attention and care they deserve. What would happen if every healthcare team adopted this same level of sensitivity and vigilance? Lives would be saved, and the standard of care would be forever changed.

As we speak, many hospitals across Massachusetts are in the homestretch of completing preparations for the Joint Commission’s Health Care Equity Certification. Unlike the triennial accreditation survey (i.e., “the Big One”) which focuses on all aspects of patient care in hospitals, and which looms over hospitals and their quality departments like a mountain, the Health Care Equity certification brings with it slightly less stress.

Ostensibly, this is an “optional” certification which hospitals would seek out to distinguish themselves as leaders in the health equity space. Similar to other Joint Commission certifications like those that exist for stroke centers, the focus here is on leadership, collaboration, data collection, and how you use that data to improve care. What makes this certification unique, at least in Massachusetts, is that this “optional” certification is now a requirement for hospitals to obtain as part of the Commonwealth’s 1115 Waiver. That means that this certification is tied to a significant amount of Medicaid money and, by extension, is not exactly optional. While Massachusetts is leading the way by mandating this certification, there are rumblings of other states possibly doing the same, including New York.

There are many components of this new certification process that can be stressful. With many DEI offices in hospitals being either downsized or reshuffled as a result of new legislation, there is a bigger question of who “owns” this certification process. For a Joint Commission Primary Stroke Center certification, it is relatively clear who needs to manage the logistics of obtaining that certification: the leadership of a hospital’s stroke team. However, health equity is more diffuse and, fundamentally, everyone’s responsibility. To repeat a phrase I recently heard, “when something is everyone’s responsibility, it is no one’s responsibility.”

There is also the issue of data overload. Hospitals are now stratifying more health information more than ever before. However, coming up with concise answers about what is being done with that data and how it is being used to improve patient care can be a stumbling block.

Yet this is where some of the good news comes in. So many of our staff intuitively know how to connect patients with the correct resources. For example, while recently rolling out a staff education tip sheet on how to accommodate patients with communication deficits, frontline nursing and social work staff actually provided the authors of the tip sheet more information around resources than the authors were even aware of!

Whether for survey preparation or for performance improvement initiatives, we should always return to the Gemba to anchor our work. Often, quality professionals think of the

Gemba as a useful tool to determine what processes we need to change in order to improve. We don’t always think of the Gemba as a tool to show us what is already working and, by extension, what we can brag about. Once we have a sense of how the frontline is already succeeding in addressing the health equity needs of our patients, we can also find a better way to leverage data to support their work. Furthermore, once we have clear processes that are working well, leaders are more inclined to take ownership of these processes and are more willing to speak to them. No one wants to “own” a process that doesn’t work, let alone describe it to a Joint Commission reviewer.

This is both the challenge and reward that certifications like this bring to hospitals. They provide an opportunity to highlight so much of the great work that is already happening in the background. The job of quality leaders is to make this work explicit: to outline successful processes, to formalize workflows, and to educate other stakeholders on what the preferred process for addressing health equity needs is. Fortunately, we as quality leaders seldom have to start from scratch.

In the high-stakes environment of inpatient psychiatric care, safety isn't just a protocol—it's a culture. And in a culture that strives for High Reliability, we must challenge the assumption that authority alone dictates insight. True safety, as every frontline worker knows, emerges not from top-down policies but from the lived realities of those closest to risk.

One policy in particular—cell phone access for psychiatric inpatients— on a unit became a flashpoint for patient agitation, yet the voices most attuned to the issue had gone unheard for too long. This blog post makes the case for change, not from the top, but from the ground up.

The Policy Gap: Disconnected from Reality

The policy allowed patients to access their personal cell phones only with a provider’s order, and even then, only to retrieve phone numbers for use on hospital landlines. Social media and direct phone use were strictly prohibited. While this may seem cautious, the reality was more complex—and more dangerous.

Patients reported feeling cut off from their support networks, unable to manage essential life tasks like banking or medical appointments. In response, the facility observed a notable spike in safety incidents, including agitation, verbal aggression, and even attempted elopements.

Who raised the alarm? Not administrators. Not policymakers. But the public safety staff—those who walk the halls, respond to calls, and de-escalate crises daily.

Deference to Expertise: Trust the People Closest to the Work

The public safety team, composed of security officers and behavioral health technicians, consistently flagged one common thread in patient unrest: frustration over restricted phone access. Approximately 50% of daily safety incidents were linked to phone-related frustrations. Patients reported feeling isolated, especially those with family abroad who relied on WhatsApp or other encrypted messaging platforms. One officer recounted an incident where a patient denied access to WhatsApp attempted to elope, citing isolation as the primary trigger.

These observations were not anecdotal noise—they were critical data. In an HRO environment, data from the front lines is gold.

A Smarter, Safer Approach: Technology with Supervision

Informed by frontline insights, the quality team proposed a new model to inform a policy change —balancing safety with dignity and patient agency. First, they proposed supervised digital access. This allowed access to key apps (e.g., WhatsApp, banking, appointment scheduling) under staff supervision in a designated area. In addition, they proposed the use of device management software to restrict usage to only approved apps, blocking access to public social media or unsafe content.

Next, they advocated for task-specific access. This permitted staff-supervised use of phones for essential functions: paying bills, scheduling appointments, or managing subscriptions.

This was followed by patient education and communication planning. The facility implemented a clear, written policy discussed at admission. They also collaborated with patients to create individualized communication plans, managing expectations and reducing resentment.

Implementation with Accountability

This was not a free-for-all. It was a structured pilot, with checks and balances: notably a 3-month trial in a controlled environment, public safety staff trained in device supervision and software protocols, monthly feedback loop with public safety voices at the table and metrics tracked on incident reports, patient satisfaction, and staff feedback.

Results – Deference to Expertise

The new policy resulted in a 25–40% reduction in safety incidents linked to phone access, and improved patient-staff relationships, built on empathy and shared goals. A collaborative safety culture ensued due to the HRO principle of Deference to Expertise. The facility listened to those who experience patient behavior by honoring their expertise.  

In the bustling heart of an inner-city hospital, where acute inpatient services and post-rehabilitation care hum with activity, Steve, a dedicated housekeeper, begins his day. It’s a routine morning—parking his car, hurrying to his workstation to clock in, ready to contribute to the hospital’s mission. But today, something catches his eye, a moment that transforms an ordinary shift into a quiet act of heroism.

As Steve strides toward the entrance, he notices an elderly man in a wheelchair, his partner struggling to push him across uneven terrain. The man’s weight and the bumpy surface conspire to make the journey arduous. The couple’s exertion is palpable sweat on their brows, strain in their movements. For a fleeting second, Steve could have kept walking, chalking it up to someone else’s responsibility. But he doesn’t. Instead, he pauses, observes, and steps in.

This is where Steve’s actions align beautifully with the principles of a High Reliability Organization (HRO), a framework that guides the hospital system he serves. HROs thrive on a reluctance to simplify—the understanding that every situation carries layers of complexity worth noticing. Steve doesn’t dismiss the couple’s struggle as just another day at the hospital. He sees the physical toll it’s taking, the potential for exhaustion or even injury. He knows that preoccupation with failure—another HRO tenet—means catching problems before they escalate into something worse. A fall, a missed appointment, a cascade of stress for this vulnerable pair—it’s all on his mind as he decides to act.

Steve’s choice reflects something deeper, too: a culture of psychological safety woven into the fabric of his workplace. He knows the hospital values its patients above all, and he feels secure in prioritizing their needs, even if it means arriving late to clock in. In a system that champions sensitivity to operations—awareness of how every role and moment interconnects—Steve understands his part in the bigger picture. He’s not just a housekeeper; he’s a guardian of care. Confident that his team will support his decision, he approaches the couple with a warm offer of help.

With steady hands and a kind word, Steve takes over, pushing the wheelchair to the appointment location. He doesn’t stop there. After checking the patient in, he shares what he witnessed with the staff—the uneven walkway, the partner’s own mobility struggles, the near-miss of a situation that could have spiraled. His voice, calm and clear, ensures the patient’s challenges are heard. Because of Steve’s compassion and attention, the hospital acts. The elderly man is assessed, referred for a mobility scooter, and later enrolled in patient transport services. No longer will he or his wife—herself grappling with mobility issues—face the daunting task of navigating that terrain alone. Future appointments will be safer, smoother, and less burdensome.

This story isn’t just about one man’s kindness; it’s about a system that empowers such acts. Steve felt psychologically safe to step outside his routine because he works in a culture that values people—patients and staff alike—over rigid rules. His actions ripple outward, improving not just one day but an entire future for this couple.

"Preoccupation with Failure" is a fundamental principle of High Reliability Organizations (HROs), particularly crucial in high-risk environments like healthcare. This principle encourages organizations to constantly assess their processes, identify potential risks, and proactively address vulnerabilities before they escalate into serious incidents.

In healthcare, where even minor mistakes can have life-threatening consequences, preoccupation with failure is essential. By continuously monitoring for potential hazards and actively seeking areas for improvement, healthcare organizations can establish a culture of safety that prioritizes patient well-being above all else. This culture is built on the principles of leadership commitment to zero harm, an organizational safety culture where all staff can speak up, and an empowered workforce that employs robust process improvement tools.

Frontline staff, including housekeepers and nurses, play a vital role in this culture of safety. Every staff member is responsible for remaining vigilant and speaking up when they identify potential risks. For instance, a housekeeper noticing a wet floor or a nurse recognizing a medication error can prevent errors before they occur. By fostering a culture where all team members feel empowered to address issues and contribute to solutions, healthcare organizations can enhance patient safety.

A practical example illustrates the impact of this principle: A housekeeper identified a leaking water cooler that could have caused a fall, potentially resulting in major injuries to patients, employees, or visitors. By acting proactively to address the water spill and its source, the housekeeper averted an untoward incident. This action not only prevented a serious injury but also prompted the hospital to implement new protocols to prevent similar incidents in the future. This example highlights the significant impact individual vigilance can have on patient safety.

The HRO principle of "Preoccupation with Failure" is essential for creating a culture of safety in healthcare. By encouraging staff at all levels to remain vigilant, identify potential risks, and proactively address vulnerabilities, organizations can minimize errors and enhance patient well-being. This commitment to learning from failures and continuously improving processes is key to preventing harm and creating a safer healthcare environment for all.

High Reliability Organizations (HROs) are the gold standard in industries where the stakes are high, and risks are ever-present. In the healthcare sector, HROs set the bar high by prioritizing patient safety and staff support. Picture a hospital where every team member is empowered to speak up and collaborate seamlessly, resulting in enhanced performance and exceptional outcomes.

In healthcare where split-second decisions can make all the difference, HRO principles offer a roadmap to success. By fostering a culture of continuous improvement and communication, healthcare organizations can navigate complexity with ease and ensure optimal care for their patients. It's not just about meeting standards – it's about cultivating a mindset of excellence that elevates the entire organization.

So, embrace the principles of HRO and watch your healthcare organization soar to new heights of success and compassion. With a commitment to innovation and a focus on patient well-being, and employee engagement you can transform your organization into a true leader in healthcare. Don't just meet expectations – exceed them, with HRO principles guiding the way.

1. If possible, allow yourself time to gain experience in quality. Taking the exam without any background in quality may be challenging. Hands-on experience in Quality can put you ahead.
2. Prepare using different resources: books, practice exams, and possibly the CHPQ review course.
3. Have a practice plan. Do not go ahead and memorize books or practice tests. Logical and practical thinking is also important.
4. Create your own flash cards. Certain styles of questions tend to be included in many of the practice exams and ultimately in the CPHQ exam.
5. As you’re reading exam books, mark pages and highlight crucial information to come back to.
6. The exam will cover four topics which are Organizational Leadership, Patient Safety, Performance and Process Improvement, and Health Data Analytics. Some of these sections such as Performance and Process Improvement will include more questions than others. You should master these sections to maximize your chances.
7. Beware of websites that offer free practice tests. Some of them provide the wrong answers to questions that may conflict with the book and mislead you.
8. Identify areas you are weak in and allot more time for them to improve your performance.
9. Give yourself a deadline by which you will want to take the test. You shouldn’t study for longer than three months or may risk forgetting what you’ve learned.
10. To motivate yourself, register for the exam before you start preparing. You’ll have three months to sit for it. The hefty cost will certainly be a big push for you to succeed.
11. Review the US CPHQ Candidate Handbook from NAHQ to learn about the exam structure, types of questions and more.
12. Complete the pretest questions at the beginning of the exam. They are not part of your final score but can help get you warmed up for the test.
13. Read the questions carefully to not miss any key information. Pay attention words such as EXCEPT, NOT, LEAST, ALWAYS, NEVER…
14. If it takes you longer than one minute to answer a question, mark it, skip it and move to the next.
15. If you are unsure of the right answer, eliminate obvious wrong answers first then choose the best answer considering logic and different alternatives.
16. Use the extra time at the end to revisit questions you skipped or were not confident in.

Have additional tips and tricks to share? Let us know in the comments below!

My journey into healthcare quality happened by accident. I had been working at an academic medical center in an operations training role when I was asked to take over the management of 6 departments and 50+ employees. As I set out to learn more about the departments and staff, it was immediately apparent that they didn’t have a clear pulse on how their departments were performing against organizational expectations, or whether or not they were meeting their individual goals.   It was clear that performance metrics needed to be introduced, but I knew it wouldn’t be easy, as many of the staff had been in the same role for 15-20 years without really knowing how well they were performing.  We started small, with industry best practice metrics for the type of job they were performing. Dashboards were created, and individual performance assessments developed.  We met weekly in each department to review metrics, and scheduled 1:1 meetings monthly to review individual performance. Though there were eye rolls, resistance, and lots of doubt in the beginning, after a while it became their normal. When performance started improving, I would find ways to celebrate those small wins with coffee/donuts or cake. Soon enough, an amazing thing happened…the staff started telling me when we were exceeding goals instead of me telling them, and they brought ideas to the table that would make them further succeed. It was a beautiful thing really, and made me realize that measuring performance against goals and talking about how to improve was fascinating and exciting.  This led me down the path of healthcare quality.

Soon after this epiphany, I left the organization that I was at for a Quality Management role at a managed behavioral health organization.  There, I developed internal strategy to measure and execute adverse incident and member grievance investigations more efficiently in accordance with regulations; I led interdisciplinary teams to work on projects that would improve our clients HEDIS measure performance, and I helped develop policies, work plans, and data measurement to support NCQA accreditation.  Subsequently, I joined a health system as the Director of Physician Network Quality, where I worked with leaders, physicians and staff improvement of preventative care metrics such as colorectal and breast cancer screening, as well as diabetes, depression, and blood pressure screening. I helped them understand patient experience metrics, and suggested ways to improve. I worked with CMS and other payers to report performance and meet regulatory requirements.  In both of these roles, it was clear that looking at and understanding data was the key to improving. It was at this time that I also joined NEAHQ with the goal of helping to create educational programs for those in healthcare quality careers or interested in pursuing them.

I recently took a role in managed care, and I’m working with Accountable Care Organizations (ACOs) on strategies to improve clinical quality metrics and coding.  I continue to be passionate about presenting data and educating my clients on ways to improve.  I love seeing pride on people’s faces when they exceed goals. It’s so gratifying, especially knowing that I’m also indirectly helping to improve the lives of the patients we serve by ensuring proper screening and management of disease.

Communicate with Empathy

Patients are often dealing with both physical and emotional aspects of their illness or injury, in addition to other socioeconomic matters – financial struggles, employment status, family dynamics.  They want to feel as though their healthcare providers and medical office staff understand what they are dealing with, and care about their feelings and needs. This means actively listening, being aware of the whole story, and acknowledging their concerns. It also involves making eye contact, sitting at their level, and incorporating caring statements such as “I can imagine this is difficult, but my staff and I are here to help you” or “This situation must be frustrating, let’s figure out how I can help.”

Manage Expectations

Patients want to know what to expect – how long will they be in your office for their follow-up visit? When will they receive test results? What type of side effects might their new medication present, and for how long? How many minutes behind is their healthcare provider running? When information is provided proactively, and they are kept informed about issues or delays, they are more likely to be content with their experience.

Be Prompt

Are patients told to show up 15 minutes prior to their appointment, only to wait 20 or more minutes to see their healthcare provider?  Are they roomed upon arrival, but waiting in the exam room wondering if they’ve been forgotten about? Recognize that patients have a sense of urgency and demonstrate that you value their time. Unnecessary wait times contribute to negative patient experiences.

Take Accountability

When mistakes happen, as they inevitably do, acknowledge and apologize with sincerity, and take accountability to mitigate the issue and prevent it from happening in the future. Follow through on commitments that are made. Provide additional service amenities for those who have been inconvenienced or may need special assistance. Limit distraction, and verify pertinent information to ensure mutual understanding. Provide effective handoffs to all care team members.   Ask “Did I answer all of your questions today?” or “Is there anything else I can help you with?”

Show Gratitude

Patients have options, but they choose to receive services at your practice. Thank them and show appreciation.  A little gratitude can go a long way, and it’s free!

Alyson Mitchell

System Director, Physician Network Quality at Covenant Health

Do you want to network with other quality professionals but don't have the time to regularly attend in-person meetings?

Have you ever wanted to ask a question of your peers or exchange best practices?
 

You can do all of this and more with NEAHQ's Member Forums! Member Forums are your online, interactive presence with other New England healthcare quality professionals: 

• Connect with professionals in your area or specialty
• Pose questions
• Exchange or inquire about best practices 
• Seek guidance and give feedback
   

There are currently three NEAHQ Member Forms focused on the following topics and subject-areas: 

• Accreditation & Compliance
• Data Analytics 
• Quality Leadership & Networking
   

Go for it! Ask a question, share a best practice, or reach out and network with your peers. 
 

Find the Member Forums under the “Groups” tab or at this link: www.neahq.org/groups/member-forum

NEAHQ’s new website has an expanded and improved members-only section, complete with access to a membership directory.  Now you can easily discover new connections and stay in touch with other members. 

Navigate to the membership directory by logging in* and selecting "Directory" under the "Membership" tag of the navigation bar.


 

Once on the directory page, use the search bar to search for companies and other members.  You can also filter by the first letter of the person's last name.

Once you find the member you're looking for, you can either click "Profile" to view their profile, or "Contact" to send a message.

*For existing members, click on “LOGIN” in the top right-hand corner of the site and simply type in the email you used to register under and click on “Forgot Password” to reset your password and create your web account. For those who wish to become members, click on “JOIN NOW” in the top right-hand corner and follow the registration prompts to join and create your online account.

NEAHQ’s new website has an expanded and improved members-only section, complete with access to a membership directory. Once you create your NEAHQ account on the website*, you can set up a personal profile, like something you would find on LinkedIn but with a healthcare quality focus. The profile you create will appear under the member directory, where other members can view your profile and message you. In addition, as a NEAHQ member you will have access to the following tools and resources:

• Healthcare Quality Job Board: Browse healthcare quality job opportunities to further your career or post an opportunity at your organization for other members to see. 
• Member Forums: Use these virtual platforms to exchange information with other NEAHQ members about healthcare quality trends and issues. Member forums allow you to ask a question of your professional peers or share a best practice from your work to move healthcare quality forward.  
• Archived Events: Did you miss an in-person event or webinar? As a NEAHQ member, you can access archived events so you will never miss an opportunity to stay up to date with the healthcare quality knowledge.

All of these improvements aim to bring the New England quality community closer together by providing a platform for shared learning and professional connection. Create your profile today and start connecting with other NEAHQ members!

*For existing members, click on “LOGIN” in the top right-hand corner of the site and simply type in the email you used to register under and click on “Forgot Password” to reset your password and create your web account. For those who wish to become members, click on “JOIN NOW” in the top right-hand corner and follow the registration prompts to join and create your online account.