Within 60 days of the official survey findings report, name the cause, the change, the owner, the measure and the date for each element JCI asks you to address, and show how you will keep it fixed. If JCI does not accept the plan, you have 30 more days to resubmit.
Read the SAFER Matrix first
JCI places each finding on the SAFER Matrix by its likelihood to harm and how widespread it is.1 Strategic Improvement Plans are required for elements scored Partially Met or Not Met in higher-risk placements, and are due within 60 days of the official survey findings report, extended from 45.2
- Start the same week. Sixty days goes quickly. Assign an owner to each finding at once.
- Find the cause. Ask why the system allowed the gap.
- Change the workflow. A reminder is not a fix. A field that cannot be skipped is.
- Choose a measure. A number you will track monthly that shows the gap has closed.
- Show it holding. Data over several months.
- Standard and element ______ SAFER placement ______
- Root cause ______
- Change made ______ Owner ______ Date ______
- Measure ______ Target ______
- How compliance will be sustained ______
Questions
How long do we have?
60 days from the official survey findings report.
What if JCI does not accept the plan?
You have 30 more days to resubmit.
Is this the same as Evidence of Standards Compliance?
No, Evidence of Standards Compliance is a US Joint Commission term. JCI uses the Strategic Improvement Plan.
Sources
- 1Joint Commission International, 2026The JCI SAFER MatrixRead source
- 2Joint Commission International, 2020SAFER and the enhanced Strategic Improvement Plan processRead source
Written by the wai team from Joint Commission International guidance, checked on 15 October 2026. This is guidance, not legal advice. JCI does not endorse wai or any software.