How do you respond to Requirements for Improvement with Evidence of Standards Compliance?

Each Requirement for Improvement in your final Summary of Survey Findings that needs it must be answered with Evidence of Standards Compliance within 60 days, giving the date every action was completed and how compliance will be sustained. Higher-risk findings on the SAFER Matrix also need leadership involvement and a preventive analysis of the underlying cause.

What a Requirement for Improvement is

Compliance with each standard is judged against its elements of performance. An element of performance out of compliance is cited as a Requirement for Improvement, or RFI.¹ Each RFI is placed on the SAFER Matrix by the likelihood it could harm patients, staff or visitors, low, moderate or high, and by its scope, limited, pattern or widespread.¹ The higher the risk, the further toward the upper right corner it sits.¹

What the ESC must contain

The Evidence of Standards Compliance is a concise report of the actions taken to correct each RFI. It includes the specific date all actions were completed and a description of the measures that ensure ongoing compliance.² Joint Commission lists the kinds of action it accepts, including review or revision of policies and procedures, new procedures, changes to job descriptions, competency assessment and forms, re-education or reassignment, staff education, leadership involvement and preventive analysis.²

The amount of information the ESC needs rises with the risk level of the RFI.¹ ESCs are submitted on Joint Commission Connect, under the Survey Process tab and Post-Survey.²

1. Read the final report. The final Summary of Survey Findings on Joint Commission Connect says which findings need an ESC within 60 days.
2. Assign each RFI an owner. One leader per finding, named in the ESC.
3. Find the cause. For higher-risk findings, analyse why the gap existed.
4. Act and date it. Make the change, and record the date every action was completed.
5. Choose a sustainment measure. A measure you will collect monthly that shows the fix holds.
6. Submit and track. Submit before day 60, and keep collecting the measure until the next survey.

1. Standard and element of performance ______
2. SAFER placement, likelihood and scope ______
3. Leader responsible ______
4. Underlying cause ______
5. Actions taken ______ Completed on ______
6. Measure of sustained compliance ______

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What happens after the ESC

Accreditation is awarded to an organisation that has addressed all RFIs in an ESC within 60 days of the report, and meets no rule for another decision.³ Accreditation with Follow-up Survey needs a follow-up survey within six months.³ Once the ESC is approved, the decision is posted on Joint Commission Connect and on Quality Check.⁴ Accreditation then runs for about three years from the last day of the survey.⁵ To prevent findings in the first place, see the Joint Commission ambulatory care checklist and the Joint Commission hub.

Questions

How long do you have to submit an ESC?

60 days, for the findings the final Summary of Survey Findings report says need one.

What is the SAFER Matrix?

Joint Commission's scoring approach that plots each Requirement for Improvement by likelihood of harm and by scope, limited, pattern or widespread.

Is the decision made at the exit conference?

No. Joint Commission makes the accreditation decision after post-survey activities, including the review of your ESC.

Sources

1. 1Joint Commission, 2026What is the SAFER Matrix?Read source
2. 2Joint Commission, 2026What is Evidence of Standards Compliance?Read source
3. 3Joint Commission, 2026Accreditation and Certification DecisionsRead source
4. 4Joint Commission, 2026Ambulatory Care Accreditation Organization Survey Activity Guide, September 2026Read source
5. 5Joint Commission, 2026Accreditation ProcessRead source

Written by the wai team from Joint Commission guidance, checked on 15 October 2026. This is guidance, not legal advice. Joint Commission does not endorse wai or any software.