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  • Writer's pictureTom Petersen

Do You Have A Master Plan? Environment of Care Master Plan

Updated: Aug 28, 2023

Environment of Care Master Plan

The Joint Commission (formerly JCAHO) requires that hospitals develop and implement a performance improvement framework for their environment of care function. This framework should include the management process and systems that affect the key Environment of Care (EC) elements. The EC Master Plan is an established mechanism for reviewing existing systems and processes and providing for the improvement of care for patients in an environment consistent with the current Environment of Care Standards established by the Joint Commission.

The Joint Commission EC Master Plan should be designed and implemented to meet the following objectives:

  • Provide a systematic, organization-wide approach to improving performance of the EC functions.

  • Ensure that the management of the EC functions are based on a comprehensive assessment of needs.

  • Facilitate improvement in the measurement of the EC activities.

  • Improve the evaluation of information and data to assess the level of performance and to identify actions needed to improve performance.

  • Promote the continued training and education of the EC Committees and others.

The Master Plan should include management plans designed for each of the following EC functions:

  • Safety Management

  • Security

  • Hazardous Materials

  • Life Safety

  • Emergency Preparedness

  • Medical Equipment

  • Utilities

  • Employee Education and Training

Management plans for each of these functional areas should be prepared to supplement the EC Master Plan. EC management plans are required by the Joint Commission for the following facilities:

  • Hospitals

  • Ambulatory Care

  • Behavioral Health Care

  • Long Term Care

  • Laboratory

  • Critical Access Hospitals

These management plans might address such issues as: Design of the plan provides an environment of care consistent with the mission, vision, and values of the hospital.

Design and implementation of each functional management plan is consistent with performance improvement plans for the EC.

Education and orientation of all staff describes their individual and collective responsibilities and roles in using the EC to support patient care.

Provide performance standards and indicators to measure and assess the hospital’s performance in maintaining and improving the EC.

Provide specific direction to implement the plan, and an adequate information and data collection and evaluation system to measure, assess, and improve the EC.

EES is available to assist you in developing and managing your EC Master Plan. Contact us for more information.

This article was written by Bernard Silverstein, CIH – EES Associate.

HE Number 2



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