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  • Writer's pictureTom Petersen

Does Your EOC Plan Have Room for Improvement?

Updated: Aug 29, 2023

This post regarding EES Healthy Environment topics is the third post in our series on the implementation, maintenance and continued improvement of the Joint Commission Environment of Care (EOC) standard. This series began in our August 2007 post that kicked off the Environment of Care development process by suggesting the use of a Master Plan. Our second article in the October 2007 post, covered the use of multidisciplinary teams for its implementation. This third article will present the evaluation systems needed to monitor performance and identify improvement opportunity.

Environment of Care – Evaluation Systems


To ensure continuous improvement of the EOC systems at your healthcare facility, you should consider routinely monitoring performance and making improvements based on the results of the monitoring. The EOC Committee should conduct an initial assessment of the existing conditions and processes available for compliance with the EOC. The outcome of this initial assessment should be used to identify performance improvement opportunities. These initial assessments can incorporate data and information from the following sources:

  • JCAHO surveys

  • Mock JCAHO surveys

  • Occupational Safety and Health Administration inspections

  • Public Health Service inspections

  • Scheduled Maintenance and project management

  • Fire Drills – Life Safety

  • Employee complaints

  • Patient/Visitor/Staff Injury reports

  • Critiques of emergencies and incidents

  • Self assessment audits

  • Self assessment surveys and questionnaires

The initial EOC assessment should then be used as a springboard in developing a long- term strategy of continuous improvement through self assessment. These self assessments and the associated review of the results can allow the EOC Committee to continually assess opportunities for improvements. Many of the sources of information identified above can be used for continuing assessments.

The EOC Committee should review and assess information and data provided from these sources on a regular, perhaps quarterly basis, as part of routine meetings of the Committee or directed sub- committees. Those reviews continue to show and validate the success of the EOC process.


Environment of Care sub-committees should use self assessments to establish performance measures related to the evaluation and successful outcome of established plans. These performance measures should be reviewed by each committee or team on a regular basis and compared to the established improvement goals. Outcome measures not meeting the established goals should be reviewed in greater depth to determine the root cause and develop improvement plans. The progress on the performance measures and the performance improvement plan and any new issues should be reported to the EOC committee for review on a regular basis.


Annually the EOC committee and each sub- committee should review their programs in their entirety and develop goals and objectives for the upcoming year. The committees should conduct an assessment of the current conditions in the environment and determine if any additional improvement opportunities are justified or needed. The performance indicators, improvements and new projects should then be monitored as they are being implemented.

EES provides assistance to hospitals in the development and implementation of EOC Evaluation Systems and in all aspects of compliance with the EOC standards.

Contact Tom Petersen, P.E. at 215-881- 9401 or by email at for further details.

HE Number 8



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