Management plans have been required for the various disciplines within the Environment of Care since the mid-1990''s. Their development is both an art and a science. To understand how to approach the management plans, it is important to determine not only what must be included but also how they''re used by The Joint Commission surveyors to assess the organization.

The surveyors receive the Environment of Care management plans during their initial document review session, with no one from the organization present to interpret them or to answer questions. This makes it imperative that the plans are clear, concise, and easy to follow. The surveyors will use information gleaned from the plans to get a snapshot of the organization''s activities within the EC. They will pick out some particular issues to look at during their building tours and identify questions to ask staff.

Initially, the organization must determine which sites are to be addressed by the management plans, typically all sites included on the accreditation certificate. Most organizations choose to write only one set of plans for all accredited sites, but that necessitates an assessment and description of differences between the sites within the plan.

The science of management plans includes fundamental concepts that must be included in all management plans, such as a description of how the organization meets each element of performance. Several basic concepts transcend all management plans. These include risk assessment, emergency procedures, reporting and investigating, and annual evaluations. Each of these concepts must be applied to the respective plans as appropriate.

Beyond these fundamentals, management plans become an art. While no format is specifically required, a standardized organization and layout of the plans can make them surveyor-friendly. Additional information about the responsibility for the function can give the surveyors a clear picture of the oversight mechanism. Organization of supporting documentation allows the selection of the best examples of compliance and results in convenience for all concerned.

Taking the plans a step farther and looking beyond strict compliance offers the opportunity to develop a comprehensive document that fully encompasses the organization''s activities within the specific EC discipline. For example, developing a scope and objectives for each plan will streamline the writing of the annual evaluation. While performance monitoring is no longer required for 2009, measurement such as this will contribute to an effective program. Inclusion of relevant aspects of standards elsewhere in the chapter or the accreditation manual will round out the plan.

Once a complete and comprehensive set of management plans have been developed, the standards must be reviewed on an annual basis to ensure compliance with any changes.