2024-11-12T12:12:38+00:00 2023-12-31 350921680 CROWE LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2023-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Suite 401 Oakbrook Terrace IL 60181 Lisa Steininger CFO/Treasurer 2024-11-12 true MALLORY FAIRLESS P01321579 3128997000 2024-11-12 2023 2024-10-15 13:58:12Z The Joint Commission Dr Jonathan Perlin One Renaissance Blvd Suite 401 Oakbrook Terrace IL 60181 237163473 false X www.jointcommission.org X 1951 IL To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. 21 19 1217 19 75222 13567 854087 859571 198963662 193560274 7751370 11656379 1341788 1423855 208910907 207500079 0 0 130499189 125663664 0 0 60938984 63599985 191438173 189263649 17472734 18236430 334608248 379570239 33867972 29443582 300740276 350126657 The Joint Commission periodically evaluates and accredits health care organizations and programs in the US. The comprehensive accreditation process evaluates an organization's compliance with Joint Commission developed standards and CMS Conditions of Participation (CoPs), and other accreditation requirements that directly and indirectly relate to the (See Schedule O) false false 129607097 178540040 SURVEY AND CERTIFICATION FEES ARE GENERATED AS A CONSEQUENCE OF PERFORMING ACCREDITATION SURVEYS THAT ARE DESIGNED TO EVALUATE AN ORGANIZATION'S COMPLIANCE WITH JOINT COMMISSION STANDARDS AND CMS CONDITIONS OF PARTICIPATION (CoPs), AND OTHER ACCREDITATION REQUIREMENTS. THE SUBSCRIPTION BILLING PROGRAM ALLOWS ORGANIZATIONS TO PAY AN ANNUAL SUBSCRIPTION FEE FOR THEIR PARTICIPATION IN THE ONGOING SERVICES PROVIDED BY THE JOINT COMMISSION. REVENUE FROM ANNUAL ACCREDITATION SUBSCRIPTION FEES IS RECOGNIZED RATABLY OVER THE PERIOD TO WHICH THE SUBSCRIPTION FEES RELATE. 7978229 7978229 The Joint Commission provides common management services, referred to as shared services fees, of the activities carried on for related organizations. See Schedule R for list of related organizations. 6038785 7042005 PERFORMANCE MEASUREMENT & RELATED ACTIVITIES AT THE JOINT COMMISSION ADVANCE HEALTHCARE QUALITY AND PATIENT SAFETY BY UNDERTAKING SCIENTIFICALLY CREDIBLE RESEARCH THAT INFORMS HEALTH SERVICES PRACTICE AND POLICY. THE PROGRAM SUPPORTS THE DEVELOPMENT OF EVIDENCE-BASED AND MEANINGFUL PERFORMANCE MEASURES, SOUND STATISTICAL AND ANALYTICAL APPROACHES TO DATA ANALYSIS, AND THE IDENTIFICATION OF PERFORMANCE IMPROVEMENT AND PATIENT SAFETY STRATEGIES. 143624111 true true false true false false false false true true true false false true true false true false false true false false false false false false false false true true false false false false false false false false false false false false false false false true true true false false true X 139 0 true 1217 true true true true SA SN CH false false false false false false false false true false X 21 19 false true false false true true true true true false false true true true true true true true true false IL X Robert Nylen 6307925682 One Renaissance Blvd STE 401 Oakbrook Terrace IL 60181 Carlos A Pellegrini MD FACS Chair 2.0 1.0 X X 51331 0 0 Jonathan B Perlin MD PhD MSHA MACP FACMI President & CEO 38.0 2.0 X X 2007614 0 46358 Michael Suk MD JD MPH MBA FACS Vice Chair 2.0 1.0 X X 0 0 0 Ana L English MBA Commissioner 1.0 0 X 0 0 0 Andrew C Dreyfus BA Commissioner 2.0 0 X 0 0 0 Christopher A Hart MEng JD Commissioner 1.0 0 X 0 0 0 Ena Williams PhD MBA RN CENP FAAN Commissioner 1.0 0 X 0 0 0 Eric Langshur Commissioner 1.0 0 X 981 0 0 Eric Schlesinger MBA BA Commissioner 1.0 0 X 1331 0 0 Jay A Gregory MS MD Commissioner 1.0 0 X 1331 0 0 Jill Hoggard Green PhD RN Commissioner 2.0 2.0 X 0 0 0 Joseph J Parks MD Commissioner 1.0 1.0 X 1291 0 0 Lenworth M Jacobs Jr MBBS MPH DSc (Hon) FACS FWACS (Hon) Commissioner 1.0 0 X 0 0 0 Marvin Strohschein Jr DDS Commissioner 2.0 0 X 1331 0 0 Melinda L Estes MD MBA Commissioner 1.0 0 X 0 0 0 Michael B Simon MD MBA FASA Commissioner 2.0 0 X 1331 0 0 Najmedin Meshkati PhD CPE Commissioner 1.0 0 X 1331 0 0 Susan Fox MBA BSN Commissioner 1.0 0 X 1331 0 0 Tracey L Henry MD MPH MS Commissioner 1.0 0 X 0 0 0 Vineet Arora MD MAPP Commissioner 1.0 0 X 0 0 0 Willie Underwood III MD MSc MPH FACS Commissioner 1.0 0 X 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer (Through Mar) 40.0 0 X 537397 0 26330 Brian Enochs JD Exec VP Bus Dev & Marketing (Through June) 40.0 0 X 1102578 0 207859 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 0 X 912356 0 331618 James Merlino EVP Chief Innovation Officer (Since Aug) 40.0 0 X 344635 0 213 Jason Miles VP & US Commercial Officer (Since Dec) 40.0 0 X 47885 0 0 Jean Courtney CPA EVP & Chief Operating Officer (Since Apr) 2.0 38.0 X 0 910864 252857 Kathryn E Spates VP Public Pol & Govt Relations (Since July) 40.0 0 X 283106 0 34353 Kenneth Grubbs Jr EVP COO Accreditation & Certification Ops (Since June) 40.0 0 X 202913 0 180 Kin Lee MS CIO & SECURITY OFFICER 40.0 0 X 1214695 0 366570 Leslie Krohn EVP & Chief Brand & Communications Ofcr (Since Dec) 40.0 0 X 7212 0 0 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 24.0 16.0 X 613206 0 362769 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations (Through June) 40.0 0 X 446232 0 141547 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 40.0 0 X 485828 0 59148 Paige Rodgers CPA Chief Financial Officer (Through May) 35.0 5.0 X 478299 0 -258317 Paul Gerrard EVP & Chief Brand & Communications Ofcr (fm Jun-Oct) 40.0 0 X 465321 0 13437 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 232767 0 33271 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 221328 0 27945 Dawn Balestrieri Director of Corporate Communications (Through Oct) 40.0 0 X 279015 0 145807 Haytham Kaafarani Chief Patient Safety Ofcr & Medical Dir (Through Aug) 40.0 0 X 380184 0 569 Mark Crafton Executive Director Strategic Alliances 40.0 0 X 221628 0 53844 Patrick Phelan National Sales Leader 40.0 0 X 234625 0 30282 Sheela Suresh Senior Director Applications Development 40.0 0 X 232457 0 27373 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops (Through Jan) 40.0 0 X 115914 0 11006 11128785 910864 1915020 382 true true false MICROSOFT CORPORATION PO BOX 842103 DALLAS TX 75284 INFORMATION TECHNOLOGY APPLICATION SOLUTIONS & SERVICES 2216805 HITACHI SOLUTIONS AMERICA LTD 100 SPECTRUM CENTER DRIVE SUITE 350 IRVINE CA 92618 SOFTWARE DEVELOPMENT & CONSULTING SERVICES 1721248 COGNIZANT TECHNOLOGY SOLUTIONS US CORPORATION 24721 NETWORK PLACE Chicago IL 60673 SOFTWARE DEVELOPMENT & CONSULTING 1226271 CONNECTION MOREDIRECT INC AKA P O BOX 536464 PITTSBURGH PA 152535906 software, hardware & equipment purchase 829419 HYATT REGENCY CHICAGO 10 S DEARBORN CHICAGO IL 60603 hotel conference lodging, meals and room services 746165 60 771953 87618 859571 Annual Subscription 541990 97167808 97167808 Survey Fees 541990 80110493 80110493 Performance Measurements 900099 7042005 7042005 Shared Services Fee From Related Tax Exempt Organizations 900099 7978229 7978229 Transaction Fees 900099 825328 825328 436411 436411 0 0 193560274 8177502 5490 8172012 1354123 1354123 0 0 33142271 29663394 3478877 0 3478877 3478877 Cafeteria Rental Income 900099 69732 69732 0 0 0 0 69732 207500079 193560274 75222 13005012 10996654 3884427 7112227 92656288 76987311 15668977 5066340 3618550 1447790 9511803 7474309 2037494 7432579 5970299 1462280 510391 510391 287220 287220 393780 393780 180860 180860 249981 249981 13144507 7229921 5914586 0 1109839 1025820 84019 1387971 490984 896987 6396394 2973214 3423180 2191187 1258178 933009 26558490 26230512 327978 1917905 1277363 640542 270262 160244 110018 5200537 3626141 1574396 1099131 535960 563171 Equipment rentals & maintenance 891358 421584 469774 Recruitment Costs 838419 30096 808323 Bad Debt Expense 378542 370288 8254 Other Miscellaneous Fees 593211 58910 534301 0 0 0 0 189263649 143624111 45639538 0 49439521 34307995 18424484 17639083 0 0 0 0 6190844 5165505 84187870 52854504 33455612 31333366 185143693 240798826 40311613 46810866 0 1642481 3514598 334608248 379570239 16759453 16961467 685242 726777 8456340 7410404 0 0 7966937 4344934 33867972 29443582 X 291424098 340044888 9316178 10081769 300740276 350126657 334608248 379570239 X 18236430 18061419 13088532 X false true X true false X 825286 753191 886503 854087 859571 4178638 182737650 139594480 180671780 198963662 193560274 895527846 0 0 0 183562936 140347671 181558283 199817749 194419845 899706484 0 0 0 0 0 0 3487949 2876956 3574122 4623399 3471195 18033621 3487949 2876956 3574122 4623399 3471195 18033621 881672863 4740707 3941505 3786562 5214353 9531625 27214752 0 0 0 0 4740707 3941505 3786562 5214353 9531625 27214752 69732 69732 0 0 0 0 0 0 188303643 144289176 185344845 205032102 204021202 926990968 0.9511 0.9570 0.03 0.02 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 286772 false false 286772 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY The Joint Commission made direct contact with legislators or their staffs and paid $180,860 in fees to a third-party firm for professional services which included lobbying activities. These activities related to health care legislation and related issues that the Joint Commission considers important to improve patient safety and quality of health care. 31014562 0 2865174 33879736 0 29884684 1129878 31014562 0 0 0 0 0 0 0.7 0.3 0.0 false false 4204400 4204400 45959118 30570631 15388487 801562 369717 431845 4444887 3505071 939816 28777903 18409085 10368818 31333366 Common & Collective Funds - Measured at NAV 37201438 F Common & Collective Funds - Hedge Funds 6118 F Common & Collective Funds - Small-cap value fund 9603310 F 46810866 Accrued pension liability 289871 Capital Lease Obligations 1755596 Operating Lease Obligations 2299467 4344934 X 238891390 18061419 13579873 31641292 207250098 249981 0 249981 207500079 189505009 0 0 189505009 249981 -491341 -241360 189263649 Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote The Internal Revenue Service has determined that The Joint Commission and its affiliates are exempt from federal income taxation under Section 501(a) as organizations described in Section 501(c)(3) of the Internal Revenue Code (IRC). The Joint Commission and its affiliates are subject to income taxes on income determined to be unrelated business taxable income (UBTI), which is taxed at the corporate income tax rate. The Joint Commission continues to evaluate its tax positions pursuant to the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) Subtopic 740-10, Income Taxes Overall. As of December 31, 2023 and 2022, The Joint Commission believes it has taken no significant uncertain tax positions. The Joint Commission and each of its affiliates have been classified as an organization that is not a private foundation under IRC Section 509(a) and may receive deductible contributions under Section 170(c). Both The Joint Commission and JCR are organizations that normally receive more than 33 1/3% of their support from contributions, membership fees, and gross receipts from activities related to its exempt functions and no more than 33 1/3% of its support from gross investment income and unrelated business taxable income under IRC Section 509(a)(2). National Quality Forum is an organization that normally receives a substantial part of its support from the general public under section 170(b)(1)(A)(vi). Schedule D, Part XI, Line 2(d) Other revenues in audited financial statements not in form 990 TRANSFER OF UNDESIGNATED NET ASSETS FROM AFFLIATE CO - JOINT COMMISSION RESOURCES, INC. EIN 36-3521721 - 6948919 CHANGE IN UNRECOGNIZED NET DEFINED-BENEFIT PLAN COSTS NOT YET RECOGNIZED IN NET PERIODIC BENEFIT COST - 6630954 Schedule D, Part XII, Line 4(b) Other expenses in form 990 not in audited financial statements CHANGE IN NET PERIODIC PENSION COSTS OTHER - -491341 Europe (Including Iceland and Greenland) 0 2 Conference Travel,Training Sending agents of the organization to attend conferences and training 20796 East Asia and the Pacific 0 2 Conference Travel Sending agents of the organization to attend conferences 20885 0 4 0 0 0 4 41681 0 41681 false false true false false true Schedule F, Part I, Line 3 Method used to account for expenditures on org's financial statements EAST ASIA AND THE PACIFIC-Accrual; EUROPE (INCLUDING ICELAND AND GREENLAND)-Accrual X X X true true X X X X true true false false false false false false false Jonathan B Perlin MD PhD MSHA MACP FACMI President & CEO 1539102 0 108150 0 360362 0 17011 0 29348 0 2053973 0 0 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops (Through Jan) 60583 0 0 0 55332 0 10936 0 70 0 126921 0 54980 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 731197 0 33216 0 147944 0 299722 0 31897 0 1243975 0 137671 0 Jean Courtney CPA EVP & Chief Operating Officer (Since Apr) 0 369921 0 113769 0 427175 0 224665 0 28192 0 1163721 0 350528 Brian Enochs JD Exec VP Bus Dev & Marketing (Through June) 248104 0 0 0 854475 0 183292 0 24566 0 1310437 0 723036 0 Paul Gerrard EVP & Chief Brand & Communications Ofcr (fm Jun-Oct) 131510 0 12519 0 321292 0 107 0 13330 0 478758 0 0 0 Kenneth Grubbs Jr EVP COO Accreditation & Certification Ops (Since June) 200000 0 0 0 2913 0 0 0 180 0 203093 0 0 0 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 421446 0 21397 0 42984 0 30430 0 28718 0 544976 0 0 0 Kin Lee MS CIO & SECURITY OFFICER 495945 0 25073 0 693678 0 338178 0 28391 0 1581265 0 687736 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer (Through Mar) 230744 0 0 0 306653 0 21462 0 4868 0 563728 0 0 0 James Merlino EVP Chief Innovation Officer (Since Aug) 293192 0 0 0 51443 0 0 0 213 0 344849 0 0 0 Paige Rodgers CPA Chief Financial Officer (Through May) 280121 0 29627 0 168551 0 -263157 0 4840 0 219982 0 167644 0 Kathryn E Spates VP Public Pol & Govt Relations (Since July) 271792 0 10000 0 1314 0 20734 0 13619 0 317458 0 0 0 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations (Through June) 222291 0 0 0 223941 0 135720 0 5827 0 587780 0 63391 0 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 487974 0 25071 0 100161 0 314355 0 48414 0 975975 0 96120 0 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 202135 0 0 0 19193 0 27311 0 634 0 249273 0 0 0 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 151131 0 0 0 81636 0 24901 0 8370 0 266038 0 0 0 Dawn Balestrieri Director of Corporate Communications (Through Oct) 174551 0 1000 0 103464 0 103345 0 42462 0 424822 0 0 0 Mark Crafton Executive Director Strategic Alliances 219287 0 0 0 2341 0 32738 0 21106 0 275472 0 0 0 Haytham Kaafarani Chief Patient Safety Ofcr & Medical Dir (Through Aug) 412713 0 -33000 0 471 0 0 0 569 0 380753 0 0 0 Patrick Phelan National Sales Leader 190393 0 11561 0 32672 0 19113 0 11169 0 264906 0 0 0 Sheela Suresh Senior Director Applications Development 231039 0 0 0 1419 0 20027 0 7346 0 259831 0 0 0 Schedule J, Part I, Line 1a First-class or charter travel The Joint Commission's staff travel policy permits staff to fly business class on international flights, excluding Europe. The Joint Commission CEO is allowed to travel first-class on business trips throughout the United States and international. First class travel benefits are not treated as taxable compensation to the interested person. Schedule J, Part I, Line 1a Discretionary spending account Two officers were provided a spending account for relocation allowances. These allowances are treated as taxable compensation and reported on Form 990, Part VII, Column D as Reportable Compensation Schedule J, Part I, Line 1a Personal services One officer utilized an allowance for tax preparation. Not all officers eligible for the services utilize them. These services are treated as taxable compensation and reported on Form 990, Part VII, Column D as Reportable Compensation Schedule J, Part I, Line 4a Severance or change-of-control payment THE JOINT COMMISSION MADE PAYMENTS PURSUANT TO AN AGREEMENT IN CONNECTION WITH STAFF SEPARATIONS. THESE PAYMENTS WERE TREATED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J, PART II COLUMN (B)(III), OTHER REPORTABLE COMPENSATION. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan All officers are allowed to participate in a nonqualified supplemental defined benefit retirement plan, but some choose not to participate and receive a lump sum instead. The increases or decreases in the value of the plan during the year are reflected in Column C Deferred Compensation on Schedule J, Part II. In the event that a participant terminates employment before becoming vested in the plan, the decreases will be reported in Column C deferred Compensation on Schedule J. A Illinois Finance Authority 861091967 000000000 2015-08-26 16000000 (SEE STATEMENT) false false false A 8510000 0 16026366 0 0 0 229946 0 0 15796420 0 0 2016 false false true true A false false true true false true 0.0077 0.0 0.0077 false false true A false false false true true false false false true A true Schedule K, Part I, Column (f) Description of Purpose Bond proceeds were used to finance a portion of the costs to renovate, remodel, and to purchase equipment for the Joint Commission headquarters building, and all necessary and attendant facilities, equipment, site work, zoning, entitlements and utilities related thereto. Schedule K, Part II, Line 3 Total Proceeds of Issue Amount Difference The total proceeds of issue reported on Schedule K, Part II, Line 3 are not identical to the issue price listed in Part I, column (e), due to investment earnings. Schedule K, Part IV, Line 2c COLUMN A Issuer name: Illinois Finance Authority The calculation for computing no rebate due was performed on 08/26/2020 Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED 1 of 6 (CONTINUATION FROM Part III, Line 1) quality and safety of care provided by the organization. THESE ACCREDITATION SERVICES ARE PROVIDED FOR HOSPITALS, CLINICAL LABORATORIES, HOME CARE, NURSING CARE CENTER, ASSISTED LIVING COMMUNITY, BEHAVIORAL HEALTH CARE, AND AMBULATORY CARE ORGANIZATIONS. JOINT COMMISSION ACCREDITATION AND CERTIFICATION ARE RECOGNIZED NATIONWIDE AS A SYMBOL OF QUALITY THAT REFLECTS AN ORGANIZATION'S COMMITMENT TO MEETING OPTIMUM ACHIEVABLE PERFORMANCE STANDARDS. TO EARN AND MAINTAIN THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL, AN ORGANIZATION MUST UNDERGO A SURVEY BY A JOINT COMMISSION SURVEY TEAM AT LEAST EVERY THREE YEARS. LABORATORIES MUST BE SURVEYED AT LEAST EVERY TWO YEARS. IN ORDER FOR A HEALTH CARE ORGANIZATION TO PARTICIPATE IN AND RECEIVE PAYMENT FROM THE MEDICARE OR MEDICAID PROGRAMS, IT MUST MEET ELIGIBILITY REQUIREMENTS FOR PROGRAM PARTICIPATION, INCLUDING A CERTIFICATION OF COMPLIANCE WITH THE CONDITIONS OF PARTICIPATION, SET FORTH IN FEDERAL REGULATIONS. THIS CERTIFICATION IS AVAILABLE ON THE BASIS OF SURVEYS CONDUCTED BY STATE AGENCIES ON BEHALF OF THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS). WHEN THE JOINT COMMISSION HAS DEVELOPED AND ENFORCES STANDARDS AND SURVEY PROCEDURES THAT MEET OR EXCEED THE FEDERAL CONDITIONS OF PARTICIPATION, CMS MAY GRANT THE JOINT COMMISSION "DEEMING" AUTHORITY AND DEEM EACH ACCREDITED HEALTH CARE ORGANIZATION AS MEETING MEDICARE AND MEDICAID CERTIFICATION REQUIREMENTS. IN FACT, FEDERAL AND STATE AGENCIES OFTEN RELY ON THE EXPERTISE AND STANDARDS OF THE JOINT COMMISSION. FEDERAL DEEMED STATUS OPTIONS ARE CURRENTLY AVAILABLE FOR AMBULATORY CARE SURGICAL CENTERS, CLINICAL LABORATORIES, CRITICAL ACCESS HOSPITALS, HOME HEALTH AGENCIES, PSYCHIATRIC HOSPITALS, HOSPICES AND HOSPITALS. TO CONDUCT ITS ACCREDITATION SURVEYS, THE JOINT COMMISSION EMPLOYS AN EXPERIENCED, TRAINED CADRE OF SURVEYORS. BEYOND BASIC EDUCATION IN THE ACCREDITATION PROCESS, SURVEYORS RECEIVE EDUCATION IN SYSTEMS THEORY, ORGANIZATION BEHAVIOR, AND EVALUATION TECHNIQUES, AND ROBUST PROCESS IMPROVEMENT METHODS AND TOOLS. THE JOINT COMMISSION ALSO AWARDS DISEASE-SPECIFIC CARE CERTIFICATION TO HEALTH PLANS, DISEASE MANAGEMENT SERVICE COMPANIES, HOSPITALS AND OTHER CARE DELIVERY SETTINGS THAT PROVIDE DISEASE MANAGEMENT AND CHRONIC CARE SERVICES. THE JOINT COMMISSION'S CERTIFICATION PROGRAMS PROVIDE COMPREHENSIVE EVALUATIONS OF DISEASE OR CONDITION-SPECIFIC SERVICES, INCLUDING BUT NOT LIMITED TO ASTHMA, DIABETES, CONGESTIVE HEART FAILURE, SKIN AND WOUND MANAGEMENT, PRIMARY STROKE CARE, JOINT REPLACEMENT, SPINAL SURGERY PROGRAMS, PALLIATIVE CARE, PERINATAL, INTEGRATED CARE, PATIENT BLOOD MANAGEMENT, AND MEDICATION COMPOUNDING. ADVANCED CERTIFICATION DISEASE-SPECIFIC CARE PROGRAMS ARE ALSO OFFERED BY THE JOINT COMMISSION, WHICH ARE DEVELOPED IN COLLABORATION WITH INDUSTRY EXPERTS, IN VARIOUS AREAS SUCH AS: CHRONIC KIDNEY DISEASE, HEART FAILURE, PRIMARY STROKE AND COMPREHENSIVE STROKE, VENTRICULAR ASSIST DEVICES, DIABETES DISEASE, AND CHRONIC PULMONARY DISEASE. THE JOINT COMMISSION'S HEALTH CARE STAFFING SERVICES CERTIFICATION PROGRAM PROVIDES INDEPENDENT, THOROUGH EVALUATIONS OF THE ABILITY OF STAFFING FIRMS TO PROVIDE COMPETENT STAFFING SERVICES. THE JOINT COMMISSION DEVELOPED THIS CERTIFICATION PROGRAM TO MEET QUALITY OVERSIGHT NEEDS THAT HAVE ARISEN BECAUSE OF THE ONGOING SHORTAGES OF NURSES AND OTHER PROFESSIONAL PERSONNEL. THESE SHORTAGES FORCE HEALTH CARE ORGANIZATIONS TO FILL POSITIONS WITH TEMPORARY EMPLOYEES PROVIDED BY STAFFING FIRMS, WHICH ARE OFTEN NOT OTHERWISE SUBJECT TO ANY QUALITY OVERSIGHT MECHANISM. AT THEIR HEART, ACCREDITATION AND CERTIFICATION ARE RISK-REDUCTION ACTIVITIES; COMPLIANCE WITH APPROPRIATE STANDARDS REDUCES THE RISK OF ADVERSE OUTCOMES. THE JOINT COMMISSION SPECIFICALLY TARGETS IMPROVEMENT IN PATIENT SAFETY THROUGH THE FOLLOWING EFFORTS: PATIENT SAFETY-RELATED STANDARDS JOINT COMMISSION STANDARDS ADDRESS PERFORMANCE OBJECTIVES AND EXPECTATIONS IN KEY FUNCTIONAL AREAS, SUCH AS PATIENT RIGHTS, MEDICATION MANAGEMENT, AND INFECTION CONTROL. THE STANDARDS AND EVALUATION PROCESS FOCUS NOT SIMPLY ON AN ORGANIZATION'S ABILITY TO PROVIDE SAFE, HIGH QUALITY CARE, BUT ON ITS ACTUAL PERFORMANCE. ALL STANDARDS RELATE DIRECTLY OR INDIRECTLY TO SAFETY AND QUALITY-RELATED PATIENT OUTCOMES. THE JOINT COMMISSION DEVELOPS AND UPDATES ITS STANDARDS IN CONSULTATION WITH HEALTH CARE EXPERTS, PROVIDERS, PRACTITIONERS, MEASUREMENT EXPERTS, PURCHASERS AND CONSUMERS. OVER FIFTY PERCENT OF JOINT COMMISSION STANDARDS RELATE DIRECTLY TO PATIENT SAFETY, ADDRESSING A WIDE RANGE OF AREAS SUCH AS SURGERY AND ANESTHESIA, BLOOD TRANSFUSION, RESTRAINT AND SECLUSION, STAFFING AND STAFF COMPETENCE, FIRE SAFETY, MEDICAL EQUIPMENT MAINTENANCE, EMERGENCY MANAGEMENT, AND SECURITY. PATIENT SAFETY STANDARDS ADDRESS THE IMPLEMENTATION OF PATIENT SAFETY PROGRAMS; THE PREVENTION OF ACCIDENTAL HARM THROUGH THE PROSPECTIVE ANALYSIS AND REDESIGN OF VULNERABLE PATIENT SYSTEMS (E.G. THE ORDERING, PREPARATION, AND DISPENSING OF MEDICATIONS); AND THE ORGANIZATION'S RESPONSIBILITY TO TELL A PATIENT ABOUT ALL OUTCOMES OF THE CARE RESPECTING THAT PATIENT, WHETHER GOOD OR BAD. (Continuation Below) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED 2 of 6 (Continuation from Above) SENTINEL EVENT POLICY THE JOINT COMMISSION'S SENTINEL EVENT POLICY IS DESIGNED TO HELP HEALTH CARE ORGANIZATIONS TO IDENTIFY THE UNDERLYING CAUSES OF SENTINEL EVENTS AND TAKE ACTION TO PREVENT THEIR RECURRENCE. A SENTINEL EVENT IS AN UNEXPECTED OCCURRENCE INVOLVING DEATH OR SERIOUS PHYSICAL - INCLUDING LOSS OF LIMB OR FUNCTION - OR PSYCHOLOGICAL INJURY, OR THE RISK THEREOF. "RISK THEREOF" MEANS THAT, ALTHOUGH NO HARM OCCURRED ON THIS OCCASION, ANY RECURRENCE WOULD CREATE ANOTHER CHANCE FOR A SERIOUS ADVERSE OUTCOME. ANY TIME A SENTINEL EVENT OCCURS, THE HEALTH CARE ORGANIZATION IS EXPECTED TO COMPLETE A THOROUGH AND CREDIBLE ROOT CAUSE ANALYSIS, IMPLEMENT IMPROVEMENTS TO REDUCE RISK, AND MONITOR THE EFFECTIVENESS OF THOSE IMPROVEMENTS. THE ROOT CAUSE ANALYSIS IS EXPECTED TO DRILL DOWN TO EXAMINE ALL RELEVANT ORGANIZATION SYSTEMS AND PROCESSES THAT COULD HAVE CONTRIBUTED THE FAILURES LEADING TO THE OCCURRENCE. THIS EXAMINATION PROVIDES THE BASIS FOR RE-DESIGN OF SYSTEMS AND PROCESSES TO PREVENT RECURRENCE OF SIMILAR OCCURRENCES IN THE FUTURE. THE SENTINEL EVENT POLICY ALSO ENCOURAGES ORGANIZATIONS TO REPORT SENTINEL EVENTS, THEIR ASSOCIATED ROOT CAUSES AND RELATED PREVENTIVE ACTIONS TO THE JOINT COMMISSION SO THAT THE JOINT COMMISSION CAN SHARE WITH OTHER ORGANIZATIONS DE-IDENTIFIED, AGGREGATE INFORMATION ABOUT "LESSONS LEARNED", AND THEREBY REDUCE THE RISK OF FUTURE SENTINEL EVENT OCCURRENCES ACROSS THE DELIVERY SYSTEM. SENTINEL EVENT ALERTS A SENTINEL EVENT ALERT IS A PERIODIC NEWSLETTER OR WEBINAR THAT ADDRESSES SPECIFIC TYPES OF SENTINEL EVENTS, DESCRIBES THEIR COMMON UNDERLYING CAUSES, AND RECOMMENDS STEPS TO PREVENT FUTURE OCCURRENCES. INFORMATION FOR A SENTINEL EVENT ALERT IS DERIVED PRINCIPALLY FROM THE JOINT COMMISSION'S SENTINEL EVENT DATABASE. SENTINEL EVENT ALERT HAS RAISED AWARENESS IN THE HEALTH CARE COMMUNITY AND THE FEDERAL GOVERNMENT ABOUT THE OCCURRENCE OF ADVERSE EVENTS AND WAYS THAT THESE EVENTS CAN BE PREVENTED IN THE FUTURE. PAST ISSUES AND WEBINARS ARE AVAILABLE ON THE JOINT COMMISSION WEBSITE. TOPICS HAVE INCLUDED MEDICATION ERRORS, WRONG-SITE SURGERY, RESTRAINT-RELATED DEATHS, BLOOD TRANSFUSION ERRORS, INPATIENT SUICIDES, INFANT ABDUCTIONS, FATAL FALLS, OPERATIVE/POST-OPERATIVE COMPLICATIONS, HEALTH CARE WORKER FATIGUE, BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY, MATERNITY DEATHS AND INJURIES, INFECTION CONTROL, AND PREVENTING RETAINED FOREIGN OBJECTS NATIONAL PATIENT SAFETY GOALS THE JOINT COMMISSION ESTABLISHED A SET OF NATIONAL PATIENT SAFETY GOALS (NPSGS) AND RELATED SPECIFIC REQUIREMENTS FOR IMPROVING THE SAFETY OF PATIENT CARE IN HEALTH CARE ORGANIZATIONS. ALL JOINT COMMISSION ACCREDITED HEALTH CARE ORGANIZATIONS ARE REQUIRED TO IMPLEMENT GOAL-RELATED REQUIREMENTS-OR ACCEPTABLE ALTERNATIVES-THAT APPLY TO THEM. THE JOINT COMMISSION DETERMINES THE HIGHEST PRIORITY PATIENT SAFETY ISSUES, INCLUDING NPSGs, FROM INPUT FROM PRACTITIONERS, PROVIDER ORGANIZATIONS, PURCHASERS, CONSUMER GROUPS, AND OTHER STAKEHOLDERS. EACH YEAR, RECOMMENDATIONS FROM SENTINEL EVENT ALERT PUBLISHED IN THE PREVIOUS YEAR AND FROM OTHER AUTHORITATIVE SOURCES ARE ADDED TO THE POOL. OFFICE OF QUALITY AND PATIENT SAFETY THE JOINT COMMISSION'S OFFICE OF QUALITY AND PATIENT SAFETY RECEIVES, EVALUATES, TRACKS, AND AS APPROPRIATE, RESPONDS TO COMPLAINTS AND REPORTS OF CONCERN ABOUT HEALTH CARE ORGANIZATIONS THAT RELATE TO SAFETY AND CARE ISSUES. THIS INFORMATION COMES FROM PATIENTS, THEIR FAMILIES, ORGANIZATION STAFF, PRACTITIONERS, GOVERNMENT AGENCIES, AND OTHERS. THE OFFICE MAINTAINS A TOLL FREE HOT LINE AND ALSO RECEIVES WRITTEN REPORTS BY MAIL OR E-MAIL. WHEN A REPORT IS SUBMITTED, THE JOINT COMMISSION REVIEWS ANY PAST REPORTS AND THE ORGANIZATION'S MOST RECENT ACCREDITATION DECISION. DEPENDING ON THE NATURE OF THE REPORTED CONCERN, THE JOINT COMMISSION WILL TAKE ONE OF THE FOLLOWING ACTIONS: * INCORPORATE THE REPORTED CONCERN INTO THE QUALITY MONITORING DATABASE THAT IS USED TO TRACK HEALTH CARE ORGANIZATIONS OVER TIME TO IDENTIFY TRENDS OR PATTERNS IN THEIR PERFORMANCE. * ASK THE ORGANIZATION TO PROVIDE A WRITTEN RESPONSE TO THE REPORTED CONCERN. * REVIEW THE REPORTED CONCERN AND COMPLIANCE WITH RELATED STANDARDS AT THE TIME OF THE ORGANIZATION'S NEXT ACCREDITATION SURVEY. * CONDUCT AN UNANNOUNCED EVALUATION OF THE ORGANIZATION IF THE REPORT RAISES SERIOUS CONCERNS ABOUT A CONTINUING THREAT TO PATIENT SAFETY OR CONTINUING FAILURE TO COMPLY WITH STANDARDS. (Continuation below) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED 3 of 6 (CONTINUATION FROM ABOVE) INFECTION PREVENTION AND CONTROL INITIATIVES INFECTION PREVENTION AND CONTROL IS A CRITICAL COMPONENT OF SAFE, QUALITY HEALTH CARE. THE JOINT COMMISSION IS ADDRESSING THIS IMPORTANT ISSUE WITH A NUMBER OF INITIATIVES AND PRODUCTS THROUGH THE EFFORTS OF THE DEPARTMENT OF HEALTH SERVICES RESEARCH. SOME EXAMPLES OF THE DEPARTMENT'S WORK INCLUDE: * In 2023, The CDC approached The Joint Commission to conduct a qualitative investigation in a small sample of accredited hospitals that experienced an increase in Central Line Associated Blood Stream Infection (CLABSI) rates during the pandemic followed by a sustained reduction in those rates. The results generally indicated that CLABSI rates increased due to staffing shortages and obligatory deviations from organizational protocols, while the sustained reduction was due to a return to evidence-based practices, and various innovative procedures (e.g., multidisciplinary relationship building, technological improvements). * In 2020, with support from The Pew Charitable Trusts, research staff conducted a cross-sectional observational study using an electronic questionnaire to determine the extent to which hospitals are currently implementing the following antibiotic stewardship practices: a) development of facility-specific treatment guidelines, b) measuring appropriate use and concordance of care with these guidelines, c) engaging clinicians while the patient is on the unit, d) diagnostic stewardship, e) measurement of antimicrobial utilization data, and f) measuring hospital-acquired Clostridioides difficile infection rates (CDI). Among 288 acute care hospitals, most were using facility-specific treatment guidelines and measuring CDI and days of therapy. Practices for active engagement with frontline staff in prospective audit and feedback varied widely. A minority of hospitals had formally assessed compliance with one or more of the treatment guidelines or had procedures in place to prevent inappropriate diagnostic testing for urine specimens. Greater understanding of barriers to assessing adherence to hospitals' treatment guidelines and implementation of effective diagnostic testing procedures is needed to improve these practices. In August 2022, the Joint Commission entered into a new agreement with Pew to conduct an 18-month study extending the antibiotic stewardship program work into the outpatient setting - specifically focused on ambulatory clinics associated with hospitals. * The Joint Commission continues to work closely with CDC, SHEA, APIC, IDSA and other groups to help ensure coordination and collaboration among organizations working to reduce the burden of infections. The Joint Commission's comprehensive accreditation standards and national patient safety goals specific to infection prevention and control have facilitated broader implementation of CDC practice recommendations. These standards emphasize infection prevention, continuous strategic surveillance for infection and infection-related risks, and timely interventions to address identified problems. * Continue to review, update, and maintain the contents of a web portal containing links to key guidance documents related to infection prevention and control and healthcare-associated infections. Access is free to all. PATIENT SAFETY RESEARCH THE JOINT COMMISSION'S DIVISION OF HEALTHCARE QUALITY EVALUATION WORKS WITH EXTERNAL COLLABORATORS TO ADVANCE THE FIELD OF PATIENT SAFETY RESEARCH. JOINT COMMISSION RESEARCH INITIATIVES INCLUDE: (Continuation below) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED 4 of 6 (Continuation from above) * Survey of leading suicide prevention practices in hospitals. Funded by The Pew Charitable Trusts, this 2022-2023 study explores suicide risk screening practices (i.e., targeted versus universal screening) and the prevalence of leading suicide prevention discharge practices (i.e., formal safety planning, lethal means assessment, warm handoffs with outpatient providers, follow-up contact post-discharge). * Development of the Health Care Equity Resource Center. Inequitable health care is, first and foremost, a quality and safety issue. As a compliment to the new health care equity accreditation and certification standards, The Joint Commission conducted a series of case studies with health care organizations that were implementing health care equity initiatives designed to address health-related social needs. Elements of these case studies were incorporated into a publicly available website to help guide and encourage organizations as they seek to comply with the new health care equity requirements. Case study examples and resources are provided to help organizations build an infrastructure that can support long-term prioritization of health care equity. * Survey of clinician wellbeing practices in hospitals and federally qualified health centers. This 2022 internally funded survey was designed to assess the state of the field on the topic of organizational practices being implemented to measure and address clinician wellbeing in hospitals and federally qualified health centers. The survey focused on leadership, measurement practices, and comprehensive improvement efforts being implemented to address the growing problem of clinician burnout, which has a direct impact on patient safety and quality of care. * A Survey of Venous Thromboembolism (VTE) Prevention Practices in U.S. Hospitals. Funder: Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities, Division of Blood Disorders. Sub-award with the Association of University Centers on Disabilities (AUCD). The purpose of this project is to support a framework for improving VTE prevention practices through the evaluation of current VTE prevention practices in U.S. hospitals and VTE risk assessment as a performance measure. Initial activities include developing and implementing a survey for U.S. hospitals that characterizes the VTE prevention practices occurring at the general medical unit and general surgical unit. * The Effects of Organizational Culture and Related Factors on Healthcare Worker (HCW) Well-being and Patient Safety: A Scoping Review of Available Evidence. Funder: Centers for Disease Control and Prevention, National Institute of Occupational Safety and Health. This project will conduct a scoping review focused on examining the effects of organizational culture and related factors on healthcare worker well-being and patient safety. The initial scoping review will examine aspects of organizational culture such as safety culture, safety climate, leadership, teamwork, communication, and learning environment. Interventions in these areas will be identified where available and examined for their impact as well as any additional research or evaluation that may enhance the effectiveness or applicability of the intervention. * Maintenance of a healthcare-specific web portal of resources related to workplace violence that affects safety for patients and workers. It addresses a wide variety of healthcare settings and topics including resources related to prevention and response for active shooter events. Access is free to all. ACCREDITATION AND CERTIFICATION STANDARDS JOINT COMMISSION STANDARDS ARE DEVELOPED WITH INPUT FROM HEALTH CARE PROFESSIONALS, PROVIDERS, SUBJECT MATTER EXPERTS, CONSUMERS, GOVERNMENT AGENCIES (INCLUDING THE CENTERS FOR MEDICARE & MEDICAID SERVICES) AND EMPLOYERS. THEY ARE INFORMED BY SCIENTIFIC LITERATURE AND EXPERT CONSENSUS AND APPROVED BY THE BOARD OF COMMISSIONERS. NEW STANDARDS ARE ADDED ONLY IF THEY RELATE TO PATIENT SAFETY OR QUALITY OF CARE, HAVE A POSITIVE IMPACT ON HEALTH OUTCOMES, MEET OR SURPASS LAW AND REGULATION, AND CAN BE ACCURATELY AND READILY MEASURED. RECENT STANDARDS DEVELOPMENT ACTIVITIES ARE DESCRIBED BELOW: * Evaluated issues related to customizing elements of performance based on organizational services and settings for our accreditation programs. Internal and external customers' input were considered, and solutions were developed and implemented. * Development of a new Responsible Use of Health Data certification (RUHD) to help safeguard patient privacy and advance healthcare innovation. It serves as a crucial tool for healthcare organizations seeking to mitigate risk and prioritize patient privacy when transferring data to third-party organizations. * Development of a new deemed Rural Health Clinic Accreditation program to meet compliance with the Medicare Conditions for Certification (CfC). (Continued below) Form 990, Part III, Line 1 Organization Mission Continued 5 of 6 (Continuation from above) * Development of a new Sustainable Healthcare Certification (SHC) program which aims to advance decarbonization in health care through helping organizations set and maintain goals to reduce their greenhouse gas emissions. This certification program will evaluate whether healthcare organizations have put in place key structures and processes to improve energy efficiency, decrease their carbon footprint, and decrease waste * Development of a new Health Care Equity (HCE) certification program to recognize hospitals and critical access hospitals that strive for excellence in their efforts to provide equitable care, treatment, and services. The new certification requirements emphasize the structures and processes that health care organizations need to decrease health care disparities in their patient populations and promote diversity, equity, and inclusion for their staff. * Development and revision of Workplace Violence Prevention standards for the home care and behavioral health care accreditation programs and development of a compendium to provide a standardized approach to healthcare workplace violence prevention, reporting, and post-incident strategies. * Revision of Emergency Management (EM) ambulatory and office based surgery standards to strengthen organizations' ability to prepare and respond to emergencies. Standards for other accreditation programs will be reviewed and revised. * Revisions to the Environment of Care and Life Safety Code chapters within all accreditation programs to strengthen alignment with NFPA code. * Revisions to all Stroke Certification programs requirements to align with American Heart Association Guidelines. * Elevation of new and revised requirements to reduce health care disparities for Joint Commission-accredited ambulatory health care organizations, behavioral health care and human services organizations, critical access hospitals, and hospitals to National Patient Safety Goals (NPSGs). These accreditation requirements promote health care equity as a quality and safety priority. * Revisions to Infection Control (IC) Chapter requirements for all accreditation programs. (Continuation below) Form 990, Part III, Line 1 Organization Mission Continued 6 of 6 (Continuation from above) THE SPEAK UP INITIATIVES FOR THE GENERAL PUBLIC THE JOINT COMMISSION, TOGETHER WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS), CONTINUE TO DEVELOP MATERIALS FOR THE NATIONAL SPEAK UP PROGRAM TO URGE PATIENTS TO TAKE AN ACTIVE ROLE IN PREVENTING HEALTH CARE ERRORS BY BECOMING INVOLVED AND INFORMED PARTICIPANTS ON THE HEALTH CARE TEAM. THE SPEAK UP PROGRAM FEATURES BROCHURES, POSTERS AND BUTTONS ON OVER 25 PATIENT SAFETY TOPICS, SUCH AS FIVE THINGS YOU CAN DO TO PREVENT INFECTION, HELP PREVENT ERRORS IN YOUR CARE, OR AVOID A RETURN TRIP TO THE HOSPITAL. SPEAK UP POSTERS ARE AVAILABLE TO THE GENERAL PUBLIC AT NO COST ON THE JOINT COMMISSION'S WEBSITE. THE JOINT COMMISSION ALSO DEVELOPED A SERIES OF ANIMATED SPEAK UP VIDEOS TO ENCOURAGE PATIENTS TO SPEAK UP AND BE ACTIVE PARTICIPANTS IN THEIR HEALTH CARE. PRODUCED BY THE JOINT COMMISSION, THESE ENTERTAINING 60-SECOND VIDEOS ARE INTENDED AS PUBLIC SERVICE ANNOUNCEMENTS AND AIR ON THE JOINT COMMISSION'S YOUTUBE CHANNEL, ON THE JOINT COMMISSION WEBSITE, AND IN OTHER VENUES. THE CAST OF CHARACTERS INTRODUCED IN THE VIDEOS ENCOUNTER EVERYDAY SITUATIONS WHERE THEY HAVE TO READ INSTRUCTIONS, INSPECT LABELS, AND "SPEAK UP" TO ASK THEIR DOCTORS AND CAREGIVERS QUESTIONS. THE VIDEOS POINT OUT THAT YOU SHOULD BE JUST AS COMFORTABLE SPEAKING UP ABOUT YOUR HEALTH CARE WHETHER IN A DOCTOR'S OFFICE OR AT THE HOSPITAL. THE VIDEOS HAVE PROVEN TO BE WIDELY POPULAR WITH AUDIENCES ALL OVER THE WORLD, AND HAVE BEEN DOWNLOADED BY ORGANIZATIONS IN MORE THAN 70 COUNTRIES. QUALITY CHECK AND QUALITY REPORTS QUALITY CHECK OFFERS A COMPREHENSIVE COMPENDIUM OF QUALITY AND SAFETY-RELATED PERFORMANCE INFORMATION ON THE NEARLY 22,000 JOINT COMMISSION-ACCREDITED HEALTH CARE ORGANIZATIONS AND PROGRAMS THROUGHOUT THE UNITED STATES. THESE QUALITY REPORTS MAKE PUBLICLY AVAILABLE SPECIFIC INFORMATION REGARDING ORGANIZATION ACCREDITATION STATUS, PERFORMANCE IN CARING FOR PATIENTS WITH COMMON CONDITIONS (SUCH AS PNEUMONIA) AND COMPLIANCE WITH NATIONAL PATIENT SAFETY GOAL REQUIREMENTS, AMONG OTHER FEATURES. QUALITY REPORTS UTILIZE A USER-FRIENDLY FORMAT WITH CHECKS, PLUSES AND MINUSES TO HELP THE PUBLIC COMPARE HEALTH CARE ORGANIZATION PERFORMANCE IN KEY AREAS. OTHER RESOURCES The Joint Commission's DASH (Data Analytics for Safe Healthcare) is a collection of proprietary business intelligence tools developed to support organizations and empower them to make more informed decisions to drive quality improvement and reduce harm. The Joint Commission provides data transparency in a convenient platform to power process and focus on relevant needs to drive efficiency and effectiveness to improve care results. The DASH business intelligence offerings include Accelerate PI, Illuminate Analytics, and SAFER Dashboard. Accelerate PI allows a health care organization to compare to national, state, and averages from Joint Commission-accredited organizations. Illuminate Analytics helps drive meaningful, actionable conclusions from disparate data sources that enhance the quality and safety of the care provided. SAFER Dashboard empowers health care leaders and business users in their efforts to deliver safe, high-quality care and better prioritize future improvement efforts. Additional resources dedicated to physicians, nurses, and consumers are available free on The Joint Commission's web site. Such dedicated resources include patient safety topics, physician leader monthly newsletter, Coronavirus (Covid-19) resources, and the latest topics around nursing and nurses roles in patient safety. Form 990, Part VI, Line 8b Committee authority to act on behalf of governing body SEE NARRATIVE FOR LINE 1A Form 990, Part VI, Line 1a Delegate broad authority to a committee The board of directors may, by resolution, appoint an executive committee. The Executive Committee shall consist of one Commissions appointed by each member of the corporation to the board of commissions and one commissioner appointed by the board of commissioners. It shall be the duty of the executive committee to exercise the powers of the board when the board is not in session, including, without limitation, to take such emergency actions for the board as may be required between meetings of the board, and otherwise exercise the authority of the Board of Commissioners in the management of the corporation to the extent that the board may lawfully provide by resolution; council with the president regarding certain matters; and act upon recommendation of the chair of the board on the appointments to the standing committees. Form 990, Part VI, Line 3 Delegation of management duties The Joint Commission hired Kim Michael-Lee through a contractual agreement with Randstad Digital LLC to perform the duties of Chief Financial Officer from May through December. Form 990, Part VI, Line 6 Classes of members or stockholders The Joint Commission has five corporate members who must approve changes to the organization's Bylaws and Articles of Incorporation. The members assist with appointing commissioners to the board. In addition, the members must approve the dissolution of the organization. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body SEE NARRATIVE FOR LINE 6 Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders SEE NARRATIVE FOR LINE 6 Form 990, Part VI, Line 11b Review of form 990 by governing body The Joint Commission's management, including the CFO, COO, Controller, Corporate Compliance & Privacy Officer, and General Counsel performed a detailed review of the Form 990 with the paid tax preparer. Once this level of review was performed, a thorough walk through of Form 990 was done with the Finance Committee prior to filing. A copy of the Form 990 was provided to the entire Board of Commissioners prior to filing. A final filed public disclosure copy of the return will be placed on the Organization's website for the public once accepted by the IRS. Form 990, Part VI, Line 12c Conflict of interest policy THE POLICY STATES THAT ANY DECISION THAT COULD RESULT IN AN ACTUAL OR PERCEIVED CONFLICT OF INTEREST MUST BE AVOIDED. ALL STAFF AND BOARD MEMBERS REVIEW THE POLICY ON AN ANNUAL BASIS AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EACH YEAR, WHICH IS DESIGNED TO IDENTIFY INTERESTS THAT COULD GIVE RISE TO POSSIBLE CONFLICTS. ALTHOUGH MANY SUCH POTENTIAL CONFLICTS ARE AND WILL BE DEEMED INCONSEQUENTIAL, EVERY INDIVIDUAL OF THE ORGANIZATION HAS AN ONGOING RESPONSIBILITY TO DISCLOSE SITUATIONS THAT INVOLVE PERSONAL, FAMILY, OR BUSINESS RELATIONSHIPS THAT COULD BE PERCEIVED AS A CONFLICT OF INTEREST. THE INTERESTS IDENTIFIED ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER, GENERAL COUNSEL, AND GOVERNANCE COMMITTEE AND APPROPRIATELY MANAGED. ALL DISCLOSURES ARE PURSUED UNTIL 100% COMPLETED. PRIOR TO ANY BOARD OR COMMITTEE MEETING, A MEMBER IS REQUIRED TO DISCLOSE A CONFLICT OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER DURING A MEETING AND THEN NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING REFLECTS THAT A DISCLOSURE WAS MADE AND THE MEMBER ABSTAINED FROM VOTING. AT THE BEGINNING OF EACH BOARD OR COMMITTEE MEETING A REQUEST IS MADE TO DISCLOSE ANY POTENTIAL CONFLICT OF INTEREST. THE COMPLIANCE OFFICER MONITORS AND REVIEWS THE CONFLICT OF INTEREST POLICY AS WELL AS THE RESPONSES TO THE QUESTIONNAIRES ON AN ANNUAL BASIS. THE ORGANIZATION ALSO HAS AVAILABLE AN INDEPENDENT HOTLINE NUMBER FOR STAFF TO REPORT ANONYMOUSLY ANY POTENTIAL CONFLICTS DURING THE YEAR. Form 990, Part VI, Line 15a Process to establish compensation of top management official The ceo's compensation arrangement is subject to an independent Board committee review and approval referred to as the human resources and executive compensation committee. The joint commission engaged an independent compensation consultant to assist in determining compensation of its ceo. In setting the ceo's compensation, the organization's human resources and executive compensation committee relies on recent compensation studies that provide compensation data for comparable position in other organizations to support its decision-making process. The human resources and executive compensation committee adequately documents its compensation determinations and deliberations regarding compensation in its committee minutes on a timely basis. Each voting committee member has been determined to be independent in Accordance with intermediate sanctions regulations and signs the Board's conflict of interest policy annually to ensure that he or she Is independent. The board engages in an active review of the compensation recommended by the Committee. In addition, the Board conducts an annual evaluation of the CEO. The process for determining the top management officials', Dr. Jonathan Perlin, ceo, compensation is undertaken annually. Form 990, Part VI, Line 15b Process to establish compensation of other employees OTHER OFFICERS: THE OTHER OFFICERS' COMPENSATION ARRANGEMENT IS SUBJECT TO AN INDEPENDENT BOARD COMMITTEE REVIEW AND APPROVAL REFERRED TO AS THE HUMAN RESOURCES AND EXECUTIVE COMPENSATION COMMITTEE. THE JOINT COMMISSION ENGAGED AN INDEPENDENT COMPENSATION CONSULTANT TO ASSIST IN DETERMINING COMPENSATION OF ITS OTHER OFFICERS. IN SETTING THE OTHER OFFICERS' COMPENSATION, THE ORGANIZATIONS' HUMAN RESOURCES AND EXECUTIVE COMPENSATION COMMITTEES RELY ON RECENT COMPENSATION STUDIES THAT PROVIDE COMPENSATION DATA FOR COMPARABLE POSITIONS IN OTHER ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS. THE HUMAN RESOURCES AND EXECUTIVE COMPENSATION COMMITTEES ADEQUATELY DOCUMENTED ITS COMPENSATION DETERMINATIONS AND DELIBERATIONS REGARDING COMPENSATION IN ITS COMMITTEE MINUTES ON A TIMELY BASIS. EACH VOTING COMMITTEE MEMBER HAS BEEN DETERMINED TO BE INDEPENDENT IN ACCORDANCE WITH INTERMEDIATE SANCTIONS REGULATIONS AND SIGNS THE BOARD'S CONFLICT OF INTEREST POLICY ANNUALLY TO ENSURE THAT HE OR SHE IS INDEPENDENT. THE BOARD ENGAGES IN AN ACTIVE REVIEW OF THE COMPENSATION RECOMMENDED BY THE COMMITTEE. IN ADDITION, AN ANNUAL PERFORMANCE EVALUATION OF THE OFFICERS IS CONDUCTED. The process for determining the organizations' other officers' compensation is undertaken annually for: dr. david baker - evp, brian Enochs - evp, michael kaba - chief HR officer, kin lee - cio, ana pujols mckee - evp, kenneth grubbs - cco & evp, paige rodgers - cfo, Lisa Diehl Vandecaveye - general counsel, Margaret Van Amringe - evp, james merlino - evp, kathryn spates - evp, jason miles - evp, and leslie krohn - evp KEY EMPLOYEES: THE JOINT COMMISSION ENGAGES ITS HUMAN RESOURCES DEPARTMENT TO ASSIST IN DETERMINING COMPENSATION OF ITS KEY EMPLOYEES. IN SETTING THE KEY EMPLOYEES' COMPENSATION, THE HUMAN RESOURCES DEPARTMENT RELIES ON INDEPENDENT SURVEY AND COMPENSATION DATA FOR COMPARABLE POSITIONS IN OTHER ORGANIZATIONS AND/OR ON THE INTERNAL JOB EVALUATION SYSTEM TO SUPPORT ITS DECISION MAKING PROCESS. THE KEY EMPLOYEES' COMPENSATION IS DETERMINED BY THE COMPENSATION POLICY AND GUIDELINES, WHICH ARE ESTABLISHED ANNUALLY BY THE HUMAN RESOURCES DEPARTMENT. INCENTIVE COMPENSATION FOR KEY EMPLOYEES IS ALSO REVIEWED BY THE ORGANIZATION'S HUMAN RESOURCES AND EXECUTIVE COMPENSATION COMMITTEE. THE PROCESS FOR DETERMINING THE ORGANIZATION'S KEY EMPLOYEES' COMPENSATION IS UNDERTAKEN ANNUALLY FOR ALL KEY EMPLOYEES. Form 990, Part VI, Line 19 Required documents available to the public THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AND THE FORM 990 AVAILABLE TO THE PUBLIC UPON REQUEST AND IN ACCORDANCE WITH APPLICABLE LAWS. THE CONFLICT OF INTEREST POLICY, FINANCIAL STATEMENTS, 990-T, AND PUBLIC DISCLOSURE COPY OF THE 990 ARE MADE AVAILABLE TO THE PUBLIC ON THE ORGANIZATION'S WEBSITE. Form 990, Part VIII, Line 2f Other Program Service Revenue Other Revenues - Total Revenue: 436411, Related or Exempt Function Revenue: 436411, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part XI, Line 9 Other changes in net assets or fund balances Change in net periodic pension costs other - -491341; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - 6630954; Transfer of Net assets to Parent co from Joint Commission Resources, Inc. EIN 36-3521721 - 6948919; Schedule K, Part IV, Line 3 Bond issue is a variable rate issue The original bond was issued at a variable rate. In 2022 the organization executed the first amendment to the bond and loan agreement referred to as the interest rate reset and amendments, which renewed the loan with the current purchaser at a fixed rate of 2.8%. JOINT COMMISSION RESOURCES INC ONE RENAISSANCE BOULEVARD SUITE 401 OAKBROOK TERRACE IL 60181 363521721 HEALTHCARE IL 501(c)(3) 10 JOINT COMMISSION true National Quality Forum 1099 14th St NW Suite 500 Washington DC 200054858 522175544 HEALTHCARE DC 501(c)(3) 7 JOINT COMMISSION true JCI ACCREDITATION (BEIJING) CO LTD Rm 1538 FL 15 Bldg 3 Yard 2 Jianguomenwai Street Chaoyang District Beijing CH 100022 SEE STATEMENT CH JCR C Corporation -110789 54719 1 true Joint Commission Arabia Management Company SEE STATEMENT SA JCR C Corporation 1659337 2081867 1.00 true true false false false false false false false false true false true true true true true true false true JOINT COMMISSION RESOURCES INC A 1354123 ACTUAL JOINT COMMISSION RESOURCES INC J 311893 ACTUAL JOINT COMMISSION RESOURCES INC L 7978229 CONTRACTUAL JOINT COMMISSION RESOURCES INC Q 1406877 ACTUAL JOINT COMMISSION RESOURCES INC S 6948919 CONTRACTUAL Schedule R, Part IV, Column (b) PRIMARY ACTIVITY PROVIDED INTERNATIONAL STANDARDS AND ACCREDITATION AND CERTIFICATION PROGRAMS FOR HEALTHCARE ORGANIZATIONS THROUGHOUT CHINA. Schedule R, Part IV, Column (b) PRIMARY ACTIVITY PROVIDES INTERNATIONAL STANDARDS AND ACCREDITATION AND CERTIFICATION PROGRAMS FOR HEALTHCARE ORGANIZATIONS THROUGHOUT Saudi Arabia