2023-11-03T17:30:45+00:00 2022-12-31 350921680 CROWE LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2022-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Suite 401 Oakbrook Terrace IL 60181 Paige Rodgers CFO/Treasurer 2023-11-03 true Jean Courtney 999009999 MALLORY FAIRLESS P01321579 3128997000 2022 2023-04-26 12:10:37Z The Joint Commission Dr Jonathan Perlin (Beg 3122) One Renaissance Blvd Suite 401 Oakbrook Terrace IL 60181 259711904 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 20 1268 20 0 0 886503 854087 180671780 198963662 11409734 7751370 1298097 1341788 194266114 208910907 0 0 0 121714528 130499189 0 0 0 50253523 60938984 171968051 191438173 22298063 17472734 309605325 334608248 30924222 33867972 278681103 300740276 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 136766904 184304130 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. 7561130 7561130 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. 4675794 7098402 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. 149003828 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 124 0 true 1268 true false true SA SN CH false false false false false false false false true false X 21 20 false false 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 Ana Pujols McKee MD Exec VP & Chief Medical Officer & Interim President (Through Feb) 38.0 2.0 X X 888241 0 49813 Carlos A Pellegrini MD FACS Vice Chair 2.0 2.0 X X 0 0 0 Jane D Englebright PhD RN CENP FAAN Chair 3.0 2.0 X X 910 0 0 Jonathan B Perlin MD FACP MPP MPH President & CEO (Beg Mar) 37.0 3.0 X X 2028212 0 16294 Ana L English MBA Commissioner 2.0 0 X 0 0 0 Aurie Hollingsworth Miller BA MA Commissioner 2.0 0 X 0 0 0 Christopher A Hart MEng JD Commissioner 2.0 0 X 0 0 0 Ena Williams PhD MBA MSM BSN RN CENP Commissioner 2.0 0 X 378 0 0 Eric Langshur Commissioner 1.0 1.0 X 0 0 0 Jay A Gregory MS MD Commissioner 2.0 0 X 730 0 0 Jill Hoggard Green PhD RN Commissioner 3.0 1.0 X 0 0 0 Joseph J Parks MD Commissioner 2.0 1.0 X 0 0 0 Lenworth M Jacobs Jr MBBS MPH DSc (Hon) FACS FWACS (Hon) Commissioner 2.0 0 X 0 0 0 Marvin Strohschein Jr DDS Commissioner 2.0 0 X 854 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 949 0 0 Michael Suk MD JD MPH MBA FACS Commissioner 1.0 0 X 0 0 0 Najmedin Meshkati PhD CPE Commissioner 2.0 1.0 X 910 0 0 Tracey L Henry MD MPH MS Commissioner 1.0 0 X 0 0 0 Victoria W Bayless FACHE 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 2.0 0 X 0 0 0 Brian Enochs JD Exec VP Bus Dev & Marketing 40.0 0 X 409344 0 223215 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 0 X 811479 0 228225 Kin Lee MS CIO & SECURITY OFFICER 40.0 0 X 483814 0 219730 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 23.0 17.0 X 1262808 0 426469 Lynn Dragisic EVP Support Op & Chief of Staff 40.0 0 X 841639 0 76212 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 40.0 0 X 488035 0 145068 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 40.0 0 X 691714 0 154186 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 40.0 0 X 439581 0 56017 Paige Rodgers CPA Chief Financial Officer 35.0 5.0 X 762814 0 197844 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 204828 0 48170 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 213255 0 26707 Anoop Verma Director Applications Development 40.0 0 X 281676 0 20320 Debra A Kiel Directir Business Ops & Analytics 40.0 0 X 296803 0 14000 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 40.0 0 X 227197 0 36204 Haytham Kaafarani Chief Patient Safety Ofcr & Medical Dir 40.0 0 X 220880 0 93 Kathryn E Spates Exec Director Federal Relations 40.0 0 X 236264 0 31751 Mark R Chassin MD FACP MPP MPH Former President & CEO 0.0 0.0 X 303525 0 3371 11096838 0 1973687 398 true true false MICROSOFT CORPORATION PO BOX 842103 DALLAS TX 75284 INFORMATION TECHNOLOGY APPLICATION SOLUTIONS & SERVICES 1679192 ALIGHT SOLUTIONS LLC TEMPO HOLDING COMPANY LLC AKA PO BOX 95135 CHICAGO IL 606945135 SOFTWARE DEVELOPMENT & CONSULTING SERVICES 1021682 DYNAMIC HEALTH IT INC 320-C MONTICELLOW AVE NEW ORLEANS LA 70121 SOFTWARE DEVELOPMENT & PAAS 850000 THE WELL ADVERTISING INC 444 WEST LAKE STREET CHICAGO IL 60606 MEDIA & ADVERTISING SERVICES 796648 COGNIZANT TECHNOLOGY SOLUTIONS US CORPORATION 24721 NETWORK PLACE CHICAGO IL 60673 Software Development & Consulting 789412 54 738576 115511 854087 Annual Subscription 541990 97289645 97289645 Survey Fees 541990 86299774 86299774 Performance Measurements 900099 7098402 7098402 Shared Services Fee From Related Tax Exempt Organizations 900099 7561130 7561130 Honorarium Fees 900099 115900 115900 598811 598811 0 0 198963662 3872565 3872565 1341788 1341788 0 0 54679802 50800997 3878805 0 3878805 3878805 0 0 0 0 0 208910907 198963662 0 9093158 11700606 3949175 7751431 95819195 81006305 14812890 5540114 4335046 1205068 9759063 8301760 1457303 7680211 6258392 1421819 355372 1036 354336 349957 349957 173904 173904 197760 197760 12808859 7803067 5005792 0 1376436 1341629 34807 1540921 504213 1036708 4965071 2198969 2766102 2128579 1181929 946650 26093483 25901599 191884 1377183 842662 534521 212777 139473 73304 5093962 3434888 1659074 908062 258852 649210 Recruitment 1042653 145420 897233 Equipment Rental & Repairs 975885 422481 553404 Bad Debt Expense 951109 947605 3504 Other Miscellaneous Expense 387011 29327 357684 0 0 0 0 191438173 149003828 42434345 0 39937247 49439521 11061346 18424484 0 0 0 0 0 3240130 6190844 102443088 68987476 31970118 33455612 185538377 185143693 32682642 40311613 0 5175465 1642481 309605325 334608248 13029520 16759453 3186922 685242 9550956 8456340 0 0 5156824 7966937 30924222 33867972 X 278681103 291424098 9316178 278681103 300740276 309605325 334608248 X 17472734 -29495809 34082248 X false true X true false X 1087455 825286 753191 886503 854087 4406522 175578868 182737650 139594480 180671780 198963662 877546440 0 0 0 176666323 183562936 140347671 181558283 199817749 881952962 0 0 0 0 0 0 2609279 3487949 2876956 3574122 4623399 17171705 2609279 3487949 2876956 3574122 4623399 17171705 864781257 4028869 4740707 3941505 3786562 5214353 21711996 0 0 0 0 0 4028869 4740707 3941505 3786562 5214353 21711996 0 0 0 0 0 0 0 180695192 188303643 144289176 185344845 205032102 903664958 0.9570 0.9588 0.02 0.02 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 257756 false false 257756 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 $173,904 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. 0 32221740 1129878 33351618 0 0 0 0 0 0 0 0 0.7 0.3 0.0 false false 4204400 4204400 45965671 28880018 17085653 801562 294614 506948 5154545 4121090 1033455 46316910 35691754 10625156 33455612 Common & Collective Funds - Measured at NAV 40282094 F Common & Collective Funds - Hedge Funds 29519 F 40311613 Accrued pension liability 3874794 Capital Lease Obligations 1744356 Operating Lease Obligations 2347787 7966937 X 215878687 -29495809 36661349 7165540 208713147 197760 0 197760 208910907 193819514 2579101 2579101 191240413 197760 0 197760 191438173 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, 2022 and 2021, 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). The Center is organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purpose of The Joint Commission under IRC Section 509(a)(3). 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 CENTER FOR TRANSFORMING HEALTHCARE EIN 26-3020947 - 2624553 TRANSFER OF BOARD-DESIGNATED NET ASSETS FROM AFFLIATE CO - JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE EIN 26-3020947 - 21089202 TRANSFER OF DONOR-RESTRICTED NET ASSETS FROM AFFLIATE CO - JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE EIN 26-3020947 - 9139978 TRANSFER OF UNDESIGNATED NET ASSETS FROM AFFLIATE CO - JOINT COMMISSION RESOURCES, INC. EIN 36-3521721 - 3807616 Schedule D, Part XII, Line 2(d) Other expenses in audited financial statements not in form 990 CHANGE IN NET PERIODIC PENSION COSTS OTHER - -240770 CHANGE IN UNRECOGNIZED NET DEFINED-BENEFIT PLAN COSTS NOT YET RECOGNIZED IN NET PERIODIC BENEFIT COST - 2819871 Europe (Including Iceland and Greenland) 0 1 Program Services Sending agents of the organization for observation of a survey 11332 Middle East and North Africa 0 1 Conference Travel Sending agents of the organization to attend conferences 24697 0 2 0 0 0 2 36029 0 36029 false false true false false true Schedule F, Part I, Line 3 Method used to account for expenditures on org's financial statements EUROPE (INCLUDING ICELAND AND GREENLAND)-Accrual; MIDDLE EAST AND NORTH AFRICA-Accrual X X true true X X X X true true false false false false false false false Mark R Chassin MD FACP MPP MPH Former President & CEO 127192 0 169371 0 6961 0 1629 0 1743 0 306896 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer & Interim President (Through Feb) 694480 0 110000 0 83761 0 32288 0 17525 0 938053 0 0 0 Jonathan B Perlin MD FACP MPP MPH President & CEO (Beg Mar) 1237297 0 500000 0 290915 0 5348 0 10946 0 2044506 0 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 641059 0 0 0 170420 0 196679 0 31546 0 1039704 0 165347 0 Lynn Dragisic EVP Support Op & Chief of Staff 217132 0 0 0 624507 0 69632 0 6579 0 917850 0 124852 0 Brian Enochs JD Exec VP Bus Dev & Marketing 405614 0 0 0 3730 0 177856 0 45358 0 632559 0 0 0 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 401597 0 0 0 37984 0 27471 0 28547 0 495599 0 0 0 Kin Lee MS CIO & SECURITY OFFICER 477973 0 0 0 5841 0 191510 0 28220 0 703544 0 0 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 544001 0 0 0 147712 0 152467 0 1719 0 845900 0 141365 0 Paige Rodgers CPA Chief Financial Officer 583556 0 0 0 179258 0 187412 0 10431 0 960657 0 176706 0 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 400528 0 0 0 87506 0 132988 0 12080 0 633102 0 78388 0 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 469696 0 0 0 793112 0 378403 0 48066 0 1689277 0 787096 0 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 212056 0 0 0 1199 0 26097 0 609 0 239961 0 0 0 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 182779 0 0 0 22048 0 22403 0 25767 0 252998 0 0 0 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 221743 0 0 0 5455 0 27403 0 8801 0 263401 0 0 0 Haytham Kaafarani Chief Patient Safety Ofcr & Medical Dir 170769 0 50000 0 111 0 0 0 93 0 220973 0 0 0 Debra A Kiel Directir Business Ops & Analytics 191816 0 3500 0 101487 0 5571 0 8429 0 310803 0 0 0 Kathryn E Spates Exec Director Federal Relations 234290 0 750 0 1224 0 17375 0 14376 0 268014 0 0 0 Anoop Verma Director Applications Development 158285 0 0 0 123391 0 4525 0 15795 0 301996 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 Personal services Four officers 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 7440000 0 16026366 0 0 0 229946 0 0 15796420 0 0 2016 false false true true A false false true true false true 0.0143 0.0 0.0143 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: * The Joint Commission, The Pew Charitable Trusts, and the CDC co-sponsored a Technical Expert Panel (TEP) meeting in May 2018 to identify specific, effective, and recommended activities that Antibiotic Stewardship Programs (ASPs) should be doing based on current scientific evidence and the experience of leading organizations. 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. * 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 2018, CDC staff approached The Joint Commission about analyzing and possibly publishing our experience with required reporting of serious infection prevention and control (IPC) breaches to state health departments. Beginning in October 2016, the Centers for Medicare and Medicaid Services (CMS) issued expanded guidance requiring accrediting organizations and state survey agencies to report serious infection control breaches to relevant state health departments. This study sought to characterize and summarize The Joint Commission's early experiences and findings in applying this guidance to facilities accredited under the ambulatory and office-based surgery programs in 2017. The analysis identified numerous opportunities for improved staff training and competencies. Results related to ambulatory settings were published in the Joint Commission Journal on Quality and Patient Safety. Phase 2 of this project is underway by applying the same methodology to reported breaches from hospitals in order to compare the number and types of breaches between hospitals and ambulatory settings. * Research staff, together with collaborators from University of Iowa, implemented a project to examine recent literature on the relationship between safety culture and infection prevention and control-related (IPC) processes and healthcare-associated infections (HAIs) in U.S. healthcare organizations. We also sought to quantitatively characterize the challenges to empirically establishing these relationships and limitations of current research. Authors frequently reported experiencing improvements in safety culture when not directly measured. The findings suggested that associations between improvement and safety culture may be bi-directional such that positive safety culture contributes to successful interventions and implementing effective interventions drives improvements in culture. * 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. * Revision of antimicrobial stewardship requirements applicable to Joint Commission-accredited hospitals and critical access hospitals to clarify requirements and incorporate leading practices. * Development of a new Advanced Disease-Specific Care (DSC) certification program for acute coronary syndrome (ACS) patient care: Comprehensive Heart Attack Center (CHAC), as well as revisions to the Primary Heart Attack Center (PHAC) and the Acute Heart Attack Ready (AHAR) certification programs. These certification programs will standardize and improve coordinated systems of care across settings for identification, assessment, monitoring, management, data sharing, and performance improvement for multidisciplinary ACS care. (Continued below) Form 990, Part III, Line 1 Organization Mission Continued 5 of 6 (Continuation from above) * Development of a Memory Care Certification (MCC) option for Joint Commission-accredited assisted living communities. The purpose of the specialty certification is to ensure that assisted living communities serving residents who have been diagnosed with Alzheimer's disease or other forms of dementia are meeting standards that support the delivery of high-quality care. New certification requirements reflect current scientific evidence and best practices in memory care, align with recommendations and practice guidelines from the Alzheimer's Association, and build on existing requirements for the assisted living community accreditation program. Revisions to the MCC certification for accredited nursing care centers were also made. * Development and revision of Workplace Violence Prevention standards for the hospital and critical access hospital accreditation programs and a compendium to provide a standardized approach to healthcare workplace violence prevention, reporting, and post-incident strategies. Standards for the behavioral health care accreditation program are in progress. * Revision of Emergency Management (EM) hospital and critical hospital standards to strengthen organizations' ability to prepare and respond to emergencies. Once these standards are complete, 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 the nursing care center accreditation program to reflect the most current clinical practice guidelines and best practices for infection control, dementia care, staff recruitment, retention and wellness, pressure injuries, and medication safety. * Revisions to all Stroke Certification programs requirements to align with American Heart Association Guidelines. * Development (in progress) of a Rural Health Clinic Accreditation program that will include deeming recognition. * Development of a new Advanced Certification for Perinatal Care program with ACOG partnership. This new program supports integrated, coordinated, patient-centered care that begins with prenatal care and continues through postpartum care. * Development 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. The new accreditation requirements address health care disparities as a quality and safety priority. * 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. * Revisions to Infection Control (IC) Chapter requirements for all accreditation programs. * Development of new requirements for Certified Community Behavioral Health Clinics (CCBHC) for the behavioral health care accreditation program. CCBHCs provide coordinated, comprehensive access to a variety of behavioral health and primary physical health services to all individuals in accordance with the Substance Abuse and Mental Health Services Administration (SAMHSA) criteria. CCBHCs are required to serve anyone who requests care for mental health or substance use, regardless of their ability to pay, place of residence, or age. * Development of new and revised requirements for critical access hospitals and hospitals certified under the Patient Blood Management certification program. The Patient Blood Management certification program is a voluntary certification based on the Association for the Advancement of Blood & Biotherapies (AABB) Standards for a Patient Blood Management Program. The two-year certification encompasses all aspects of the transfusion decision-making process, including patient evaluation and clinical management. The program is designed to reduce the need for allogenic blood transfusions and reduce costs while ensuring that blood components are available for patients who need them. * Additionally, The Joint Commission is working with experts to explore the following safety and quality issues that may be considered for inclusion in standards: * Medications for opioid use disorder * Environmental sustainability in healthcare * Hospital at Home * Telehealth * Restraint/Seclusion requirement revisions for the behavioral health care program (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 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, lynn dragisic - evp, brian Enochs - evp, michael kaba - chief HR officer, kin lee - cio, ana pujols mckee - evp, mark pelletier - cco & evp, paige rodgers - cfo, Lisa Diehl Vandecaveye - general counsel, and Margaret Van Amringe - 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 TEH 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 Revenue - Total Revenue: 598811, Related or Exempt Function Revenue: 598811, 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 - 240770; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - -2819871; Transfer of undesignated net assets to parent co from Center for Transforming Healthcare EIN 26-3020947 - 2624553; Transfer of Board-designated net assets to Parent co from Center for Transforming Healthcare EIN 26-3020947 - 21089202; Transfer of Donor-Restricted Net assets to Parent co from Center for Transforming Healthcare EIN 26-3020947 - 9139978; Transfer of Net assets to Parent co from Joint Commission Resources, Inc. EIN 36-3521721 - 3807616; COVID-19 Impact IN MARCH 2020, THE WORLD HEALTH ORGANIZATION RECOGNIZED COVID-19 AS A GLOBAL PANDEMIC, PROMPTING MANY NATIONAL, REGIONAL, AND LOCAL GOVERNMENTS TO IMPLEMENT PREVENTIVE OR PROTECTIVE MEASURES SUCH AS TRAVEL AND BUSINESS RESTRICTIONS AND WIDE-SWEEPING QUARANTINES AND STAY-AT-HOME ORDERS. THE JOINT COMMISSION AND ITS WHOLLY CONTROLLED AFFILIATES OPERATIONS CONTINUED TO BE MATERIALLY AFFECTED BY THE PANDEMIC THROUGH MUCH 2021. MANAGEMENT FORECASTS SUGGEST IT MAY TAKE SEVERAL YEARS FOR REVENUE STREAMS TO RETURN TO HISTORICAL LEVELS. MANAGEMENT CONTINUES TO MONITOR THE SITUATION CAREFULLY AND IS PREPARED TO TAKE THE ACTIONS NEEDED TO MAINTAIN THE FINANCIAL HEALTH OF THE ENTERPRISE. JOINT COMMISSION RESOURCES INC 1515 WEST 22ND STREET STE 1300W OAKBROOK IL 60523 363521721 HEALTHCARE IL 501(c)(3) 10 JOINT COMMISSION true JOINT COMMISSION CENTER FOR TRANSFORMING HLTCR ONE RENAISSANCE BLVD OAKBROOK TERRACE IL 60181 263020947 HEALTHCARE IL 501(c)(3) Type I 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 360117 503263 1 false true false false false false false false false true true false true true true true true true false true joint commission resources inc A 1341788 actual joint commission resources inc I 52192 actual joint commission center for transforming healthcare I 185785 actual joint commission resources inc J 297175 actual joint commission resources inc L 6937292 contractual joint commission center for transforming healthcare L 623838 contractual joint commission resources inc Q 6003980 actual joint commission center for transforming healthcare Q 838028 actual joint commission resources inc S 3807616 contractual joint commission center for transforming healthcare S 32853733 Actual Schedule R, Part IV, Column (b) PRIMARY ACTIVITY PROVIDES INTERNATIONAL STANDARDS AND ACCREDITATION AND CERTIFICATION PROGRAMS FOR HEALTHCARE ORGANIZATIONS THROUGHOUT CHINA.