2022-11-09T20:30:18-06:00 2021-12-31 350921680 CROWE LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2021-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers CFO/Treasurer 2022-11-09 true Paige Rodgers 999009999 MALLORY FAIRLESS P01321579 3128997000 2021 2022-09-23 18:48:47Z The Joint Commission DR JON PERLIN (BEG 3122) One Renaissance Blvd Oakbrook Terrace IL 60181 212725762 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 1208 20 0 0 728776 886503 139618895 180671780 16819755 11409734 1216746 1298097 158384172 194266114 0 0 0 102278886 121714528 0 0 0 38959046 50253523 141237932 171968051 17146240 22298063 280065876 309605325 37567363 30924222 242498513 278681103 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 116570848 166593493 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. 8431650 7235382 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. 6842905 6842905 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. 131845403 true true false true false false false false false true true false false true true false true false false false 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 83 0 true 1208 true false true 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 Paige Rodgers 6307925685 One Renaissance Blvd Oakbrook Terrace IL 60181 Carlos A Pellegrini MD FACS Vice Chair 2.0 2.0 X X 0 0 0 Jane D Englebright PhD RN CENP FAAN Chair 4.0 2.0 X X 0 0 0 Mark R Chassin MD FACP MPP MPH President & CEO 36.0 4.0 X X 1822887 0 77700 Adam L Myers MD MHCM FACHE CHCQM CPHRM Commissioner 1.0 0 X 0 0 0 Ana L English MBA Commissioner 1.0 0 X 0 0 0 Aurie Hollingsworth Miller BA MA Commissioner 2.0 0 X 0 0 0 Christopher A Hart JD Commissioner 2.0 1.0 X 0 0 0 Eric Langshur Commissioner 2.0 1.0 X 0 0 0 Jay A Gregory MS MD Commissioner 2.0 0 X 0 0 0 Jill Hoggard Green PhD RN Commissioner 2.0 0 X 0 0 0 Joseph J Parks MD Commissioner 2.0 0 X 0 0 0 Lenworth M Jacobs Jr MBBS MPH DSc (Hon) FACS FWACS (Hon) Commissioner 2.0 0 X 0 0 0 Mark A Kelley MD MACP FRCP Commissioner 2.0 1.0 X 0 0 0 Marvin Strohschein Jr DDS Commissioner 2.0 0 X 0 0 0 Michael B Simon MD MBA FASA Commissioner 1.0 0 X 0 0 0 Michael Suk MD JD MPH MBA FACS Commissioner 2.0 0 X 0 0 0 Najmedin Meshkati PhD Commissioner 1.0 1.0 X 0 0 0 Scott C Malaney FACHE Commissioner 1.0 1.0 X 0 0 0 Victoria W Bayless FACHE Commissioner 2.0 0 X 0 0 0 Vineet Arora MD MAPP Commissioner 2.0 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 40.0 0 X 809605 0 44013 Brian Enochs JD Exec VP Bus Dev & Marketing 40.0 0 X 398569 0 79030 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 0 X 767808 0 230253 Kin Lee MS CIO & SECURITY OFFICER 40.0 0 X 433334 0 95961 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 22.0 18.0 X 427576 0 160101 Lynn Dragisic EVP Support Op & Chief of Staff 40.0 0 X 592880 0 145169 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 40.0 0 X 494877 0 137239 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 40.0 0 X 671430 0 168087 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 40.0 0 X 384662 0 52129 Paige Rodgers CPA Chief Financial Officer 35.0 5.0 X 634588 0 257998 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 189358 0 41744 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 215881 0 25278 Anoop Verma Director Applications Development 40.0 0 X 221660 0 45327 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 40.0 0 X 224965 0 34187 Kathryn E Spates Exec Director Federal Relations 40.0 0 X 225899 0 28446 Mark A Crafton Exec Dir Strategic Alliances 40.0 0 X 209929 0 53010 Robert A Nylen Controller 40.0 0 X 208486 0 79236 8934392 0 1754909 371 false true false APERVITA INC 1 NORTH LASALLE STREET SUITE 1825 Chicago IL 60602 Software & Hardware Platform Hosting 2690975 MICROSOFT CORP C/O BANK OF AMERICA 1950 N STEMMONS FWY DALLAS TX 75207 Information Technology Application Services 1438943 COGNIZANT TECHNOLOGY SOLUTIONS 24721 NETWORK PLACE CHICAGO IL 60673 Software Development & Consulting 974868 AMP Agency Inc Advantage Sales Marketing LLC PO BOX 744347 ATLANTA GA 303744347 Consulting Services - Marketing 866572 Alight Solutions LLC PO BOX 95135 CHICAGO IL 606945135 Software Development & Consulting 822429 42 784863 101640 886503 Annual Subscription 541990 93911552 93911552 Survey Fees 541990 72353245 72353245 Performance Measurements 900099 7235382 7235382 Shared Services Fee From Related Tax Exempt Organizations 900099 6842905 6842905 Honorarium Fees 900099 87625 87625 241071 241071 0 0 180671780 2488465 2488465 1298097 1298097 0 0 27380917 18459648 8921269 0 8921269 8921269 0 0 0 0 0 194266114 180671780 0 12707831 9358155 3641056 5717099 90792916 74354277 16438639 6176144 5785329 390815 8525930 6188750 2337180 6861383 5534109 1327274 290957 27772 263185 332058 332058 165624 165624 317242 317242 9584116 6967557 2616559 0 1902767 1543790 358977 895633 587606 308027 6077854 3810202 2267652 1943477 639539 1303938 17579868 17579868 482192 389756 92436 206793 85281 121512 5902693 3568341 2334352 1110307 1110307 Equipment Rental & Repairs 690997 216688 474309 Bad Debt Expense 713420 709419 4001 Reference Materials 447466 4468 442998 Recruitment 1377946 204594 1173352 232113 7001 225112 0 171968051 131845403 40122648 0 50549887 39937247 0 7958608 11061346 0 0 0 0 6159 0 3049591 3240130 97514813 65544695 37088888 31970118 142326782 185538377 39085961 32682642 0 0 5175465 280065876 309605325 10840481 13029520 3934769 3186922 10602592 9550956 0 0 12189521 5156824 37567363 30924222 X 242498513 278681103 242498513 278681103 280065876 309605325 X 22298063 2449260 11435267 X false true X true false X 2148318 1087455 825286 753191 886503 5700753 165171516 175578868 182737650 139594480 180671780 843754294 0 0 0 167319834 176666323 183562936 140347671 181558283 849455047 0 0 0 0 0 0 2848072 2609279 3487949 2876956 3574122 15396378 2848072 2609279 3487949 2876956 3574122 15396378 834058669 3940913 4028869 4740707 3941505 3786562 20438556 0 0 0 0 0 0 3940913 4028869 4740707 3941505 3786562 20438556 0 0 0 0 0 0 0 171260747 180695192 188303643 144289176 185344845 869893603 0.9588 0.9579 0.02 0.02 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 260440 false false 260440 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 $165,624 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. 4204400 4204400 45932009 27175735 18756274 801562 219510 582052 43992665 36241092 7751573 2584177 1908358 675819 31970118 Common & Collective Funds - Measured at NAV 32568439 F Common & Collective Funds - Hedge Funds 114203 F 32682642 Accrued pension liability 4511826 Capital Lease Obligations 644998 5156824 X 196533642 2449260 0 2449260 194084382 181732 0 181732 194266114 160351052 0 0 160351052 181732 11435267 11616999 171968051 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, 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 XII, Line 4(b) Other expenses in form 990 not in audited financial statements Change in net periodic pension costs other - 1171524 Change in unrecognized net defined-benefit plan costs not yet recognized in net periodic benefit cost - 10263743 X X true true X X X X false true false false false false false false false Mark R Chassin MD FACP MPP MPH President & CEO 1431882 0 169371 0 221633 0 31601 0 46099 0 1900586 0 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 596246 0 0 0 171562 0 184013 0 46240 0 998061 0 167494 0 Lynn Dragisic EVP Support Op & Chief of Staff 487455 0 0 0 105425 0 129119 0 16050 0 738048 0 10368 0 Brian Enochs JD Exec VP Bus Dev & Marketing 394937 0 0 0 3632 0 35590 0 43441 0 477599 0 0 0 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 346677 0 0 0 37984 0 25120 0 27009 0 436791 0 0 0 Kin Lee MS CIO & SECURITY OFFICER 427492 0 0 0 5841 0 68884 0 27077 0 529294 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer 670695 0 55000 0 83911 0 27791 0 16221 0 853618 0 0 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 522258 0 0 0 149172 0 166535 0 1552 0 839517 0 143154 0 Paige Rodgers CPA Chief Financial Officer 565468 0 0 0 69120 0 237822 0 20176 0 892586 0 66913 0 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 406166 0 0 0 88710 0 127105 0 10134 0 632116 0 82683 0 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 423509 0 0 0 4066 0 113943 0 46159 0 587677 0 0 0 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 204697 0 10000 0 1184 0 24670 0 608 0 241159 0 0 0 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 177380 0 10000 0 1977 0 19758 0 21986 0 231101 0 0 0 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 220348 0 1000 0 3617 0 25895 0 8293 0 259152 0 0 0 Mark A Crafton Exec Dir Strategic Alliances 208157 0 0 0 1772 0 28856 0 24155 0 262940 0 0 0 Robert A Nylen Controller 204464 0 2250 0 1772 0 33471 0 45766 0 287722 0 0 0 Kathryn E Spates Exec Director Federal Relations 218301 0 6500 0 1098 0 14716 0 13730 0 254346 0 0 0 Anoop Verma Director Applications Development 218821 0 1000 0 1839 0 20380 0 24946 0 266987 0 0 0 Schedule J, Part I, Line 1a First-class or charter travel The Joint Commission Board Travel Policy permits reimbursement for the purchase of upgrade coupons for first-class air 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 and one officer utilized an allowance for financial planning services. 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 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 6370000 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 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). * 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. * Pfizer Independent Grants for Learning and Change (IGLC) and The Joint Commission have been collaborating since 2012 on projects that support antimicrobial stewardship. The goal was to accelerate the development and adoption of evidence-based approaches that have the capacity to prevent or contain antimicrobial resistance and that support and promote appropriate use of antimicrobial agents. In 2018, this work was expanded to include an RFP for research on antimicrobial stewardship practices in the Asia-Pacific region. Six two-year projects were awarded funding, covering antibiotic stewardship practices in India, Cambodia, Vietnam, Micronesia, Nepal, Philippines, Malaysia and China. * 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) * A Survey of 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. After obtaining internal and external voice of customers and evaluating issues with IT processes, we developed and are implementing solutions. * Revision of antimicrobial stewardship requirements applicable to Joint Commission-accredited hospitals and critical access hospitals to include leading practices and revisions for clarity. * 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. All 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. * Development of new Advanced Disease-Specific Care (DSC) certification program for spine surgery (ACSS). This certification program will standardize and improve practices related to spine surgery including: program composition and collaboration, standardization of care utilizing clinical practice guidelines, preoperative optimization, and performance measures. * Development of and revisions to requirements for resuscitative care in hospitals and critical access hospitals with the aim to strengthen resuscitation care processes to optimize survival after in-hospital cardiac arrest. The requirements are informed by updated 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC). * Development of and revisions to Performance Improvement (PI) requirements. The proposed requirements aim to strengthen the link between leadership priority and goal setting and organizational quality assessment and performance improvement efforts. The proposed revisions encourage use of evidence-based improvement methodologies to achieve and sustain improved performance. (Continued below) Form 990, Part III, Line 1 Organization Mission Continued 5 of 6 (Continuation from above) * Development of an Assisted Living Community (ALC) Accreditation Program. The care provided in these settings is rapidly changing and these settings are taking on much more complex residents. As more and more of the aging population are seeking alternatives to long term care facilities and as the aging population rapidly increases the need for assisted living oversight is becoming more relevant. * 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. This project is expanding to other accreditation programs. * Revision of Emergency Management (EM) hospital and critical hospital standards to strengthen organizations' ability to prepare and respond to emergencies. Once the hospital and critical access hospital standards are complete, standards for other accreditation programs will be reviewed and revised. * Development of a Maternal Levels of Care Verification program. This new program was developed utilizing the American College of Obstetricians and Gynecologists Obstetric Care Consensus from 2015. The program ensures that mothers are being cared for at the right facility that has the proper resources, personnel, training, and equipment for the complexity of the pregnancy. * New and revised standards for water management programs for hospital, critical access hospital, and nursing care centers accreditation programs to help protect immunocompromised patients and residents from waterborne pathogen-related illnesses. * Revisions to the Advanced Disease-Specific Care Certification requirements for chronic obstructive pulmonary disease (COPD). * Revisions to the Health Care Staffing Services Certification program requirements along with development of off-site review process. * Revisions to the requirements for the Advanced Certification program for ventricular assist devices (VADs) that incorporates best practices based on a decision memo released in December 2020 by the Centers for Medicare & Medicaid Services. * 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. Revisions to the current certification program to include all complexities of pregnancy and delivery. * Development of new requirements to reduce health care disparities for all accreditation programs. * Revisions to behavioral health care accreditation requirements to enhance the quality, safety, and ethical practice related to Medication Assisted Treatment and Office Based Opioid Treatment. * Revisions to Infection Control (IC) Chapter requirements for all accreditation programs. * Development (in progress) of new requirements for Certified Community Behavioral Health Clinics (CCBHC) for the behavioral health care accreditation program. * The Joint Commission is working with experts to explore the following safety and quality issues that may be considered for inclusion in standards: * EHR Safety * Cybersecurity * Hospital at Home * Telehealth * Restraint/Seclusion requirement revisions for the behavioral health care program * Alignment with ISO 15189 requirements for laboratory accreditation 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 President, CFO, 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. Mark Chassin, 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: 241071, Related or Exempt Function Revenue: 241071, 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 - 1171524; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - 10263743; COVID-19 Impact In March 2020, the World Health Organization declared the outbreak of a coronavirus to be a pandemic. In that same month, the United States of America declared a national public health emergency concerning the COVID-19 outbreak. Consequently, The Joint Commission enterprise suspended all on-site customer engagements. Shortly thereafter, virtual engagement models were created for accreditation, certification, education, consultative technical assistance, and high reliability training activities; these models of service delivery began to roll out in May 2020, increasing in volume over the course of the year. In June 2020, on-site engagements were restarted and continued through December 31, 2020 on a limited basis. In addition, The Joint Commission aggressively reduced costs to mitigate the impact of lost on-site revenues. Despite these measures, the pandemic resulted in a significant operating deficit in 2020. Although vaccines for COVID-19 are currently available to the general public in the U.S. and around the world, ongoing outbreaks continued to have an adverse impact on the organization in 2021. Management forecasts suggest it may take several years before the enterprise returns to historical revenue levels. To date, the organization has been able to sustain its operations through operating cash and has kept its reserves intact. Management continues to monitor the situation very carefully and is prepared to take any actions needed to keep the organization financially sound. 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 1268944 1144083 1 false true false false false false false false false false true false true true true true true true false false joint commission resources inc A 1298097 actual joint commission resources inc L 6247647 contractual joint commission center for transforming healthcare L 595258 contractual joint commission resources inc Q 4612357 actual joint commission center for transforming healthcare Q 574050 contractual joint commission resources inc J 252749 Actual joint commission resources inc M 77675 actual Schedule R, Part IV, Column (h) FORM 5471 FILING OBLIGATION JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (TJC) indirectly owns 100% of the ownership in JCI ACCREDITATION (BEIJING) CO., LTD through their control of JOINT COMMISSION RESOURCES, INC. (JCR) (EIN: 36-3521721). JCR FILED THE FORM 5471 ON BEHALF OF TJC. THEREFORE, THE FORM 5471 FILING OBLIGATION FOR TJC HAS BEEN SATISFIED PURSUANT TO REGS. §1.6038-2(J). Schedule R, Part IV, Column (b) PRIMARY ACTIVITY PROVIDES INTERNATIONAL STANDARDS AND ACCREDITATION AND CERTIFICATION PROGRAMS FOR HEALTHCARE ORGANIZATIONS THROUGHOUT CHINA.