2021-11-12T11:31:29-06:00 2020-12-31 350921680 CROWE LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2020-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers CFO/TREASURER 2021-11-12 true Paige Rodgers 999009999 RACHEL SPURLOCK P00520729 3128997000 2020 2022-09-23 18:48:47Z The Joint Commission Dr Mark Chassin One Renaissance Blvd Oakbrook Terrace IL 60181 193113539 false X www.jointcommission.org X 1951 IL To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. 21 19 520 19 0 5868 825286 728776 182737650 139618895 8216662 16819755 1192177 1216746 192971775 158384172 0 0 0 118612741 102278886 0 0 0 60162816 38959046 178775557 141237932 14196218 17146240 267866159 280065876 45798444 37567363 222067715 242498513 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 89808487 0 124340103 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. 8344477 0 7216202 PERFORMANCE MEASUREMENT & RELATED ACTIVITIES (ORYX) 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. 8038175 0 8038175 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. 106191139 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 78 0 true 520 true false true SN CH false false false false false false false false true false X 21 19 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 David Perrott DDS MD MBA FACS Chair 3.0 2.0 X X 50000 0 0 Jane D Englebright PhD RN CENP FAAN Vice Chair 3.0 2.0 X X 0 0 0 Mark R Chassin MD FACP MPP MPH President & CEO 36.0 4.0 X X 1527514 0 74602 Adam L Myers MD MHCM FACHE CHCQM CPHRM Commissioner 2.0 0 X 0 0 0 Aurie Hollingsworth Miller BA MA Commissioner 2.0 0 X 0 0 0 Carlos A Pellegrini MD FACS Commissioner 3.0 1.0 X 0 0 0 Eric Langshur Commissioner 1.0 1.0 X 0 0 0 Jay A Gregory MD Commissioner 2.0 0 X 0 0 0 Joan Doyle RN MSN MBA Commissioner 2.0 0 X 0 0 0 Joan Shinkus Clark DNP RN NEA-BC CENP FACHE FAONL FAAN Commissioner 2.0 0 X 0 0 0 John A Babiarz Commissioner 1.0 0 X 0 0 0 Joseph J Parks MD Commissioner 2.0 0 X 0 0 0 LD Britt MD MPH DSC FACS FCCM FRCSEng FRCSEd FWACS FRCSI FCS FRCS Commissioner 1.0 0 X 0 0 0 Mark A Kelley MD MACP FRCP 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 1.0 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 1.0 0 X 0 0 0 Vineet Arora MD MAPP Commissioner 2.0 0 X 0 0 0 William A McDade MD PhD Commissioner 1.0 0 X 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer 40.0 0 X 703429 0 44056 Brian Enochs JD Exec VP Bus Dev & Marketing 40.0 0 X 356732 0 166393 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 0 X 1368713 0 417983 Kin Lee MS CIO & SECURITY OFFICER 40.0 0 X 369126 0 152182 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 21.0 19.0 X 379423 0 170597 Lynn Dragisic EVP Support Op & Chief of Staff 39.0 1.0 X 523768 0 145470 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 39.0 1.0 X 0 442191 128439 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 39.0 1.0 X 1530984 0 432018 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 39.0 1.0 X 329317 0 38820 Paige Rodgers CPA Chief Financial Officer 34.0 6.0 X 764675 0 148460 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 39.0 0 X 167767 0 31118 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 196229 0 15654 Anoop Verma Director Applications Development 40.0 0 X 214748 0 34414 Edward Pollak Patient Safety Officer & Medical Director 40.0 0 X 307208 0 6374 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 40.0 0 X 210879 0 25339 Mark A Crafton Exec Dir Strategic Alliances 40.0 0 X 198938 0 42415 Olga Levin Enterprise Marketing Leader 40.0 0 X 197394 0 26286 Anne Marie Benedicto MPP MPH JC Center for Transforming Hltcr Vice President 0.0 40.0 X 0 324525 159040 9396844 766715 2259659 185 true true false AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75235 PROFESSIONAL SERVICES/CERTIFICATIONS 3673420 APERVITA INC 1 NORTH LASALLE STREET SUITE 1825 Chicago IL 60602 IT Applications 3540000 COGNIZANT TECHNOLOGY SOLUTIONS 24721 NETWORK PLACE CHICAGO IL 60673 IT Applications 1208418 VAR TECHNOLOGY FINANCE VAR RESOURCES LLC AKA PO BOX 5066 HARTFORD CT 061025066 IT Applications 1118870 MICROSOFT CORP C/O BANK OF AMERICA 1950 N STEMMONS FWY DALLAS TX 75207 IT Applications 990206 42 682121 46655 728776 Annual Subscription 541990 92546063 92546063 Survey Fees 541990 31167917 31167917 Performance Measurements 900099 7216202 7216202 Shared Services Fee From Related Tax Exempt Organizations 900099 8038175 8038175 Honorarium Fees 900099 46600 46600 603938 603938 0 0 139618895 2724759 2724759 1216746 1216746 0 0 48824363 0 34657587 71780 14166776 -71780 14094996 14094996 0 0 0 0 0 158384172 139618895 0 18036501 10055030 5431077 4623953 75332797 60214933 15117864 3052606 2362258 690348 7752786 6100268 1652518 6085667 4820952 1264715 68886 43198 25688 253975 253975 193630 193630 323677 323677 9019114 6730501 2288613 0 910977 571791 339186 739035 514039 224996 6692092 3883780 2808312 1873062 604819 1268243 8548701 8548701 914686 851348 63338 241515 98925 142590 6234973 3788317 2446656 1031599 741729 289870 Equipment Rental & Repairs 679457 217311 462146 Bad Debt Expense 526253 526253 Reference Materials 292269 19802 272467 Recruitment 273832 121137 152695 141313 0 141313 0 141237932 106191139 35046793 0 0 0 26805029 50549887 0 0 13338621 7958608 0 0 0 0 0 0 12250 6159 3152423 3049591 96416289 59327401 40733775 37088888 150344069 142326782 33479992 39085961 0 0 0 0 0 267866159 280065876 13990535 10840481 0 0 3747394 3934769 11657307 10602592 0 0 0 0 0 0 0 0 16403208 12189521 45798444 37567363 X 222067715 242498513 0 0 0 0 0 0 0 0 222067715 242498513 267866159 280065876 X 17146240 4954061 -1669503 X false true X true false X 2062010 2148318 1087455 825286 753191 6876260 155707872 165171516 175578868 182737650 139594480 818790386 0 0 0 157769882 167319834 176666323 183562936 140347671 825666646 0 0 0 0 0 0 3831758 2848072 2609279 3487949 2876956 15654014 3831758 2848072 2609279 3487949 2876956 15654014 810012632 3262992 3940913 4028869 4740707 3941505 19914986 0 0 0 0 0 0 3262992 3940913 4028869 4740707 3941505 19914986 0 0 0 0 0 0 0 161032874 171260747 180695192 188303643 144289176 845581632 0.9579 0.9593 0.02 0.0227 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 274000 false false 274000 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 $193,630 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 45744775 25492636 20252139 801562 144407 657155 43081375 32643391 10437984 2584177 1046967 1537210 37088888 Common & Collective Funds - Measured at NAV 38990271 F Common & Collective Funds - Hedge Funds 95690 F 39085961 Unrestricted Operating Pledge to Affiliate - Center for Transforming Hltcr EIN 26-3020947 0 Accrued pension liability 10682056 Capital Lease Obligations 1507465 Fair value of hedge 12189521 X 166881666 4954061 3650000 8604061 158277605 178347 -71780 106567 158384172 146450868 5391283 5391283 141059585 178347 0 178347 141237932 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, 2020 and 2019, The Joint Commission believes it has taken no significant uncertain tax positions. JCRs Singapore branch is subject to Singapore taxes on its operations. As of December 31, 2020 and 2019, a tax of $0 and a tax refund $9,752 have been recorded in other accrued expenses in the accompanying consolidated statements of financial position, respectively. JCR actively analyzes its income tax exposure in foreign jurisdictions and evaluates the potential effect that status changes will have on its financial and business operations. As of December 31, 2020 and 2019, JCR does not believe that such future changes would have a material impact on the consolidated financial statements. 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). JCAHO Surveyor and QHR Consultant Corporation is organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purpose of The Joint Commission and JCR under IRC Section 509(a)(3), while 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 RETURN OF NET ASSETS FROM AFFILIATE - CENTER FOR TRANSFORMING HLTCR EIN 26-3020947 - 3650000 Schedule D, Part XI, Line 4(b) Other revenues in form 990 not in audited financial statements Loss on sale of Fixed Assets - -71780 Schedule D, Part XII, Line 2(d) Other expenses in audited financial statements not in form 990 CHANGE IN NET PERIODIC PENSION COSTS OTHER - 1383281 RETURN OF NET ASSETS TO AFFILIATE - JOINT COMMISSION RESOURCES, INC. EIN 36-3521721 - 3360216 CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COSTS NOT YET RECOGNIZED IN NET PERIODIC BENEFIT COST - 576006 LOSS ON SALE OF FIXED ASSETS - 71780 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 1307407 0 0 0 220107 0 31456 0 43146 0 1602116 0 0 0 Anne Marie Benedicto MPP MPH JC Center for Transforming Hltcr Vice President 0 298924 0 0 0 25601 0 118625 0 40415 0 483565 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 537842 0 0 0 830871 0 374696 0 43288 0 1786696 0 826803 0 Lynn Dragisic EVP Support Op & Chief of Staff 415761 0 0 0 108007 0 134287 0 11183 0 669238 0 92703 0 Brian Enochs JD Exec VP Bus Dev & Marketing 354051 0 0 0 2680 0 125854 0 40539 0 523125 0 0 0 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 295783 0 0 0 33534 0 13591 0 25228 0 368137 0 0 0 Kin Lee MS CIO & SECURITY OFFICER 364177 0 0 0 4949 0 126822 0 25359 0 521308 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer 575758 0 50000 0 77671 0 28662 0 15394 0 747485 0 0 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 467841 0 0 0 1063144 0 430365 0 1654 0 1963003 0 1057176 0 Paige Rodgers CPA Chief Financial Officer 505888 0 0 0 258787 0 128965 0 19495 0 913135 0 256580 0 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 0 357978 0 0 0 84213 0 118739 0 9700 0 570630 0 78186 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 373406 0 0 0 6016 0 127390 0 43207 0 550019 0 0 0 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 195890 0 0 0 340 0 15003 0 651 0 211883 0 0 0 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 166035 0 0 0 1732 0 11038 0 20080 0 198886 0 0 0 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 207312 0 0 0 3567 0 15987 0 9351 0 236218 0 0 0 Mark A Crafton Exec Dir Strategic Alliances 197166 0 0 0 1772 0 19200 0 23215 0 241354 0 0 0 Olga Levin Enterprise Marketing Leader 196542 0 0 0 852 0 0 0 26286 0 223680 0 0 0 Edward Pollak Patient Safety Officer & Medical Director 305791 0 0 0 1416 0 5673 0 701 0 313581 0 0 0 Anoop Verma Director Applications Development 212908 0 0 0 1839 0 10958 0 23456 0 249162 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 Six 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. The increases in the value of the plan during the year are reflected in Column C Deferred Compensation on Schedule J, Part II. A Illinois Finance Authority 861091967 000000000 2015-08-26 16000000 (SEE STATEMENT) false false false A 5300000 0 16026366 0 0 0 229946 0 0 15796420 0 0 2016 false false true true A false false true true true true 0.0143 0.0 0.0143 false false true A false true false false 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. Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) quality and safety of care provided by the organization. THESE ACCREDITATION SERVICES ARE PROVIDED FOR HOSPITALS, CLINICAL LABORATORIES, HOME CARE, NURSING CARE CENTER, 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. (CONTINUATION BELOW) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) 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. 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. (CONTINUATION BELOW) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) 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. 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. To determine the degree to which identified practices are currently being implemented within ASPs around the country, The Joint Commission is currently working on a research project (funded by Pew) to determine which of the leading practices identified by the TEP have been implemented in their ASPs and whether and what barriers to implementation exist. * 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. (CONTINUATION BELOW) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) 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: * 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: * Development of new antimicrobial stewardship requirements applicable to Joint Commission-accredited ambulatory health care organizations that routinely prescribe antimicrobial medications. Scientific literature emphasizes the need to reduce the use of inappropriate antimicrobials in all health care settings due to antimicrobial resistance which threatens the effective prevention and treatment of infections. The inappropriate use of antimicrobial medications contributes to antibiotic resistance and adverse drug events; improving antimicrobial prescribing practices is a patient safety priority. * 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 new Provision of Care, Treatment, and Services (PC) standards to improve the quality and safety of perinatal care in Joint Commission-accredited hospitals. The new standards require organizations to look at their processes and procedures surrounding the care of women experiencing hemorrhage and severe hypertension/preeclampsia. * Application of National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 on suicide prevention to critical access hospitals. Because rates of death by suicide are very high in rural communities, it was determined that this NPSG also should apply to critical access hospitals. A critical access hospital Technical Advisory Panel was held with representatives from critical access hospitals throughout the nation. The advisory panel supported applying NPSG.15.01.01 to critical access hospitals. Review of current national patient safety goals for all accredited programs resulted in some editorial revisions and incorporation of some national patient safety goals as standards. (CONTINUATION BELOW) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) * Development of a requirement related to dosimetry monitoring for office-based surgery (OBS) practices that provide fluoroscopy services. The requirement aligns with current radiological practice standards for OBS practices that provide fluoroscopy services. * Development of and revisions to elements of performance for hospital-based palliative care programs certified under The Joint Commission's Advanced Certification for Palliative Care program. The new and revised requirements align with updated clinical practice guidelines aimed to improve the safety and quality of services for patients receiving palliative care. * Development of and revisions to elements of performance for community-based palliative care programs certified under The Joint Commission's Home Care Accreditation program. The new and revised requirements align with updated clinical practice guidelines aimed to improve the safety and quality of services for patients receiving palliative care. * 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 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. * Collaboration with accredited organizations and key stakeholders to inform revisions to requirements related to minimum elements of a complete medication order and to the administration and documentation of titrated medications. * Development of new and revised standards for behavioral health care organizations that provide substance use disorder treatment services. The new and revised requirements are intended to improve the quality and safety of care provided by these types of organizations. Improvements in this field are needed for treating individuals at an appropriate level of care, care transitions, discharge expectations, and proper uses of urine drug testing. The standards revisions are intended to incorporate best practices and decrease variation among organizations to further improve safety and quality of care. * Research and development of requirements for residents receiving services and care in Assisted Living Communities. 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 standards for molecular testing, pathology, and embryology. In recent years, molecular testing has become more routine in providing accurate results for identification and DNA/RNA measurement of infectious pathogens, tumors, and human genes. By adopting molecular diagnostics and changing the role of pathologists in the laboratories there is a greater impact on the treatment and care of patients. These advanced systems are helping physicians treat infectious diseases sooner and with more precision. Waiting two days or longer for test results, which can delay important treatment for patients, is no longer necessary. For embryology, the incorporation of updated Society of Assisted Reproductive Technology (SART) recommendations address gaps in safety for IVF labs. * Revisions to Patient Blood Management certification to align with American Association of Blood Banks (AABB) standards. * Development and revision of Workplace Violence Prevention standards and a compendium to provide a standardized approach to healthcare workplace violence prevention, reporting, and post-incident strategies. * 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. * Research and 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. * Development of Child Welfare standards that focus on the care and coordination of children while they are displaced from their homes. Multiple domains were explored and included in the new standards, creating a well-rounded program focused on the mental well-being of children in the child welfare system. * The Joint Commission is working with experts to explore the following safety and quality issues that may be considered for inclusion in standards: * Safety and quality related to the management of biosafety threats * Digital Health - monitoring key issues and identifying potential areas for product development in the areas of EHR safety and telehealth * Reducing healthcare disparities * Hospital at Home * Workplace violence * Rural Health Clinic Accreditation * Safety and quality related to Certified Community Behavioral Health Clinics * Safety and quality related to Medication Assisted Treatment and Office Based Opioid Treatment 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. (CONTINUATION BELOW) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) 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 ESTABLISHED THE HEALTH CARE-ASSOCIATED INFECTIONS (HAI) PORTAL IN 2011. THE WEBSITE IS A RICH RESOURCE OF INFORMATION RELATED TO HEALTH CARE-ASSOCIATED INFECTIONS. ALL INFORMATION ON THE WEBSITE IS AVAILABLE FREE TO THE PUBLIC. INFORMATION PROVIDED INCLUDES HAI CURRENT TOPICS, HAI INFORMATION BY HEALTH CARE SETTING IN THE U.S., AND INFECTION PREVENTION AND CONTROL RESOURCES. THE JOINT COMMISSION ESTABLISHED THE PHYSICAL ENVIRONMENT PORTAL DURING 2014. THE PURPOSE OF THE PORTAL IS TO PROVIDE GUIDANCE AND EDUCATION SPECIFIC TO FREQUENTLY IDENTIFIED STANDARDS AND ELEMENTS OF PERFORMANCE (EP). THE JOINT COMMISSION HAS IDENTIFIED SEVERAL STANDARDS THAT HAVE BEEN CITED DURING SURVEY ACTIVITY OVER THE YEARS. THE PORTAL WILL PROVIDE INFORMATION TO REDUCE THE FINDINGS OF NON-COMPLIANCE IMPROVING PATIENT SAFETY WITH BEST PRACTICES AND ENSURING COMPLIANCE. ALL INFORMATION ON THE SITE IS AVAILABLE FREE TO THE PUBLIC. THE JOINT COMMISSION ALSO HAS A PORTAL FOR TRANSITIONS OF CARE. THE PORTAL IS A VALUABLE SOURCE OF INFORMATION FROM THE JOINT COMMISSION AND OTHER HEALTH CARE ORGANIZATIONS RELATED TO TOPICS OF TRANSITIONS OF CARE OR THE MOVEMENT OF PATIENTS BETWEEN VARIOUS HEALTH CARE SETTINGS. The Joint Commission's SAFER Dashboard is a powerful business intelligence tool available exclusively to Joint Commission accredited organizations, empowering timely, data-driven decisions that drive the delivery of safe, high-quality care. Its unique features equip leaders responsible for multiple locations across a corporation or system with unparalleled intelligence at their fingertips to more efficiently power performance improvements. Other benefits to the organization include empowering staff and leadership teams, strengthening decision making abilities, impacting safe care delivery, and boosts organization's efficiency, saving valuable time and resources. Form 990, Part VI, Line 8b Committee authority to act on behalf of governing body All board committees document their meetings and actions taken. However, no board committees have authority to act on behalf of the governing board except by board resolution. 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 CEO, CFO, 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, CODE OF CONDUCT, FINANCIAL STATEMENTS, 990-T, AND PUBLIC DISCLOSURE COPY OF THE 990 ARE MADE AVAILABLE TO THE PUBLIC ON THE ORGANIZATION'S WEBSITE. Form 990, Part VIII, Line 2f Other Program Service Revenue Other Revenues - Total Revenue: 603938, Related or Exempt Function Revenue: 603938, 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 - -1383281; Return of net assets to Affiliate - Joint Commission Resources, Inc. EIN 36-3521721 - -3360216; Return of net assets from Affiliate - Center for Transforming Hltcr EIN 26-3020947 - 3650000; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - -576006; 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, increasing in volume over the course of the year. In June, on-site engagements were restarted and continued through year-end 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, it will take time for the vaccines to materially affect the spread of the virus and the outbreak could have a continued adverse impact on the organization. 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 JCAHO SURVEYOR & QHR CONSULTANT CORP ONE RENAISSANCE BLVD OAKBROOK TERRACE IL 60181 363673595 ADMIN JC AND AFFILIATES Payroll 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 1139651 828530 1 false true false false false false false false false false true false true true true true true true true true joint commission resources inc A 1216746 actual joint commission resources inc L 7029684 contractual joint commission center for transforming healthcare L 1008491 contractual joint commission resources inc Q 15723905 actual joint commission center for transforming healthcare Q 1077892 contractual joint commission center for transforming healthcare S 3650000 contractual jcaho surveyor & qhr consultant corporation P 43055919 actual joint commission resources inc J 270158 Actual joint commission resources inc R 3360216 contractual 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.