2020-11-16T13:30:44-06:00 2019-12-31 350921680 CROWE LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2019-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers CFO/TREASURER 2020-11-16 true RACHEL SPURLOCK P00520729 3128997000 2019 2021-01-29 14:40:06Z The Joint Commission Dr Mark Chassin One Renaissance Blvd Oakbrook Terrace IL 60181 202698429 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 19 556 19 -1522 -3522 1087455 825286 175578868 182737650 7664363 8216662 1211154 1192177 185541840 192971775 0 0 0 117337645 118612741 0 0 56327504 60162816 173665149 178775557 11876691 14196218 234221474 267866159 45420252 45798444 188801222 222067715 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 122206712 167296435 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. 8325486 7138684 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. 8302531 8302531 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. 138834729 true true false true false false false false false true true false false true true false true false false true false false false false false false false false true true false false false false false false false false false false false false false false false true true true false false true 93 0 true 556 true false false false false false false false false false false true false X 21 19 false false true 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 6.0 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 1631180 0 69827 Albert J Osbahr III MD MSCM 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 Grant C Davies FACHE Commissioner 2.0 1.0 X 612 0 0 Gregg S Meyer MD MSc Commissioner 2.0 0 X 912 0 0 Jay A Gregory MD Commissioner 2.0 0 X 0 0 0 Joan Doyle RN MSN MBA Commissioner 3.0 0 X 0 0 0 Joan Shinkus Clark DNP RN NEA-BC CENP FACHE 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 612 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 Commissioner 3.0 0 X 912 0 0 Michael B Simon MD MBA FASA Commissioner 2.0 0 X 391 0 0 Najmedin Meshkati PhD Commissioner 2.0 1.0 X 847 0 0 Roger W Bush MD MACP Commissioner 4.0 0 X 912 0 0 Scott C Malaney FACHE Commissioner 3.0 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 731740 0 40839 Brian Enochs JD Exec VP Bus Dev & Marketing 40.0 0 X 377516 0 122825 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 0 X 572182 0 202310 Kin Lee MS CIO & SECURITY OFFICER 40.0 0 X 386205 0 108239 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 29.0 11.0 X 403630 0 128567 Lynn Dragisic EVP Support Op & Chief of Staff 39.0 1.0 X 533239 0 145721 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 39.0 1.0 X 0 456013 128882 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 39.0 1.0 X 498323 0 168906 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 39.0 1.0 X 348389 0 46617 Paige Rodgers CPA Chief Financial Officer 33.0 7.0 X 701990 0 241972 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 170191 0 36608 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 197165 0 23132 Anoop Verma Director Applications Development 40.0 0 X 217709 0 37891 Edward Pollak Patient Safety Officer & Medical Director 40.0 0 X 443011 0 23386 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 40.0 0 X 213849 0 32562 Mark A Crafton Exec Dir Strategic Alliances 40.0 0 X 202984 0 41679 Tricia K Elliott Director Quality Measurement 40.0 0 X 209821 0 18255 Anne Marie Benedicto MPP MPH JC Center for Transforming Hltcr Vice President 0.0 40.0 X 0 346262 133249 Cheryl Hoying Former Officer 0.0 0.0 X 0 220000 0 7894320 1022274 1751466 196 true true false AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75235 PROFESSIONAL SERVICES/CERTIFICATIONS 3218345 APERVITA INC 1 NORTH LASALLE STREET SUITE 1825 Chicago IL 60602 IT Applications 3102510 WINWIRE TECHNOLOGIES INC 2350 MISSION COLLEGE BLVD SUITE 925 SANTA CLARA CA 95054 IT Applications 1393390 HYATT REGENCY O'HARE PO BOX 98314 CHICAGO IL 60693 HOSPITALITY 1023759 AMP AGENCY INC 77 N WASHINGTON ST BOSTON MA 02114 Web Marketing 897340 47 688172 137114 825286 Annual Subscription 541900 88456043 88456043 Survey Fees 541900 77741276 77741276 Performance Measurements 900099 7138684 7138684 Shared Services Fee From Related Tax Exempt Organizations 900099 8302531 8302531 Honorarium Fees 900099 109700 109700 989416 989416 0 0 182737650 3547008 -1522 3548530 1192177 1192177 0 0 14396308 9726654 4669654 0 4669654 4669654 0 0 0 0 0 192971775 182737650 -1522 9410361 7887312 3141736 4745576 89558630 72819662 16738968 5253192 4335571 917621 9183898 7662112 1521786 6729709 5418157 1311552 136300 34987 101313 448548 448548 160400 160400 1115522 1115522 9384234 6517193 2867041 0 1374064 1144906 229158 980609 634438 346171 6185106 3402253 2782853 1887031 676242 1210789 26445938 26277805 168133 2562519 2162668 399851 252230 105861 146369 5634652 2950517 2684135 1526550 741729 784821 Recruitment 401515 164988 236527 Equipment Rental & Repairs 639307 256575 382732 Bad Debt Expense 349870 349870 Sundry Expense 264422 264422 413999 37459 376540 0 178775557 138834729 39940828 0 15938170 26805029 18595435 13338621 0 0 0 0 11609 12250 3003043 3152423 94637102 53903327 39944913 40733775 127960927 150344069 28767377 33479992 0 0 0 234221474 267866159 13818861 13990535 3035647 3747394 12710096 11657307 0 0 15855648 16403208 45420252 45798444 X 188801222 222067715 188801222 222067715 234221474 267866159 X 14196218 18493265 577010 X false true X true false X 1510988 2062010 2148318 1087455 825286 7634057 151717613 155707872 165171516 175578868 182737650 830913519 0 0 0 153228601 157769882 167319834 176666323 183562936 838547576 0 0 0 0 0 0 2739155 3831758 2848072 2609279 3487949 15516213 2739155 3831758 2848072 2609279 3487949 15516213 823031363 3471863 3262992 3940913 4028869 4740707 19445344 0 0 0 0 0 0 3471863 3262992 3940913 4028869 4740707 19445344 0 0 0 0 0 0 0 156700464 161032874 171260747 180695192 188303643 857992920 0.9593 0.9605 0.0227 0.0213 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 228090 false false 228090 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 $160,400 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 45204745 23839187 21365558 801562 69303 732259 41870818 29806869 12063949 2555577 187968 2367609 40733775 Common & Collective Funds - Measured at NAV 33350648 F Common & Collective Funds - Hedge Funds 129344 F 33479992 Unrestricted Operating Pledge to Affiliate - Center for Transforming Hltcr EIN 26-3020947 3650000 Accrued pension liability 10385599 Capital Lease Obligations 2367609 Fair value of hedge 16403208 X 215799637 18493265 4507985 23001250 192798387 173388 0 173388 192971775 182533144 3930975 3930975 178602169 173388 0 173388 178775557 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. 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, 2019 and 2018, 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). 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 TRANSFER OF NET ASSETS TO PARENT CO FROM JOINT COMMISSION RESOURCES, INC. EIN 36-3521721 - 3360216 CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COSTS NOT YET RECOGNIZED IN NET PERIODIC BENEFIT COST - 1147769 Schedule D, Part XII, Line 2(d) Other expenses in audited financial statements not in form 990 TRANSFER OF NET ASSETS TO AFFILIATE FOR OPERATING - CENTER FOR TRANSFORMING HLTCR EIN 26-3020947 - 3650000 Change in net periodic pension costs other - 280975 Europe (Including Iceland and Greenland) 0 1 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences. 4183 East Asia and the Pacific 0 1 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences 8285 Middle East and North Africa 0 4 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences 22857 North America (Canada & Mexico only) 0 1 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences 1790 0 7 0 0 0 7 37115 0 37115 false false true false false true Schedule F, Part IV, Line 3 Form 5471 Filing Obligation Joint Commission Resources, Inc. (EIN: 36-3521721) filed the Form 5471 on behalf of Joint Commission on Accreditation of Healthcare Organizations (TJC). Therefore, the Form 5471 filing obligation for TJC has been satisfied pursuant to Regs. §1.6038-2(j). Schedule F, Part IV, Line 6 Form 5713 Filing Obligation The filing organization is a member in a controlled group as defined in section 993(a)(3). As a member of a controlled group, the filing organization must include a statement accompanying the taxpayer's annual filing disclosing any operations in or activities related to a boycotting country conducted by another member of the controlled group, Joint Commission Resources, Inc. (EIN: 36-3521721). This statement has been included with the Form 990-T for the filing organization. This statement certifies the filing organization had no operations in or related to a boycotting country and the operations or activities related to a boycotting country conducted by the controlled group member have been satisfied by the controlled group member's submission of Form 5713. X X true true X X X X true true false true false true true false false Mark R Chassin MD FACP MPP MPH President & CEO 1386777 0 28969 0 215434 0 29977 0 39850 0 1701007 0 0 0 Anne Marie Benedicto MPP MPH JC Center for Transforming Hltcr Vice President 0 318454 0 1020 0 26787 0 96059 0 37190 0 479511 0 0 Cheryl Hoying Former Officer 0 0 0 0 0 220000 0 0 0 0 0 220000 0 0 Lynn Dragisic EVP Support Op & Chief of Staff 440348 0 1020 0 91871 0 131989 0 13733 0 678960 0 82310 0 Michael Kaba MS CHIEF HUMAN RESOURCES OFFICER 313885 0 1020 0 33484 0 23442 0 23175 0 395006 0 0 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 491360 0 1020 0 5943 0 167297 0 1609 0 667229 0 0 0 Paige Rodgers CPA Chief Financial Officer 531775 0 1020 0 169195 0 223752 0 18220 0 943962 0 166213 0 Margaret VanAmringe MHS Exec VP Public Policy & Govnt Relations 0 377820 0 1020 0 77172 0 118342 0 10539 0 584894 0 70865 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 397394 0 1020 0 5216 0 89305 0 39261 0 532196 0 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 567094 0 1020 0 4068 0 175897 0 26413 0 774492 0 0 0 Brian Enochs JD Exec VP Bus Dev & Marketing 373873 0 1020 0 2624 0 85543 0 37283 0 500342 0 0 0 Kin Lee MS CIO & SECURITY OFFICER 380336 0 1020 0 4849 0 84562 0 23678 0 494444 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer 607437 0 46020 0 78283 0 26443 0 14396 0 772579 0 0 0 Suzanne C Murray SENIOR DIRECTOR FIELD OPERATIONS 195965 0 1020 0 180 0 22492 0 640 0 220297 0 0 0 Deborah Ryan SENIOR DIRECTOR FIELD OPERATIONS 167535 0 1020 0 1636 0 17774 0 18833 0 206798 0 0 0 Frances Carroll Corp Compliance Officer & Sr Assist Gen'l Counsel 209104 0 1270 0 3475 0 23798 0 8764 0 246411 0 0 0 Mark A Crafton Exec Dir Strategic Alliances 200223 0 1020 0 1741 0 20727 0 20952 0 244663 0 0 0 Tricia K Elliott Director Quality Measurement 191828 0 16590 0 1403 0 17628 0 627 0 228075 0 0 0 Edward Pollak Patient Safety Officer & Medical Director 425056 0 16020 0 1935 0 22400 0 986 0 466397 0 0 0 Anoop Verma Director Applications Development 214880 0 1020 0 1808 0 18897 0 18993 0 255599 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 Five 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 4a Severance or change-of-control payment THE JOINT COMMISSION MADE PAYMENTS PURSUANT TO AN AGREEMENT IN CONNECTION WITH STAFF SEPARATIONS. THESE PAYMENTS WERE TREATED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J, PART II COLUMN (B)(III), OTHER REPORTABLE COMPENSATION. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan All officers are allowed to participate in a nonqualified supplemental defined benefit retirement plan. The increases in the value of the plan during the year are reflected in Column C Deferred Compensation on Schedule J, Part II. Schedule J, Part I, Line 5a Compensation contingent on revenues of the organization The Joint Commission's Human Resources and Compensation Committee approved the 2018 and 2019 gainshare plans, which provide financial awards to staff for performance that contributes to the mission and objectives of the Joint commission. The plan is self-funded, in that all awards for 2018 and 2019 were contingent upon whether the actual financial results for the Joint Commission exceeded the Joint Commission's budgeted net earnings in excess of 2% over budget, the actual financial results met or exceeded the Organization's budgeted revenues, and the Joint Commission met or exceeded a net promoter score rating. Individual gainsharing awards were capped at $3,000 for both 2018 and 2019. The 2018 awards were accrued for in the year ended December 31, 2018 and were paid out in 2019. There were no 2019 awards accrued for in the year ended December 31, 2019 . Schedule J, Part I, Line 6a Compensation contingent on net earnings of the organization The Joint Commission's Human Resources and Compensation Committee approved the 2018 and 2019 gainshare plans, which provide financial awards to staff for performance that contributes to the mission and objectives of the Joint commission. The plan is self-funded, in that all awards for 2018 and 2019 were contingent upon whether the actual financial results for the Joint Commission exceeded the Joint Commission's budgeted net earnings in excess of 2% over budget, the actual financial results met or exceeded the Organization's budgeted revenues, and the Joint Commission met or exceeded a net promoter score rating. Individual gainsharing awards were capped at $3,000 for both 2018 and 2019. The 2018 awards were accrued for in the year ended December 31, 2018 and were paid out in 2019. There were no 2019 awards accrued for in the year ended December 31, 2019. Schedule J, Part I, Line 6b Compensation contingent on net earnings of a related organization For the corporate gainsharing plan to be paid, all awards were contingent upon whether the actual operating margin financial results for the Enterprise exceeded the Enterprise's budgeted net earnings excess of 2% over budget. A Illinois Finance Authority 861091967 000000000 2015-08-26 16000000 (SEE STATEMENT) false false false A 4225000 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 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, LONG TERM CARE, 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 AN ON-SITE 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 ON-SITE 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 ON-SITE 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 an 18-month 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 have been submitted for publication in the Joint Commission Journal on Quality and Patient Safety. * Completed work on a research project funded by the CDC titled, Adaptation and Dissemination of Outpatient Infection Prevention (ADOPT) Guidance. This project was designed to prevent healthcare associated infections in outpatient settings by identifying gaps and inconsistencies in current CDC infection control materials for outpatient settings and by developing adapted infection prevention and control guides for specific outpatient settings. The ADOPT Guidance team is worked with 12 ambulatory-focused professional associations and 11 ambulatory health care systems on all project-related activities. Release of the adapted guides, as well as a general outpatient infection prevention customizable, fillable checklist (based on the existing CDC Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care) was completed in 2018. * Completed work on the CDC BAA supported project entitled "Implementing standardized measurement of infections in nursing homes: challenges and facilitators." There were 36 nursing homes enrolled who were supported through the process of NHSN enrollment and data submission in the C. difficile Lab-Id module. * Completed a collaborative research project related to respiratory protection. This project was supported through a contract with the CDC, National Institute for Occupational Safety and Health (NIOSH), and National Personal Protective Laboratory (NPPTL). The project had two aims: (1) To assess the usefulness of two resources related to respiratory protection, and (2) to identify clinical situations whereby clarification regarding clinical use of respiratory protection might be needed. The team worked with an eight-member Technical Advisory Panel and a scientific officer to identify clinical conundrums related to respiratory protection, as well as continuing operational challenges. A final report was submitted to CDC in October 2017 and the manuscript was published in Q1 2019. * 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: * 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. * Development of new Advanced Disease-Specific Care (DSC) certification programs for ST-elevation myocardial infarction (STEMI) heart attack patient care: the Primary Heart Attack Center (PHAC) and the Acute Heart Attack Ready (AHAR) certification programs. Both certification programs will standardize and improve coordinated systems of care across settings for identification, assessment, monitoring, management, data sharing, and performance improvement for multidisciplinary STEMI heart attack care. * 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. Maternal morbidity and mortality have been on the rise since 2009, ranking the United States 65th among other developed countries for outcomes surrounding perinatal care. Cases involving hemorrhage or severe hypertension/preeclampsia are among the leading causes of maternal mortality and morbidity; however, they also are preventable. 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 elements of the national patient safety goal on suicide prevention to Critical Access Hospitals. A research and technical advisory panel representing Critical Access Hospitals indicated that rates of death by suicide are very high in rural communities. * Review of current national patient safety goals for all accredited programs resulting 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 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. * The Joint Commission is working with experts to explore the following safety and quality issues that may be considered for inclusion in standards: * Substance use disorder treatment programs including medication assisted treatment (MAT) * Age-friendly health systems * Weighing all patients in kilograms * Safety and quality in child welfare * 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, telehealth, and texting/emailing orders * Leading board practices/governance * Workplace violence * Molecular, pathology, and anatomy laboratory standards revisions and additions 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. 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 4 Significant changes to organizational documents Effective January 1, 2019: * The Board of Commissioners shall be composed of twenty-one members (reduced from thirty-two). * Of which members will consist of: a) Two Commissioners shall be appointed by the American College of Physicians, two by the American College of Surgeons, one by the American Dental Association, four by the American Hospital Association, and four by the American Medical Association; and b) In addition, In addition, the Board of Commissioners shall appoint seven additional Commissioners who shall serve as members of the Board based on the strategic needs of the Corporation as determined by the Board from time to time in its discretion. All appointments by the Board of Commissioners shall be made upon the affirmative vote of three-fourths of the Commissioners present at a regular or special meeting of the Board at which a quorum is present. And c) The President of The Joint Commission shall serve on the Board of Commissioners as an ex officio member with vote. 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, THE BOARD CONDUCTS AN ANNUAL EVALUATION OF THE OFFICERS. 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 AGREEMENT IS SUBJECT TO A REVIEW AND APPROVAL BY THE CHIEF HUMAN RESOURCES OFFICER. INCENTIVE COMPENSATION FOR KEY EMPLOYEES IS ALSO REVIEWED AND APPROVED BY THE ORGANIZATION'S HUMAN RESOURCES AND COMPENSATION COMMITTEES. 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: 989416, Related or Exempt Function Revenue: 989416, 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 - -280975; Transfer of net assets to Parent Co from Joint Commission Resources, Inc. EIN 36-3521721 - 3360216; Transfer of net assets to Affiliate for Operating - Center for Transforming Hltcr EIN 26-3020947 - -3650000; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - 1147769; 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 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 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 1192177 actual joint commission resources inc L 7183927 contractual joint commission center for transforming healthcare L 1118604 contractual joint commission resources inc Q 18645056 actual joint commission center for transforming healthcare Q 1231080 contractual joint commission center for transforming healthcare R 3650000 contractual joint commission resources inc S 3360216 contractual jcaho surveyor & qhr consultant corporation P 55065655 actual joint commission resources inc J 53022 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