2018-11-07T19:00:11-06:00 2017-12-31 350921680 CROWE LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2017-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers Chief Financial Officer 2018-11-07 true RACHEL SPURLOCK P00520729 3128997000 2017 2019-02-21 02:37:17Z The Joint Commission Dr Mark Chassin One Renaissance Blvd Oakbrook Terrace IL 60181 206397215 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. 32 30 534 29 2850 0 2062010 2148318 149232506 157367240 5114994 11541781 7546725 8973710 163956235 180031049 0 0 104511111 112812387 0 0 48819609 52552838 153330720 165365225 10625515 14665824 219756393 241594314 52726735 44539427 167029658 197054887 The Joint Commission periodically evaluates and accredits nearly 21,000 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 quality and safety of care provided by the organization (See Schedule O). false false 118657818 153955295 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. ABOUT 15,000 SURVEYS WERE COMPLETED AT THE REQUEST OF HEALTHCARE ORGANIZATIONS TO DETERMINE IF THE ORGANIZATION MEETS THE STANDARDS FOR ACCREDITATION. 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. ABOUT 20,800 ORGANIZATIONS WERE ENROLLED IN 2017 FOR A SUBSCRIPTION FEE PLAN. 7804276 7804276 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. 2677371 3411945 PERFORMANCE MEASUREMENT & RELATED ACTIVITIES (ORYX) AT THE JOINT COMMISSION ADVANCES 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. 129139465 true true false true false 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 true false false false false false false false false false false false false false true true true false false true 161 0 true 534 true true true false false false false false true false false false false X 32 30 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 L Bronson MD MACP FRCP Edin Chair 3.0 2.0 X X 50000 0 0 Mark R Chassin MD FACP MPP MPH President & CEO 36.0 4.0 X X 1616219 0 64169 David Perrott DDS MD MBA FACS Vice Chair 3.0 2.0 X X 0 0 0 John A Babiarz Commissioner 2.0 1.0 X 0 0 0 LD Britt MD MPH FACS FCCM FRCSEng (Hon) FRCSEd (Hon) Commissioner 2.0 1.0 X 0 0 0 Charles R Buck Jr SCD Commissioner 2.0 0 X 0 0 0 Roger W Bush MD MACP Commissioner 5.0 0 X 0 0 0 Joan Shinkus Clark DNP RN NEA-BC CENP FACHE FAAN Commissioner 2.0 0 X 0 0 0 Ilene Corina Commissioner 1.0 0 X 0 0 0 Grant C Davies FACHE Commissioner 3.0 1.0 X 0 0 0 Joan Doyle RN MSN MBA Commissioner 2.0 0 X 0 0 0 Jane D Englebright PHD RN CENP FAAN Commissioner 2.0 1.0 X 0 0 0 Jay A Gregory MD Commissioner 2.0 0 X 0 0 0 Mark A Kelley MD MACP Commissioner 2.0 0 X 635 0 0 Marie E Knedler RN MS MBA FACHE Commissioner 2.0 0 X 635 0 0 Scott C Malaney FACHE Commissioner 2.0 0 X 635 0 0 Connie S March-Curtis RN MSN Commissioner 2.0 0 X 0 0 0 William A McDade MD PHD Commissioner 2.0 0 X 338 0 0 Mary H McGrath MD MPH FACS Commissioner 4.0 0 X 0 0 0 Najmedin Meshkati PHD Commissioner 2.0 1.0 X 635 0 0 Gregg S Meyer MD MSC Commissioner 2.0 1.0 X 0 0 0 Aurie Hollingsworth Miller BA MA Commissioner 3.0 0 X 0 0 0 Albert J Osbahr III MD MSCM Commissioner 2.0 0 X 0 0 0 Joseph J Parks MD Commissioner 3.0 0 X 680 0 0 Carlos A Pellegrini MD FACS Commissioner 3.0 1.0 X 0 0 0 Stephen R Permut MD JD Commissioner 2.0 0 X 0 0 0 David B Pryor MD Commissioner 3.0 1.0 X 680 0 0 Christopher J Queram Commissioner 1.0 0 X 0 0 0 R Timothy Rice FACHE Commissioner 2.0 0 X 707 0 0 Steven S Sharfstein MD MPA Commissioner 2.0 1.0 X 635 0 0 Michael B Simon MD MBA FASA Commissioner 2.0 0 X 0 0 0 Carl A Sirio MD Commissioner 3.0 0 X 0 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 0 X 501090 0 144875 Ann Scott Blouin PHD RN FACHE Exec VP Customer Relations 40.0 0 X 462878 0 138728 Lynn Dragisic EVP Support Op & Chief of Staff 39.0 1.0 X 483466 0 152707 Brian Enochs JD Exec VP Bus Dev & Marketing 40.0 0 X 357447 0 125146 Mike Kaba MS CHIEF HUMAN RESOURCES OFFICER 39.0 1.0 X 331645 0 32347 Kin Lee MS CIO & SECURITY OFFICER 40.0 0 X 360657 0 85867 Ana Pujols McKee MD Exec VP & Chief Medical Officer 40.0 0 X 641121 0 37408 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 39.0 1.0 X 427807 0 127233 Paige Rodgers CPA Chief Financial Officer 38.0 2.0 X 495015 0 267654 Margaret Van Amringe MHS Exec VP Public Policy & Govnt Relations 39.0 1.0 X 0 424416 122859 Lisa Diehl Vandecaveye JD MBA HRM FACHE General Counsel 36.0 4.0 X 376147 0 132085 Susan Boylan Murray SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 183374 0 20480 Frances Carroll Corporate Compliance & Privacy Officer 40.0 0 X 202915 0 27425 David Gilmartin Associate General Counsel 40.0 0 X 257232 0 49431 Debra Kiel IT DIRECTOR STRATEGIC PLANNING 40.0 0 X 197783 0 34916 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 40.0 0 X 199105 0 57701 Anoop Verma Dir Applications Development 40.0 0 X 203941 0 34965 Anne Marie Benedicto MPP MPH JC Center for Transforming Hltcr Vice President 0.0 40.0 X 0 328466 165819 7353422 752882 1821815 183 true true false AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75235 PROFESSIONAL SERVICES/CERTIFICATIONS 3325267 Hyatt Corp PO Box 98314 Chicago IL 60693 Hospitality Services 1232471 Microsoft Corp 1950 N Stemmons Fwy Dallas TX 75207 Software Services 1195604 AMP Agency Inc 77 N Washington St Boston MA 02134 Market Strategy Services 1106734 AmericanEaglecom 2600 S River Rd DesPlaines IL 60018 Web design services 991902 82 1934584 213734 2148318 Annual Subscription 541900 78667689 78667689 Survey Fees 541900 74589448 74589448 Performance Measurements 900099 3411945 3411945 Honorarium Fees 900099 150467 150467 Other Revenue 900099 547691 547691 0 0 0 0 157367240 2774329 2850 2771479 1169434 1169434 0 0 35133618 26366166 8767452 0 8767452 8767452 Shared Services Fee from Related Tax Exempt Organizations 900099 7804276 7804276 0 0 0 0 7804276 180031049 165171516 2850 12708365 0 0 0 0 0 0 7565566 3167586 4397980 0 86560019 71287233 15272786 4440947 3649059 791888 7830528 6573280 1257248 6415327 5263665 1151662 129500 83871 45629 337857 337857 148000 148000 847729 847729 7735847 5092721 2643126 0 912214 728146 184068 1073899 734092 339807 2795605 580894 2214711 1981819 632563 1349256 25528237 25367133 161104 2042369 1588413 453956 529814 213039 316775 4976112 2676491 2299621 745895 330111 415784 Recruitment 902413 502634 399779 Equipment Rental & Repairs 594116 87129 506987 Bad Debt Expense 563622 562322 1300 Sundry Expense 355895 355895 351895 19083 332812 0 165365225 129139465 36225760 0 14654176 14148405 14539108 18170682 0 0 0 12642 9226 2817351 3524309 90649964 50280712 42483835 40369252 61258246 134995373 83991035 30377067 0 0 0 219756393 241594314 14167021 14347026 3532937 3141952 21161581 17074603 0 13865196 9975846 52726735 44539427 X 167029658 197054887 167029658 197054887 219756393 241594314 X 14665824 8312985 7046420 X false true X true false X 1902807 1154242 1510988 2062010 2148318 8778365 142545602 139684281 145954509 149232506 157367240 734784138 0 0 0 144448409 140838523 147465497 151294516 159515558 743562503 0 0 0 0 0 0 3566647 2885800 2739155 3831758 2760369 15783729 3566647 2885800 2739155 3831758 2760369 15783729 727778774 3781039 2742699 3471863 3262992 12711215 25969808 0 0 0 0 0 0 3781039 2742699 3471863 3262992 12711215 25969808 0 5006477 5437147 5763104 6475366 7804276 30486370 153235925 149018369 156700464 161032874 180031049 800018681 0.9097 0.9423 0.0325 0.0217 X Schedule A, Part III, Line 12 Other Income DESCRIPTION - SHARED SERVICES FEES FROM RELATED ORGANIZATIONS, COLUMN A - 5006477.0, COLUMN B - 5437147.0, COLUMN C - 5763104.0, COLUMN D - 6475366.0, COLUMN E - 7804276.0, COLUMN F - 30486370.0; false true false false false false true 154636 false false 154636 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 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 believes will help improve patient safety and quality of health care. 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 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 believes will help improve patient safety and quality of health care. 4204400 4204400 45154328 20597230 24557098 271266 249640 21626 11101652 7895675 3205977 29918318 21538167 8380151 40369252 Mutual & Comingled Funds - Domestic Equity Funds Mutual & Comingled Funds - International Equity Funds Mutual & Comingled Funds - Fixed Income & Bonds Mutual & Comingled Funds - Domestic Equity Funds F Mutual & Comingled Funds - International Equity Funds F Mutual & Comingled Funds - Fixed Income & Bonds F Common & Collective Funds - Measured at NAV 30088541 F Common & Collective Funds - Hedge Funds 288526 F 30377067 Deferred Swap 5192 Unrestricted Operating Pledge to Affiliate - Center for Transforming Hltcr EIN 26-3020947 1350000 Fair value of hedge 48953 Accrued pension liability 8571701 Due to Affiliate 9975846 X 196566810 8312985 8396420 16709405 179857405 173644 0 173644 180031049 166541581 1350000 1350000 165191581 173644 0 173644 165365225 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. The Joint Commission and its affiliates are subject to income taxes on income determined to be unrelated business taxable income. The Joint Commission accounts for income tax uncertainties in accordance with the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) 740-10, Income Taxes - Overall, which prescribes a comprehensive model for how an organization should measure, recognize, present, and disclose in its financial statements uncertain tax positions that an organization has taken or expects to take on a tax return. The Joint Commission has analyzed tax positions taken for filing with the Internal Revenue Service and all state jurisdictions where it operates. The Joint Commission believes that income tax filing positions will be sustained upon examination and does not anticipate any adjustments that would result in a material adverse effect on The Joint Commission's financial condition, results of operations, or cash flows. Accordingly, The Joint Commission has not recorded any reserves, or related accruals for interest and penalties for uncertain income tax positions at December 31, 2017 or 2016 for its U.S. operations. Schedule D, Part XI, Line 2(d) Other revenues in audited financial statements not in form 990 CHANGE IN FAIR VALUE OF HEDGE-INTEREST RATE SWAP - 146582 TRANSFER OF ASSETS TO PARENT COMPANY FROM JOINT COMMISSION RESOURCES, INC. EIN 36-3521721 - 5437039 Change in unrecognized net defined benefit plan costs - 2812799 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 Hlthcr EIN 26-3020947 - 1350000 Europe (Including Iceland and Greenland) 0 4 Program Services,Conference Travel Sending agents of the organization to perform accreditation survey services to evaluate an organization's compliance with state-of-the-art accreditation standards and Sending an agent of organization to attend a conference. 17480 East Asia and the Pacific 0 2 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences 20754 Middle East and North Africa 0 1 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences 4630 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 1369 0 8 0 0 0 8 44233 0 44233 false false false false false false X X true true X X X X false true false true false true true false false Mark R Chassin MD FACP MPP MPH President & CEO 1316697 0 56400 0 243122 0 27206 0 36963 0 1680388 0 0 0 Anne Marie Benedicto MPP MPH JC Center for Transforming Hltcr Vice President 0 302703 0 750 0 25013 0 131613 0 34206 0 494285 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 495126 0 3000 0 2964 0 120241 0 24634 0 645965 0 0 0 Ann Scott Blouin PHD RN FACHE Exec VP Customer Relations 332969 0 32250 0 97659 0 118706 0 20022 0 601606 0 93861 0 Lynn Dragisic EVP Support Op & Chief of Staff 401189 0 3000 0 79277 0 116825 0 35882 0 636173 0 70871 0 Brian Enochs JD Exec VP Bus Dev & Marketing 352682 0 3000 0 1765 0 90810 0 34336 0 482593 0 0 0 Mike Kaba MS CHIEF HUMAN RESOURCES OFFICER 292291 0 11500 0 27854 0 10900 0 21447 0 363992 0 0 0 Kin Lee MS CIO & SECURITY OFFICER 340758 0 15000 0 4899 0 64086 0 21781 0 446524 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer 561275 0 3000 0 76846 0 23912 0 13496 0 678529 0 0 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 420763 0 3000 0 4044 0 125653 0 1580 0 555040 0 0 0 Paige Rodgers CPA Chief Financial Officer 489808 0 3000 0 2207 0 242512 0 25142 0 762669 0 0 0 Margaret Van Amringe MHS Exec VP Public Policy & Govnt Relations 0 344389 0 3000 0 77027 0 114246 0 8613 0 547275 0 72455 Lisa Diehl Vandecaveye JD MBA HRM FACHE General Counsel 367865 0 3000 0 5282 0 95754 0 36331 0 508232 0 0 0 Susan Boylan Murray SENIOR DIRECTOR FIELD OPERATIONS 180184 0 3000 0 190 0 19891 0 589 0 203854 0 0 0 Frances Carroll Corporate Compliance & Privacy Officer 197787 0 3000 0 2128 0 20727 0 6698 0 230340 0 0 0 David Gilmartin Associate General Counsel 240050 0 4300 0 12882 0 25168 0 24263 0 306663 0 0 0 Debra Kiel IT DIRECTOR STRATEGIC PLANNING 193109 0 3000 0 1674 0 27784 0 7132 0 232699 0 0 0 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 194196 0 4462 0 447 0 21274 0 36427 0 256806 0 0 0 Anoop Verma Dir Applications Development 199600 0 3000 0 1341 0 16772 0 18193 0 238906 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. First class travel benefits are not treated as taxable compensation to the interested person. Schedule J, Part I, Line 1a Personal services Certain officers are offered an allowance for tax preparation and 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. Schedule J, Part I, Line 5a Compensation contingent on revenues of the organization The Joint Commission's Human Resources and Compensation Committee approved the 2016 and 2017 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 2016 and 2017 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 2016 and 2017. The 2016 awards were accrued for in the year ended December 31, 2016 and were paid out in 2017. The 2017 awards were accrued for in the year ended December 31, 2017 and will be paid out in 2018. 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 2016 and 2017 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 2016 and 2017 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 2016 and 2017. The 2016 awards were accrued for in the year ended December 31, 2016 and were paid out in 2017. The 2017 awards were accrued for in the year ended December 31, 2017 and will be paid out in 2018. 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 2075000 0 16026366 0 0 0 229946 0 0 15796420 0 0 2016 false false true true A false false true true true true 0.0144 0.0 0.0144 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) 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 APPROXIMATELY 580 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 GOALS AND REQUIREMENTS ARE DRAWN FROM A "POOL" OF RECOMMENDATIONS IDENTIFIED BY THE PATIENT SAFETY ADVISORY GROUP AS EVIDENCE- OR CONSENSUS-BASED, COST-EFFECTIVE, AND FEASIBLE TO IMPLEMENT. 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: * Continue work on a research project funded by the CDC titled, Adaptation and Dissemination of Outpatient Infection Prevention (ADOPT) Guidance. This project is 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 working 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 is expected in late 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. A manuscript is in development. * Completed work on a project with AHA's Health Research and Educational Trust (HRET) to implement a Comprehensive Unit-based Safety Program (CUSP) to reduce catheter-associated urinary tract infection (CAUTI) in long term care facilities. * 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. * 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. Findings from three research projects have been presented at national conferences and have led to development of several peer-reviewed publications. * Completed work on a multi-year project on the maintenance, update and dissemination of internet based resources for the project: Strategies for Improving Rapid influenza testing in Ambulatory Settings (SIRAS II). This project was supported through a cooperative agreement with CDC, Center for Surveillance, Epidemiology, and Laboratory Services, Division of Laboratory Systems. The project included the development and dissemination of six educational modules on influenza preparedness and influenza pandemic preparedness in ambulatory settings and, translation of modules into Spanish language. The Joint Commission uses multiple media channels to promote and disseminate the modules. * Continue 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. * 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 HAVE INCLUDED: * An AHRQ-funded project that created two Informed Consent online learning modules to help hospital leaders and providers improve their informed consent process. The leaders course helps hospitals develop clear and unambiguous informed consent policy that are effective in honoring the patient's right to give or withhold informed consent. The health care providers module provides health care professionals with strategies and tools to improve the informed consent process to help patients make an informed choice for healthcare. * Work with Pfizer Independent Grants for Learning and Change and Bristol Myers-Squibb (BMS) Independent Medical Education, to utilize an established Request for Proposal process to identify, fund and oversee four projects related to transitions of care among a defined venous thromboembolism patient population. * Work on a project funded by BMS/Pfizer to determine whether or not comprehensive patient education or discharge materials are available for venous thromboembolism (VTE) patients being discharged on anticoagulants other than warfarin. This project resulted in the publication of a Compendium of Resources for VTE patients discharged on anticoagulants that highlighted 70 resources from over 30 key professional associations and stakeholders. * Ongoing work with CDC NIOSH to identify research priorities related to patient and worker safety for the National Occupational Research Agenda. * Launched in October 2016, The Joint Commission maintains and updates 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: *New and revised pain assessment and management standards for the Hospital accreditation program. In early 2016, The Joint Commission conducted an extensive literature review on contemporary guidelines and best practices for pain assessment and management in order to identify disparities between current accreditation requirements and contemporary guidance. The standards address: (a)Identifying a leader or leadership team that is responsible for pain management and safe opioid prescribing; (b)Involving patients in developing their treatment plans and setting realistic expectations and measurable goals; (c)Promoting safe opioid use by identifying high-risk patients; (d)Monitoring high-risk patients; (e)Facilitating clinician access to prescription drug monitoring program databases *New requirements addressing antimicrobial stewardship for hospitals, critical access hospitals, and nursing care centers. Current 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 Centers for Disease Control and Prevention (CDC) identified that 20%-50% of all antibiotics prescribed in U.S. acute care hospitals are either unnecessary or inappropriate, and that antibiotics are among the most commonly prescribed medications in nursing homes. Expansion of the requirements to ambulatory care are being considered. *Revised requirements for National Patient Safety Goals on multidrug-resistant organisms (MDRO), central-line associated bloodstream infections (CLABSI), and catheter-associated urinary tract infections (CAUTI) to reflect the most current evidence-based practices for preventing these infections. The CAUTI and MDRO Goals were also expanded to the Nursing Care Center accreditation program. *Developed a new certification program in collaboration with the American Heart Association and American Stroke Association that recognizes thrombectomy capable stroke centers to improve the quality and safety of care for stroke patients. The Joint Commission continues to monitor the rapidly changing science in this field to assure requirements align with current science. *Revision of the Emergency Management standards to reflect new requirements from CMS related to planning, training, and conducting exercises. These modifications apply to the critical Access Hospital, Hospital, Ambulatory Care, and Home Care accreditation programs. (CONTINUATION BELOW) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) *Adoption of an updated version of the Life Safety Code by CMS resulted in revisions to relevant Joint Commission standards in the Life Safety and Environment of Care chapters in the standards manuals for all accreditation programs. *Development of a medication compounding certification program addressing quality and safety issues. The program evaluates a pharmacy's compliance with standards that are based on the sterile and non-sterile compounding requirements issued by the USP in its chapters. A chapter on medication compounding was also added to the Home Care accreditation manual. * The development of a new requirement related to documentation of maternal status upon admission to labor and delivery. The requirement relates to the documentation of status for HIV, hepatitis B, GBS, and syphilis in order to improve the quality and safety of care for the mother and the newborn. *The Joint Commission is working with experts to explore the following safety and quality issues that may be considered for inclusion in standards: *The safe delivery of fluoroscopy services *Reporting of abnormal test results *Anticoagulant treatment with direct oral anticoagulants *Mis-identification of newborns *Modification of existing National Patient Safety Goal on suicide risk assessment 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 WHAT YOU SHOULD KNOW ABOUT PAIN MANAGEMENT. 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 40 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 21,000 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 PHYSICIAN 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 6 Classes of members or stockholders THE JOINT COMMISSION HAS CORPORATE MEMBERS AS NOTED IN THEIR BYLAWS. EACH MEMBER IS GRANTED A CERTAIN NUMBER OF VOTES WHEN VOTING ON ISSUES BROUGHT UP DURING MEMBER MEETINGS. THE FOLLOWING CORPORATIONS ARE MEMBERS OF THE JOINT COMMISSION: AMERICAN COLLEGE OF PHYSICIANS, THREE VOTES; AMERICAN COLLEGE OF SURGEONS, THREE VOTES; AMERICAN DENTAL ASSOCIATION, ONE VOTE; AMERICAN HOSPITAL ASSOCIATION, SEVEN VOTES; AND AMERICAN MEDICAL ASSOCIATION, SEVEN VOTES. THE NUMBER OF VOTES TO WHICH ANY ADDITIONAL MEMBERS SHALL BE ENTITLED SHALL BE ESTABLISHED BY AMENDMENT TO THE BYLAWS 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 Legal 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 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, FAMILIAR, OR BUSINESS RELATIONSHIPS THAT COULD BE PERCEIVED AS A CONFLICT OF INTEREST. THE INTERESTS IDENTIFIED ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AND MANAGER AND APPROPRIATELY MANAGED. ALL DISCLOSURES ARE PURSUED UNTIL 100% COMPLETED. THE BOARD 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. 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 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 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 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 process for determining the ceo's 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 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 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 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 process for determining the organizations' top management officials' compensation is undertaken annually for: dr. mark chassin - president, dr. david baker - vp, ann scott Blouin - vp, lynn dragisic - vp, brian Enochs - vp, mike kaba - vp, kin lee - cio, ana pujols mckee - vp, mark pelletier - vp, paige rodgers - cfo, Lisa Diehl Vandecaveye - vp, and Margaret Van Amringe - vp. 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 DECISIONMAKING 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 XI, Line 9 Other changes in net assets or fund balances Change in fair value of hedge - interest rate swap - 146582; Transfer of net assets to Parent Co from Joint Commmission Resources, Inc. EIN 36-3521721 - 5437039; Transfer of net assets to Affiliate for Operating - Center for Transforming Hltcr EIN 26-3020947 - -1350000; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - 2812799; 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 true false false false false false false false false false false true true true true true true true true Joint commission resources inc A 1169434 actual joint commission resources inc L 6476804 contractual joint commission center for transforming healthcare L 1327472 contractual joint commission resources inc Q 18826766 actual joint commission center for transforming healthcare Q 918165 actual joint commission center for transforming healthcare R 1350000 contractual joint commission resources inc S 5437039 contractual joint commission resources inc M 203895 actual jcaho surveyor & qhr consultant corporation P 51302148 actual