2017-11-06T09:00:16-06:00 2016-12-31 350921680 CROWE HORWATH LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2016-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers Chief Financial Officer 2017-10-24 true John Woodhull P01305268 3128997000 2016 2017-02-10 21:41:12Z The Joint Commission Dr Mark Chassin One Renaissance Blvd Oakbrook Terrace IL 60181 232799102 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 30 521 30 0 -4001 1510988 2062010 145954509 149232506 6043969 5114994 6802228 7546725 160311694 163956235 0 0 100274834 104511111 0 0 47060086 48819609 147334920 153330720 12976774 10625515 209280318 219756393 62254592 52726735 147025726 167029658 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 state-of-the-art standards 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 114708760 145684146 SURVEY AND CERTIFICATION FEES ARE GENERATED AS A CONSEQUENCE OF PERFORMING ACCREDITATION SURVEYS THAT ARE DESIGNED TO EVALUATE AN ORGANIZATION'S COMPLIANCE WITH STATE-OF-THE-ART STANDARDS AND THEIR ACCREDITATION REQUIREMENTS. ABOUT 13,400 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 20,500 ORGANIZATIONS WERE ENROLLED IN 2016 FOR A SUBSCRIPTION FEE PLAN. 3997892 3548360 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. 118706652 true true false true false false false false false false true true false false true true false true false false false false false false false false false false false true true false true false false false false false false false false false false false false false true true true false false true 162 0 true 521 true false false false false false false false 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 X Paige Rodgers 6307925685 One Renaissance Blvd Oakbrook Terrace IL 60181 David L Bronson MD MACP FRCP Vice Chair 5.0 2.0 X X 833 0 0 Mark R Chassin MD FACP MPP MPH President & CEO 36.0 4.0 X X 1611146 0 60985 Craig W Jones FACHE Chair 5.0 2.0 X X 50964 0 0 John A Babriaz Commissioner 4.0 1.0 X 0 0 0 LD Britt MD MPH FACS FCCM Commissioner 3.0 1.0 X 833 0 0 Charles R Buck Jr SCD Commissioner 3.0 0 X 0 0 0 Roger W Bush MD MACP FRCP Commissioner 3.0 0 X 1025 0 0 Joan Shinkus Clark Commissioner 3.0 0 X 0 0 0 Ilene Corina Commissioner 3.0 0 X 964 0 0 Grant C Davies FACHE Commissioner 3.0 1.0 X 0 0 0 Joan Doyle RN MSN MBA Commissioner 3.0 0 X 976 0 0 Jane D Englebright PHD RN CENP FAAN Commissioner 3.0 1.0 X 0 0 0 Jay A Gregory MD FACS Commissioner 3.0 0 X 976 0 0 Aurie Hollingsworth Miller BA MA Commissioner 3.0 0 X 1025 0 0 Mark A Kelley MD MACP Commissioner 3.0 0 X 964 0 0 Marie E Knedler RN MS MBA FACHE Commissioner 3.0 0 X 964 0 0 Scott C Malaney FACHE Commissioner 3.0 0 X 0 0 0 Connie S March-Curtis RN MSN Commissioner 4.0 0 X 0 0 0 Mary Anne McCaffree MD FAAP FCCP Commissioner 3.0 0 X 833 0 0 Mary H McGrath MPH FACS Commissioner 3.0 0 X 0 0 0 Najmedin Meshkati PHD Commissioner 3.0 0 X 976 0 0 Gregg S Meyer MD Commissioner 3.0 0 X 1025 0 0 Albert J Osbahr III MD MSCM Commissioner 4.0 0 X 0 0 0 Joseph J Parks MD Commissioner 3.0 0 X 964 0 0 Carlos A Pellegrini MD FACS Commissioner 3.0 0 X 0 0 0 Stephen R Permut MD JD Commissioner 3.0 0 X 0 0 0 David Perrott MD DDS MBA FACS Commissioner 4.0 1.0 X 0 0 0 David B Pryor MD Commissioner 3.0 1.0 X 833 0 0 Christopher J Queram Commissioner 3.0 1.0 X 0 0 0 Steven S Sharfstein MD MPA Commissioner 3.0 1.0 X 976 0 0 Michael B Simon MD MBA Commissioner 3.0 0 X 0 0 0 Carl A Sirio MD Commissioner 4.0 0 X 964 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 0 X 481037 0 106845 Ann Scott Blouin PHD RN FACHE Exec VP Customer Relations 40.0 0 X 507040 0 127627 Lynn Dragisic Exec VP Support Operations 39.0 1.0 X 451162 0 130517 Brian Enochs JD Exec VP Bus Dev & Marketing 40.0 0 X 346965 0 89385 Mike Kaba CHIEF HUMAN RESOURCES OFFICER 39.0 1.0 X 167754 0 3492 Kin Lee CIO & SECURITY OFFICER 40.0 0 X 44417 0 18049 John Mache Chief Information Officer (Part of year) 40.0 0 X 772852 0 4903 Ana Pujols McKee MD Exec VP & Chief Medical Officer 40.0 0 X 620701 0 31930 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 39.0 1.0 X 404926 0 56351 Paige Rodgers Chief Financial Officer 38.0 2.0 X 474830 0 57057 Margaret Van Amringe MHS Exec VP Public Policy & Govnt Relations 39.0 1.0 X 0 424022 118700 Lisa Diehl Vandecaveye JD MBA HRM FACHE General Counsel 36.0 4.0 X 360200 0 102385 Susan Boylan Murray SENIOR DIRECTOR FIELD OPERATIONS 40.0 0 X 177654 0 15249 Michael DeGraff Director Tech Services & Security 40.0 0 X 156006 0 24461 Anoop Verma Dir Applications Development 40.0 0 X 195280 0 33211 Fran Carroll Corporate Compliance & Privacy Officer 40.0 0 X 195324 0 26638 David Gilmartin Associate General Counsel 40.0 0 X 246343 0 46856 Debra Kiel IT DIRECTOR STRATEGIC PLANNING 40.0 0 X 205015 0 34136 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 40.0 0 X 193156 0 52847 Ronald Wyatt MD Medical Director & Chief Safety Officer 40.0 0 X 279878 0 28709 BARBARA BUTURUSIS FORMER DIRECTOR DEVELOPMENT FIELD STAFF 0.0 0 X 180751 0 47010 8138532 424022 1217343 187 true true true Leopardo Companies Inc 333 W Wacker Drive Suite 250 Chicago IL 60606 Headquarters Construction & Remodeling Contractor 9907699 AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75235 PROFESSIONAL SERVICES/CERTIFICATIONS 3084024 Corporate Concepts Inc PO Box 83324 Chicago IL 60691 Office Furniture Distributor 1884138 Hyatt Corp PO Box 98314 Chicago IL 60693 Hospitality Services 899191 Cognizant Technology Solutions 24721 Network Place Chicago IL 60673 Software Development Projects 773502 52 1906355 155655 2062010 Survey Fees 900099 69189824 69189824 Annual Subscription 900099 75903181 75903181 Performance Measurements 900099 3548360 3548360 Honorarium Fees 900099 140678 140678 Other Revenue 532000 450463 450463 0 0 0 0 149232506 2191633 2191633 1071359 1071359 0 0 71766228 68842867 2923361 0 2923361 2923361 Shared Services Fee from Related Tax Exempt Organizations 900099 6475366 6475366 0 0 0 0 6475366 163956235 155707872 0 6186353 7634415 2965709 4668706 79040645 65743392 13297253 5287224 4370265 916959 6581617 5345215 1236402 5967210 4876227 1090983 520001 78824 441177 359534 359534 189983 189983 880764 880764 7092012 4269105 2822907 0 880336 598166 282170 1252307 824321 427986 2043289 260386 1782903 2039736 667300 1372436 23329383 23094663 234720 2046277 1581478 464799 676368 277243 399125 4354744 2133131 2221613 967477 967478 -1 Equipment Rental & Repairs 678916 143253 535663 Reference Materials 300335 19553 280782 Bad Debt Expense 360685 360685 Recruitment 546609 130258 416351 300853 0 300853 0 153330720 118706652 34624068 0 35645996 14654176 12410992 14539108 0 0 0 10804 12642 2723594 2817351 88047854 45564019 32408043 42483835 57499257 61258246 68275867 83991035 0 305765 0 0 209280318 219756393 14932935 14167021 3765789 3532937 24924235 21161581 18631633 13865196 62254592 52726735 X 147025726 167029658 147025726 167029658 209280318 219756393 X 10625515 4271724 5106693 X false true X true false X 3125663 1902807 1154242 1510988 2062010 9755710 137010728 142545602 139684281 145954509 149232506 714427626 0 0 0 140136391 144448409 140838523 147465497 151294516 724183336 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 724183336 3452041 3781039 2742699 3471863 3262992 16710634 0 0 0 0 0 3452041 3781039 2742699 3471863 3262992 16710634 0 4932412 5006477 5437147 5763104 6475366 27614506 148520844 153235925 149018369 156700464 161032874 768508476 0.9423 0.9435 0.0217 0.0232 X Schedule A, Part III, Line 12 Other Income DESCRIPTION - FEES FROM RELATED ORGANIZATIONS, COLUMN A - 4932412.0, COLUMN B - 5006477.0, COLUMN C - 5437147.0, COLUMN D - 5763104.0, COLUMN E - 6475366.0, COLUMN F - 27614506.0; RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 189983 false false 189983 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 45177343 18986368 26190975 271266 228013 43253 10281431 6829711 3451720 28113414 19519927 8593487 42483835 Mutual & Comingled Funds - Domestic Equity Funds Mutual & Comingled Funds - International Equity Funds Mutual & Comingled Funds - Fixed Income & Bonds Mutual & Comingled Funds - Domestic Equity Funds 31089260 F Mutual & Comingled Funds - International Equity Funds 31958652 F Mutual & Comingled Funds - Fixed Income & Bonds 697684 F Common & Collective Funds - Measured at NAV 20245439 F 83991035 Deferred Swap 21347 Unrestricted Operating Pledge to Affiliate 1600000 Fair value of hedge 195535 Accrued pension liability 12048314 Due to Affiliate 13865196 X 174780657 4271724 6706693 10978417 163802240 153995 0 153995 163956235 151576725 0 0 151576725 153995 1600000 1753995 153330720 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, 2016 or 2015 for its U.S. operations. JCR's Singapore branch is subject to Singapore taxes on its operations. As of December 31, 2016 and 2015, a tax liability of $45,542 and $0 have been recorded in the accompanying consolidated statements of financial position, respectively. 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 - 227302 TRANSFER OF NET ASSETS TO PARENT CO - 3508957 CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COSTS NOT YET - 2970434 Schedule D, Part XII, Line 4(b) Other expenses in form 990 not in audited financial statements TRANSFER OF NET ASSETS TO AFFILIATE - OPERATING - 1600000 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 881916 0 489930 0 239300 0 25908 0 35077 0 1672131 0 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 468277 0 697 0 12063 0 83448 0 23397 0 587882 0 0 0 Ann Scott Blouin PHD RN FACHE Exec VP Customer Relations 372628 0 16072 0 118340 0 106647 0 20980 0 634667 0 106073 0 Lynn Dragisic Exec VP Support Operations 374804 0 930 0 75428 0 96777 0 33740 0 581679 0 61779 0 Brian Enochs JD Exec VP Bus Dev & Marketing 336581 0 233 0 10151 0 56992 0 32393 0 436350 0 0 0 Mike Kaba CHIEF HUMAN RESOURCES OFFICER 140919 0 25000 0 1835 0 0 0 3492 0 171246 0 0 0 John Mache Chief Information Officer (Part of year) 59344 0 0 0 713508 0 1319 0 3584 0 777755 0 377059 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer 533663 0 930 0 86108 0 23092 0 8838 0 652631 0 0 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 393600 0 930 0 10396 0 54992 0 1359 0 461277 0 0 0 Paige Rodgers Chief Financial Officer 462485 0 930 0 11415 0 33226 0 23831 0 531887 0 0 0 Margaret Van Amringe MHS Exec VP Public Policy & Govnt Relations 0 335535 0 12804 0 75683 0 106966 0 11734 0 542722 0 71111 Lisa Diehl Vandecaveye JD MBA HRM FACHE General Counsel 347049 0 465 0 12686 0 67396 0 34989 0 462585 0 0 0 BARBARA BUTURUSIS FORMER DIRECTOR DEVELOPMENT FIELD STAFF 174830 0 3019 0 2902 0 13608 0 33402 0 227761 0 0 0 Susan Boylan Murray SENIOR DIRECTOR FIELD OPERATIONS 168909 0 7938 0 807 0 14684 0 565 0 192903 0 0 0 Michael DeGraff Director Tech Services & Security 153361 0 930 0 1715 0 13154 0 11307 0 180467 0 0 0 Anoop Verma Dir Applications Development 192253 0 930 0 2097 0 15814 0 17397 0 228491 0 0 0 Fran Carroll Corporate Compliance & Privacy Officer 190257 0 2230 0 2837 0 19697 0 6941 0 221962 0 0 0 David Gilmartin Associate General Counsel 243800 0 930 0 1613 0 23663 0 23193 0 293199 0 0 0 Debra Kiel IT DIRECTOR STRATEGIC PLANNING 186727 0 16258 0 2030 0 27333 0 6803 0 239151 0 0 0 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 191049 0 930 0 1177 0 19396 0 33451 0 246003 0 0 0 Ronald Wyatt MD Medical Director & Chief Safety Officer 276953 0 930 0 1995 0 2543 0 26166 0 308587 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 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 2015 and 2016 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 2015 and 2016 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 promotor score rating. Individual gainsharing awards were capped at $3,000 for both 2015 and 2016. There were no 2015 awards accrued for in the year ended December 31, 2015. The 2016 awards were accrued for in the year ended December 31, 2016 and will be paid out in 2017. 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 2015 and 2016 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 2015 and 2016 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 promotor score rating. Individual gainsharing awards were capped at $3,000 for both 2015 and 2016. There were no 2015 awards accrued for in the year ended December 31, 2015. The 2016 awards were accrued for in the year ended December 31, 2016 and will be paid out in 2017. 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 2015-08-26 16000000 (SEE STATEMENT) false false false A 0 0 16024520 0 389239 0 229946 0 0 14588472 0 1206102 2016 false false true A false false true true true true 0.0 0.0 0.0 false false true A false true true false false false true A true Schedule K, Part I, Column (f) Description of Purpose Bond proceeds are 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 550 SURVEYORS THAT INCLUDE LIFE SAFETY SPECIALISTS. 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. *The Joint Commission conducted a project (through a CDC cooperative agreement) to develop an educational on-line course for care providers regarding the use of Rapid Influenza Diagnostic Testing (RIDTs) in ambulatory settings. The Joint Commission continues to host, promote, and update course to educate clinicians about the appropriate use of RIDTs within the context of circulating influenza types and prevalence. In addition, another course was developed focusing on influenza pandemic preparedness. *The Joint Commission conducted a project to identify how high reliability practices can be applied in facility-based long term care settings to reduce transmission of infection. Two products resulted from this project: an online, easy-to-use, engaging 50-minute e-learning module designed for the long term care (nursing home, assisted living) settings, which has been disseminated internationally; and, a searchable index of related resources, derived from a scoping literature review, that is intended to identify effective practices that improve reliability and reduce transmission of infections in nursing homes and assisted living facilities. Both products are available at no charge. *The Joint Commission continually works 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. *The Joint Commission collaborated with CDC/NIOSH/NPPTL to develop an educational monograph designed to assist hospitals in addressing common challenges and barriers in the implementation of respiratory protection programs. The monograph, "Implementing Hospital Respiratory Protection Programs: Strategies from the Field," features case study examples, strategies, and new resources. The Joint Commission embarked on expanded dissemination of this monograph TO INCLUDE PRESENTATIONS AT NATIONAL FORUMS AND AN EDUCATIONAL WEBINAR HOSTED BY NIOSH IN SEPTEMBER OF 2015. In September of 2016 work began on another related project, "Hospital Respiratory Protection Programs: Usefulness of Resources and Informational Gaps." This project seeks to obtain feedback on two published respiratory protection program resources and to identify ongoing clinical issues whereby more guidance regarding use of respirators is needed. *The Joint Commission continues work on a CDC three-year project titled, "Adaptation and Dissemination of Outpatient Infection Prevention (ADOPT) Guidance." This project is designed to prevent healthcare associated infections in ambulatory settings by identifying gaps and inconsistencies in current infection control materials for outpatient settings and adapting materials to better meet the needs of outpatient settings. *The Joint Commission began work on a CDC-supported project titled "Implementing standardized measurement of infections in nursing homes: challenges and facilitators." Thirty-six nursing homes have enrolled and are being supported through the process of NHSN enrollment in the C. difficile Lab-Id module. This 12-month project is scheduled to conclude in September of 2017. *The Joint Commission collaborated with Len Mermel MD and members from the Society for Healthcare Epidemiology of America on a nationally representative survey of hospitals to estimate staff and supply costs and benefits associated with preparation for Ebola patients. *In collaboration with the Centers for Disease Control and Prevention (CDC), The Joint Commission began a project with the overall goal to facilitate the use of National Healthcare Safety Network (NHSN) information for improvement in hospitals and explore incorporating this information in the accreditation process. (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: *Work on a project to create and pilot test an Informed Consent toolkit to help hospitals improve their informed consent process. *Work with Pfizer Independent Grants for Learning and Change (IGLC), previously known as the Pfizer Medical Education Group (PMEG), to successfully pilot test a partnership with the long-term goal to support an array of projects designed to accelerate the adoption of evidence-based innovations that improve patient care. This collaboration was designed to utilize the Request for Proposal (RFP) process to identify, fund and oversee projects related to specific improvement objectives that align the mutual interests of patients, health care providers and the two partner organizations. Phase II is focused on projects related to transitions of care (TOC) among a defined venous thromboembolism patient population. Five awards were issued for two year research projects starting in 2016. *WORK ON A PROJECT WITH AHA'S HEALTH RESEARCH AND EDUCATIONAL TRUST (HRET) TO IMPLEMENT A COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP) TO REDUCT CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI) IN LONG TERM CARE FACILITIES. *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. *Ongoing work with CDC NIOSH to identify research priorities related to patient and worker safety for the National Occupational Research Agenda. 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. *Work with the American Heart Association and American Stroke Association to develop thrombectomy-ready requirements 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 the Centers for Medicare and Medicaid Services (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 797 and 795. A chapter on medication compounding was also added to the Home Care accreditation manual. *The Joint Commission added several new requirements applicable to accredited behavioral health care organizations as follows: (a) New standards were developed that provide care for individuals with eating disorders. Eating disorders have the highest mortality rate of any behavioral health disorder, making it very important that these programs provide the safest and highest-quality care possible. (b) Standards were developed for permanent housing support services related to a "housing first" program model. For organizations that do provide these case management services, the standards are designed to help "raise the bar" and ensure a uniform provision of services from one organization to the next. Research has shown that when an individual's housing needs are met and are secure, improvements can often be made in other areas of the individual's life. (c) Revision of a standard that requires organizations to assess outcomes through the use of a standardized tool or instrument. Results of these assessments would then be used to inform goals and objectives identified in individual plans of care, treatment, or services as needed, and evaluate outcomes of care, treatment, or services provided to the population(s) served. The enhancements to this standard will help accredited customers increase the quality of the care, treatment, and services they provide. *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 *Minimum qualifications for physicians interpreting sleep studies *Use of scribes *Documenting maternal health status *Telehealth issues across health care settings *Identification of newborns *Hair coverings in the OR *Modification of existing National Patient Safety Goal on suicide risk assessment THE SPEAK UP INITIATIVES THE JOINT COMMISSION, TOGETHER WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS), CONTINUE TO DEVELOP MATIERALS WITH A 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 A VARIETY OF PATIENT SAFETY TOPICS INCLUDING THOSE LISTED BELOW. SPEAK UP BROCHURES ARE AVAILABLE TO THE GENERAL PUBLIC AT NO COST ON THE JOINT COMMISSION'S WEBSITE. *HELP PREVENT ERRORS IN YOUR CARE *HELP AVOID MISTAKES IN YOUR SURGERY *TIPS FOR YOUR DOCTOR'S VISIT *INFORMATION FOR LIVING ORGAN DONORS *FIVE THINGS YOU CAN DO TO PREVENT INFECTION *HELP AVOID MISTAKES WITH YOUR MEDICINE *WHAT YOU SHOULD KNOW ABOUT RESEARCH STUDIES *PLANNING YOUR FOLLOW-UP CARE *HELP PREVENT MEDICAL TEST MISTAKES *KNOW YOUR RIGHTS *UNDERSTANDING YOUR DOCTORS AND OTHER CAREGIVERS *PREVENT ERROR'S IN YOUR CHILD'S CARE *WHAT YOU SHOULD KNOW ABOUT PAIN MANAGEMENT *REDUCE YOUR RISK OF FALLING *DIALYSIS - FIVE WAYS TO BE ACTIVE IN YOUR CARE AT THE HOSPITAL *DIABETES - FIVE WAYS TO BE ACTIVE IN YOUR CARE AT THE HOSPITAL *WHAT YOU NEED TO KNOW ABOUT BREASTFEEDING *WHAT YOU SHOULD KNOW ABOUT STROKE *WHAT YOU SHOULD KNOW ABOUT MEMORY PROBLEMS & DEMENTIA *WHAT YOU SHOULD KNOW ABOUT YOUR DEPRESSION *ASK YOUR ADVOCATE TO SPEAK UP *SPEAK UP: AT HOME, KID POWER, & AT THE DOCTOR'S OFFICE *WHAT YOU SHOULD KNOW ABOUT YOUR SERIOUS ILLNESS & PALLIATIVE CARE *SPEAK UP: RIGHT ID, RIGHT CARE *The ABCs of C-sections *Avoid a Return Trip to the Hospital THE JOINT COMMISSION HAS 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 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 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 See narrative for Part VI, line 15b Form 990, Part VI, Line 19 Required documents available to the public THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AND IN ACCORDANCE WITH APPLICABLE LAWS. THE CONFLICT OF INTEREST POLICY, CODE OF CONDUCT, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC. Form 990, Part XI, Line 9 Other changes in net assets or fund balances Change in fair value of hedge - interest rate swap - 227302; Transfer of net assets to Parent Co - 3508957; Transfer of net assets to Affiliate - Operating - -1600000; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - 2970434; 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 1071359 ACTUAL JOINT COMMISSION RESOURCES INC L 5026256 CONTRACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE L 1449110 CONTRACTUAL JOINT COMMISSION RESOURCES INC Q 16962068 ACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE Q 639201 ACTUAL Joint Commission Center for Transforming Healthcare R 1600000 Contractual Joint Commission Resources Inc S 3508957 Contractual Joint Comission Resources Inc M 157780 Actual Jcaho Surveyor & QHR Consultant Corporation P 45250334 Actual