2016-11-08T13:01:06-06:00 2015-12-31 350921680 CROWE HORWATH LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2015-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers Chief Financial Officer 2016-10-14 true John Woodhull P01305268 3128997000 2015 2017-02-10 21:41:12Z The Joint Commission Dr Mark Chassin One Renaissance Blvd Oakbrook Terrace IL 60181 216191883 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 30 517 30 0 0 1154242 1510988 139684281 145954509 4760508 6043969 6419188 6802228 152018219 160311694 0 0 93747292 100274834 0 0 45317753 47060086 139065045 147334920 12953174 12976774 190047985 209280318 46884508 62254592 143163477 147025726 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 111264283 142259059 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 13,000 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 20,000 ORGANIZATIONS WERE ENROLLED IN 2015 FOR A SUBSCRIPTION FEE PLAN. 4061251 3695450 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. 115325534 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 132 0 true 517 true true true 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 Mark Chassin MD MPP MPH President & CEO 35.0 5.0 X X 1280679 0 55942 Craig W Jones FACHE Chair 4.0 3.0 X X 50598 0 0 David L Bronson MD Vice Chair 4.0 3.0 X X 598 0 0 John A Babiarz Commissioner 2.0 2.0 X 0 0 0 LD Britt MD Commissioner 3.0 1.0 X 0 0 0 Charles R Buck Jr ScD Commissioner 2.0 X 0 0 0 Roger W Bush MD Commissioner 5.0 X 626 0 0 Joan Shinkus Clark Commissioner 2.0 X 0 0 0 Ilene Corina Commissioner 2.0 X 0 0 0 Grant C Davies FACHE Commissioner 3.0 X 526 0 0 Joan Doyle RN MSN MBA Commissioner 3.0 X 598 0 0 Jane D Englebright PhD Commissioner 2.0 X 0 0 0 Michael F Hogan PhD Commissioner 2.0 X 0 0 0 M Nicole Jamali MD Commissioner 2.0 X 72 0 0 Mark A Kelley MD Commissioner 2.0 X 0 0 0 Marie E Knedler RN MS MBA FACHE Commissioner 2.0 X 626 0 0 Connie S March Commissioner 3.0 X 0 0 0 Mary Anne McCaffree MD Commissioner 2.0 X 626 0 0 Mary H McGrath MD Commissioner 5.0 X 0 0 0 Gregg S Meyer MD Commissioner 2.0 X 526 0 0 Aurie Hollingsworth Miller Commissioner 3.0 X 681 0 0 Albert J Osbahr III MD Commissioner 3.0 X 0 0 0 Carlos A Pellegrini MD Commissioner 3.0 X 526 0 0 Stephen R Permut MD Commissioner 3.0 X 598 0 0 David Perrott DDS MD Commissioner 6.0 1.0 X 0 0 0 David B Pryor MD Commissioner 2.0 2.0 X 526 0 0 Christopher Queram Commissioner 2.0 2.0 X 681 0 0 R Timothy Rice FACHE Commissioner 3.0 X 72 0 0 Steven S Sharfstein MD Commissioner 2.0 X 598 0 0 J B Silvers PhD Commissioner 2.0 2.0 X 681 0 0 Carl A Sirio MD Commissioner 3.0 X 0 0 0 Rebecca J Patchin MD Commissioner 2.0 1.0 X 0 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 40.0 X 448202 0 96021 Anne Marie Benedicto Chief of Staff & Exec VP 39.0 1.0 X 231001 0 24944 Ann Scott Blouin PhD RN FACHE Exec VP Customer Relations 40.0 X 1176302 0 412213 Harold Bressler General Counsel 39.0 1.0 X 320234 0 68612 Lynn Dragisic Exec VP Support Operations 39.0 1.0 X 393355 0 159980 Brian Enochs JD Exec VP Bus Dev & Marketing 40.0 X 86665 0 24294 John Mache Chief Information Officer 40.0 X 343148 0 209029 Ana Pujols McKee MD Exec VP & Chief Medical Officer 40.0 X 617989 0 28215 Charles Mowll Executive Vice President 40.0 X 238563 0 31299 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 39.0 1.0 X 403432 0 153356 Paige Rodgers CPA Chief Financial Officer 38.0 2.0 X 472575 0 511521 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 39.0 1.0 X 203202 0 44934 Margaret Van Amringe MHS Exec VP Public Policy & Govnt Relations 39.0 1.0 X 0 407460 121758 Barbara Buturusis Director Development Field Staff 40.0 X 188527 0 43068 Michael DeGraff Director Tech Services & Security 40.0 X 157325 0 22483 Anoop Verma Dir Applications Development 40.0 X 211918 0 16666 Fran Carroll Corporate Compliance & Privacy Officer 40.0 X 200402 0 24998 David Gilmartin Associate General Counsel 40.0 X 248414 0 43431 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 40.0 X 202234 0 48089 Michele Sacco Executive Director-Business Dev 40.0 X 213843 0 16678 Ronald Wyatt MD Medical Director & Chief Safety Officer 40.0 X 307144 0 46072 Paul Schyve Sr Advisor-Healthcare Improvement 20.0 X 215965 0 50331 8220278 407460 2253934 204 true true true LEOPARDO COMPANIES INC 333 W WACKER DRIVE CHICAGO IL 60606 Office Remodeling Services 5436293 AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75235 PROFESSIONAL SERVICES/CERTIFICATIONS 2728775 TILTON KELLY & BELL LLC 55 WEST MONROE ST CHICAGO IL 60603 Architect & Office Remodeling Services 692172 Experis IT Services US LLC PO Box 905378 Charlotte NC 28290 IT CONSULTING SERVICES 689278 LOGICALIS INC P O BOX 67000 DETROIT MI 482671723 IT CONSULTING SERVICES 657104 47 1418464 92524 1510988 Survey Fees 900099 67056903 67056903 Annual Subscription 900099 74573796 74573796 Performance Measurements 900099 3695450 3695450 Honorarium Fees 900099 147606 147606 Other Revemue 532000 480754 480754 0 0 0 0 145954509 2432739 2432739 1039124 1039124 0 0 59491419 55880189 3611230 0 3611230 3611230 Shared Services Fee from Related Tax Exempt Organizations 900099 5763104 5763104 0 0 0 0 5763104 160311694 151717613 0 7083093 8675696 3948147 4727549 74477041 62306928 12170113 5138343 4225277 913066 6354801 5749345 605456 5628953 4659899 969054 754000 143861 610139 213495 23000 190495 224575 0 224575 711410 711410 6880488 4372941 2507547 0 801540 569373 232167 1361303 859342 501961 1737896 214650 1523246 1979077 741617 1237460 23230680 22948638 282042 1559387 1084204 475183 506651 237670 268981 3756401 1389945 2366456 911068 911068 Equipment Rental & Repairs 858824 534336 324488 Reference Materials 267095 17985 249110 Bad Debt Expense 268063 268063 0 Recruitment 761065 116245 644820 277068 0 277068 0 147334920 115322534 32012386 0 25716206 35645996 10280979 12410992 0 0 10864 10804 2608379 2723594 74368745 41960702 24295375 32408043 56676978 57499257 70348737 68275867 0 110467 305765 0 0 190047985 209280318 12441397 14932935 2926334 3765789 11840000 24924235 19676777 18631633 46884508 62254592 X 143163477 147025726 143163477 147025726 190047985 209280318 X 12976774 -6750759 -2360766 X false true X true false X 2487209 3125663 1902807 1154242 1510988 10180909 127333477 137010728 142545602 139684281 145954509 692528597 0 0 0 129820686 140136391 144448409 140838523 147465497 702709506 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 702709506 3849715 3452041 3781039 2742699 3471863 17297357 0 0 0 0 0 0 3849715 3452041 3781039 2742699 3471863 17297357 0 3682007 4932412 5006477 5437147 5763104 24821147 137352408 148520844 153235925 149018369 156700464 744828010 0.9435 0.9444 0.0232 0.0244 X Schedule A, Part III, Line 12 Other Income DESCRIPTION - FEES FROM RELATED ORGANIZATIONS, COLUMN A - 3682007.0, COLUMN B - 4932412.0, COLUMN C - 5006477.0, COLUMN D - 5437147.0, COLUMN E - 5763104.0, COLUMN F - 24821147.0; RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 224575 false false 224575 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 36966316 17586948 19379368 271266 206387 64879 8346574 5609130 2737444 24580189 18558237 6021952 32408043 Mutual & Comingled Funds - Domestic Equity Funds Mutual & Comingled Funds - International Equity Funds Mutual & Comingled Funds - Fixed Income & Bonds Mutual & Comingled Funds - Domestic Equity Funds 25883709 F Mutual & Comingled Funds - International Equity Funds 28254577 F Mutual & Comingled Funds - Fixed Income & Bonds 553652 F Common & Collective Funds - Measured at NAV 13583929 F 68275867 0 Deferred Swap 47305 Unrestricted Operating Pledge to Affiliate 2000000 Fair value of hedge 422837 Accrued pension liability 16161491 Due to Affiliate 18631633 X 155462362 -6750759 2070757 -4680002 160142364 169330 0 169330 160311694 151600113 4431523 4431523 147168590 169330 0 169330 147337920 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(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 (formerly known as FASB Interpretation No. 48, Accounting for uncertainty in Income taxes), 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 affect 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, 2015 or 2014 for its United States 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 - 294694 Transfer of net assets to Parent Co - 1776063 Schedule D, Part XII, Line 2(d) Other expenses in audited financial statements not in form 990 Transfer of net assets to Affiliate - operating - 2000000 Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - 2431523 Europe (Including Iceland and Greenland) 0 3 Program Services Sending agents of the organization to perform accreditation survey services to evaluate an organization's compliance with state-of-the-art accreditation standards 15493 East Asia and the Pacific 0 1 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences 5003 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 9139 North America (Canada & Mexico only) 0 3 Speaking engagements,Conference Travel Sending agents of the organization to attend and/or speak at seminars and conferences 6705 0 8 0 0 0 8 36340 0 36340 false false false false false false X X true true X X X X true true false true false true true false false Mark Chassin MD MPP MPH President & CEO 913139 0 126850 0 240690 0 25053 0 30889 0 1336621 0 0 0 David Baker MD MPH FACP Exec VP Health Care Quality Evaluation 392955 0 45000 0 10247 0 78917 0 17104 0 544223 0 0 0 Anne Marie Benedicto Chief of Staff & Exec VP 224278 0 0 0 6723 0 6490 0 18454 0 255945 0 0 0 Ann Scott Blouin PhD RN FACHE Exec VP Customer Relations 382042 0 0 0 794260 0 394005 0 18208 0 1588515 0 780471 0 Harold Bressler General Counsel 253709 0 0 0 66525 0 52768 0 15844 0 388846 0 57689 0 Lynn Dragisic Exec VP Support Operations 317406 0 0 0 75949 0 130867 0 29113 0 553335 0 58743 0 John Mache Chief Information Officer 334560 0 0 0 8588 0 178234 0 30795 0 552177 0 0 0 Ana Pujols McKee MD Exec VP & Chief Medical Officer 532921 0 0 0 85068 0 22159 0 6056 0 646204 0 0 0 Charles Mowll Executive Vice President 166403 0 0 0 72160 0 19493 0 11806 0 269862 0 65425 0 Mark Pelletier RN MS Chief Operating Officer, Accred & Cert Ops 391692 0 0 0 11740 0 152627 0 729 0 556788 0 0 0 Paige Rodgers CPA Chief Financial Officer 459808 0 0 0 12767 0 490622 0 20899 0 984096 0 0 0 Lisa Diehl Vandecaveye JD HRM FACHE General Counsel 170727 0 20000 0 12475 0 35629 0 9305 0 248136 0 0 0 Margaret Van Amringe MHS Exec VP Public Policy & Govnt Relations 0 332439 0 0 0 75021 0 115130 0 6628 0 529218 0 69342 Barbara Buturusis Director Development Field Staff 181047 0 4642 0 2838 0 13613 0 29455 0 231595 0 0 0 Michael DeGraff Director Tech Services & Security 155050 0 0 0 2275 0 12713 0 9770 0 179808 0 0 0 Anoop Verma Dir Applications Development 195160 0 13900 0 2858 0 1575 0 15091 0 228584 0 0 0 Fran Carroll Corporate Compliance & Privacy Officer 188077 0 8834 0 3491 0 19189 0 5809 0 225400 0 0 0 David Gilmartin Associate General Counsel 244121 0 1900 0 2393 0 23048 0 20383 0 291845 0 0 0 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 192721 0 7746 0 1767 0 19923 0 28166 0 250323 0 0 0 Michele Sacco Executive Director-Business Dev 128721 0 7829 0 77293 0 0 0 16678 0 230521 0 0 0 Ronald Wyatt MD Medical Director & Chief Safety Officer 302848 0 0 0 4296 0 16250 0 29822 0 353216 0 0 0 Paul Schyve Sr Advisor-Healthcare Improvement 214211 0 0 0 1754 0 41814 0 8517 0 266296 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 2014 and 2015 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 2014 and 2015 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 2014 and 2015. There were no 2014 awards accrued for in the year ended December 31, 2014. The 2015 awards were accrued for in the year ended December 31, 2015 and will be paid out in 2016. 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 2014 and 2015 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 2014 and 2015 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 2014 and 2015. There were no 2014 awards accrued for in the year ended December 31, 2014. The 2015 awards were accrued for in the year ended December 31, 2015 and will be paid out in 2016. 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 16000000 0 81911 0 229946 0 0 4180810 0 11589244 false false false 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. 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 500 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, CORONARY ARTERY DISEASE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, SKIN AND WOUND MANAGEMENT, PRIMARY STROKE CARE, JOINT REPLACEMENT, SPINAL SURGERY PROGRAMS, PALLIATIVE CARE, PERINATAL, INTEGRATED, AND PATIENT BLOOD MANAGEMENT. 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. THE JOINT COMMISSION BEGAN PUBLISHING SENTINEL EVENT ALERTS IN 1998 TO REDEFINE THE PRINCIPAL PURPOSE OF ADVERSE EVENT REPORTING AS BEING FOR LEARNING. 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 IN JULY 2002, THE JOINT COMMISSION ESTABLISHED ITS FIRST SET OF SIX NATIONAL PATIENT SAFETY GOALS (NPSGS) AND 11 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 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 to determine the effectiveness of universal glove and gowning procedures in reducing HAI rates in the ICU. * The Joint Commission conducted a project to determine whether a pre-operative antibiotic prophylaxis algorithm that includes the use of antibiotics shown to be effective against resistant gram-positive organisms is effective in reducing the number of SSIs attributable to resistant gram-positive organisms. * 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 2015, The Joint Commission received funding from CDC to embark on a three-year funded 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 collaborated with SHEA on a National hospital survey to estimate costs and benefits associated with measures required to prepare for handling Ebola patients. (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: * DEVELOPMENT OF A MONOGRAPH ON THE OPPORTUNITIES FOR SYNERGY, COLLABORATION, AND INNOVATION BETWEEN PATIENT SAFETY AND WORKER SAFETY IN HEALTH CARE. * Work on a project to create and pilot test an Informed Consent toolkit to help hospitals improve their informed consent process. * Work with the Office of the National Coordinator to analyze Sentinel Event data associated with Health IT and development of a free online course (providing CE credit), titled "Investigating and Preventing Health Information Technology-Related Patient Safety Events" to teach staff how to identify, report and address health IT-related safety concerns in health care organizations. * 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. 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 HAVE INCLUDED: * WORK WITH THE AMERICAN HEART ASSOCIATION AND AMERICAN STROKE ASSOCIATION TO DEVELOP ACUTE STOKE-READY REQUIREMENTS RELEASED IN JULY 2015 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. * WORK WITH EXPERTS IN THE DIAGNOSTIC IMAGING FIELD TO IMPLEMENT STANDARDS TO ENSURE THE SAFE DELIVERY OF DIAGNOSTIC IMAGING SERVICES TO PATIENTS RECEIVING COMPUTED TOMOGRAPHY (CT), NUCLEAR MEDICINE (NM), POSITRON EMISSION TOMOGRAPHY (PET), AND MAGNETIC RESONANCE IMAGING (MRI) SERVICES. THE JOINT COMMISSION IS CURRENTLY DEVELOPING STANDARDS ADDRESSING ADDITIONAL DIAGNOSTIC IMAGING TECHNOLOGIES. * WORK WITH EXPERTS TO DEVELOP A perinatal care (PNC) CERTIFICATION PROGRAM RELEASED IN JULY 2015 that focus on achieving integrated, coordinated, patient-centered care that starts with prenatal care through postpartum care. This certification focuses on the essential, high-value requirements that will improve perinatal outcomes for mothers and newborns who have been assessed as clinically uncomplicated. * EXPANSION OF THE integrated care certification (ICC) program TO INCLUDE EVALUATION OF INPATIENT, OUTPATIENT AND NOW, POST-ACUTE CLINICAL CARE PARTNERS TO DO THE following: A. Establish AND MAINTAIN a strong foundation for care coordination and clinical integration B. Decrease variation in the management of chronic disease and increase adherence to well-researched, evidence-based clinical practices C. Create and demonstrate the capacity to efficiently coordinate and integrate patient care, treatment, and services D. Build upon what these providers are already doing independently for patient care, treatment, and services and strengthen their capacities to support patients as they move among providers and home. (CONTINUATION BELOW) Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED (CONTINUATION FROM ABOVE) * Research on telehealth issues across health care settings. Existing standards are being evaluated and modified as necessary to reflect contemporary practices. * Develop a Total Hip and Total Knee Replacement (THKR) Certification program for patients undergoing total hip and total knee replacement procedures. This is an optional certification that is open to accredited organizations that provide total hip and total knee replacement procedures. The requirements will support quality, consistency, and safety throughout the pre-operative, intra-operative, and post-operative phases of care. It will address transitions that occur within each of those phases. The program will apply to surgeries performed in inpatient, hospital-based outpatient, and ambulatory surgery settings. * Develop a Community Based Palliative Care (CBPC) Certification program for the Home Care program. This is an optional Certification that is open to accredited Home Health and Hospice organizations that provide palliative care services to patients and families in their homes. CBPC is provided by an interdisciplinary team of doctors, nurses, social workers, chaplains, and other home care providers who work together to coordinate care, treatment, and services for the patient. The CBPC standards and elements of performance (EPs) are based on the 2013 Clinical Practice Guidelines for Quality Palliative Care, 3rd ed; the National Hospice and Palliative Care Organization's Standards of Practice for Pediatric Palliative Care and Hospice (2010); and other current palliative care professional literature. * Development of a Comprehensive Cardiac Center Certification program for Joint Commission- accredited hospitals. This is an optional certification program to recognize hospitals that demonstrate they deliver excellence in comprehensive cardiac care through a combination of standards compliance, clinical performance on targeted metrics, and achievement and/or maintenance of required Advanced Disease-Specific Care requirements. THE SPEAK UP INITIATIVES SINCE 2002, 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 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, david baker - vp, anne marie benedicto - vp, ann scott Blouin - vp, Harold Bressler - vp, brian Enochs - vp, john mache - vp, ana pujols mckee - vp, Charles mowll - 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 - 294694; Transfer of net assets to Parent Co - 1776063; Transfer of net assets to Affiliate - Operating - -2000000; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - -2431523; JOINT COMMISSION RESOURCES INC 1515 WEST 22ND STREET STE 1300W OAKBROOK IL 60523 363521721 HEALTHCARE IL 501(c)(3 9 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 1039124 Actual Joint Commission Resources Inc L 4651580 Contractual Joint Commission Center for Transforming Healthcare L 1111524 Contractual Joint Commission Resources Inc Q 17203588 Actual Joint Commission Center for Transforming Healthcare Q 499663 Actual Joint Commission Center for Transforming Healthcare R 2000000 Contractual Joint Commission Resources Inc S 1776063 Contractual Joint Commission Resources Inc M 102500 Actual JCAHO Surveyor & QHR Consultant Corporation P 37641171 Actual