2015-07-30T22:00:12-05:00 2014-12-31 350921680 CROWE HORWATH LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2014-01-01 263020947 The Joint Commission Center for Transforming Healthcare JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers Chief Financial Officer 2015-07-30 true John Woodhull P01305268 3128997000 2014 2016-03-07 17:11:31Z Center for Transforming Healthcare Dr Mark Chassin One Renaissance Blvd Oakbrook Terrace IL 60181 11404817 false X www.centerfortransforminghealthcare.org X 2008 IL The Center will improve health care for the public by developing and disseminating solutions to health care's most critical quality and safety problems through collaboration with health care organizations. 7 5 12 5 0 0 8537365 4037279 0 0 611485 1500898 0 0 9148850 5538177 0 0 0 0 1642150 1819426 0 0 230202 1920925 1854622 3563075 3674048 5585775 1864129 45710882 46844509 545009 378923 45165873 46465586 The Center for Transforming Healthcare has been established to solve the most pressing quality and safety problems that are all too prevalent in health care today. (see Schedule O for continuation). true false 1723082 23000 QUALITY OF CARE/PATIENT SAFETY- THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE WORKS WITH A NETWORK OF APPROXIMATELY 27 LEADING HOSPITALS AND HEALTH SYSTEMS TO DEVELOP SOLUTIONS TO THE MOST PRESSING QUALITY AND SAFETY PROBLEMS FACING HEALTH CARE ORGANIZATIONS TODAY. THESE HOSPITALS AND HEALTH SYSTEMS HAVE A COMMITMENT AND COMPETENCY IN APPLYING ROBUST PROCESS IMPROVEMENT (RPI) METHODS AND TOOLS TO IMPROVE HEALTH CARE QUALITY AND PATIENT SAFETY. THESE METHODS INCLUDE LEAN SIX SIGMA, AND CHANGE MANAGEMENT TOOLS TO ACHIEVE HIGH RELIABILITY. 345072 89430 PATIENT SAFETY & QUALITY PROGRAM (THE PROGRAM) - THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE COLLABORATES WITH HEALTHCARE ORGANIZATIONS WHO STRIVE TO BUILD SYSTEMS AND STRUCTURES NECESSARY FOR HIGHLY RELIABLE HEALTH CARE ACROSS ALL SETTINGS. THE PROGRAM COMPONENTS INCLUDE GUIDANCE ON CREATING ROBUST MEASUREMENT SYSTEMS AND IMPLEMENTING SUSTAINABLE IMPROVEMENTS, ANALYSIS, DEVELOPMENT AND USE OF THE CENTER'S TARGETED SOLUTIONS TOOLS (TST) AND HIGH RELIABILITY SELF-ASSESSMENT TOOL (HRST), AND TRAINING AND USE OF ROBUST PROCESS IMPROVEMENT TOOLS (RPI). IN ADDITION, THE CENTER WILL CONDUCT ON-SITE TRAINING BY RPI TRAINERS THAT ARE EXPERIENCED IN LEAN, SIX SIGMA AND CHANGE MANAGEMENT. 2068154 true true false false false false false false true true true false false false true false true false false false false false false false false false false false true false false false false false false false false false false false false false true false false false true 20 0 true 12 true false false false false false false false false false false X 7 5 false false false false true true true true true false false true true true true true true true true false AL AK AZ AR CA CO CT DC FL GA HI IL KS KY ME MD MA MI MN MS NH NJ NM NY NC ND OH OK OR PA RI SC TN UT VA WA WV WI NV X X Paige Rodgers 6307925685 One Renaissance Blvd Oakbrook Terrace IL 60181 REBECCA J PATCHIN MD CHAIR & BOARD MEMBER 1.00 4.00 X X 0 50000 0 JB SILVERS PhD TREASURER & BOARD MEMBER 1.00 4.00 X X 0 0 0 MARK CHASSIN PRESIDENT & BOARD MEMBER 3.00 37.00 X X 0 1254764 54697 CRAIG W JONES FACHE BOARD MEMBER 1.00 4.00 X 0 0 0 LaMAR S McGINNIS JR MD BOARD MEMBER 1.00 4.00 X 0 0 0 DAVID PERROTT DDS MD BOARD MEMBER 1.00 7.00 X 0 0 0 David L Bronson MD Board Member 1.00 4.00 X 0 424 0 ANNE MARIE BENEDICTO CHIEF OF STAFF/ EXEC VP 1.00 39.00 X 0 341304 191704 PAIGE RODGERS CHIEF FINANCIAL OFFICER 1.00 39.00 X 0 433815 169696 ERIN DUPREE VICE PRESIDENT & CHIEF MEDICAL OFFICER 39.00 1.00 X 0 514551 18022 KLAUS NETHER DIRECTOR 40.00 X 125755 0 32129 TEENA WILSON DIRECTOR 40.00 X 101992 0 19066 JOHN CULLINAN Director 40.00 0.00 X 111254 0 26320 BRIAN PATTERSON Center Project Lead & Black belt 40.00 0.00 X 104500 0 16103 Coleen Smith Director 40.00 0.00 X 102825 0 23624 546326 2594858 551361 5 false true false JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS ONE RENAISSANCE BLVD OAKBROOK TERRACE IL 60181 MANAGEMENT FEE FOR SERVICES 1010422 THE BOSTON CONSULTING GROUP INC P O BOX 75200 CHICAGO IL 606755200 Management Consulting 240000 COGNIZANT TECHNOLOGY SOLUTIONS 24721 NETWORK PLACE CHICAGO IL 60673 IT Consulting 166019 TEKSYSTEMS INC P O 198568 ATLANTA GA 303848568 IT Consulting 143560 4 X 3800000 237279 4037279 0 0 0 0 0 1247525 1247525 0 0 6120013 5866640 253373 0 253373 253373 0 0 0 0 0 5538177 0 0 1500898 X 532573 372801 159772 958274 844244 58050 55980 17638 16629 143 866 224103 145957 69794 8352 86838 64437 18202 4199 2850 2850 1436573 898874 392745 144954 44654 42078 201 2375 30901 20140 7358 3403 120827 72492 41795 6540 63067 61895 989 183 154750 140408 10992 3350 Bad debt 1000 1000 0 0 0 0 3674048 2680955 762891 230202 1028717 1775688 5991653 600000 3489918 3812217 0 0 0 0 0 0 2765 3791 1248730 361418 570715 887312 34627114 35643075 0 4122426 0 0 0 0 0 45710882 46844509 455579 309924 0 0 89430 68999 0 0 0 0 0 0 0 0 0 0 0 545009 378923 X 34848825 36140191 0 0 10317048 10325395 0 0 0 0 0 0 45165873 46465586 45710882 46844509 1864129 -564416 0 X false true X true false X 2317788 12038452 9970877 8537365 4037279 36901761 2317788 12038452 9970877 8537365 4037279 36901761 31849098 5052663 310389 325273 292505 611485 1500898 3040550 0 0 0 0 0 0 39942311 1000 0.1265 0.2025 X 10% Facts and Circumstances Test To be classified as a public charity using the 10% facts and circumstances test under Treas. Regs. Section 1.170A-9(f), two requirements must be satisfied. First, the organization must derive at least 10 percent of its support from governmental units or from direct or indirect contributions from the general public, or a combination of both. In addition, the organization must also be organized and operated so that it will attract further support on a continuous basis. This means the organization must maintain a continuous and bona fide fundraising program or carry on programs designed to attract support from governmental units or other public charities. Compliance with both requirements is mandatory in order to meet the facts-and-circumstances test. As of December 31, 2014, the Center's public support is 12.65%, above the minimum 10% requirement described above. This includes a large contribution from the Joint Commission of $3.8 million. As evidence of the Center's bona fide fundraising efforts, it should be noted that the organization has registered in 38 states across the country in those states that requires charitable organizations to register in order to solicit charitable contributions. The Center has been soliciting charitable contributions from businesses, companies, associations and charitable foundation that work in the healthcare field. In addition to satisfying the two mandatory requirements of the facts-and-circumstances test, additional facts and circumstances are evaluated to determine whether the organization is publicly supported. Based on the information below, we believe that the Center clearly satisfies the 10% facts and circumstances public support test. Actual Percentage of "Public Support" The regulations indicate that "the higher the public support percentage is above the 10% level, the more indicative of broad base public support". As indicated above, the Center's public support percentage through the end of 2014 is 12.65%. Sources of Support: The regulations indicate that the fact that "an organization meets the requirement above through support from governmental units or directly or indirectly from a representative number of persons, rather than receiving almost all of its support from the members of a single family, will be taken into consideration in determining whether the organization is publicly supported". In addition to contributions from the Joint Commission, a publicly supported organization itself, the Center has received significant contributions from thirteen contributors. The contributors represent a broad spectrum support from companies in the healthcare field, including pharmaceutical companies, equipment manufacturers, health insurance providers as well as health care trade associations and charitable foundations. Representative Governing Body: The regulations indicate that "the fact that an organization has a governing body which represents the broad interest of the public, rather than the personal or private interest of a limited number of donors" will be taken into account in determining whether an organization is publicly supported. Other factors in the regulations indicating a public board representing the broad interests of the public is whether it is comprised of individuals having special knowledge and expertise in the particular field or discipline in which the organization is operating. The Center's board of directors clearly would be considered a "representative governing body". All of its members have special knowledge and expertise in the healthcare field and with healthcare quality issues. Availability of Public Services; Public Participation in Programs: The regulations indicate the fact that an organization which provides educational services to the public through the distribution of educational materials on a continuing basis, will be considered as evidence that the organization is publicly supported. The Center's entire focus is to work with hospitals and improve the safety and quality of the healthcare services provided by these institutions. The downloadable articles, videos, podcasts and any public speaking which is done at no charge are freely available on the Center's website. The ultimate beneficiaries of these activities are the patients and the public. The active participation in, and sponsorship of these healthcare quality and safety programs by members of the board, is further evidence that the organization is publicly supported. RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 40380406 8346 -421716 0 39967036 35595834 5037122 -379875 -127325 40380406 30472963 5089419 106020 72568 35595834 18468202 12038451 -163176 -129486 30472963 16025451 2317788 435352 310389 18468202 0.7417 0.2583 0.0 false false 859620 361418 498202 389110 389110 887312 4122426 F 4122426 0 X 4973761 -564416 0 -564416 5538177 0 0 5538177 3674048 0 0 3674048 0 0 3674048 Schedule D, Part V, Line 4 Intended uses of endowment funds The Center will rely on these endowment funds and its investment earnings to partially finance its projects and engage in the dissemination of the knowledge gained. Schedule D, Part X, Line 2 FIN 48 (ASC 740) footnote The Internal Revenue Service has determined that The Joint Commission and its affiliate the Center 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 and its affiliate, The Center, accounts for income tax uncertainties in accordance with the Financial Accounting Standards Board (FASB) Accounting Standards Codification (ASC) 740-10 (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 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, 2014 or 2013 for its United States operations. X X true true X X X X X false true false false false false true false false MARK CHASSIN PRESIDENT & BOARD MEMBER 0 885740 0 137800 0 231224 0 23850 0 30847 0 1309461 0 0 ANNE MARIE BENEDICTO CHIEF OF STAFF/ EXEC VP 0 331335 0 2000 0 7969 0 163510 0 28194 0 533008 0 0 PAIGE RODGERS CHIEF FINANCIAL OFFICER 0 428360 0 2000 0 3455 0 148780 0 20916 0 603511 0 0 ERIN DUPREE VICE PRESIDENT & CHIEF MEDICAL OFFICER 0 445931 0 0 0 68620 0 0 0 18022 0 532573 0 0 KLAUS NETHER DIRECTOR 121327 0 2000 0 2428 0 12763 0 19366 0 157884 0 0 0 Schedule J, Part I, Line 1a First-class or charter travel THE CENTER BOARD TRAVEL POLICY PERMITS REIMBURSEMENT FOR THE PURCHASE OF UPGRADE COUPONS FOR FIRST-CLASS AIR TRAVEL. THE CENTER'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 SCHEDULE J-2, PART I, COLUMN D AS REPORTABLE COMPENSATION. Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation THE CENTER FOR TRANSFORMING HEALTHCARE RELIES ON THE PROCESS OF THE JOINT COMMISSION (A RELATED ORGANIZATION) FOR APPROVAL OF TOP MANAGEMENT OFFICIALS' COMPENSATION. THE TOP MANAGEMENT OFFICIALS' 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 TOP MANAGEMENT OFFICIALS. IN SETTING THE TOP MANAGEMENT OFFICIALS' COMPENSATION, THE ORGANIZATIONS' HUMAN RESOURCES AND COMPENSATION COMMITTEES RELY ON RECENT COMPENSATION STUDIES THAT PROVIDE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS. THE JOINT COMMISSION'S HUMAN RESOURCES AND COMPENSATION COMMITTEES ADEQUATELY DOCUMENT ITS COMPENSATION DETERMINATIONS AND DELIBERATIONS REGARDING COMPENSATION IN ITS COMMITTEE MINUTES ON A TIMELY BASIS. EACH 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 INSURE THAT HE OR SHE IS INDEPENDENT. THE PROCESS FOR DETERMINING THE ORGANIZATIONS' TOP MANAGEMENT OFFICIALS' COMPENSATION IS UNDERTAKEN ANNUALLY IN APRIL FOR DR. CHASSIN-PRESIDENT; PAIGE RODGERS-CHIEF FINANCIAL OFFICER; ANNE MARIE BENEDICTO-CHIEF OF STAFF/EXECUTIVE VP & DR. ERIN DUPREE-CHIEF MEDICAL OFFICER &VP. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan ALL OFFICERS ARE ALLOWED TO PARTICIPATE IN A NONQUALIFIED SUPPLEMENTAL DEFINED BENEFIT RETIREMENT PLAN UNDER THE JOINT COMMISSION, A RELATED ORGANIZATION. THE INCREASES IN THE VALUE OF THE PLAN DURING THE YEAR ARE REFLECTED IN COLUMN C DEFERRED COMPENSATION ON SCHEDULE J. Schedule J, Part I, Line 6b Compensation contigent on net earnings of a related organization ALL CENTER EMPLOYEES ARE ALLOWED TO PARTICIPATE IN THE JOINT COMMISSION'S GAINSHARING PLAN. THE JOINT COMMISSION'S HUMAN RESOURCES AND COMPENSATION COMMITTEE APPROVED THE 2013 AND 2014 GAINSHARING PLANS, WHICH PROVIDES FINANCIAL AWARDS TO STAFF FOR PERFORMANCE THAT CONTRIBUTES TO THE MISSION AND OBJECTIVES OF THE JOINT COMMISSION AND THE CENTER. THE PLAN IS SELF-FUNDED, IN THAT ALL PAYOUTS FOR 2013 AND 2014 WERE CONTINGENT UPON WHETHER THE ACTUAL FINANCIAL RESULTS FOR THE JOINT COMMISSION EXCEEDED THE JOINT COMMISSION'S BUDGETED NET EARNINGS EXCESS OF 2% OVER BUDGET. IN 2014, INDIVIDUAL GAINSHARING PAYOUTS WERE CAPPED AT $3,000 . THE 2013 AWARDS WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2013 AND PAID OUT IN 2014. NO AWARDS FOR 2014 WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2014 . Form 990, Part III, Line 1 ORGANIZATION'S MISSION THE CENTER FOR TRANSFORMING HEALTHCARE (THE CENTER) HAS BEEN ESTABLISHED TO SOLVE THE MOST PRESSING QUALITY AND SAFETY PROBLEMS THAT ARE ALL TOO PREVALENT IN HEALTH CARE TODAY. THESE ARE THE PROBLEMS THAT THREATEN LIVES AND INCREASE COSTS. WORKING WITH A CADRE OF LEADING HOSPITALS AND HEALTH SYSTEMS, THE CENTER DEVELOPS SOLUTIONS TO THESE PROBLEMS THROUGH THE APPLICATION OF METHODS SUCH AS LEAN SIX SIGMA AND CHANGE MANAGEMENT. THE LEADING HOSPITALS AND HEALTH SYSTEMS IN THE CENTER'S NETWORK HAVE SIGNIFICANT EXPERTISE IN THE APPLICATION OF THESE METHODS AND TOOLS TO HEALTH CARE. ULTIMATELY, THE GOAL OF THE CENTER IS TO TRANSFORM HEALTH CARE INTO A HIGH RELIABILITY INDUSTRY. ONCE SOLUTIONS ARE DEVELOPED THROUGH THIS COLLABORATIVE METHOD, THEY ARE MADE PUBLICLY AVAILABLE THROUGH THE CENTER'S WEB SITE. THE SOLUTIONS ARE ALSO MADE AVAILABLE THROUGH THE TARGETED SOLUTIONS TOOL (TST). THE TST IS A WEB-BASED TOOL THAT GUIDES JOINT COMMISSION-ACCREDITED HEALTH CARE ORGANIZATIONS TO MEASURE THEIR OWN PERFORMANCE AND CUSTOMIZE SOLUTIONS TO ADDRESS THE CONTRIBUTING FACTORS THAT UNDERLIE THEIR OWN BREAKDOWNS IN QUALITY AND SAFETY. HAND HYGIENE IS CRITICALLY IMPORTANT TO SAFE, HIGH QUALITY PATIENT CARE. UNFORTUNATELY, MANY INFECTIONS ARE TRANSMITTED BY HEALTH CARE PERSONNEL. THE TST PROVIDES THE FOUNDATION AND FRAMEWORK OF AN IMPROVEMENT METHOD THAT, IF IMPLEMENTED WELL, WILL IMPROVE AN ORGANIZATION'S HAND HYGIENE COMPLIANCE AND CONTRIBUTE SUBSTANTIALLY TO ITS EFFORTS TO REDUCE THE FREQUENCY OF HEALTH CARE-ASSOCIATED INFECTIONS. THE HAND HYGIENE SOLUTIONS HAVE ACHIEVED AND CONTINUE TO SHOW MAJOR AND SUSTAINED GAINS IN HAND HYGIENE. AT THE START OF THE PROJECT IN APRIL 2009, THE RATE OF HAND HYGIENE COMPLIANCE AVERAGED 48 PERCENT. BY JUNE 2010 THEY HAD REACHED AN AVERAGE RATE OF 81 PERCENT THAT HAS BEEN SUSTAINED. THE TST DATA COLLECTED DEMONSTRATED THAT HEALTH CARE ORGANIZATIONS ARE SIGNIFICANTLY IMPROVING THEIR HAND HYGIENE COMPLIANCE RATES THROUGHOUT THE U.S. ON AVERAGE, ORGANIZATIONS HAVE IMPROVED 43 PERCENT OVER THEIR BASELINE MEASUREMENTS AND ARE SUSTAINING THOSE RESULTS. IN ADDITION, SOME ORGANIZATIONS HAVE LINKED USE OF THE TST TO A REDUCTION IN HEALTH CARE-ASSOCIATED INFECTIONS. THE WRONG SITE SURGERY PROJECT HAS INVOLVED THE DEVELOPMENT OF A RIGOROUS PROCESS FOR REDUCING THE RISK OF WRONG-SITE SURGERY. ACROSS THE PERIOPERATIVE PROCESS, THERE ARE MANY OPPORTUNITIES FOR EVEN TINY SLIPS, LAPSES AND MISTAKES THAT CAN HEIGHTEN THE RISK OF WRONG-SITE SURGERY. BY IDENTIFYING THESE RISK POINTS, THIS PROJECT HAS RESULTED IN A DEEPER UNDERSTANDING OF THE MANY CONTRIBUTING FACTORS THAT CAN RESULT IN A WRONG-SITE SURGERY. THE CENTER'S PROJECT IDENTIFIED MANY CAUSES OF WRONG SITE SURGERIES THAT OCCURRED DURING SCHEDULING, IN PRE-OP/HOLDING OR IN THE OPERATING ROOM, OR WHICH STEMMED FROM THE ORGANIZATIONAL CULTURE. OVER THE COURSE OF THE PROJECT, THE PARTICIPATING ORGANIZATIONS WERE ABLE TO REDUCE THE NUMBER OF CASES WITH RISKS BY 46 PERCENT IN THE SCHEDULING AREA, BY 63 PERCENT IN PRE-OP, AND BY 51 PERCENT IN THE OPERATING ROOM. THE HAND-OFF COMMUNICATIONS PROJECT FOCUSES ON THE QUALITY OF PATIENT INFORMATION THAT IS COMMUNICATED BETWEEN "SENDERS" AND "RECEIVERS" WHEN THE CARE OF THE PATIENT IS BEING HANDED-OFF TO ANOTHER CAREGIVER. DURING THE MEASURE PHASE OF THE PROJECT, PARTICIPATING HOSPITALS FOUND THAT HAND-OFFS WERE DEFECTIVE AND DIDN'T ALLOW THE RECEIVER TO SAFELY CARE FOR PATIENTS 37 PERCENT OF THE TIME ON AVERAGE. SENDERS WERE DISSATISFIED WITH THE QUALITY OF THE HAND-OFF 21 PERCENT OF THE TIME. BY USING SOLUTIONS TARGETED TO THE SPECIFIC CAUSES OF AN INADEQUATE HAND-OFF, ORGANIZATIONS THAT FULLY IMPLEMENTED THE SOLUTIONS ACHIEVED AN AVERAGE OF OVER 50 PERCENT REDUCTION IN DEFECTIVE HAND-OFFS. USING THE TST AND THE SOLUTIONS FROM THE HAND-OFF COMMUNICATIONS PROJECT, HEALTH CARE ORGANIZATIONS REPORTED AN INCREASE IN PATIENT AND FAMILY SATISFACTION, STAFF SATISFACTION, AND SUCCESSFUL TRANSFERS OF PATIENTS (REDUCED BOUNCE BACKS), AND A REDUCTION IN READMISSIONS. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, SURGICAL SITE INFECTIONS (SSIS) ACCOUNT FOR APPROXIMATELY 25 PERCENT OF ALL HEALTH CARE-ASSOCIATED INFECTIONS IN THE U.S. EACH YEAR. AS A CONSEQUENCE, SSIS ARE A MAJOR SOURCE OF PREVENTABLE PATIENT HARM AND UNNECESSARY HEALTH CARE COSTS. THE SCOPE OF THE SSI PROJECT HAS BEEN NARROWED TO COLORECTAL SURGERY AND PROCEDURES, WHICH IS OFTEN ASSOCIATED WITH SSIS. THIS PROJECT IS IN COLLABORATION WITH PARTICIPATING HOSPITALS AND THE AMERICAN COLLEGE OF SURGEONS. DURING PILOT TESTING, THE PARTICIPATING HOSPITALS REDUCED SUPERFICIAL INCISIONAL COLORECTAL SSIS BY 45 PERCENT AND ALL TYPES OF COLORECTAL SSIS BY 32 PERCENT. THEY ATTAINED AN ESTIMATED COST SAVINGS OF MORE THAN $3.7 MILLION FOR THE 135 ESTIMATED COLORECTAL SSIS THAT WERE AVOIDED. IN ADDITION, THEY DECREASED THE AVERAGE LENGTH OF STAY FOR HOSPITAL PATIENTS WITH ANY TYPE OF COLORECTAL SSI FROM 15 TO 13 DAYS. THE CENTER ALSO HAS A PROJECT WHICH AIMS TO PREVENT AVOIDABLE HOSPITALIZATIONS FOR PEOPLE WITH HEART FAILURE. A CHRONIC DISEASE, HEART FAILURE IS THE MOST COMMON REASON FOR ADMISSION TO THE HOSPITAL AMONG OLDER ADULTS. THE GOAL OF THIS PROJECT IS TO BETTER UNDERSTAND WHY PATIENTS WITH HEART FAILURE PERIODICALLY EXPERIENCE SEVERE WORSENING OF THEIR CONDITION TO A DEGREE THAT LEADS TO HOSPITALIZATION. Form 990, Part III, Line 4a PROGRAM SERVICE ACCOMPLISHMENT (CONTINUATION) THERE ARE ELEVEN PROJECTS UNDER THIS PROGRAM: 1) HAND HYGIENE PROJECT FOR IMPROVING PATIENT SAFETY TO LIMIT HOSPITAL ACQUIRED INFECTIONS THROUGH THE INCREASED USE OF HAND HYGIENE TECHNIQUES. 2) HAND-OFF COMMUNICATIONS FOR TRANSFER AND ACCEPTANCE OF PATIENT CARE RESPONSIBILITY ACHIEVED THROUGH EFFECTIVE COMMUNICATION 3) WRONG SITE SURGERY TO IMPROVE THE SAFEGUARDS TO PREVENT PATIENTS FROM WRONG SITE 4) WRONG SIDE AND WRONG PATIENT SURGICAL PROCEDURES, SURGICAL SITE INFECTIONS (SSI) WHICH AIMS TO REDUCE SSI'S IN PATIENTS HAVING COLORECTAL SURGERY 5) PREVENTING AVOIDABLE HEART FAILURE HOSPITALIZATIONS FOR PEOPLE WITH HEART FAILURE 6) IMPROVED SAFETY CULTURE THAT REINFORCES AND SUPPORTS THE PREVENTION OF PATIENT HARM AND 7) PREVENTION OF FALLS THAT OCCUR IN HEALTH CARE FACILITIES THAT RESULT IN INJURY. 8) REDUCING SEPSIS MORTALITY 9) SAFE USE OF INSULIN 10) REDUCING CLOSTRIDIUM DIFFICILE INFECTIONS 11) AND PREVENTING VENOUS THROMBOEMBOLISM (VTE) Form 990, Part III, Line 1 ORGANIZATION'S MISSION (CONTINUATION FROM ABOVE) THE CENTER LAUNCHED ITS SIXTH PROJECT WHICH AIMS TO OPTIMIZE BEHAVIORS AND PRACTICES RESULTING IN AN IMPROVED SAFETY CULTURE THAT REINFORCES AND SUPPORTS THE PREVENTION OF PATIENT HARM. A SAFETY CULTURE ENABLES TRUST. IT EMPOWERS STAFF TO SPEAK UP ABOUT RISKS TO PATIENTS, AND REPORT ERRORS AND NEAR MISSES, ALL OF WHICH DRIVE IMPROVEMENT. A SAFETY CULTURE WITHIN HEALTH CARE CAN BE DEFINED AS THE SUMMARY OF KNOWLEDGE, ATTITUDES, BEHAVIORS AND BELIEFS THAT STAFF SHARE ABOUT THE PRIMARY IMPORTANCE OF THE WELL-BEING AND CARE OF THE PATIENTS THEY SERVE, SUPPORTED BY SYSTEMS AND STRUCTURES THAT REINFORCE THE FOCUS ON PATIENT SAFETY. DESPITE WIDESPREAD ATTENTION TO THE IMPORTANCE OF SAFETY CULTURE IN PERFORMANCE IMPROVEMENT, MANY - IF NOT MOST - HEALTH CARE ORGANIZATIONS STRUGGLE TO ACHIEVE IT. IN FACT, LACK OF SAFETY CULTURE WAS A PROMINENT UNDERLYING FACTOR OF THE ISSUES ADDRESSED BY THE FIRST FOUR CENTER PROJECTS. THE PREVENTING FALLS WITH INJURY PROJECT AIMS TO PREVENT FALLS THAT OCCUR IN HEALTH CARE FACILITIES AND RESULT IN INJURY TO PATIENTS. TENS OF THOUSANDS OF PATIENTS FALL IN HEALTH CARE FACILITIES EVERY YEAR AND MANY OF THESE FALLS RESULT IN MODERATE TO SEVERE INJURIES. THESE INJURIES CAN PROLONG HOSPITAL STAYS AND REQUIRE THE PATIENT TO UNDERGO ADDITIONAL TREATMENT. FALLS HAVE BEEN IDENTIFIED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) AS A "NEVER EVENT" - AN EVENT THAT IS PREVENTABLE AND SHOULD NEVER OCCUR. UP TO HALF OF ALL HOSPITALIZED PATIENTS ARE AT RISK FOR FALLS, AND ALMOST HALF OF THOSE WHO FALL SUFFER AN INJURY. THESE INJURIES RESULT IN AN AVERAGE ADDITIONAL HOSPITAL STAY FOR THE PATIENT OF 6.3 DAYS OR LONGER (THE AVERAGE LENGTH OF A HOSPITAL STAY IS 4.8 DAYS) AND COST FOR A SERIOUS FALL WITH INJURY IS ABOUT $14,056 THE CENTER'S EIGHTH PROJECT AIMS TO REDUCE SEPSIS MORTALITY. SEPSIS IS THE BODY'S LIFE-THREATENING INFLAMMATORY RESPONSE TO AN INFECTION. THE LEADING CAUSE OF DEATH IN HOSPITALIZED PATIENTS, SEPSIS HAS A MORTALITY RATE ESTIMATED BETWEEN 25-50 PERCENT. IN ADDITION, SEPSIS IS THE MOST EXPENSIVE DISEASE TO TREAT IN THE HOSPITAL, COSTING APPROXIMATELY $17 BILLION DOLLARS ANNUALLY. EARLY DETECTION AND APPROPRIATE TREATMENT OF SEPSIS CAN DECREASE MORTALITY, IMPROVE PATIENT OUTCOMES AND DECREASE THE LENGTH OF STAY IN HOSPITALS. THE CENTER'S NINTH PROJECT AIMS TO REDUCE INSULIN RELATED MEDICATION ERRORS IN THE HOSPITAL SETTING. HOSPITALIZED PATIENTS WITH DIABETES WHO ARE TAKING INSULIN MAY BE UNABLE TO MANAGE THEIR GLUCOSE READINGS AND INSULIN ADMINISTRATION, AND STAFF MAY NOT BE TRAINED OR AVAILABLE TO HELP WITH THESE CRITICAL TASKS. GLYCEMIC CONTROL IS NOT ONLY FUNDAMENTAL TO THE MANAGEMENT OF DIABETES, BUT IS ALSO ESSENTIAL TO HELP PREVENT HYPERGLYCEMIC EVENTS. SAFE USE OF INSULIN TO ACHIEVE OPTIMAL BLOOD GLUCOSE HAS BEEN DIRECTLY ASSOCIATED WITH IMPROVED PATIENT OUTCOMES. THE CENTERS FOR MEDICARE & MEDICAID SERVICES INCLUDES POOR GLYCEMIC MANAGEMENT ON ITS 2013 LIST OF 15 HOSPITAL-ACQUIRED CONDITIONS OR HACS AND WILL NO LONGER REIMBURSE HOSPITALS FOR ADDITIONAL COSTS ASSOCIATED WITH THESE PREVENTABLE MEDICAL ERRORS. THE OCCURRENCE OF THESE PREVENTABLE ADVERSE DRUG REACTIONS AND EVENTS CAN BE REDUCED AND INSULIN CAN BE USED SAFELY TO ACHIEVE OPTIMAL GLYCEMIC CONTROL FOR HOSPITALIZED PATIENTS. THE CENTER IS WORKING ON A NEW TOOL FOR RELEASE IN 2015. THE HIGH RELIABILITY SELF-ASSESSMENT TOOL (HRST) WILL ASSIST HOSPITALS IN THEIR TRANSFORMATION TO HIGHLY RELIABLE ORGANIZATIONS BY STRENGTHENING THE SYSTEMS AND STRUCTURES NECESSARY TO PROVIDE PATIENT CARE THAT IS CONSISTENTLY EXCELLENT AND SAFE. THE WEB-BASED APPLICATION WILL PROVIDE THE HOSPITAL WITH 1) PERFORMANCE BUILDING BLOCKS THAT CONTRIBUTE TO THE ACHIEVEMENT OF CONSISTENT EXCELLENCE IN PATIENT CARE; 2) A DIAGNOSTIC TOOL THAT WILL HELP IDENTIFY THEIR PERFORMANCE IMPROVEMENT OPPORTUNITIES; AND 3) SOLUTIONS, TOOLS AND METHODS FOR PROGRESS. IN DECEMBER 2013, THE CENTER LAUNCHED ITS 10TH PROJECT, WHICH AIMS TO REDUCE THE FREQUENCY OF CLOSTRIDIUM DIFFICILE (C. DIFFICILE)-RELATED INFECTIONS. THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) ESTIMATES THAT THERE WERE APPROXIMATELY 337,000 HOSPITALIZATIONS RELATED TO CDI DURING 2009. THIS REPRESENTS A 300 PERCENT INCREASE IN THESE RATES FROM 1993. THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) ESTIMATES THAT CDI-RELATED DIARRHEA IS LINKED TO APPROXIMATELY 14,000 DEATHS PER YEAR. THE FINANCIAL IMPACT OF CDI IS ALSO STAGGERING. THE JAMA INTERNAL MEDICINE ESTIMATES THAT THE CURRENT RATES OF CDI ADD AN ADDITIONAL $1.5 BILLION ANNUALLY TO THE COST OF HEALTH CARE. SINCE CDI DISPROPORTIONATELY AFFECTS OLDER PATIENTS, MEDICARE PAYS FOR 68 PERCENT OF ALL CDI-RELATED HOSPITAL STAYS. CDI RATES AND MORTALITY CAN BE REDUCED THROUGH A FOCUS ON A WIDE RANGE OF PATIENT CARE ASPECTS THAT INCLUDE EARLY IDENTIFICATION, ANTIBIOTIC STEWARDSHIP, AND EFFECTIVE ENVIRONMENTAL HYGIENE PRACTICES.The results for this project are targeted for publication in 2015. In October 2014, the Center for Transforming Healthcare launched its eleventh project, which aims to prevent rates of venous thromboembolism (VTE). VTE is a major cause of morbidity and mortality in the United States. It has been estimated that up to 900,000 VTE's occur per year resulting in approximately 100,000 deaths. In addition to the toll on mortality, VTE is expensive to treat, costing the United States alone approximately $8-10 billion in direct medical costs each year, not including the costs of associated complications. Approximately 50-60 percent of incident VTE cases are associated with a hospital stay that occurred within the past 3-6 months, making hospital-acquired VTE a serious problem. The current accepted guidelines are not implemented consistently leading to continued VTEs in hospitalized patients. There is variation in the assessment of VTE risk factors across different hospital patient populations and in the selection of appropriate mechanical and/or pharmacological prophylaxis. The Center is collaborating with participating organizations and the Centers for Disease Control on this project. Form 990, Part III, Line 2 New program services PATIENT SAFETY & QUALITY PROGRAM (THE PROGRAM) - THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE STARTED ON A NEW PROGRAM SERVICE WHERE THE CENTER WILL PROVIDE RESOURCES TO HEALTHCARE ORGANIZATIONS WHO STRIVE TO BUILD SYSTEMS AND STRUCTURES NECESSARY FOR HIGHLY RELIABLE HEALTHCARE ACROSS ALL SETTINGS. THE PROGRAM COMPONENTS INCLUDE TRAINING AND GUIDANCE ON CREATING ROBUST MEASUREMENT SYSTEMS, ANALYSIS, AND DEVELOPMENT OF TARGETED SOLUTIONS. THE PROGRAM INCLUDES DEVELOPMENT OF THE CENTER'S TARGETED SOLUTIONS TOOL (TST), TRAINING AND USE OF ROBUST PROCESS IMPROVEMENT TOOLS (RPI) AND THE HIGH RELIABILITY SELF-ASSESSMENT TOOL (HRST). IN ADDITION, THE CENTER WILL CONDUCT ON-SITE TRAINING BY RPI TRAINERS THAT ARE EXPERIENCED IN LEAN, SIX SIGMA AND CHANGE MANAGEMENT. Form 990, Part VI, Line 13 WHISTLEBLOWER POLICY ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION WHISTLEBLOWER POLICY. Form 990, Part VI, Line 14 DOCUMENT RETENTION ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION RECORDS RETENTION POLICY. Form 990, Part VI, Line 1a Delegate broad authority to a committee As the sole member of The Center for Transforming Healthcare, The Joint Commission, a related tax-exempt organization, has broad authority to act on behalf of the governing body. Please see the narratives for Part VI, Lines 6, 7a and 7b for a description of such authority. Form 990, Part VI, Line 6 Classes of members or stockholders The Organization has one sole member, The Joint Commission. The Joint Commission has the power to: 1) Appoint all directors to the board of directors and remove them, with or without cause. 2) Approve the election of the Chairman and the Treasurer of the Organization and remove them, with or without cause, provided that an individual so removed may have a claim for compensation if the removal breaches any contract approved by the Organization. 3) Approve amendments to the articles of incorporation and bylaws. 4) Approve all mission and/or vision statements and all strategic or long-term plans of the organization. 5) Approve all creations of subsidiaries or controlled affiliates, mergers, consolidations, permanent or long-term affiliations and all joint ventures of the organization involving capital investments in excess of $250,000. 6) Approve the sale of encumbrance of all or substantially all the assets of the Organization and all long-term debt in excess of $250,000. 7) Approve the organization's annual operating and capital budgets and material amendments thereto. 8) Approve the dissolution of and all liquidations from the organization. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body See response to Line 6 Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders See response to Line 6 Form 990, Part VI, Line 11b Review of form 990 by governing body The Organization's management and the management of The Joint Commission, 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 Center's governing body 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 All Center staff and board members are obligated to follow The Joint Commission on Accreditation of Healthcare Organizations' 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 any potential conflicts during the year anonymously. Form 990, Part VI, Line 15a Process to establish compensation of top management official The Center relies on the process of the Joint Commission for approval of top managements compensation. The 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 the Center's officers. In setting the officers' compensation, the Joint Commission's Human Resources and Compensation Committee relies on recent compensation studies that provide compensation data for similarly qualified persons in comparable 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 insure that he or she is independent. The process for determining the officers compensation is undertaken annually for all officers. Form 990, Part VI, Line 15b Process to establish compensation of other employees Please see the narrative for Part VI, Line 15a Form 990, Part VI, Line 19 Required documents available to the public The organization does not make its governing documents available to the public. The conflict of interest policy and financial statements are available to the public on The Joint Commission website Form 990, Part VIII, Line 2f Other Program Service Revenue - Total Revenue: , Related or Exempt Function Revenue: , Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part IX, Line 11g Other Fees Other fees - Total Expense: 426151, Program Service Expense: 339937, Management and General Expenses: 23393, Fundraising Expenses: 62821; Mgmt Fee for Service to Related Organization - Total Expense: 1010422, Program Service Expense: 558937, Management and General Expenses: 369352, Fundraising Expenses: 82133; THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATION ONE RENAISSANCE BLVD OAKBROOK TERRACE IL 60181 362229255 HEALTHCARE IL 501(c)(3 9 JOINT COMMISSION false JOINT COMMISSION RESOURCES INC 1515 WEST 22ND STREET STE 1300 W OAKBROOK IL 60523 363521721 HEALTHCARE IL 501(c)(3 9 JOINT COMMISSION false JCAHO SURVEYOR & QHR CONSULTANT CORP ONE RENAISSANCE BLVD OAKBROOK TERRACE IL 60181 363673595 ADMIN JC AND AFFILIATES PAYOLL IL 501(c)(3 Type I JOINT COMMISSION false false false true false false false false false false false false true true true true false false true