2015-11-10T10:02:33-06:00 2014-12-31 350921680 CROWE HORWATH LLP 225 West Wacker Drive Suite 2600 Chicago IL 606061224 990 2014-01-01 362229255 Joint Commission on Accreditation of Healthcare Organizations JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 Paige Rodgers Chief Financial Officer 2015-11-03 true John Woodhull P01305268 3128997000 2014 2016-04-25 22:37:26Z The Joint Commission Dr Mark Chassin One Renaissance Blvd Oakbrook Terrace IL 60181 154928858 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. 29 27 516 32 0 -12407 1902807 1154242 142545602 139684281 6975596 4760508 5953503 6419188 157377508 152018219 0 0 0 0 98020711 93747292 0 0 0 45037835 45317753 143058546 139065045 14318962 12953174 185173917 190047985 43284878 46884508 141889039 143163477 The Joint Commission periodically evaluates and accredits more than 20,500 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 105071998 136262786 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 12,240 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 20,400 ORGANIZATIONS WERE ENROLLED IN 2014 FOR A SUBSCRIPTION FEE PLAN. 3558240 3421495 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. 108630238 true true false true 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 false false false false false false false false false false false false false true true true false false true 136 0 true 516 true true true false false false false false false false false false X 29 27 false false false false true true true true true false false true true true true true true true false false IL X X Paige Rodgers 6307925685 One Renaissance Blvd Oakbrook Terrace IL 60181 Mark Chassin MD MPP MPH President/CEO 35.00 5.00 X X 1254764 0 54697 Rebecca J Patchin MD Chair 3.00 3.00 X X 50000 0 0 Craig W Jones FACHE Vice Chair 3.00 3.00 X X 0 0 0 Michael F Hogan PhD Commissioner 3.00 X 313 0 0 Mary Anne McCaffree MD Commissioner 2.00 X 457 0 0 R Timothy Rice FACHE Commissioner 2.00 X 0 0 0 Charles R Buck JR ScD Commissioner 3.00 X 0 0 0 David B Pryor MD Commissioner 3.00 X 529 0 0 JB Silvers PhD Commissioner 3.00 3.00 X 0 0 0 John A Babiarz Commissioner 2.00 2.00 X 0 0 0 JOAN DOYLE RNMSNMBA COMMISSIONER 3.00 X 0 0 0 Nancy Howell Agee Commissioner 3.00 X 0 0 0 Roger W Bush MD FACP Commissioner 3.00 X 0 0 0 T Anthony Denton JD MHA Commissioner 1.00 X 0 0 0 David L Bronson MD FACP Commissioner 4.00 1.00 X 424 0 0 Carl A Sirio MD FACP FCCP FCCM Commissioner 3.00 X 0 0 0 LD Britt MD MPH FACS Commissioner 3.00 X 0 0 0 Albert J Osbahr lllMD MSCM Commissioner 3.00 X 0 0 0 M Nicole Jamali MD Commissioner 2.00 X 529 0 0 Connie S March RN MSN Commissioner 3.00 X 0 0 0 Steven S Sharfstein MD MPA Commissioner 3.00 X 0 0 0 LaMar S McGinnis Jr MD FACS Commissioner 3.00 3.00 X 0 0 0 Stephen R Permut MD JD Commissioner 3.00 X 0 0 0 David Perrott DDS MD MBA FACS Commissioner 4.00 1.00 X 0 0 0 Ilene Corina Commissioner 2.00 X 0 0 0 Christopher J Queram Commissioner 3.00 2.00 X 0 0 0 Mark A Kelley MD MACP Commissioner 3.00 X 0 0 0 Grant C Davies FACHE Commissioner 3.00 X 424 0 0 Jane D Englebright PhD RN CENP FAAN Commissioner 3.00 X 0 0 0 Gregg S Meyer MD MSc Commissioner 3.00 X 0 0 0 Aurie Hollingsworth Holly Miller BA MA Commissioner 3.00 X 0 0 0 Mary H McGrath MD MPH FACS Commissioner 3.00 X 0 0 0 Paige Rodgers Chief Financial Officer 38.00 2.00 X 433815 0 169696 John Mache Chief Information Officer 40.00 X 318025 0 114282 Harold Bressler General Counsel 39.00 1.00 X 372109 0 126292 Ann Scott Blouin Executive Vice President 40.00 X 369103 0 105675 Anne Marie Benedicto Chief of Staff/Exec VP 39.00 1.00 X 341304 0 191704 Mark Pelletier Chief Operating Officer 39.00 1.00 X 382582 0 85943 Charles Mowll Executive Vice President 40.00 X 421380 0 132825 Lynn Dragisic Vice President 39.00 1.00 X 330696 0 116302 Ana Pujols McKee VP & Chief Medical Officer 40.00 X 573306 0 23845 Margaret Van Amringe Executive Vice President 39.00 1.00 X 0 391435 104316 Debra Kiel Director, Strategic Planning IT 40.00 X 188184 0 36304 Michael DeGraff Director- Tech Services 40.00 X 150506 0 21517 BARBARA BUTURUSIS DIR. SURVEYOR MGMT & SUPPORT 40.00 X 175739 0 41941 Mark Crafton Executive Director, External Relations 40.00 X 182911 0 51476 Daniel Castillio Medical Director 40.00 X 319304 0 8911 David Gilmartin Associate General Counsel 40.00 X 230717 0 41266 Ronald Wyatt Medical Director 40.00 X 286687 0 45106 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 40.00 X 194614 0 46795 Paul Schyve Sr Advisor-Healthcare Improvement 20.00 X 245744 0 51573 6824166 391435 1570466 168 true true false AMERICAN HEART ASSOCIATION 7272 GREENVILLE AVE DALLAS TX 75235 PROFESSIONAL SERVICES/CERTIFICATIONS 2510438 INSTITUTE FOR MEDICAL QUALITY INC 221 MAIN STREET SUITE 210 SAN FRANCISCO CA 94105 PROFESSIONAL SERVICES/ACCREDITATION 616965 Cognizant Technology Solutions 24721 Network Place Chicago IL 60673 IT CONSULTING SERVICES 583782 Experis IT Services US LLC PO Box 905378 Charlotte NC 28290 IT CONSULTING SERVICES 564260 Sundgard Availability Services LP 680 E Swedesford Road Wayne PA 19087 Disastor Recovery Services 530071 36 1130014 24228 1154242 SURVEY FEES 900099 62248777 62248777 ANNUAL SUBSCRIPTION FEES 900099 73549569 73549569 PERFORMANCE MEASUREMENT & RELATED ACTIVITIES 900099 3421495 3421495 HONORARIUM FEES 900099 77509 77509 OTHER REVENUE 532000 386931 386931 0 0 0 0 139684281 1760658 1760658 982041 982041 0 0 5910489 0 2910639 2999850 0 2999850 2999850 FEE FOR SERVICE FROM RELATED TAX EXEMPT ORGANIZATIONS 900099 5437147 5437147 0 0 0 0 5437147 152018219 145121428 0 5742549 7028288 1982623 5045665 71290675 59797681 11492994 4266198 3563947 702251 5861587 5228177 633410 5300544 4341480 959064 395639 214252 181387 261072 19450 241622 223674 223674 604280 604280 6783496 4304318 2479178 0 714203 454955 259248 206830 163892 42938 1559919 207213 1352706 2111108 878658 1232450 21865828 21547761 318067 1264753 881804 382949 682136 351368 330768 3610110 1520333 2089777 1131772 1131772 Telephone 914599 745485 169114 Equipment rental 714032 193805 520227 Postage & shipping 216469 95086 121383 Recruitment 598411 50644 547767 1459422 955534 503888 0 139065045 108630238 30434807 0 24390914 25716206 14073030 10280979 0 0 11028 10864 1839697 2608379 64422899 40127524 24463215 24295375 112636136 56676978 7596575 70348737 0 163322 110467 0 0 185173917 190047985 13767486 12441397 2173728 2926334 14245000 11840000 0 13098664 19676777 43284878 46884508 X 141889039 143163477 141889039 143163477 185173917 190047985 X 12953174 1250243 -12928979 X false true X true true true X 2625473 2487209 3125663 1902807 1154242 11295394 119131593 127333477 137010728 142545602 139684281 665705681 121757066 129820686 140136391 144448409 140838523 677001075 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 677001075 3648455 3849715 3452041 3781039 2742699 17473949 0 0 0 0 3648455 3849715 3452041 3781039 2742699 17473949 3359702 3682007 4932412 5006477 5437147 22417745 128765223 137352408 148520844 153235925 149018369 716892769 0.9444 0.9443 0.0244 0.0264 X Schedule A, Part III, Line 12 Other Income DESCRIPTION - FEES FROM RELATED ORGANIZATIONS, COLUMN A - 3359702.0, COLUMN B - 3682007.0, COLUMN C - 4932412.0, COLUMN D - 5006477.0, COLUMN E - 5437147.0, COLUMN F - 22417745.0; RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 223674 false false 223674 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. 4204400 4204400 29696716 16661664 13035052 271266 184761 86505 7409264 4856850 2552414 22841253 18424249 4417004 24295375 Mutual & Comingled Funds - Domestic Equity Funds 41876550 F Mutual & Comingled Funds - International Equity Funds 27838867 F Mutual & Comingled Funds - Fixed Income & Bonds 633320 F 70348737 Deferred Swap 82306 Unrestricted Operating Pledge to Affiliate 3800000 Fair value of hedge 717531 Accrued pension liability 15059182 Due to Affiliate 17758 Board Designated 19676777 X 154594443 1250243 1469969 2720212 151874231 143988 0 143988 152018219 153320005 14398948 14398948 138921057 143988 0 143988 139065045 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, 2014 or 2013 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 - 365028 TRANSFER OF NETS ASSETS TO PARENT CO - 1104941 Schedule D, Part XII, Line 2(d) Other expenses in audited financial statements not in form 990 TRANSFER OF NET ASSETS TO AFFILIATE - OPERATING - 3800000 CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COSTS NOT YET RECONIZED IN NET PERIODIC BENEFIT COST - 10598948 X X true true X X X X false true false true false true true false false Mark Chassin MD MPP MPH President/CEO 885740 0 137800 0 231224 0 23850 0 30847 0 1309461 0 0 0 Paul Schyve Sr Advisor-Healthcare Improvement 224744 0 1000 0 20000 0 41032 0 10541 0 297317 0 0 0 Paige Rodgers Chief Financial Officer 428360 0 2000 0 3455 0 148780 0 20916 0 603511 0 0 0 John Mache Chief Information Officer 314601 0 2000 0 1424 0 83547 0 30735 0 432307 0 0 0 Harold Bressler General Counsel 291308 0 2000 0 78801 0 95823 0 30469 0 498401 0 55978 0 Ann Scott Blouin Executive Vice President 356169 0 2000 0 10934 0 87653 0 18022 0 474778 0 0 0 Anne Marie Benedicto Chief of Staff/Exec VP 331335 0 2000 0 7969 0 163510 0 28194 0 533008 0 0 0 Mark Pelletier Chief Operating Officer 367458 0 2000 0 13124 0 85212 0 731 0 468525 0 0 0 Charles Mowll Executive Vice President 330977 0 2000 0 88403 0 104861 0 27964 0 554205 0 74070 0 Lynn Dragisic Vice President 260198 0 2000 0 68498 0 87408 0 28894 0 446998 0 55177 0 Ana Pujols McKee VP & Chief Medical Officer 500057 0 2000 0 71249 0 20907 0 2938 0 597151 0 0 0 Margaret Van Amringe Executive Vice President 0 321991 0 2000 0 67444 0 98016 0 6300 0 495751 0 63223 Debra Kiel Director, Strategic Planning IT 184109 0 2000 0 2075 0 23646 0 12658 0 224488 0 0 0 Michael DeGraff Director- Tech Services 147410 0 2000 0 1096 0 11787 0 9730 0 172023 0 0 0 BARBARA BUTURUSIS DIR. SURVEYOR MGMT & SUPPORT 172664 0 2000 0 1075 0 12332 0 29609 0 217680 0 0 0 Mark Crafton Executive Director, External Relations 180511 0 2000 0 400 0 20859 0 30617 0 234387 0 0 0 Daniel Castillio Medical Director 317512 0 1500 0 292 0 8623 0 288 0 328215 0 0 0 David Gilmartin Associate General Counsel 228193 0 2000 0 524 0 20933 0 20333 0 271983 0 0 0 Ronald Wyatt Medical Director 282757 0 2000 0 1930 0 15600 0 29506 0 331793 0 0 0 Marion Panagopoulos Sr. Dir Quality Evaluation & Strategy 192337 0 2000 0 277 0 18670 0 28125 0 241409 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 99, Part VII, Column D as Reportable Compensation. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan All officers are allowed to participate in a nonqualified supplemental defined benefit retirement plan. The increases in the value of the plan during the year are reflected in Column C Deferred Compensation on Schedule J, Part II. Schedule J, Part I, Line 5a Compensation contigent on revenues of the organization The Joint Commission's Human Resources and Compensation Committee approved the 2013 and 2014 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 2013 and 2014 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 2013 and 2014. The 2013 awards were accrued for in the year ended December 31, 2013 and paid out in 2014. There were no 2014 awards accrued for in the year ended December 31, 2014. Schedule J, Part I, Line 6a Compensation contigent on net earnings of the organization The Joint Commission's Human Resources and Compensation Committee approved the 2013 and 2014 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 2013 and 2014 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 2013 and 2014. The 2013 awards were accrued for in the year ended December 31, 2013 and paid out in 2014. There were no 2014 awards accrued for in the year ended December 31, 2014. Schedule J, Part I, Line 6b Compensation contigent 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. 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 IS ALSO THE FIRST ACCREDITING BODY TO REQUIRE ITS SURVEYOR CADRE TO ACHIEVE AND MAINTAIN CERTIFICATION THROUGH FORMAL PERIODIC EXAMINATIONS. 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, AND PALLIATIVE CARE. AN ADVANCED CERTIFICATION IN DISEASE-SPECIFIC CARE PROGRAM IS 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 CENTERS, COMPREHENSIVE STROKE CENTERS, VENTRICULAR ASSIST DEVICES, AND ETC. 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. * THE JOINT COMMISSION DEVELOPED "TDAP VACCINATION STRATEGIES FOR ADOLESCENTS AND ADULTS, INCLUDING HEALTH CARE PERSONNEL: STRATEGIES FROM RESEARCH AND PRACTICE," A FREE MONOGRAPH, FOCUSING ON BARRIERS TO SUCCESSFUL TDAP VACCINATION PROGRAMS AND STRATEGIES FOR OVERCOMING THEM. * THE JOINT COMMISSION HAS TEAMED UP WITH THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) ON THE INITIATIVE TO INCREASE IMMUNIZATION RATES OF HEALTHCARE WORKERS FOR SEASONAL INFLUENZA. * THE JOINT COMMISSION, ALONG WITH THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY (APIC), PARTNERED WITH THE SOCIETY FOR HOSPITAL EPIDEMIOLOGY OF AMERICAN (SHEA) AND THE INFECTIOUS DISEASES SOCIETY OF AMERICA TO UPDATE THE "COMPENDIUM OF STRATEGIES TO PREVENT HEALTHCARE-ASSOCIATED INFECTIONS IN ACUTE CARE." THE COMPENDIUM, PREVIOUSLY PUBLISHED IN 2008, CONTAINED IMPLEMENTATION-FOCUSED STRATEGIES TO ADDRESS CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTION, VENTILATOR ASSOCIATED PNEUMONIA, CATHETER ASSOCIATED URINARY TRACT INFECTION, SURGICAL SITE INFECTION, METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS, AND CLOSTRIDIUM DIFFICILE INFECTION. NEWLY DEVELOPED AND PUBLISHED IN THE 2014 UPDATE WERE STRATEGIES TO PREVENT HEALTHCARE-ASSOCIATED INFECTIONS THROUGH HAND HYGIENE. * THE JOINT COMMISSION DEVELOPED THE NURSING-SENSITIVE BLOOD STREAM INFECTION MEASURE, URINARY CATHETER-ASSOCIATED URINARY TRACT INFECTION FOR INTENSIVE CARE UNIT (ICU) PATIENTS MEASURE, AND VENTILATOR-ASSOCIATED PNEUMONIA FOR ICU PATIENTS MEASURE. * The Joint Commission, with funding from the Center for Disease Control and Prevention (CDC), studied the validity of race and ethnicity in vaccination for influenza in vulnerable elderly, and determined whether race might influence immunization rates of long-term care facility residents. * The Joint Commission and its affiliates received funding for an international project "Prevention of Central Line-Associated Bloodstream Infections (CLABSI): Preferred Practices and Use of Technology." The project consisted of two phases. Phase one produced a free monograph, "Preventing Central Line-associated Bloodstream Infections: A Global Challenge, A Global Perspective," highlighting evidence-based practices known to minimize and prevent CLABSI (2012). As a result of phase two, a toolkit was developed to support organizational self-assessment relative to recommended practices and to provide guidance respecting achievement of the preferred state of practice (2013). * The Joint Commission was awarded an IDIQ contract under the CDC Safety and Healthcare Epidemiology Prevention Research Development (SHEPheRD) program. This funding mechanism is designed to solicit required services through issuance of individual task orders in support of healthcare acquired infection (HAI) prevention research studies that meet public health priorities for CDC. The Joint Commission works with their project partners to continually respond to task order requests for proposals stemming from this program. * 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. * To reduce the risk of healthcare-associated infections, National Patient Safety Goals have been implemented focusing on preventing central line bloodstream infections and catheter-associated urinary tract infections (both central venous catheters and peripherally inserted central catheter lines) in patients in hospitals. * 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 is currently embarking on expanded dissemination of this monograph. (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 FIELD GUIDE ADVANCING EFFECTIVE COMMUNICATION, CULTURAL COMPETENCE, AND PATIENT- AND FAMILY-CENTERED CARE TO LESBIAN, GAY, BISEXUAL AND TRANSGENDER PATIENTS AND FAMILIES. * CREATION OF AN INTERNATIONAL, COLLABORATIVE LEARNING NETWORK THAT FOSTERS THE SHARING OF KNOWLEDGE AND EXPERIENCE IN IMPLEMENTING INNOVATIVE, STANDARDIZED OPERATING PROTOCOLS THAT ADDRESS PATIENT SAFETY. * DEVELOPMENT OF A MONOGRAPH ON THE OPPORTUNITIES FOR SYNERGY, COLLABORATION, AND INNOVATION BETWEEN PATIENT SAFETY AND WORKER SAFETY IN HEALTH CARE. * DEVELOPMENT OF A PROTOCOL DESIGNED TO HELP CLOSE THE GAPS IN IMPLEMENTATION OF THE UNIVERSAL PROTOCOL BY SYSTEMATICALLY ADDRESSING AND PREVENTING LAPSES IN IMPLEMENTATION. THE JOINT COMMISSION IS CURRENTLY TESTING THE PROTOCOL IN ONE HOSPITAL AS PART OF A RESEARCH PROJECT FUNDED BY THE AMERICAN SOCIETY FOR HEALTHCARE RISK MANAGEMENT. * Collaboration on the CMS Partnership for Patients, Hospital Engagement Network. Worked with Joint Commission Resources (a HEN contractor) to design the evaluation methodology and assist participating hospitals with data collection and analysis of data across 11 adverse event areas. The goal of this three year projects was to achieve a 40% reduction in hospital adverse events and a 20% reduction in hospital readmissions.. * 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 I of this project focused on providing a funding opportunity for antimicrobial stewardship. Three project awards were issued. Phase II is focused on projects related to transitions of care (TOC) among a defined venous thromboembolism patient population. 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 COMPREHENSIVE STROKE CENTER REQUIREMENTS TO IMPROVE THE QUALITY AND SAFETY OF CARE FOR COMPLEX 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. * Development of certification requirements for perinatal care 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. For the future, The Joint Commission is considering the development of a program focused on requirements for addressing high-risk pregnancies and births. * Development of an integrated care center certification (ICC) program that provides a pathway for inpatient and outpatient providers that form an ICC to do the following: A. Establish 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. The initial focus is on hospitals and ambulatory care settings; future expansion to home care and nursing care centers is planned. * Research on telehealth issues across health care settings. Existing standards are being evaluated and modified as necessary to reflect contemporary practices. * Research on a potential new optional certification program for accredited organizations for patients undergoing 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. THE SPEAK UP INITIATIVES IN MARCH 2002, THE JOINT COMMISSION, TOGETHER WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS), LAUNCHED 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: * 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 ADULT 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 BROCHURES ARE AVAILABLE TO THE GENERAL PUBLIC AT NO COST ON THE JOINT COMMISSION'S WEBSITE. 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 35 COUNTRIES. 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 20,500 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. 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 organization'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 ensure that he or she is independent. The process for determining the organization's other officers' compensation is undertaken annually for all other officers. 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 similarly qualified persons in comparable organizations and/or on the internal job evaluation system to support its decision making process. The key employees' compensation agreement is subject to a review and approval by the vice president of human resources. Incentive compensation for key employees is also reviewed and approved by the organization's human resources and compensation committee. 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 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 ensure that he or she Is independent. The process for determining the ceo's compensation is undertaken annually. 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 - 365028; TRANSFER OF NET ASSETS TO PARENT CO - 1104941; TRANSFER OF NET ASSETS TO AFFILIATE - OPERATING - -3800000; CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COSTS NOT YET RECOGNIZED IN NET PERIODIC BENEFIT COST - -10598948; 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 9 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 false true true true true true true JOINT COMMISSION RESOURCES INC A 982041 ACTUAL JOINT COMMISSION RESOURCES INC L 4426725 CONTRACTUAL JOINT COMMISSION RESOURCES INC L 331502 ACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE L 1010422 CONTRACTUAL JOINT COMMISSION RESOURCES INC Q 15318223 ACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE Q 998910 ACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE R 3800000 CONTRACTUAL JOINT COMMISSION RESOURCES INC S 1122699 CONTRACTUAL