2012-11-02T17:00:35-05:00 2011-12-31 CROWE HORWATH LLP 70 West Madison Street Suite 700 Chicago IL 606024903 990 2011-01-01 362229255 JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS JOIN 6307925000 One Renaissance Blvd Oakbrook Terrace IL 60181 PAIGE RODGERS 2012-09-17 true P01305268 3128997000 2011 2016-02-24 21:20:13Z THE JOINT COMMISSION DR MARK CHASSIN One Renaissance Blvd Oakbrook Terrace IL 60181 171164392 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 27 483 32 0 0 2625473 2487209 119132283 127333477 3916930 4360544 4422120 4607201 130096806 138788431 125867 0 0 0 80890186 84589897 0 0 0 34836363 37728084 115852416 122317981 14244390 16470450 146500090 152071523 42747682 57050198 103752408 95021325 X THE JOINT COMMISSION PERIODICALLY EVALUATES AND ACCREDITS NEARLY 22,000 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 91180212 0 127566439 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 10,800 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 20,300 ORGANIZATIONS WERE ENROLLED IN 2011 FOR A SUBSCRIPTION FEE PLAN. 3171431 0 3449045 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. 94351643 true true false true false false false false true 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 127 0 true 483 true false false false false false false false false false false X 29 27 false false true 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 X CRAIG W JONES FACHE 5.00 X X 354 0 0 GERALD M SHEA 4.00 X X 0 0 0 ISABEL V HOVERMAN MD MACP 6.00 X X 50180 0 0 MARK CHASSIN MD MPP MPH 35.00 X X 942216 0 46974 REBECCA J PATCHIN MD 4.00 X X 295 0 0 ALEXANDER M CAPRON 4.00 X 0 0 0 BENJAMIN K CHU MD MPH MACP 5.00 X 0 0 0 CARL A SIRIO MD FACP FCCP FCCM 4.00 X 0 0 0 CHARLES R BUCK JR SCD 4.00 X 0 0 0 CHRISTOPHER J QUERAM 4.00 X 180 0 0 DAVID A WHISTON DDS 4.00 X 354 0 0 DAVID L BRONSON MD FACP 4.00 X 0 0 0 EDWARD L LANGSTON MD RPH 5.00 X 295 0 0 ILENE CORINA 4.00 X 0 0 0 JB SILVERS PHD 3.00 X 0 0 0 JOEL T ALLISON FACHE 4.00 X 0 0 0 JOSIE R WILLIAMS MD MMM 5.00 X 0 0 0 JULIANNE M MORATH RN MS 3.00 X 0 0 0 KURT D NEWMAN MD FACS 3.00 X 0 0 0 LAMAR S MCGINNIS JR MD FACS 5.00 X 0 0 0 M NICOLE JAMALI MD 6.00 X 0 0 0 MARY ANNE MCCAFFREE MD 3.00 X 0 0 0 MARY H MCGRATH MD MPH 6.00 X 0 0 0 NANCY HOWELL AGEE 3.00 X 0 0 0 R TIMOTHY RICE FACHE 4.00 X 360 0 0 RALPH W MULLER 3.00 X 0 0 0 ROGER W BUSH MD FACP 6.00 X 0 0 0 STEVEN S SHAFSTEIN MD MPA 3.00 X 0 0 0 T ANTHONY DENTON JD MHA 3.00 X 0 0 0 ANA PUJOLS MCKEE 40.00 X 454398 0 72463 ANN SCOTT BLOUIN 39.00 X 530471 0 115085 ANNE MARIE BENEDICTO 34.00 X 302226 0 106400 CHARLES MOWLL 40.00 X 1431763 0 51999 HAROLD BRESSLER 40.00 X 352856 0 111611 JEROD LOEB 40.00 X 357872 0 193160 JOHN MACHE 40.00 X 274267 0 95626 LYNN DRAGISIC 39.00 X 327874 0 52589 PAIGE RODGERS 38.00 X 379501 0 56512 PAUL SCHYVE 40.00 X 453115 0 87200 DEBRA KIEL 40.00 X 173306 0 41798 GINA VAL ZIMMERMAN 40.00 X 161895 0 49951 CATHERINE BARRY IPEMA 40.00 X 180111 0 46458 DAVID GILMARTIN 40.00 X 197915 0 38175 FRANCES CARROLL 40.00 X 168749 0 19871 JOHN CULLINAN 40.00 X 168002 0 35735 MARK PELLETIER 40.00 X 240892 0 7407 DENNIS O'LEARY 0.00 X 385632 0 15401 ROBERT WISE 0.00 X 160551 0 39114 7695630 0 1283529 133 true true false SHERATON CHICAGO HOTEL & TOWERS 301 EAST NORTH WATER CHICAGO IL 60611 CONFERENCE ROOM & FOOD SERVICES 1089918 GOLDMAN SACHS BANK USA 85 BROADWAY STREET 26TH NEW YORK NY 10004 INTEREST RATE SWAP FEES 617458 THE BOSTON CONSULTING GROUP INC POBOX 75200 CHICAGO IL 606755200 PROFESSIONAL SERVICES/ CONSULTING 600000 HIPSKIND TECHNOLGY SOLUTIONS GROUP 12 SALT CREEK LANE HINSDALE IL 60521 SOFTWARE/HARDWARE MAINT. & CONSULTING 510615 GNC CONSULTING INC 21195 S LAGRANGE RD FRANKFORT IL 60423 SOFTWARE CONSULTING 455195 37 1499543 987666 2487209 SURVEY FEES 900099 61658038 61658038 ANNUAL SUBSCRIPTION FEES 900099 61621232 61621232 PERFORMANCE MEASUREMENT & RELATED ACTIVITIES 900099 3358095 3358095 HONORARIUM FEES 900099 173455 173455 APPLICATION FEES 900099 144750 144750 377907 377907 0 0 127333477 2924521 2924521 0 925194 925194 0 0 0 33811984 32375961 1436023 0 1436023 1436023 0 0 0 FEE FOR SERVICE FROM RELATED TAX EXEMPT ORGANIZATIONS 3682007 3682007 0 0 0 0 3682007 138788431 131015484 0 5285738 0 0 0 0 4808757 1411664 3397093 0 64659696 53968718 10690978 4459959 3598701 861258 6006171 4563044 1443127 4655314 3818777 836537 0 196377 126943 69434 230065 26250 203815 186267 186267 0 635424 635424 4084490 1571763 2512727 1376716 1081438 295278 451851 205519 246332 705605 40854 664751 0 2150998 855325 1295673 18748638 18548181 200457 0 888622 571855 316767 756922 360522 396400 0 3065872 1006107 2059765 956898 956898 TELEPHONE 896684 753817 142867 EQUIPMENT RENTAL 802790 43829 758961 POSTAGE & SHIPPING 263546 172109 91437 RECRUITMENT 319324 68825 250499 1010995 600504 410491 0 122317981 94351643 27966338 0 0 19999721 21352893 14347375 11823660 4527 5811 1446412 2279033 65826854 41521959 23947833 24304895 42060066 52365336 44694156 39939895 0 0 0 0 146500090 152071523 11738220 12183726 935769 1035234 20385000 18500000 9688693 25331238 42747682 57050198 103752408 95021325 103752408 95021325 146500090 152071523 X 16470450 -25201533 X false true true X true true X 2068118 2391006 2324665 2625473 2487209 11896471 98919524 110796686 115797728 119131593 127333477 571979008 0 0 0 100987642 113187692 118122393 121757066 129820686 583875479 0 0 0 0 0 0 0 0 583875479 3901283 4308525 3567554 3648455 3849715 19275532 7620 13961 1660 0 0 23241 3908903 4322486 3569214 3648455 3849715 19298773 0 4547629 3521851 3293084 3359702 3682007 18404273 109444174 121032029 124984691 128765223 137352408 621578525 0.93930 0.93560 0.03100 0.03160 X OTHER INCOME, SCHEDULE A, PART III, LINE 12, DESCRIPTION - FEES FROM RELATED ORGANIZATIONS, COLUMN A - 4547629, COLUMN B - 3521851, COLUMN C - 3293084, COLUMN D - 3359702, COLUMN E - 3682007, COLUMN F - 18404273;, RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false true false false false false true 186267 false false 186267 false Description of the activities reported on Lines 1a through 1i Schedule C, Part II-B, Line 1 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 JOINT COMMISSION BELIEVES WILL HELP IMPROVE PATIENT SAFETY AND QUALITY OF CARE. 0 0 0 0 0 0 0 0.00000 0.00000 0.00000 false true true 4204400 4204400 27620296 14372086 13248210 166293 125411 40882 6958611 4754340 2204271 26877254 22270122 4607132 24304895 COMMON & COLLECTIVE TRUST FUNDS 39939895 F 39939895 0 ACCRUED PENSION LIABILITY 12202472 FAIR VALUE OF HEDGE 1956675 OTHER LIABILITIES 1172091 PLEDGE TO AFFILIATE 10000000 25331238 138788431 122317981 16470450 0 0 16470450 141374714 2864958 2864958 138509756 278675 0 278675 138788431 150105797 3640128 24426363 28066491 122039306 278675 0 278675 122317981 Intended uses of endowment funds Schedule D, Part V, Line 4 THE JOINT COMMISSION PROVIDED $10,000,000 TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE; $8,900,000 OF WHICH WAS PAID IN 2009 AND $1,100,000 PAID IN JANUARY 2010. THE JOINT COMMISSION'S CONTRIBUTION IS REPORTED AS BOARD-DESIGNATED FUNDS FUNCTIONING AS ENDOWMENT IN THE AUDITED CONSOLIDATED FINANCIAL STATEMENTS. IN 2011, THE JOINT COMMISSION HAS COMMITTED TO PROVIDING ADDITIONAL CONTRIBUTIONS OF $10,000,000 TO THE CENTER PAYABLE IN 2012. THE BOARD-DESIGNATED FUNDS FUNCTIONING AS ENDOWMENT HAS A CARRYING VALUE, NET OF INVESTMENT GAINS/LOSSES AND OPERATING NET LOSS, AS OF DECEMBER 31, 2011 OF $20,262,070. SEE NOTE #7 TO THE CONSOLIDATED FINANCIAL STATEMENTS FOR DETAILS. FIN 48 (ASC 740) footnote Schedule D, Part X, Line 2 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. AS OF JANUARY 2009, THE JOINT COMMISSION ADOPTED THE FINANCIAL ACCOUNTING STANDARDS BOARD 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 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, 2011 FOR ITS UNITED STATES OPERATIONS. X X true true X X X X false true false false false true true false false GINA VAL ZIMMERMAN 158666 0 3000 0 229 0 21665 0 28286 0 211846 0 0 0 DENNIS O'LEARY 0 0 0 0 385632 0 0 0 15401 0 401033 0 385632 0 JOHN CULLINAN 165002 0 3000 0 0 0 19731 0 16004 0 203737 0 0 0 MARK PELLETIER 237362 0 3000 0 530 0 6665 0 742 0 248299 0 0 0 CATHERINE BARRY IPEMA 177111 0 3000 0 0 0 22359 0 24099 0 226569 0 0 0 FRANCES CARROLL 165104 0 3000 0 645 0 14936 0 4935 0 188620 0 0 0 DEBRA KIEL 170306 0 3000 0 0 0 20716 0 21082 0 215104 0 0 0 MARK CHASSIN MD MPP MPH 762264 0 3000 0 176952 0 20534 0 26440 0 989190 0 0 0 PAUL SCHYVE 346019 0 3000 0 104096 0 76543 0 10657 0 540315 0 91689 0 JEROD LOEB 339481 0 3000 0 15391 0 167825 0 25335 0 551032 0 0 0 CHARLES MOWLL 310262 0 3000 0 1118501 0 29488 0 22511 0 1483762 0 1106773 0 ANN SCOTT BLOUIN 518026 0 3000 0 9445 0 93633 0 21452 0 645556 0 0 0 PAIGE RODGERS 376182 0 3000 0 319 0 38424 0 18088 0 436013 0 0 0 LYNN DRAGISIC 231025 0 3000 0 93849 0 29217 0 23372 0 380463 0 78317 0 ROBERT WISE 158751 0 1800 0 0 0 20981 0 18133 0 199665 0 0 0 ANNE MARIE BENEDICTO 291382 0 3000 0 7844 0 83698 0 22702 0 408626 0 0 0 HAROLD BRESSLER 277500 0 3000 0 72356 0 88548 0 23063 0 464467 0 56225 0 DAVID GILMARTIN 194652 0 3000 0 263 0 14567 0 23608 0 236090 0 0 0 JOHN MACHE 271368 0 2250 0 649 0 69433 0 26193 0 369893 0 0 0 ANA PUJOLS MCKEE 379954 0 25000 0 49444 0 67260 0 5203 0 526861 0 0 0 First-class or charter travel Schedule J, Part I, Line 1a 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. Personal services Schedule J, Part I, Line 1a 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. Supplemental nonqualified retirement plan Schedule J, Part I, Line 4b 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. Compensation contingent on net earnings of the organization Schedule J, Part I, Line 6a THE JOINT COMMISSION'S HUMAN RESOURCES AND COMPENSATION COMMITTEE APPROVED THE 2010 AND 2011 GAINSHARE PLANS, WHICH PROVIDES 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 2010 AND 2011 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. INDIVIDUAL GAINSHARING AWARDS WERE CAPPED AT $3,000 FOR 2010 AND 2011, RESPECTIVELY. THE 2010 AWARDS WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2010 AND PAID OUT IN 2011. THE 2011 AWARDS WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2011 AND WILL BE PAID OUT IN 2012. Compensation contingent on net earnings of a related organization Schedule J, Part I, Line 6b 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. ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 (CONTINUATION FROM PART III, LINE 1) 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 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 MORE THAN 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, AND PRIMARY STROKE CARE, AND PALLIATIVE CARE. THE JOINT COMMISSION LAUNCHED A HEALTH CARE STAFFING SERVICES CERTIFICATION PROGRAM IN 2004. THIS 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. 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 SENTINEL EVENT ALERT IS A PERIODIC NEWSLETTER THAT ADDRESSES SPECIFIC TYPES OF SENTINEL EVENTS, DESCRIBES THEIR COMMON UNDERLYING CAUSES, AND RECOMMENDS STEPS TO PREVENT FUTURE OCCURRENCES. INFORMATION FOR SENTINEL EVENT ALERT IS DERIVED PRINCIPALLY FROM THE JOINT COMMISSION'S SENTINEL EVENT DATABASE. THE JOINT COMMISSION BEGAN PUBLISHING SENTINEL EVENT ALERT 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 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, AND OPERATIVE/POST-OPERATIVE COMPLICATIONS. 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. ONE NEW NPSG GOAL WAS APPROVED FOR 2012 THAT FOCUSES ON CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI). CAUTI IS THE MOST FREQUENT TYPE OF HEALTH CARE-ASSOCIATED INFECTION, AND REPRESENTS AS MUCH AS 80% OF INFECTIONS IN HOSPITALS. (CONTINUATION BELOW) ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 (CONTINUATION FROM ABOVE) OFFICE OF QUALITY MONITORING THE JOINT COMMISSION'S OFFICE OF QUALITY MONITORING 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 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 RELEASED "PROVIDING A SAFER ENVIRONMENT FOR HEALTH CARE PERSONNEL AND PATIENTS THROUGH INFLUENZA VACCINATION: STRATEGIES FROM RESEARCH AND PRACTICE," A FREE MONOGRAPH, TO HELP HEALTH CARE ORGANIZATIONS OF ALL TYPES IMPROVE SEASONAL INFLUENZA VACCINATION RATES IN HEALTH CARE PERSONNEL. * THE JOINT COMMISSION RELEASED "MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES," TO HELP HEALTH CARE ORGANIZATIONS TARGET THEIR EFFORTS IN MEASURING HAND HYGIENE PERFORMANCE. THE MONOGRAPH IS DESIGNED TO ADDRESS "EVERYTHING YOU EVER WANTED TO KNOW ABOUT HAND HYGIENE MEASUREMENT BUT WERE AFRAID TO ASK." THE AIM OF THE MONOGRAPH IS TO BROADEN UNDERSTANDING OF THE ISSUES AND PROVIDE PRACTICAL SOLUTIONS FOR STRENGTHENING MEASUREMENT AND IMPROVEMENT ACTIVITIES. * 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 FUNCTIONS AS THE PRIMARY ORGANIZATION ON THE TASK FORCE, COMPENDIUM OF STRATEGIES TO PREVENT HEALTHCARE-ASSOCIATED INFECTIONS IN ACUTE CARE, WHOSE INITIATIVE IS TO MAINTAIN IMPLEMENTATION-FOCUSED STRATEGIES FOR SIX HEALTH ACQUIRED INFECTIONS INCLUDING: CENTRAL LINE ACUTE BLOOD STREAM INFECTION, VENTILATOR ASSOCIATED PNEUMONIA, CATHETER ASSOCIATED URINARY TRACK INFECTION, SURGICAL SITE INFECTION, METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS, AND CLOSTRIDIUM DIFFICILE INFECTION. * THE JOINT COMMISSION HAS DEVELOPED THE NURSING-SENSITIVE 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 HAS TEAMED UP WITH THE CENTER FOR DISEASE CONTROL (CDC) TO STUDY THE VALIDITY OF RACE AND ETHNICITY IN VACCINATION FOR INFLUENZA IN VULNERABLE ELDERLY, AND DETERMINE WHETHER RACE MIGHT INFLUENCE IMMUNIZATION RATES OF LONG-TERM CARE FACILITY RESIDENTS. * THE CENTER FOR DISEASE CONTROL (CDC) AND THE JOINT COMMISSION ARE DEVELOPING A NATIONAL MONOGRAPH OF EFFECTIVE PRACTICES FOR RESPIRATORY PROTECTION PROGRAMS FOR U.S. ACUTE CARE HOSPITALS TO REINFORCE HEALTHCARE WORKERS' PROPER USE OF RESPIRATORY PROTECTION. * THE JOINT COMMISSION AND ITS AFFILIATES RECEIVED FUNDING FOR AN INTERNATIONAL PROJECT FOCUSING ON THE "PREVENTION OF CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS (CLABSI): PREFERRED PRACTICES AND USE OF TECHNOLOGY". THE PROJECT IS DIVIDED INTO THREE PHASES: 1) PUBLISHED IN MAY 2012 WAS A MONOGRAPH HIGHLIGHTING EVIDENCE-BASED PRACTICES KNOWN TO MINIMIZE AND PREVENT CLABSI; 2) DEVELOP A TOOLKIT DESIGNED TO SUPPORT ORGANIZATIONAL SELF-ASSESSMENT RELATIVE TO RECOMMENDED PRACTICES AND PROVIDE GUIDANCE RESPECTING ACHIEVEMENT OF THE PREFERRED STATE OF PRACTICE; AND 3) DEVELOPMENT OF AN EDUCATIONAL APPROACH DESIGNED TO TEACH USERS ABOUT THE PRACTICE APPLICATIONS OF THE CONTENT AND TOOLS DEVELOPED IN PHASES I AND II. * THE CDC DIVISION OF HEALTHCARE QUALITY PROMOTION (DHQP) AWARDED THE JOINT COMMISSION THE SAFETY AND HEALTHCARE EPIDEMIOLOGY PREVENTION RESEARCH DEVELOPMENT (SHEPHERD) PROGRAM, TO PROVIDE A MECHANISM TO OBTAIN 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 IS CONDUCTING TRIALS TO DETERMINE THE EFFECTIVENESS OF UNIVERSAL GLOVE AND GOWNING PROCEDURES IN REDUCING HAI RATES IN THE ICU. (CONTINUATION BELOW) ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 (CONTINUATION FROM ABOVE) PATIENT SAFETY RESEARCH THE JOINT COMMISSION'S DIVISION OF HEALTH SERVICES RESEARCH INCLUDES THE CENTER FOR PATIENT SAFETY RESEARCH (PSR), WHICH WORKS WITH EXTERNAL COLLABORATORS AND CONSULTANTS TO ADVANCE THE FIELD OF PATIENT SAFETY RESEARCH AND THE DESIGN OF ADVERSE EVENT REPORTING SYSTEMS. JOINT COMMISSION RESEARCH INITIATIVES HAVE INCLUDED: * CREATION OF A STANDARDIZED PATIENT SAFETY TAXONOMY AND ONTOLOGY TO SUPPORT NATIONAL ADVERSE EVENT REPORTING SYSTEMS. * DEVELOPMENT OF AN INTERNATIONAL PATIENT SAFETY CLASSIFICATION (IPSEC) TO FACILITATE THE GLOBAL EXCHANGE AND DISSEMINATION OF INFORMATION AMONG USERS OF DISPARATE INCIDENT REPORTING SYSTEMS. * DEVELOPMENT OF BEST PRACTICES FOR PATIENT SAFETY, A COLLABORATION WITH THE CENTER FOR HEALTH POLICY AND THE CENTER FOR PRIMARY CARE AND OUTCOMES RESEARCH AT STANFORD UNIVERSITY. THIS PROJECT INVOLVES FORMULATION AND IMPLEMENTATION OF A SURVEY OF HOSPITAL ORGANIZATION CULTURE AS A TOOL FOR ASSESSING DETERMINANTS OF PATIENT SAFETY. * PERFORMANCE OF RESEARCH AND THE CONVENING OF A ROUNDTABLE TARGETED AT MEASURING AND IMPROVING CARE FOR PATIENTS WITH OSTEOPOROSIS. * EXPLORATION OF METHODS FOR IMPROVING PATIENT COMMUNICATION AND QUALITY OF CARE IN UNDERSERVED POPULATIONS. * THE JOINT COMMISSION'S HOSPITALS, LANGUAGE, AND CULTURE: A SNAPSHOT OF THE NATION (HLC) STUDY WAS DESIGNED TO GATHER INFORMATION ABOUT THE ACTIVITIES HOSPITALS ARE UNDERTAKING TO ADDRESS CULTURAL AND LANGUAGE NEEDS AMONG AN INCREASINGLY DIVERSE PATIENT POPULATION. * EVALUATION OF HOW RAPID TESTS FOR INFLUENZA ARE IMPLEMENTED AND USED IN OUTPATIENT MEDICAL SETTINGS IN SOLO AND GROUP PRACTICE PHYSICIAN OFFICES. * AN ASSESSMENT OF NATIONAL HOSPITAL SMOKE-FREE CAMPUS POLICIES AND THE DEVELOPMENT OF A TOOLKIT THAT FACILITATES HOSPITALS' TRANSITION TO SMOKE-FREE CAMPUSES. * DEVELOPMENT OF A MONOGRAPH HIGHLIGHTING SUCCESSFUL STRATEGIES TO IMPROVE IMMUNIZATION RATES FOR TDAP AMONG HEALTH CARE PERSONNEL AND THE ADULT PATIENTS THEY SERVE. * DEVELOPMENT OF A FIELD GUIDE ADVANCING EFFECTIVE COMMUNICATION, CULTURAL COMPETENCE, AND PATIENT- AND FAMILY-CENTERED CARE FOR THE CONVENING OF STAKEHOLDERS TO IDENTIFY AND DISCUSS KEY RECOMMENDATIONS TO PROVIDE EQUITABLE CARE TO LESBIAN, GAY, BISEXUAL AND TRANSGENDER PATIENTS AND FAMILIES. * CREATION OF NEW ALGORITHMS AND THEIR COMPARISON AGAINST STANDARD ALGORITHMS FOR ADMINISTERING PREOPERATIVE ANTIBIOTIC PROPHYLAXIS OF SURGICAL SITE INFECTIONS IN CERTAIN CARDIAC AND ORTHOPEDIC PROCEDURES. * DEVELOPMENT OF A MONOGRAPH THAT PROVIDES GLOBAL PERSPECTIVE ON IDENTIFICATION AND DISSEMINATION OF PREFERRED PRACTICES AND TECHNOLOGY TO PREVENT CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLABSI). * A CLUSTER RANDOMIZED TRIAL TO DETERMINE THE EFFECTIVENESS OF UNIVERSAL GLOVE AND GOWNING PROCEDURES IN REDUCING HEALTHCARE ASSOCIATED INFECTION (HAI) RATES IN THE INTENSIVE CARE UNIT (ICU). * BUILDING AN INTERNATIONAL, COLLABORATIVE LEARNING NETWORK THAT FOSTERS THE SHARING OF KNOWLEDGE AND EXPERIENCE IN IMPLEMENTING INNOVATIVE, STANDARDIZED OPERATING PROTOCOLS THAT ADDRESS PATIENT SAFETY. * EXPLORATION OF THE SYNERGIES BETWEEN PATIENT SAFETY AND WORKER HEALTH AND SAFETY ACTIVITIES IN HEALTH CARE. THE SPEAK UP INITIATIVES IN MARCH 2002, THE JOINT COMMISSION, TOGETHER WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS), LAUNCHED A NATIONAL 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 ORGANIZATION'S MISSION FORM 990, PART III, LINE 1 (CONTINUATION FROM ABOVE) SPEAK UP BROCHURES ARE AVAILABLE TO THE GENERAL PUBLIC AT NO COST ON THE JOINT COMMISSION'S WEBSITE. THE JOINT COMMISSION IS SCHEDULED TO RELEASED IN MARCH 2011 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 WILL AIR ON THE JOINT COMMISSION'S YOUTUBE CHANNEL, ON 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 IN EVERYDAY LIFE SUCH AS ORDERING ITEMS FROM A BAKERY OR RESTAURANT, OR VALET PARKING A CAR. 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. QUALITY CHECK AND QUALITY REPORTS QUALITY CHECK OFFERS A COMPREHENSIVE COMPENDIUM OF QUALITY AND SAFETY-RELATED PERFORMANCE INFORMATION ON THE NEARLY 22,000 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. STRATEGIC SURVEILLANCE SYSTEM IN JULY 2007, THE JOINT COMMISSION LAUNCHED THE STRATEGIC SURVEILLANCE SYSTEM (S3) TO ACCREDITED HOSPITALS. THIS SYSTEM, PROVIDED AT NO ADDITIONAL COST, IS A VALUE ADDED ELEMENT OF THE ACCREDITATION PROCESS INTENDED TO HELP ACCREDITED HOSPITALS IDENTIFY AND PRIORITIZE AREAS FOR IMPROVEMENT. THIS NEW TOOL PROVIDES A SERIES OF RISK ASSESSMENT AND COMPARATIVE PERFORMANCE MEASURE REPORTS TO HELP HOSPITALS IMPROVE THEIR CARE PROCESSES AND PRIORITIZE THE ACTIONS TO TAKE FOR IMPROVEMENT. S3 USES DATA THE JOINT COMMISSION CURRENTLY HAS, INCLUDING PAST SURVEY FINDINGS, ORYX® CORE MEASURE DATA, DATA FROM THE OFFICE OF QUALITY MONITORING (COMPLAINTS AND NON SELF-REPORTED SENTINEL EVENTS), DATA FROM AN ORGANIZATION'S E-APP, AND MEDPAR DATA. REPORTS ARE POSTED AND UPDATED QUARTERLY ON EACH HOSPITAL'S SECURE JOINT COMMISSION EXTRANET SITE. S3 OFFERS THE FOLLOWING BENEFITS TO HOSPITALS: * HOSPITALS WILL HAVE ACCESS TO NATIONAL AND STATE BENCHMARKS AS WELL AS SELECT GROUPS, TO COMPARE THEMSELVES TO OTHERS. * HOSPITALS WITH A COMMON OWNER WILL BE ABLE TO COMPARE S3 DATA AMONG EACH HOSPITAL TO IDENTIFY TRENDS OR COMMON AREAS FOR IMPROVEMENT. * S3 HELPS DRIVE AND MONITOR SYSTEMS IMPROVEMENT THROUGHOUT AN ORGANIZATION BY PROVIDING ONGOING QUANTITATIVE FEEDBACK. * S3 ALLOWS ORGANIZATIONS TO DRILL-DOWN TO CERTAIN PERFORMANCE AREAS SO THEY CAN COMPARE THEMSELVES TO OTHERS ON A WELL-DEFINED BASIS. 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. Significant changes to organizational documents Form 990, Part VI, Section A, Line 4 THE ORGANIZATION AMENDED IT'S BYLAWS THIS YEAR TO INCREASE THE NUMBER OF VOTING COMMISSIONERS FROM 29 TO 32 MEMBERS. Classes of members or stockholders Form 990, Part VI, Section A, Line 6 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 Members or stockholders electing members of governing body Form 990, Part VI, Section A, Line 7a SEE NARRATIVE FOR LINE 6 Decisions requiring approval by members or stockholders Form 990, Part VI, Section A, Line 7b SEE NARRATIVE FOR LINE 6 Review of form 990 by governing body Form 990, Part VI, Section B, Line 11b 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. Conflict of interest policy Form 990, Part VI, Section B, Line 12c 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. Process used to establish compensation of top management official Form 990, Part VI, Section B, Line 15a 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 ITS 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 JOINT COMMISSION'S OFFICERS COMPENSATION IS UNDERTAKEN ANNUALLY FOR ALL OFFICERS. Process used to establish compensation of other officers/key employees Form 990, Part VI, Section B, Line 15b THE JOINT COMMISSION ENGAGES ITS HUMAN RESOURCES DEPARTMENT TO ASSIST IN DETERMINING COMPENSATION OF ITS KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES. IN SETTING THE KEY AND HIGHEST COMPENSATED EMPLOYEES' COMPENSATION, THE HUMAN RESORUCES 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 AND HIGHEST COMPENSATED EMPLOYEES' COMPENSATION AGREEMENT IS SUBJECT TO A REVIEW AND APPROVAL BY THE VICE PRESIDENT OF HUMAN RESOURCES. THE COMPENSATION OF KEY AND HIGHEST COMPENSATED EMPLOYEES IS ADEQUATELY DOCUMENTED IN AN ANNUAL PERFORMANCE APPRAISAL WHICH REQUIRES APPROVAL BY A VICE PRESIDENT. THE PROCESS FOR DETERMINING THE JOINT COMMISSION'S KEY AND HIGHEST COMPENSATED EMPLOYEES' COMPENSATION IS UNDERTAKEN ANNUALLY IN FEBRUARY FOR ALL KEY EMPLOYEES. Governing documents, conflict of interest policy and financial statements available to the public Form 990, Part VI, Section C, Line 19 THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC. THE CONFLICT OF INTEREST POLICY, CODE OF CONDUCT, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC. COMPENSATION OF OFFICERS, DIRECTORS, TRUSTEES, KEY EMPLOYEES, ETC. FORM 990, PART VII, SECTION A, LINE 1B CHRISTOPHER QUERAM, COMMISSIONER - 1 HOUR A WEEK TO JOINT COMMISSION RESOURCES. ISABEL V. HOVERMAN, CHAIRMAN- 1 HOUR A WEEK TO JOINT COMMISSION RESOURCES; 1 HOUR A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. CRAIG W. JONES, SECRETARY- 1 HOUR A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. LAMAR S. MCGINNIS, COMMISSIONER- 1 HOUR A WEEK TO JOINT COMMISSION RESOURCES; 1 HOUR A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. REBECCA J. PATCHIN, TREASURER- 1 HOUR A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. GERALD M. SHEA, TREASURER- 1 HOUR A WEEK TO JOINT COMMISSION RESOURCES; 1 HOUR A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. J.B. SILVERS, COMMISSIONER - 1 HOUR A WEEK TO JOINT COMMISSION RESOURCES. DAVID A. WHISTON, COMMISSIONER- 1 HOUR A WEEK TO JOINT COMMISSION RESOURCES; 1 HOUR A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. MARK CHASSIN, PRESIDENT & CHIEF EXECUTIVE OFFICER- 2 HOURS A WEEK FOR JOINT COMMISSION RESOURCES; 3 HOURS A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. ANN SCOTT BLOUIN, EXECUTIVE VICE PRESIDENT- 1 HOUR A WEEK TO JCAHO SURVEYOR & QHR CONSULTANT CORP. PAIGE RODGERS, CHIEF FINANCIAL OFFICER- 1 HOUR A WEEK TO JCAHO SURVEYOR & QHR CONSULTANT CORP; 1 HOUR A WEEK FOR THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. ANNE MARIE BENEDICTO, CHIEF OF STAFF & EXECUTIVE VICE PRESIDENT- 6 HOURS A WEEK TO THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE. LYNN DRAGISIC, VICE PRESIDENT- 1 HOUR A WEEK TO JCAHO SURVEYOR & QHR CONSULTANT CORP. Other changes in net assets or fund balances Form 990, Part XI, Line 5 NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - -3640128; CHANGE IN FAIR VALUE OF HEDGE-INTEREST RATE SWAP - 46988; CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COASTS NOT YET RECOGNIZED IN NET PERIODIC BENEFIT COST - -9426363; TRANSFER OF NET ASSETS TO PARENT COMPANY - 2817970; TRANSFER OF NET ASSETS FROM PARENT COMPANY - -5000000; BOARD DESIGNATED FUNDS FUNCTIONING AS ENDOWMENT - -10000000; 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) 11 - Type I JOINT COMMISSION true true true false true false false false false false false true false true true true true false true JOINT COMMISSION RESOURCES INC P 14129517 ACTUAL JOINT COMMISSION RESOURCES INC R 2933431 CONTRACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE B 10000000 CONTRACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE D 320270 ACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE P 1530935 ACTUAL JOINT COMMISSION RESOURCES INC K 3067600 CONTRACTUAL JOINT COMMISSION RESOURCES INC A 925194 ACTUAL JOINT COMMISSION RESOURCES INC K 396163 CONTRACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE K 614407 CONTRACTUAL JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE B 4062600 ACTUAL