Attach to Form 990 or Form 990-EZ.
See separate instructions.| (i) Name of supported organization |
(ii) EIN |
(iii) Type of organization (described on lines 1- 9 above or IRC section (see instructions)) |
(iv) Is the organization in col. (i) listed in your governing document? |
(v) Did you notify the organization in col. (i) of your support? |
(vi) Is the organization in col. (i) organized in the U.S.? |
(vii) Amount of support? |
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|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | ||||
| Total | |||||||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | 12,202,467 | 3,658,872 | 2,317,788 | 12,038,452 | 30,217,579 | |
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf....... | 0 | |||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | 0 | |||||
| 4 | Total. Add lines 1 through 3.. | 0 | 12,202,467 | 3,658,872 | 2,317,788 | 12,038,452 | 30,217,579 |
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | 23,412,442 | |||||
| 6 | Public Support. Subtract line 5 from line 4. | 6,805,137 | |||||
| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 0 | 12,202,467 | 3,658,872 | 2,317,788 | 12,038,452 | 30,217,579 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 201,955 | 310,389 | 325,273 | 837,617 | ||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | 0 | |||||
| 10 | Other income. (Explain in Part IV.) Do not include gain or loss from the sale of capital assets.. | 0 | |||||
| 11 | Total support (Add lines 7 through 10). | 31,055,196 | |||||






| Calendar year(or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose...... | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513.. | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 6 | Total. Add lines 1 through 5. | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons... | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public Support (Subtract line 7c from line 6.) | ||||||
| Calendar year (or fiscal year beginning in) | (a) 2007 | (b) 2008 | (c) 2009 | (d) 2010 | (e) 2011 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) | ||||||
| 13 | Total support (Add lines 9, 10c, 11 and 12.). | ||||||




| Facts And Circumstances Test |
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| Explanation |
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| 10% FACTS AND CIRCUMSTANCES TEST, PART IV, TO BE CLASSIFIED AS A PUBLIC CHARITY USING THE 10% FACTS AND CIRCUMSTANCES TEST UNDER TREAS. REGS. SECTION 1.170A-9(F), TWO REQUIREMENTS MUST BE SATISFIED. FIRST, THE ORGANIZATION MUST DERIVE AT LEAST 10 PERCENT OF ITS SUPPORT FROM GOVERNMENTAL UNITS OR FROM DIRECT OR INDIRECT CONTRIBUTIONS FROM THE GENERAL PUBLIC, OR A COMBINATION OF BOTH. IN ADDITION, THE ORGANIZATION MUST ALSO BE ORGANIZED AND OPERATED SO THAT IT WILL ATTRACT FURTHER SUPPORT ON A CONTINUOUS BASIS. THIS MEANS THE ORGANIZATION MUST MAINTAIN A CONTINUOUS AND BONA FIDE FUNDRAISING PROGRAM OR CARRY ON PROGRAMS DESIGNED TO ATTRACT SUPPORT FROM GOVERNMENTAL UNITS OR OTHER PUBLIC CHARITIES. COMPLIANCE WITH BOTH REQUIREMENTS IS MANDATORY IN ORDER TO MEET THE FACTS-AND-CIRCUMSTANCES TEST. AS OF DECEMBER 31, 2011, THE CENTER'S PUBLIC SUPPORT IS APPROXIMATELY 22%, WELL ABOVE THE MINIMUM 10% REQUIREMENT DESCRIBED ABOVE. THIS INCLUDES TWO LARGE CONTRIBUTIONS FROM THE JOINT COMMISSION TOTALING NEARLY $20 MILLION. AS EVIDENCE OF THE CENTER'S BONA FIDE FUNDRAISING EFFORTS, IT SHOULD BE NOTED THAT THE ORGANIZATION HAS REGISTERED IN 38 STATES ACROSS THE COUNTRY IN THOSE STATES THAT REQUIRES CHARITABLE ORGANIZATIONS TO REGISTER IN ORDER TO SOLICIT CHARITABLE CONTRIBUTIONS. THE CENTER HAS BEEN AGGRESSIVELY SOLICITING CHARITABLE CONTRIBUTIONS FROM BUSINESSES, COMPANIES, ASSOCIATIONS AND CHARITABLE FOUNDATION THAT WORK IN THE HEALTHCARE FIELD . IN ADDITION TO SATISFYING THE TWO MANDATORY REQUIREMENTS OF THE FACTS-AND-CIRCUMSTANCES TEST, ADDITIONAL FACTS AND CIRCUMSTANCES ARE EVALUATED TO DETERMINE WHETHER THE ORGANIZATION IS PUBLICLY SUPPORTED. BASED ON THE INFORMATION BELOW, WE BELIEVE THAT THE CENTER CLEARLY SATISFIES THE 10% FACTS AND CIRCUMSTANCES PUBLIC SUPPORT TEST. ACTUAL PERCENTAGE OF "PUBLIC SUPPORT" THE REGULATIONS INDICATE THAT "THE HIGHER THE PUBLIC SUPPORT PERCENTAGE IS ABOVE THE 10% LEVEL, THE MORE INDICATIVE OF BROAD BASE PUBLIC SUPPORT". AS INDICATED ABOVE, THE CENTER'S PUBLIC SUPPORT PERCENTAGE THROUGH THE END OF 2012 IS APPROXIMATELY 22% AND THIS PUBLIC SUPPORT PERCENT HAS BEEN INCREASING EACH YEAR REFLECTING ITS ACTIVE FUND RAISING EFFORTS. SOURCES OF SUPPORT THE REGULATIONS INDICATE THAT THE FACT THAT "AN ORGANIZATION MEETS THE REQUIREMENT ABOVE THROUGH SUPPORT FROM GOVERNMENTAL UNITS OR DIRECTLY OR INDIRECTLY FROM A REPRESENTATIVE NUMBER OF PERSONS, RATHER THAN RECEIVING ALMOST ALL OF ITS SUPPORT FROM THE MEMBERS OF A SINGLE FAMILY, WILL BE TAKEN INTO CONSIDERATION IN DETERMINING WHETHER THE ORGANIZATION IS PUBLICLY SUPPORTED". IN ADDITION TO CONTRIBUTIONS FROM THE JOINT COMMISSION, A PUBLICLY SUPPORTED ORGANIZATION ITSELF, THE CENTER HAS RECEIVED SIGNIFICANT CONTRIBUTIONS FROM TWELVE CONTRIBUTORS. THE CONTRIBUTORS REPRESENT A BROAD SPECTRUM SUPPORT FROM COMPANIES IN THE HEALTHCARE FIELD, INCLUDING PHARMACEUTICAL COMPANIES, EQUIPMENT MANUFACTURERS, HEALTH INSURANCE PROVIDERS AS WELL AS HEALTH CARE TRADE ASSOCIATIONS AND CHARITABLE FOUNDATIONS. REPRESENTATIVE GOVERNING BODY THE REGULATIONS INDICATE THAT "THE FACT THAT AN ORGANIZATION HAS A GOVERNING BODY WHICH REPRESENTS THE BROAD INTEREST OF THE PUBLIC, RATHER THAN THE PERSONAL OR PRIVATE INTEREST OF A LIMITED NUMBER OF DONORS" WILL BE TAKEN INTO ACCOUNT IN DETERMINING WHETHER AN ORGANIZATION IS PUBLICLY SUPPORTED. OTHER FACTORS IN THE REGULATIONS INDICATING A PUBLIC BOARD REPRESENTING THE BROAD INTERESTS OF THE PUBLIC IS WHETHER IT IS COMPRISED OF INDIVIDUALS HAVING SPECIAL KNOWLEDGE AND EXPERTISE IN THE PARTICULAR FIELD OR DISCIPLINE IN WHICH THE ORGANIZATION IS OPERATING. THE CENTER'S BOARD OF DIRECTORS CLEARLY WOULD BE CONSIDERED A "REPRESENTATIVE GOVERNING BODY". ALL OF ITS MEMBERS HAVE SPECIAL KNOWLEDGE AND EXPERTISE IN THE HEALTHCARE FIELD AND WITH HEALTHCARE QUALITY ISSUES. AVAILABILITY OF PUBLIC SERVICES; PUBLIC PARTICIPATION IN PROGRAMS THE REGULATIONS INDICATE THE FACT THAT AN ORGANIZATION WHICH PROVIDES EDUCATIONAL SERVICES TO THE PUBLIC THROUGH THE DISTRIBUTION OF EDUCATIONAL MATERIALS ON A CONTINUING BASIS, WILL BE CONSIDERED AS EVIDENCE THAT THE ORGANIZATION IS PUBLICLY SUPPORTED. THE CENTER'S ENTIRE FOCUS IS TO WORK WITH TAX EXEMPT HOSPITALS AND IMPROVE THE SAFETY AND QUALITY OF THE HEALTHCARE SERVICES PROVIDED BY THESE INSTITUTIONS. THE ULTIMATE BENEFICIARIES OF THESE ACTIVITIES ARE THE PATIENTS AND THE PUBLIC. THE ACTIVE PARTICIPATION IN, AND SPONSORSHIP OF THESE HEALTHCARE QUALITY AND SAFETY PROGRAMS BY MEMBERS OF THE BOARD, IS FURTHER EVIDENCE THAT THE ORGANIZATION IS PUBLICLY SUPPORTED., |
| OTHER INCOME, SCHEDULE A, PART II, LINE 10, <OTHERINCOME> <INCOME> <DESCRIPTION /> <COLUMNA /> <COLUMNB /> <COLUMNC /> <COLUMND /> <COLUMNE /> <COLUMNF /> </INCOME> </OTHERINCOME>, |
| OTHER INCOME, SCHEDULE A, PART II, LINE 10, DESCRIPTION - , COLUMN A - , COLUMN B - , COLUMN C - , COLUMN D - , COLUMN E - , COLUMN F - ;, |
| Software ID: | 11000230 |
| Software Version: | v2011.1.0 |
Attach to Form 990 or 990-EZ.| Identifier | Return Reference | Explanation |
|---|---|---|
| ORGANIZATION'S MISSION | FORM 990, PART III, LINE 1 | THE CENTER FOR TRANSFORMING HEALTHCARE HAS BEEN ESTABLISHED TO SOLVE THE MOST PRESSING QUALITY AND SAFETY PROBLEMS THAT ARE ALL TOO PREVALENT IN HEALTH CARE TODAY. THESE ARE THE PROBLEMS THAT THREATEN LIVES AND INCREASE COSTS. WORKING WITH A CADRE OF LEADING HOSPITALS AND HEALTH SYSTEMS, THE CENTER DEVELOPS SOLUTIONS TO THESE PROBLEMS THROUGH THE APPLICATION OF THE SAME ROBUST PROCESS IMPROVEMENT METHODS AND TOOLS THAT OTHER INDUSTRIES HAVE LONG RELIED UPON TO IMPROVE QUALITY, SAFETY AND EFFICIENCY. THESE METHODS INCLUDE LEAN SIX SIGMA AND CHANGE ACCELERATION PROCESS. THE LEADING HOSPITALS AND HEALTH SYSTEMS IN THE CENTER'S NETWORK HAVE SIGNIFICANT EXPERTISE IN THE APPLICATION OF THESE METHODS AND TOOLS TO HEALTH CARE. TOGETHER, WE DEVELOP AND TEST THE SOLUTIONS THAT EMANATE FROM THE CENTER. ULTIMATELY, THE GOAL OF THE CENTER IS TO TRANSFORM HEALTH CARE INTO A HIGH RELIABILITY INDUSTRY. ONCE SOLUTIONS ARE DEVELOPED THROUGH THIS COLLABORATIVE METHOD, THEY ARE MADE PUBLICLY AVAILABLE THROUGH CENTER'S WEB SITE. JOINT COMMISSION SURVEYORS ARE ABLE TO SHARE THE SOLUTIONS WITH HEALTH CARE ORGANIZATIONS UNDERGOING AN ON-SITE JOINT COMMISSION SURVEY AS PART OF THE ACCREDITATION PROCESS. THE SOLUTIONS ARE ALSO MADE AVAILABLE THROUGH THE TARGETED SOLUTIONS TOOL (TST). THE TST IS A WEB-BASED TOOL THAT ALLOWS JOINT COMMISSION-ACCREDITED HEALTH CARE ORGANIZATIONS TO MEASURE THEIR OWN PERFORMANCE AND CUSTOMIZE SOLUTIONS TO ADDRESS THE CONTRIBUTING FACTORS THAT UNDERLIE THEIR OWN BREAKDOWNS IN QUALITY AND SAFETY. THE TST WAS LAUNCHED IN SEPTEMBER 2010 AND CURRENTLY INCLUDES THE UNDERLYING CAUSES AND SOLUTIONS FOR POOR HAND HYGIENE, HAND-OFF COMMUNICATION, AND WRONG SITE SURGERY. IN DECEMBER 2008, THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE BEGAN WORK ON ITS FIRST IMPROVEMENT PROJECT: ADDRESSING FAILURES IN HAND HYGIENE. EIGHT OF THE CENTER'S PARTICIPATING HOSPITALS WERE ENGAGED IN THE PROJECT TO UNDERSTAND THE SPECIFIC ROOT CAUSES OF FAILURES IN HAND HYGIENE AND TO DEVELOP SOLUTIONS FOR EACH OF THESE CAUSES. HAND HYGIENE IS CRITICALLY IMPORTANT TO SAFE, HIGH QUALITY PATIENT CARE. UNFORTUNATELY, MANY INFECTIONS ARE TRANSMITTED BY HEALTH CARE PERSONNEL. TO SUSTAIN IMPROVEMENT AND MAKE A DIFFERENCE, A SIMPLE SLOGAN OR CAMPAIGN IS NOT ENOUGH; DEMANDING THAT HEALTH CARE WORKERS TRY HARDER IS NOT THE ANSWER. COMPREHENSIVE, SYSTEMATIC AND SUSTAINABLE CHANGE IS THE ONLY SOLUTION. THE TST PROVIDES THE FOUNDATION AND FRAMEWORK OF AN IMPROVEMENT METHOD THAT, IF IMPLEMENTED WELL, WILL IMPROVE AN ORGANIZATION'S HAND HYGIENE COMPLIANCE AND CONTRIBUTE SUBSTANTIALLY TO ITS EFFORTS TO REDUCE THE FREQUENCY OF HEALTH CARE-ASSOCIATED INFECTIONS. TOGETHER, THE EIGHT LEADING HOSPITALS AND HEALTH CARE SYSTEMS THAT DEVELOPED THE HAND HYGIENE SOLUTIONS HAVE ACHIEVED AND CONTINUE TO SHOW MAJOR AND SUSTAINED GAINS IN HAND HYGIENE. AT THE START OF THE PROJECT IN APRIL 2009, THEY WERE SURPRISED TO LEARN THAT THEIR RATE OF HAND HYGIENE COMPLIANCE AVERAGED 48 PERCENT. BY JUNE 2010 THEY HAD REACHED AN AVERAGE RATE OF 82 PERCENT THAT HAD BEEN SUSTAINED FOR EIGHT MONTHS. SINCE ITS LAUNCH ON SEPTEMBER 13, 2010, THE TST HAS COLLECTED NEARLY 400,000 HAND HYGIENE OBSERVATIONS. THE TST DATA COLLECTED DEMONSTRATE THAT HEALTH CARE ORGANIZATIONS ARE SIGNIFICANTLY IMPROVING THEIR HAND HYGIENE COMPLIANCE RATES THROUGHOUT THE U.S. ON AVERAGE, ORGANIZATIONS HAVE IMPROVED 46 PERCENT OVER THEIR BASELINE MEASUREMENTS AND ARE SUSTAINING THOSE RESULTS. IN ADDITION, SOME ORGANIZATIONS HAVE LINKED USE OF THE TST TO A REDUCTION IN HEALTH CARE-ASSOCIATED INFECTIONS. THE SOLUTIONS FROM THE CENTER USE THE ACRONYM SHARE, WHICH ADDRESSES THE SPECIFIC REASONS WHY HANDS-OFFS ARE UNSUCCESSFUL. SHARE STANDS FOR: STANDARDIZE CRITICAL CONTENT, HARDWIRE WITHIN YOUR SYSTEM, ALLOW OPPORTUNITIES TO ASK QUESTIONS, REINFORCE QUALITY AND MEASUREMENT, AND EDUCATE AND COACH. THE WRONG SITE SURGERY PROJECT, LAUNCHED IN JULY 2009, HAS INVOLVED THE DEVELOPMENT OF A RIGOROUS PROCESS FOR REDUCING THE RISK OF WRONG-SITE SURGERY. ACROSS THE PERIOPERATIVE PROCESS, THERE ARE MANY OPPORTUNITIES FOR EVEN TINY SLIPS, LAPSES AND MISTAKES THAT CAN HEIGHTEN THE RISK OF WRONG-SITE SURGERY. BY IDENTIFYING THESE RISK POINTS, THIS PROJECT HAS RESULTED IN A DEEPER UNDERSTANDING OF THE MANY CONTRIBUTING FACTORS THAT CAN RESULT IN A WRONG-SITE SURGERY. THE ORGANIZATIONS THAT PARTICIPATED IN THE CENTER'S PROJECT IDENTIFIED 29 MAIN CAUSES OF WRONG SITE SURGERIES THAT OCCURRED DURING SCHEDULING, IN PRE-OP/HOLDING OR IN THE OPERATING ROOM, OR WHICH STEMMED FROM THE ORGANIZATIONAL CULTURE. OVER THE COURSE OF THE PROJECT, THE ORIGINAL PARTICIPATING ORGANIZATIONS WERE ABLE TO REDUCE THE NUMBER OF CASES WITH RISKS BY 46 PERCENT IN THE SCHEDULING AREA, BY 63 PERCENT IN PRE-OP, AND BY 51 PERCENT IN THE OPERATING ROOM. MANY OTHER HOSPITALS AND AMBULATORY SURGERY CENTERS ACROSS THE COUNTRY COLLABORATED WITH THE CENTER TO TEST THE WORK OF THE ORIGINAL ORGANIZATIONS THAT PARTICIPATED IN THE PROJECT AND PROVIDE GUIDANCE ON THE DEVELOPMENT OF THE TST FOR WRONG SITE SURGERY. THESE ORGANIZATIONS EXPERIENCED THE SAME GAINS AS THE ORIGINAL PARTICIPATING ORGANIZATIONS. THE HAND-OFF COMMUNICATIONS PROJECT, WHICH ALSO LAUNCHED IN 2009, FOCUSED ON THE QUALITY OF PATIENT INFORMATION THAT IS COMMUNICATED BETWEEN "SENDERS" AND "RECEIVERS" WHEN THE CARE OF THE PATIENT IS BEING HANDED-OFF OR RELEASED TO ANOTHER CAREGIVER OR TEAM OF CAREGIVERS. DURING THE MEASURE PHASE OF THE PROJECT, PARTICIPATING HOSPITALS FOUND THAT HAND-OFFS WERE DEFECTIVE AND DIDN'T ALLOW THE RECEIVER TO SAFELY CARE FOR PATIENTS 37 PERCENT OF THE TIME ON AVERAGE. SENDERS WERE DISSATISFIED WITH THE QUALITY OF THE HAND-OFF 21 PERCENT OF THE TIME. BY USING SOLUTIONS TARGETED TO THE SPECIFIC CAUSES OF AN INADEQUATE HAND-OFF, ORGANIZATIONS THAT FULLY IMPLEMENTED THE SOLUTIONS ACHIEVED AN AVERAGE OF OVER 50 PERCENT REDUCTION IN DEFECTIVE HAND-OFFS. USING THE TST AND THE SOLUTIONS FROM THE CENTER'S HAND-OFF COMMUNICATIONS PROJECT, HEALTH CARE ORGANIZATIONS REPORTED AN INCREASE IN PATIENT AND FAMILY SATISFACTION, STAFF SATISFACTION, AND SUCCESSFUL TRANSFERS OF PATIENTS (REDUCED BOUNCE BACKS), AND A REDUCTION IN READMISSIONS. THE CENTER LAUNCHED ITS FOURTH PROJECT ADDRESSING SURGICAL SITE INFECTIONS IN AUGUST 2010. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, SURGICAL SITE INFECTIONS (SSIS) ACCOUNT FOR APPROXIMATELY 25 PERCENT OF ALL HEALTH CARE-ASSOCIATED INFECTIONS IN THE U.S. EACH YEAR. AS A CONSEQUENCE, SSIS ARE A MAJOR SOURCE OF PREVENTABLE PATIENT HARM AND UNNECESSARY HEALTH CARE COSTS. THE SCOPE OF THE SSI PROJECT HAS BEEN NARROWED TO COLORECTAL SURGERY AND COLORECTAL PROCEDURES, WHICH IS OFTEN ASSOCIATED WITH SSIS. SEVEN OF THE CENTER'S PARTICIPATING HOSPITALS HAVE BEEN ENGAGED IN THIS PROJECT IN COLLABORATION WITH THE AMERICAN COLLEGE OF SURGEONS. THE ACS'S NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP) SURGICAL OUTCOME DATA EXPERTISE IS GUIDING THE SSI PROJECT'S DATA COLLECTION AND ANALYSIS. THE HOSPITALS HAVE WORKED TO IDENTIFY THE ROOT CAUSES OF SURGICAL SITE INFECTIONS SO THAT SOLUTIONS FOR EACH OF THOSE CAUSES CAN BE DEVELOPED. THE SOLUTIONS FOR THIS PROJECT ARE TARGETED FOR PUBLICATION IN 2013. IN MARCH 2011, A FIFTH PROJECT WHICH AIMS TO PREVENT AVOIDABLE HOSPITALIZATIONS FOR PEOPLE WITH HEART FAILURE WAS LAUNCHED. A CHRONIC DISEASE, HEART FAILURE IS THE MOST COMMON REASON FOR ADMISSION TO THE HOSPITAL AMONG OLDER ADULTS. THE GOAL OF THIS PROJECT IS TO BETTER UNDERSTAND WHY PATIENTS WITH HEART FAILURE PERIODICALLY EXPERIENCE SEVERE WORSENING OF THEIR CONDITION TO A DEGREE THAT LEADS TO HOSPITALIZATION. IDENTIFYING THE SPECIFIC CAUSES OF SUCH DETERIORATIONS WILL PERMIT PARTICIPATING HOSPITALS TO DESIGN AND IMPLEMENT FOCUSED INTERVENTIONS TARGETED TO EACH IMPORTANT CAUSE. THE HOSPITALS AND HEALTH SYSTEMS PARTICIPATING IN THIS PROJECT, WHICH WAS LAUNCHED IN COLLABORATION WITH THE AMERICAN COLLEGE OF PHYSICIANS, WILL INVESTIGATE HOW HOSPITALS AND COMMUNITY-BASED PHYSICIAN PRACTICES CAN WORK TOGETHER MORE EFFECTIVELY TO PREVENT AVOIDABLE HOSPITALIZATIONS FOR PEOPLE WITH HEART FAILURE. THE SOLUTIONS FOR THIS PROJECT ARE TARGETED FOR PUBLICATION IN EARLY 2013. |
| ORGANIZATION'S MISSION | FORM 990, PART III, LINE 1 | (CONTINUATION FROM ABOVE) THE CENTER LAUNCHED ITS SIXTH PROJECT WHICH AIMS TO OPTIMIZE BEHAVIORS AND PRACTICES RESULTING IN AN IMPROVED SAFETY CULTURE THAT REINFORCES AND SUPPORTS THE PREVENTION OF PATIENT HARM IN OCTOBER 2011. A SAFETY CULTURE ENABLES TRUST. IT EMPOWERS STAFF TO SPEAK UP ABOUT RISKS TO PATIENTS, AND REPORT ERRORS AND NEAR MISSES, ALL OF WHICH DRIVE IMPROVEMENT. A SAFETY CULTURE WITHIN HEALTH CARE CAN BE DEFINED AS THE SUMMARY OF KNOWLEDGE, ATTITUDES, BEHAVIORS AND BELIEFS THAT STAFF SHARE ABOUT THE PRIMARY IMPORTANCE OF THE WELL-BEING AND CARE OF THE PATIENTS THEY SERVE, SUPPORTED BY SYSTEMS AND STRUCTURES THAT REINFORCE THE FOCUS ON PATIENT SAFETY. ORGANIZATIONS THAT ACHIEVE HIGH RELIABILITY HAVE LONG EMPHASIZED SAFETY CULTURE AS A KEY FACTOR NECESSARY TO PERFORMANCE THAT IS CONSISTENTLY EXCELLENT. DESPITE WIDESPREAD ATTENTION TO THE IMPORTANCE OF SAFETY CULTURE IN PERFORMANCE IMPROVEMENT, MANY - IF NOT MOST - HEALTH CARE ORGANIZATIONS STRUGGLE TO ACHIEVE IT. IN FACT, LACK OF SAFETY CULTURE WAS A PROMINENT UNDERLYING FACTOR OF THE ISSUES ADDRESSED BY THE FIRST FOUR CENTER PROJECTS. THE SOLUTIONS FOR THIS PROJECT ARE TARGETED FOR PUBLICATION IN 2013 FOLLOWING A RIGOROUS PILOT TESTING PROCESS. THE PREVENTING FALLS WITH INJURY PROJECT WAS LAUNCHED IN NOVEMBER 2011, WHICH AIMS TO PREVENT FALLS THAT OCCUR IN HEALTH CARE FACILITIES AND RESULT IN INJURY TO PATIENTS. TENS OF THOUSANDS OF PATIENTS FALL IN HEALTH CARE FACILITIES EVERY YEAR AND MANY OF THESE FALLS RESULT IN MODERATE TO SEVERE INJURIES. THESE INJURIES CAN PROLONG HOSPITAL STAYS AND REQUIRE THE PATIENT TO UNDERGO ADDITIONAL TREATMENT. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC), IN 2007 MORE THAN 18,000 OLDER ADULTS DIED FROM UNINTENTIONAL FALL-RELATED INJURIES. FALLS HAVE BEEN IDENTIFIED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) AS A "NEVER EVENT" - AN EVENT THAT IS PREVENTABLE AND SHOULD NEVER OCCUR. UP TO HALF OF ALL HOSPITALIZED PATIENTS ARE AT RISK FOR FALLS, AND ALMOST HALF OF THOSE WHO FALL SUFFER AN INJURY. THESE INJURIES RESULT IN AN AVERAGE ADDITIONAL HOSPITAL STAY FOR THE PATIENT OF 12.3 DAYS OR LONGER (THE AVERAGE LENGTH OF A HOSPITAL STAY IS 4.8 DAYS) AND A 61 PERCENT INCREASE IN PATIENT CARE COSTS.1 THE CDC AND OTHERS HAVE ESTIMATED THE AVERAGE COST OF A FALL WITH INJURY TO BE BETWEEN $7,000-$19,000. SEVEN OF THE CENTER'S PARTICIPATING HOSPITALS HAVE BEEN ENGAGED IN THIS PROJECT. THE SOLUTIONS FOR THIS PROJECT ARE TARGETED FOR PUBLICATION IN LATE 2012. THE JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE LAUNCHED IT HEALING HEALTHCARE PARTNERSHIP IN LATE 2011. THE PARTNERSHIP BRINGS TOGETHER ACCREDITED HEALTH CARE ORGANIZATIONS AND INDUSTRY TO IMPROVE PATIENT SAFETY AND LOWER THE COST OF HEALTH CARE. HEALTH CARE ORGANIZATIONS ARE SEEKING SPECIFIC GUIDANCE ON HOW TO SOLVE HEALTH CARE'S MOST CRITICAL SAFETY AND QUALITY PROBLEMS. TO HELP SOLVE THESE PERSISTENT PROBLEMS, JOINT COMMISSION ACCREDITED ORGANIZATIONS ARE ENCOURAGED TO JOIN THE HEALING HEALTHCARE PARTNERSHIP AND TO USE THE RESOURCES OF THE CENTER, INCLUDING THE TARGETED SOLUTIONS TOOL TO HELP THEM UNDERSTAND THE SPECIFIC UNDERLYING CAUSES OF THESE PROBLEMS, AND TO ALLOW THEM TO CUSTOMIZE SOLUTIONS TARGETED TO THOSE CAUSES AT THEIR ORGANIZATIONS. CURRENTLY THERE ARE APPROXIMATELY 345 ORGANIZATIONS THAT HAVE JOINED THE PARTNERSHIP. |
| PROGRAM SERVICE ACCOMPLISHMENT | FORM 990, PART III, LINE 4A | (CONTINUATION) IN ADDITION TO MEETING THESE REQUIREMENTS, THESE HOSPITALS HAVE TAKEN A LEADERSHIP ROLE IN PATIENT SAFETY AND QUALITY IMPROVEMENT AND HAVE DEMONSTRATED THAT THEY CAN CREATE AN ORGANIZATIONAL CULTURE THAT IS CONDUCIVE TO SUPPORTING AND MOTIVATING STAFF TO ASPIRE TO EXCELLENCE.THERE ARE SEVEN PROJECTS UNDER THIS PROGRAM: 1) HAND HYGIENE PROJECT FOR IMPROVING PATIENT SAFETY TO LIMIT HOSPITAL ACQUIRED INFECTIONS THROUGH THE INCREASED USE OF HAND HYGIENE TECHNIQUES. 2) HAND-OFF COMMUNICATIONS FOR TRANSFER AND ACCEPTANCE OF PATIENT CARE RESPONSIBILITY ACHIEVED THROUGH EFFECTIVE COMMUNICATION 3) WRONG SITE SURGERY TO IMPROVE THE SAFEGUARDS TO PREVENT PATIENTS FROM WRONG SITE 4) WRONG SIDE AND WRONG PATIENT SURGICAL PROCEDURES, SURGICAL SITE INFECTIONS (SSI) WHICH AIMS TO REDUCE SSI'S IN PATIENTS HAVING COLORECTAL SURGERY 5) PREVENTING AVOIDABLE HEART FAILURE HOSPITALIZATIONS FOR PEOPLE WITH HEART FAILURE 6) IMPROVED SAFETY CULTURE THAT REINFORCES AND SUPPORTS THE PREVENTION OF PATIENT HARM AND 7) AND PREVENTION OF FALLS THAT OCCUR IN HEALTH CARE FACILITIES THAT RESULT IN INJURY. |
| Classes of members or stockholders | Form 990, Part VI, Section A, Line 6 | THE ORGANIZATION HAS ONE SOLE MEMBER, THE JOINT COMMISSION. THE JOINT COMMISSION HAS THE POWER TO: 1) APPOINT ALL DIRECTORS TO THE BOARD OF DIRECTORS AND REMOVE THEM, WITH OR WITHOUT CAUSE. 2) APPROVE THE ELECTION OF THE CHAIRMAN AND THE TREASURER OF THE ORGANIZATION AND REMOVE THEM, WITH OR WITHOUT CAUSE, PROVIDED THAT AN INDIVIDUAL SO REMOVED MAY HAVE A CLAIM FOR COMPENSATION IF THE REMOVAL BREACHES ANY CONTRACT APPROVED BY THE ORGANIZATION. 3) APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS. 4) APPROVE ALL MISSION AND/OR VISION STATEMENTS AND ALL STRATEGIC OR LONG-TERM PLANS OF THE ORGANIZATION. 5) APPROVE ALL CREATIONS OF SUBSIDIARIES OR CONTROLLED AFFILIATES, MERGERS, CONSOLIDATIONS, PERMANENT OR LONG-TERM AFFILIATIONS AND ALL JOINT VENTURES OF THE ORGANIZATION INVOLVING CAPITAL INVESTMENTS IN EXCESS OF $250,000. 6) APPROVE THE SALE OF ENCUMBRANCE OF ALL OR SUBSTANTIALLY ALL THE ASSETS OF THE ORGANIZATION AND ALL LONG-TERM DEBT IN EXCESS OF $250,000. 7) APPROVE THE ORGANIZATION'S ANNUAL OPERATING AND CAPITAL BUDGETS AND MATERIAL AMENDMENTS THERETO. 8) APPROVE THE DISSOLUTION OF AND ALL LIQUIDATIONS FROM THE ORGANIZATION. |
| Members or stockholders electing members of governing body | Form 990, Part VI, Section A, Line 7a | SEE RESPONSE TO LINE 6 |
| Decisions requiring approval by members or stockholders | Form 990, Part VI, Section A, Line 7b | SEE RESPONSE TO LINE 6 |
| Review of form 990 by governing body | Form 990, Part VI, Section B, Line 11b | THE ORGANIZATION'S MANAGEMENT AND THE MANAGEMENT OF THE JOINT COMMISSION, INCLUDING THE CEO, CFO, CORPORATE COMPLIANCE & PRIVACY OFFICER, AND LEGAL COUNSEL PERFORMED A DETAILED REVIEW OF THE FORM 990 WITH THE PAID TAX PREPARER. ONCE THIS LEVEL OF REVIEW WAS PERFORMED, A THOROUGH WALK THROUGH OF FORM 990 WAS DONE WITH THE CENTER'S GOVERNING BODY PRIOR TO FILING. A FINAL FILED COPY OF THE RETURN WILL BE PLACED ON THE ORGANIZATION'S WEBSITE FOR THE PUBLIC ONCE ACCEPTED BY THE IRS |
| Conflict of interest policy | Form 990, Part VI, Section B, Line 12c | ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS' CONFLICT OF INTEREST POLICY. THE POLICY STATES THAT ANY DECISION THAT COULD RESULT IN AN ACTUAL OR PERCEIVED CONFLICT OF INTEREST MUST BE AVOIDED. ALL STAFF AND BOARD MEMBERS REVIEW THE POLICY ON AN ANNUAL BASIS AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EACH YEAR, WHICH IS DESIGNED TO IDENTIFY INTERESTS THAT COULD GIVE RISE TO POSSIBLE CONFLICTS. ALTHOUGH MANY SUCH POTENTIAL CONFLICTS ARE AND WILL BE DEEMED INCONSEQUENTIAL, EVERY INDIVIDUAL OF THE ORGANIZATION HAS AN ONGOING RESPONSIBILITY TO DISCLOSE SITUATIONS THAT INVOLVE PERSONAL, FAMILIAR, OR BUSINESS RELATIONSHIPS THAT COULD BE PERCEIVED AS A CONFLICT OF INTEREST. THE INTERESTS IDENTIFIED ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AND MANAGER AND APPROPRIATELY MANAGED. ALL DISCLOSURES ARE PURSUED UNTIL 100% COMPLETED. THE BOARD IS REQUIRED TO DISCLOSE A CONFLICT OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER DURING A MEETING AND THEN NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING REFLECTS THAT A DISCLOSURE WAS MADE AND THE MEMBER ABSTAINED FROM VOTING. THE COMPLIANCE OFFICER MONITORS AND REVIEWS THE CONFLICT OF INTEREST POLICY AS WELL AS THE RESPONSES TO THE QUESTIONNAIRES ON AN ANNUAL BASIS. THE ORGANIZATION ALSO HAS AVAILABLE AN INDEPENDENT HOTLINE NUMBER FOR STAFF TO REPORT ANY POTENTIAL CONFLICTS DURING THE YEAR ANONYMOUSLY. |
| WHISTLEBLOWER POLICY | FORM 990, PART VI, LINE 13 | ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION WHISTLEBLOWER POLICY. |
| DOCUMENT RETENTION | FORM 990, PART VI, LINE 14 | ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION RECORDS RETENTION POLICY. |
| Process used to establish compensation of top management official | Form 990, Part VI, Section B, Line 15a | THE CENTER RELIES ON THE PROCESS OF THE JOINT COMMISSION FOR APPROVAL OF TOP MANAGEMENTS COMPENSATION. THE OFFICERS' COMPENSATION ARRANGEMENT IS SUBJECT TO AN INDEPENDENT BOARD COMMITTEE REVIEW AND APPROVAL REFERRED TO AS THE HUMAN RESOURCES AND COMPENSATION COMMITTEE. THE JOINT COMMISSION ENGAGED AN INDEPENDENT COMPENSATION CONSULTANT TO ASSIST IN DETERMINING COMPENSATION OF THE CENTER'S OFFICERS. IN SETTING THE OFFICERS' COMPENSATION, THE JOINT COMMISSION'S HUMAN RESOURCES AND COMPENSATION COMMITTEE RELIES ON RECENT COMPENSATION STUDIES THAT PROVIDE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE ADEQUATELY DOCUMENTS ITS COMPENSATION DETERMINATIONS AND DELIBERATIONS REGARDING COMPENSATION IN ITS COMMITTEE MINUTES ON A TIMELY BASIS. EACH VOTING COMMITTEE MEMBER HAS BEEN DETERMINED TO BE INDEPENDENT IN ACCORDANCE WITH INTERMEDIATE SANCTIONS REGULATIONS AND SIGNS THE BOARD'S CONFLICT OF INTEREST POLICY ANNUALLY TO INSURE THAT HE OR SHE IS INDEPENDENT. THE PROCESS FOR DETERMINING THE OFFICERS COMPENSATION IS UNDERTAKEN ANNUALLY FOR ALL OFFICERS. |
| Process used to establish compensation of other officers/key employees | Form 990, Part VI, Section B, Line 15b | THE CENTER RELIES ON THE PROCESS OF THE JOINT COMMISSION FOR APPROVAL OF ITS KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES' COMPENSATION. 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 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 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 AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC ON THE JOINT COMMISSION WEBSITE. |
| Average hours worked per week for related organization | Form 990, Part VII, Section A, Column B | CRAIG W. JONES, FACHE - SECRETARY & BOARD MEMBER, DEVOTES APPROXIMATELY 5 HOURS A WEEK AS THE SECRETARY, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION ISABEL V. HOVERMAN, MD - BOARD CHAIR, DEVOTES APPROXIMATELY 6 HOURS A WEEK AS THE CHAIR OF THE BOARD, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION LAMAR S. MCGINNIS, JR, MD - BOARD MEMBER, DEVOTES APPROXIMATELY 5 HOURS A WEEK AS THE COMMISSIONER, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION GERALD M. SHEA - BOARD MEMEBER , DEVOTES APPROXIMATELY 4 HOURS A WEEK AS THE COMMISSIONER & VICE CHAIR, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION REBECCA J PATCHIN, MD - TREASURER & BOARD MEMBER, DEVOTES APPROXIMATELY 4 HOURS A WEEK AS THE TREASURER, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION MARK CHASSIN - PRESIDENT & BOARD MEMBER, DEVOTES APPROXIMATELY 35 HOURS A WEEK AS THE PRESIDENT & CHEIF EXECUTIVE OFFICER, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION DAVID A. WHISTON, DDS - BOARD MEMBER, DEVOTES APPROXIMATELY 4 HOURS A WEEK AS THE COMMISSIONER, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION PAIGE RODGERS - CFO, DEVOTES APPROXIMATELY 38 HOURS A WEEK AS THE CFO TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION ANNE MARIE BENEDICTO - CHIEF OF STAFF/ EXEC VP, DEVOTES APPROXIMATELY 34 HOURS A WEEK AS THE CHIEF OF STAFF/ EXEC VP, TO THE JOINT COMMISSION, A RELATED 501(C)(3) ORGANIZATION |
| Other changes in net assets or fund balances | Form 990, Part XI, Line 5 | NET UNREALIZED GAINS (LOSSES) ON INVESTMENTS - -33692; CAPITAL CONTRIBUTION TRANSFER FROM THE JOINT COMMISSION - 5000000; |
| Software ID: | 11000230 |
| Software Version: | v2011.1.0 |