Attach to Form 990 or Form 990-EZ.
See separate instructions.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (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 monetary support | |||
|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | ||||
| Total | |||||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2009 | (b) 2010 | (c) 2011 | (d) 2012 | (e) 2013 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") .... | 3,658,872 | 2,317,788 | 12,038,452 | 9,970,877 | 8,537,365 | 36,523,354 |
| 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 | 3,658,872 | 2,317,788 | 12,038,452 | 9,970,877 | 8,537,365 | 36,523,354 |
| 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).. | 28,774,043 | |||||
| 6 | Public support. Subtract line 5 from line 4. | 7,749,311 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2009 | (b) 2010 | (c) 2011 | (d) 2012 | (e) 2013 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 3,658,872 | 2,317,788 | 12,038,452 | 9,970,877 | 8,537,365 | 36,523,354 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 201,955 | 310,389 | 325,273 | 292,505 | 611,485 | 1,741,607 |
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.).. | 0 | 0 | 0 | 0 | 0 | 0 |
| 11 | Total support (Add lines 7 through 10). | 38,264,961 | |||||






Calendar year (or fiscal year beginning in) ![]() |
(a) 2009 | (b) 2010 | (c) 2011 | (d) 2012 | (e) 2013 | (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) 2009 | (b) 2010 | (c) 2011 | (d) 2012 | (e) 2013 | (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 |
|---|
| Explanation |
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| Software ID: | 13000248 |
| Software Version: | 2013v3.1 |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| FORM 990, PART III, LINE 1, ORGANIZATION'S MISSION | THE CENTER FOR TRANSFORMING HEALTHCARE (THE CENTER) HAS BEEN ESTABLISHED TO SOLVE THE MOST PRESSING QUALITY AND SAFETY PROBLEMS THAT ARE ALL TOO PREVALENT IN HEALTH CARE TODAY. THESE ARE THE PROBLEMS THAT THREATEN LIVES AND INCREASE COSTS. WORKING WITH A CADRE OF LEADING HOSPITALS AND HEALTH SYSTEMS, THE CENTER DEVELOPS SOLUTIONS TO THESE PROBLEMS THROUGH THE APPLICATION OF METHODS SUCH AS LEAN SIX SIGMA AND CHANGE 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. ULTIMATELY, THE GOAL OF THE CENTER IS TO TRANSFORM HEALTH CARE INTO A HIGH RELIABILITY INDUSTRY. ONCE SOLUTIONS ARE DEVELOPED THROUGH THIS COLLABORATIVE METHOD, THEY ARE MADE PUBLICLY AVAILABLE THROUGH THE CENTER'S WEB SITE. THE SOLUTIONS ARE ALSO MADE AVAILABLE THROUGH THE TARGETED SOLUTIONS TOOL (TST). THE TST IS A WEB-BASED TOOL THAT 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. HAND HYGIENE IS CRITICALLY IMPORTANT TO SAFE, HIGH QUALITY PATIENT CARE. UNFORTUNATELY, MANY INFECTIONS ARE TRANSMITTED BY HEALTH CARE PERSONNEL. THE TST PROVIDES THE FOUNDATION AND FRAMEWORK OF AN IMPROVEMENT METHOD THAT, IF IMPLEMENTED WELL, WILL IMPROVE AN ORGANIZATION'S HAND HYGIENE COMPLIANCE AND CONTRIBUTE SUBSTANTIALLY TO ITS EFFORTS TO REDUCE THE FREQUENCY OF HEALTH CARE-ASSOCIATED INFECTIONS. THE HAND HYGIENE SOLUTIONS HAVE ACHIEVED AND CONTINUE TO SHOW MAJOR AND SUSTAINED GAINS IN HAND HYGIENE. AT THE START OF THE PROJECT IN APRIL 2009, THE RATE OF HAND HYGIENE COMPLIANCE AVERAGED 48 PERCENT. BY JUNE 2010 THEY HAD REACHED AN AVERAGE RATE OF 81 PERCENT THAT HAS BEEN SUSTAINED. THE TST DATA COLLECTED DEMONSTRATED THAT HEALTH CARE ORGANIZATIONS ARE SIGNIFICANTLY IMPROVING THEIR HAND HYGIENE COMPLIANCE RATES THROUGHOUT THE U.S. ON AVERAGE, ORGANIZATIONS HAVE IMPROVED 43 PERCENT OVER THEIR BASELINE MEASUREMENTS AND ARE SUSTAINING THOSE RESULTS. IN ADDITION, SOME ORGANIZATIONS HAVE LINKED USE OF THE TST TO A REDUCTION IN HEALTH CARE-ASSOCIATED INFECTIONS. THE WRONG SITE SURGERY PROJECT HAS INVOLVED THE DEVELOPMENT OF A RIGOROUS PROCESS FOR REDUCING THE RISK OF WRONG-SITE SURGERY. ACROSS THE PERIOPERATIVE PROCESS, THERE ARE MANY OPPORTUNITIES FOR EVEN TINY SLIPS, LAPSES AND MISTAKES THAT CAN HEIGHTEN THE RISK OF WRONG-SITE SURGERY. BY IDENTIFYING THESE RISK POINTS, THIS PROJECT HAS RESULTED IN A DEEPER UNDERSTANDING OF THE MANY CONTRIBUTING FACTORS THAT CAN RESULT IN A WRONG-SITE SURGERY. THE CENTER'S PROJECT IDENTIFIED MANY CAUSES OF WRONG SITE SURGERIES THAT OCCURRED DURING SCHEDULING, IN PRE-OP/HOLDING OR IN THE OPERATING ROOM, OR WHICH STEMMED FROM THE ORGANIZATIONAL CULTURE. OVER THE COURSE OF THE PROJECT, THE PARTICIPATING ORGANIZATIONS WERE ABLE TO REDUCE THE NUMBER OF CASES WITH RISKS BY 46 PERCENT IN THE SCHEDULING AREA, BY 63 PERCENT IN PRE-OP, AND BY 51 PERCENT IN THE OPERATING ROOM. THE HAND-OFF COMMUNICATIONS PROJECT FOCUSES ON THE QUALITY OF PATIENT INFORMATION THAT IS COMMUNICATED BETWEEN "SENDERS" AND "RECEIVERS" WHEN THE CARE OF THE PATIENT IS BEING HANDED-OFF TO ANOTHER CAREGIVER. DURING THE MEASURE PHASE OF THE PROJECT, PARTICIPATING HOSPITALS FOUND THAT HAND-OFFS WERE DEFECTIVE AND DIDN'T ALLOW THE RECEIVER TO SAFELY CARE FOR PATIENTS 37 PERCENT OF THE TIME ON AVERAGE. SENDERS WERE DISSATISFIED WITH THE QUALITY OF THE HAND-OFF 21 PERCENT OF THE TIME. BY USING SOLUTIONS TARGETED TO THE SPECIFIC CAUSES OF AN INADEQUATE HAND-OFF, ORGANIZATIONS THAT FULLY IMPLEMENTED THE SOLUTIONS ACHIEVED AN AVERAGE OF OVER 50 PERCENT REDUCTION IN DEFECTIVE HAND-OFFS. USING THE TST AND THE SOLUTIONS FROM THE HAND-OFF COMMUNICATIONS PROJECT, HEALTH CARE ORGANIZATIONS REPORTED AN INCREASE IN PATIENT AND FAMILY SATISFACTION, STAFF SATISFACTION, AND SUCCESSFUL TRANSFERS OF PATIENTS (REDUCED BOUNCE BACKS), AND A REDUCTION IN READMISSIONS. ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND PREVENTION, SURGICAL SITE INFECTIONS (SSIS) ACCOUNT FOR APPROXIMATELY 25 PERCENT OF ALL HEALTH CARE-ASSOCIATED INFECTIONS IN THE U.S. EACH YEAR. AS A CONSEQUENCE, SSIS ARE A MAJOR SOURCE OF PREVENTABLE PATIENT HARM AND UNNECESSARY HEALTH CARE COSTS. THE SCOPE OF THE SSI PROJECT HAS BEEN NARROWED TO COLORECTAL SURGERY AND PROCEDURES, WHICH IS OFTEN ASSOCIATED WITH SSIS. THIS PROJECT IS IN COLLABORATION WITH PARTICIPATING HOSPITALS AND THE AMERICAN COLLEGE OF SURGEONS. DURING PILOT TESTING, THE PARTICIPATING HOSPITALS REDUCED SUPERFICIAL INCISIONAL COLORECTAL SSIS BY 45 PERCENT AND ALL TYPES OF COLORECTAL SSIS BY 32 PERCENT. THEY ATTAINED AN ESTIMATED COST SAVINGS OF MORE THAN $3.7 MILLION FOR THE 135 ESTIMATED COLORECTAL SSIS THAT WERE AVOIDED. IN ADDITION, THEY DECREASED THE AVERAGE LENGTH OF STAY FOR HOSPITAL PATIENTS WITH ANY TYPE OF COLORECTAL SSI FROM 15 TO 13 DAYS. THE CENTER ALSO HAS A PROJECT WHICH AIMS TO PREVENT AVOIDABLE HOSPITALIZATIONS FOR PEOPLE WITH HEART FAILURE. A CHRONIC DISEASE, HEART FAILURE IS THE MOST COMMON REASON FOR ADMISSION TO THE HOSPITAL AMONG OLDER ADULTS. THE GOAL OF THIS PROJECT IS TO BETTER UNDERSTAND WHY PATIENTS WITH HEART FAILURE PERIODICALLY EXPERIENCE SEVERE WORSENING OF THEIR CONDITION TO A DEGREE THAT LEADS TO HOSPITALIZATION. |
| FORM 990, PART III, LINE 1, ORGANIZATION'S MISSION | (CONTINUATION FROM ABOVE) THE CENTER LAUNCHED ITS SIXTH PROJECT WHICH AIMS TO OPTIMIZE BEHAVIORS AND PRACTICES RESULTING IN AN IMPROVED SAFETY CULTURE THAT REINFORCES AND SUPPORTS THE PREVENTION OF PATIENT HARM. A SAFETY CULTURE ENABLES TRUST. IT EMPOWERS STAFF TO SPEAK UP ABOUT RISKS TO PATIENTS, AND REPORT ERRORS AND NEAR MISSES, ALL OF WHICH DRIVE IMPROVEMENT. A SAFETY CULTURE WITHIN HEALTH CARE CAN BE DEFINED AS THE SUMMARY OF KNOWLEDGE, ATTITUDES, BEHAVIORS AND BELIEFS THAT STAFF SHARE ABOUT THE PRIMARY IMPORTANCE OF THE WELL-BEING AND CARE OF THE PATIENTS THEY SERVE, SUPPORTED BY SYSTEMS AND STRUCTURES THAT REINFORCE THE FOCUS ON PATIENT SAFETY. DESPITE WIDESPREAD ATTENTION TO THE IMPORTANCE OF SAFETY CULTURE IN PERFORMANCE IMPROVEMENT, MANY - IF NOT MOST - HEALTH CARE ORGANIZATIONS STRUGGLE TO ACHIEVE IT. IN FACT, LACK OF SAFETY CULTURE WAS A PROMINENT UNDERLYING FACTOR OF THE ISSUES ADDRESSED BY THE FIRST FOUR CENTER PROJECTS. THE PREVENTING FALLS WITH INJURY PROJECT 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. FALLS HAVE BEEN IDENTIFIED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) AS A "NEVER EVENT" - AN EVENT THAT IS PREVENTABLE AND SHOULD NEVER OCCUR. UP TO HALF OF ALL HOSPITALIZED PATIENTS ARE AT RISK FOR FALLS, AND ALMOST HALF OF THOSE WHO FALL SUFFER AN INJURY. THESE INJURIES RESULT IN AN AVERAGE ADDITIONAL HOSPITAL STAY FOR THE PATIENT OF 6.3 DAYS OR LONGER (THE AVERAGE LENGTH OF A HOSPITAL STAY IS 4.8 DAYS) AND COST FOR A SERIOUS FALL WITH INJURY IS ABOUT $14,056 THE CENTER'S EIGHTH PROJECT AIMS TO REDUCE SEPSIS MORTALITY. SEPSIS IS THE BODY'S LIFE-THREATENING INFLAMMATORY RESPONSE TO AN INFECTION. THE LEADING CAUSE OF DEATH IN HOSPITALIZED PATIENTS, SEPSIS HAS A MORTALITY RATE ESTIMATED BETWEEN 25-50 PERCENT. IN ADDITION, SEPSIS IS THE MOST EXPENSIVE DISEASE TO TREAT IN THE HOSPITAL, COSTING APPROXIMATELY $17 BILLION DOLLARS ANNUALLY. EARLY DETECTION AND APPROPRIATE TREATMENT OF SEPSIS CAN DECREASE MORTALITY, IMPROVE PATIENT OUTCOMES AND DECREASE THE LENGTH OF STAY IN HOSPITALS. THE CENTER'S NINTH PROJECT AIMS TO REDUCE INSULIN RELATED MEDICATION ERRORS IN THE HOSPITAL SETTING. HOSPITALIZED PATIENTS WITH DIABETES WHO ARE TAKING INSULIN MAY BE UNABLE TO MANAGE THEIR GLUCOSE READINGS AND INSULIN ADMINISTRATION, AND STAFF MAY NOT BE TRAINED OR AVAILABLE TO HELP WITH THESE CRITICAL TASKS. GLYCEMIC CONTROL IS NOT ONLY FUNDAMENTAL TO THE MANAGEMENT OF DIABETES, BUT IS ALSO ESSENTIAL TO HELP PREVENT HYPERGLYCEMIC EVENTS. SAFE USE OF INSULIN TO ACHIEVE OPTIMAL BLOOD GLUCOSE HAS BEEN DIRECTLY ASSOCIATED WITH IMPROVED PATIENT OUTCOMES. THE CENTERS FOR MEDICARE & MEDICAID SERVICES INCLUDES POOR GLYCEMIC MANAGEMENT ON ITS 2013 LIST OF 15 HOSPITAL-ACQUIRED CONDITIONS OR HACS AND WILL NO LONGER REIMBURSE HOSPITALS FOR ADDITIONAL COSTS ASSOCIATED WITH THESE PREVENTABLE MEDICAL ERRORS. THE OCCURRENCE OF THESE PREVENTABLE ADVERSE DRUG REACTIONS AND EVENTS CAN BE REDUCED AND INSULIN CAN BE USED SAFELY TO ACHIEVE OPTIMAL GLYCEMIC CONTROL FOR HOSPITALIZED PATIENTS. TO BETTER INFORM THE PATIENTS, THE CENTER LAUNCHED ITS "THE SAFER PATIENT" NEWSLETTER DURING 2012. THE FREE NEWSLETTER PROVIDED TO THE PUBLIC OFFERS TIPS AND INFORMATION SO THE PATIENT CAN TAKE A MORE ACTIVE ROLE IN THEIR OWN CARE. THE SAFER PATIENT NEWSLETTER INCLUDES TIPS ON HOW TO BETTER NAVIGATE THE HEALTH SYSTEM, HOW TO BE AN ACTIVE MEMBER OF THE HEALTH CARE TEAM, AND HOW TO ADVOCATE FOR OTHERS TO HELP ASSURE THE SAFETY AND QUALITY OF CARE. THE CENTER IS WORKING ON A NEW TOOL FOR RELEASE IN 2015. THE HIGH RELIABILITY SELF-ASSESSMENT TOOL (HRST) WILL ASSIST HOSPITALS IN THEIR TRANSFORMATION TO HIGHLY RELIABLE ORGANIZATIONS BY STRENGTHENING THE SYSTEMS AND STRUCTURES NECESSARY TO PROVIDE PATIENT CARE THAT IS CONSISTENTLY EXCELLENT AND SAFE. THE WEB-BASED APPLICATION WILL PROVIDE THE HOSPITAL WITH 1) PERFORMANCE BUILDING BLOCKS THAT CONTRIBUTE TO THE ACHIEVEMENT OF CONSISTENT EXCELLENCE IN PATIENT CARE; 2) A DIAGNOSTIC TOOL THAT WILL HELP IDENTIFY THEIR PERFORMANCE IMPROVEMENT OPPORTUNITIES; AND 3) SOLUTIONS, TOOLS AND METHODS FOR PROGRESS. IN DECEMBER 2013, THE CENTER LAUNCHED ITS 10TH PROJECT, WHICH AIMS TO REDUCE THE FREQUENCY OF CLOSTRIDIUM DIFFICILE (C. DIFFICILE)-RELATED INFECTIONS. THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) ESTIMATES THAT THERE WERE APPROXIMATELY 337,000 HOSPITALIZATIONS RELATED TO CDI DURING 2009. THIS REPRESENTS A 300 PERCENT INCREASE IN THESE RATES FROM 1993. THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) ESTIMATES THAT CDI-RELATED DIARRHEA IS LINKED TO APPROXIMATELY 14,000 DEATHS PER YEAR. THE FINANCIAL IMPACT OF CDI IS ALSO STAGGERING. THE JAMA INTERNAL MEDICINE ESTIMATES THAT THE CURRENT RATES OF CDI ADD AN ADDITIONAL $1.5 BILLION ANNUALLY TO THE COST OF HEALTH CARE. SINCE CDI DISPROPORTIONATELY AFFECTS OLDER PATIENTS, MEDICARE PAYS FOR 68 PERCENT OF ALL CDI-RELATED HOSPITAL STAYS. CDI RATES AND MORTALITY CAN BE REDUCED THROUGH A FOCUS ON A WIDE RANGE OF PATIENT CARE ASPECTS THAT INCLUDE EARLY IDENTIFICATION, ANTIBIOTIC STEWARDSHIP, AND EFFECTIVE ENVIRONMENTAL HYGIENE PRACTICES. |
| FORM 990, PART III, LINE 4A, PROGRAM SERVICE ACCOMPLISHMENT | (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 TEN PROJECTS UNDER THIS PROGRAM: 1) HAND HYGIENE PROJECT FOR IMPROVING PATIENT SAFETY TO LIMIT HOSPITAL ACQUIRED INFECTIONS THROUGH THE INCREASED USE OF HAND HYGIENE TECHNIQUES. 2) HAND-OFF COMMUNICATIONS FOR TRANSFER AND ACCEPTANCE OF PATIENT CARE RESPONSIBILITY ACHIEVED THROUGH EFFECTIVE COMMUNICATION 3) WRONG SITE SURGERY TO IMPROVE THE SAFEGUARDS TO PREVENT PATIENTS FROM WRONG SITE 4) WRONG SIDE AND WRONG PATIENT SURGICAL PROCEDURES, SURGICAL SITE INFECTIONS (SSI) WHICH AIMS TO REDUCE SSI'S IN PATIENTS HAVING COLORECTAL SURGERY 5) PREVENTING AVOIDABLE HEART FAILURE HOSPITALIZATIONS FOR PEOPLE WITH HEART FAILURE 6) IMPROVED SAFETY CULTURE THAT REINFORCES AND SUPPORTS THE PREVENTION OF PATIENT HARM AND 7) PREVENTION OF FALLS THAT OCCUR IN HEALTH CARE FACILITIES THAT RESULT IN INJURY. 8) REDUCING SEPSIS MORTALITY 9) SAFE USE OF INSULIN 10) AND REDUCING CLOSTRIDIUM DIFFICILE INFECTIONS |
| Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders | THE ORGANIZATION HAS ONE SOLE MEMBER, THE JOINT COMMISSION. THE JOINT COMMISSION HAS THE POWER TO: 1) APPOINT ALL DIRECTORS TO THE BOARD OF DIRECTORS AND REMOVE THEM, WITH OR WITHOUT CAUSE. 2) APPROVE THE ELECTION OF THE CHAIRMAN AND THE TREASURER OF THE ORGANIZATION AND REMOVE THEM, WITH OR WITHOUT CAUSE, PROVIDED THAT AN INDIVIDUAL SO REMOVED MAY HAVE A CLAIM FOR COMPENSATION IF THE REMOVAL BREACHES ANY CONTRACT APPROVED BY THE ORGANIZATION. 3) APPROVE AMENDMENTS TO THE ARTICLES OF INCORPORATION AND BYLAWS. 4) APPROVE ALL MISSION AND/OR VISION STATEMENTS AND ALL STRATEGIC OR LONG-TERM PLANS OF THE ORGANIZATION. 5) APPROVE ALL CREATIONS OF SUBSIDIARIES OR CONTROLLED AFFILIATES, MERGERS, CONSOLIDATIONS, PERMANENT OR LONG-TERM AFFILIATIONS AND ALL JOINT VENTURES OF THE ORGANIZATION INVOLVING CAPITAL INVESTMENTS IN EXCESS OF $250,000. 6) APPROVE THE SALE OF ENCUMBRANCE OF ALL OR SUBSTANTIALLY ALL THE ASSETS OF THE ORGANIZATION AND ALL LONG-TERM DEBT IN EXCESS OF $250,000. 7) APPROVE THE ORGANIZATION'S ANNUAL OPERATING AND CAPITAL BUDGETS AND MATERIAL AMENDMENTS THERETO. 8) APPROVE THE DISSOLUTION OF AND ALL LIQUIDATIONS FROM THE ORGANIZATION. |
| Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body | SEE RESPONSE TO LINE 6 |
| Form 990, Part VI, Sec A, Line 7b, Decisions requiring approval by members or stockholders | SEE RESPONSE TO LINE 6 |
| Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body | THE ORGANIZATION'S MANAGEMENT AND THE MANAGEMENT OF THE JOINT COMMISSION, INCLUDING THE CEO, CFO, CORPORATE COMPLIANCE & PRIVACY OFFICER, AND LEGAL COUNSEL PERFORMED A DETAILED REVIEW OF THE FORM 990 WITH THE PAID TAX PREPARER. ONCE THIS LEVEL OF REVIEW WAS PERFORMED, A THOROUGH WALK THROUGH OF FORM 990 WAS DONE WITH THE CENTER'S GOVERNING BODY PRIOR TO FILING. A FINAL FILED COPY OF THE RETURN WILL BE PLACED ON THE ORGANIZATION'S WEBSITE FOR THE PUBLIC ONCE ACCEPTED BY THE IRS |
| Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy | ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS' CONFLICT OF INTEREST POLICY. THE POLICY STATES THAT ANY DECISION THAT COULD RESULT IN AN ACTUAL OR PERCEIVED CONFLICT OF INTEREST MUST BE AVOIDED. ALL STAFF AND BOARD MEMBERS REVIEW THE POLICY ON AN ANNUAL BASIS AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EACH YEAR, WHICH IS DESIGNED TO IDENTIFY INTERESTS THAT COULD GIVE RISE TO POSSIBLE CONFLICTS. ALTHOUGH MANY SUCH POTENTIAL CONFLICTS ARE AND WILL BE DEEMED INCONSEQUENTIAL, EVERY INDIVIDUAL OF THE ORGANIZATION HAS AN ONGOING RESPONSIBILITY TO DISCLOSE SITUATIONS THAT INVOLVE PERSONAL, FAMILIAR, OR BUSINESS RELATIONSHIPS THAT COULD BE PERCEIVED AS A CONFLICT OF INTEREST. THE INTERESTS IDENTIFIED ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AND MANAGER AND APPROPRIATELY MANAGED. ALL DISCLOSURES ARE PURSUED UNTIL 100% COMPLETED. THE BOARD IS REQUIRED TO DISCLOSE A CONFLICT OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER DURING A MEETING AND THEN NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING REFLECTS THAT A DISCLOSURE WAS MADE AND THE MEMBER ABSTAINED FROM VOTING. THE COMPLIANCE OFFICER MONITORS AND REVIEWS THE CONFLICT OF INTEREST POLICY AS WELL AS THE RESPONSES TO THE QUESTIONNAIRES ON AN ANNUAL BASIS. THE ORGANIZATION ALSO HAS AVAILABLE AN INDEPENDENT HOTLINE NUMBER FOR STAFF TO REPORT ANY POTENTIAL CONFLICTS DURING THE YEAR ANONYMOUSLY. |
| FORM 990, PART VI, LINE 13, WHISTLEBLOWER POLICY | ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION WHISTLEBLOWER POLICY. |
| FORM 990, PART VI, LINE 14, DOCUMENT RETENTION | ALL CENTER STAFF AND BOARD MEMBERS ARE OBLIGATED TO FOLLOW THE JOINT COMMISSION RECORDS RETENTION POLICY. |
| Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official | THE CENTER RELIES ON THE PROCESS OF THE JOINT COMMISSION FOR APPROVAL OF TOP MANAGEMENTS COMPENSATION. THE OFFICERS' COMPENSATION ARRANGEMENT IS SUBJECT TO AN INDEPENDENT BOARD COMMITTEE REVIEW AND APPROVAL REFERRED TO AS THE HUMAN RESOURCES AND COMPENSATION COMMITTEE. THE JOINT COMMISSION ENGAGED AN INDEPENDENT COMPENSATION CONSULTANT TO ASSIST IN DETERMINING COMPENSATION OF THE CENTER'S OFFICERS. IN SETTING THE OFFICERS' COMPENSATION, THE JOINT COMMISSION'S HUMAN RESOURCES AND COMPENSATION COMMITTEE RELIES ON RECENT COMPENSATION STUDIES THAT PROVIDE COMPENSATION DATA FOR SIMILARLY QUALIFIED PERSONS IN COMPARABLE ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE ADEQUATELY DOCUMENTS ITS COMPENSATION DETERMINATIONS AND DELIBERATIONS REGARDING COMPENSATION IN ITS COMMITTEE MINUTES ON A TIMELY BASIS. EACH VOTING COMMITTEE MEMBER HAS BEEN DETERMINED TO BE INDEPENDENT IN ACCORDANCE WITH INTERMEDIATE SANCTIONS REGULATIONS AND SIGNS THE BOARD'S CONFLICT OF INTEREST POLICY ANNUALLY TO INSURE THAT HE OR SHE IS INDEPENDENT. THE PROCESS FOR DETERMINING THE OFFICERS COMPENSATION IS UNDERTAKEN ANNUALLY FOR ALL OFFICERS. |
| Form 990, Part VI, Sec B, Line 15b, Process to establish compensation of other employees | 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. |
| Form 990, Part VI, Sec C, Line 19, Required documents available to the public | THE ORGANIZATION DOES NOT MAKE ITS GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC. THE CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS ARE AVAILABLE TO THE PUBLIC ON THE JOINT COMMISSION WEBSITE. |
| Form 990, Part IX, Line 11g, Other Expenses | OTHER FEES - TOTAL EXPENSE: 467729, PROGRAM SERVICE EXPENSE: 312659, MANAGEMENT AND GENERAL EXPENSES: 15070, FUNDRAISING EXPENSES: 140000; MGMT FEE FOR SERVICE TO RELATED ORGANIZATION - TOTAL EXPENSE: 1038784, PROGRAM SERVICE EXPENSE: 635215, MANAGEMENT AND GENERAL EXPENSES: 346714, FUNDRAISING EXPENSES: 56855; |
| Software ID: | 13000248 |
| Software Version: | 2013v3.1 |