TY 2013 Form 990

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)
(1) CRAIG W JONES FACHE........................................................................ VICE CHAIR	3.00 .......................2.00	X	X	0	0
(2) JB SILVERS PHD........................................................................ TREASURER	4.00 .......................2.00	X	X	0	0
(3) MARK CHASSIN MD MPP MPH........................................................................ PRESIDENT/CEO	35.00 .......................5.00	X	X	1,116,634	50,379
(4) REBECCA J PATCHIN MD........................................................................ CHAIR	5.00 .......................2.00	X	X	50,000	0
(5) ALBERT J OSBAHR LLLMD MSCM........................................................................ COMMISSIONER	4.00 .......................	X		0	0
(6) CARL A SIRIO MD FACP FCCP FCCM........................................................................ COMMISSIONER	3.00 .......................	X		0	0
(7) CHARLES R BUCK JR SCD........................................................................ COMMISSIONER	4.00 .......................	X		0	0
(8) CHRISTOPHER J QUERAM........................................................................ COMMISSIONER	4.00 .......................	X		0	0
(9) CONNIE S MARCH RN MSN........................................................................ COMMISSIONER	3.00 .......................	X		0	0
(10) DAVID B PRYOR MD........................................................................ COMMISSIONER	3.00 .......................	X		0	0
(11) DAVID L BRONSON MD FACP........................................................................ COMMISSIONER	4.00 .......................1.00	X		230	0
(12) DAVID PERROTT DDS MD MBA FACS........................................................................ COMMISSIONER	7.00 .......................1.00	X		0	0
(13) GERALD M SHEA........................................................................ COMMISSIONER	3.00 .......................	X		260	0
(14) ILENE CORINA........................................................................ COMMISSIONER	4.00 .......................	X		0	0
(15) JOAN DOYLE RNMSNMBA........................................................................ COMMISSIONER	4.00 .......................	X		0	0
(16) JOEL T ALLISON FACHE........................................................................ COMMISSIONER	4.00 .......................	X		0	0
(17) JOHN A BABIARZ........................................................................ COMMISSIONER	3.00 .......................1.00	X		0	0

(A) Name and Title	(B) Average hours per week (list any hours for related organizations below dotted line)	(C) Position (do not check more than one box, unless person is both an officer and a director/trustee)	(E) Reportable compensation from related organizations (W- 2/1099-MISC)	(F) Estimated amount of other compensation from the organization and related organizations
(18) JULIANNE M MORATH RN MS........................................................................ COMMISSIONER	3.00 .......................	X					0	0	0
(19) LAMAR S MCGINNIS JR MD FACS........................................................................ COMMISSIONER	4.00 .......................2.00	X					271	0	0
(20) LD BRITT MD MPH FACS........................................................................ COMMISSIONER	3.00 .......................	X					0	0	0
(21) M NICOLE JAMALI MD........................................................................ COMMISSIONER	3.00 .......................	X					375	0	0
(22) MARK A KELLEY MD MACP........................................................................ COMMISSIONER	4.00 .......................	X					0	0	0
(23) MARY ANNE MCCAFFREE MD........................................................................ COMMISSIONER	3.00 .......................	X					0	0	0
(24) MARY H MCGRATH MD MPH........................................................................ COMMISSIONER	5.00 .......................	X					0	0	0
(25) MICHAEL F HOGAN PHD........................................................................ COMMISSIONER	5.00 .......................	X					0	0	0
(26) NANCY HOWELL AGEE........................................................................ COMMISSIONER	3.00 .......................	X					0	0	0
(27) R TIMOTHY RICE FACHE........................................................................ COMMISSIONER	4.00 .......................	X					375	0	0
(28) RALPH W MULLER........................................................................ COMMISSIONER	3.00 .......................	X					0	0	0
(29) ROGER W BUSH MD FACP........................................................................ COMMISSIONER	5.00 .......................	X					271	0	0
(30) STEPHEN R PERMUT MD JD........................................................................ COMMISSIONER	4.00 .......................	X					260	0	0
(31) STEVEN S SHAFSTEIN MD MPA........................................................................ COMMISSIONER	5.00 .......................	X					271	0	0
(32) T ANTHONY DENTON JD MHA........................................................................ COMMISSIONER	3.00 .......................	X					0	0	0
(33) ANA PUJOLS MCKEE........................................................................ VP & CHIEF MEDICAL OFFICER	40.00 .......................		X				541,726	0	25,434
(34) ANN SCOTT BLOUIN........................................................................ EXECUTIVE VICE PRESIDENT	40.00 .......................		X				369,532	0	110,281
(35) ANNE MARIE BENEDICTO........................................................................ CHIEF OF STAFF/EXEC VP	34.00 .......................6.00		X				328,675	0	65,080
(36) CHARLES MOWLL........................................................................ EXECUTIVE VICE PRESIDENT	40.00 .......................		X				428,542	0	128,745
(37) HAROLD BRESSLER........................................................................ GENERAL COUNSEL	40.00 .......................		X				363,007	0	121,840
(38) JEROD LOEB........................................................................ EXECUTIVE VICE PRESIDENT	40.00 .......................		X				503,890	0	115,460
(39) JOHN MACHE........................................................................ CHIEF INFORMATION OFFICER	40.00 .......................		X				304,551	0	88,245
(40) LYNN DRAGISIC........................................................................ VICE PRESIDENT	39.00 .......................1.00		X				334,597	0	115,314
(41) MARGARET VAN AMRINGE........................................................................ EXECUTIVE VICE PRESIDENT	39.00 .......................1.00		X				0	374,807	102,636
(42) MARK PELLETIER........................................................................ CHIEF OPERATING OFFICER	39.00 .......................1.00		X				353,668	0	78,786
(43) PAIGE RODGERS........................................................................ CHIEF FINANCIAL OFFICER	38.00 .......................2.00		X				415,063	0	45,097
(44) BARBARA BUTURUSIS........................................................................ DIR. SURVEYOR MGMT & SUPPORT	40.00 .......................			X			169,945	0	36,005
(45) DEBRA KIEL........................................................................ DIRECTOR, STRATEGIC PLANNING IT	40.00 .......................			X			183,924	0	39,718
(46) DANIEL CASTILLIO........................................................................ MEDICAL DIRECTOR	40.00 .......................				X		299,720	0	339
(47) DAVID GILMARTIN........................................................................ ASSOCIATE GENERAL COUNSEL	40.00 .......................				X		224,869	0	38,927
(48) JOHN CULLINAN........................................................................ DIRECTOR, DATA ANALYSIS & APPLICATIONS	40.00 .......................				X		178,599	0	40,211
(49) MARION PANAGOPOULOS........................................................................ SR. DIR QUALITY EVALUATION & STRATEGY	40.00 .......................				X		188,073	0	42,407
(50) RONALD WYATT........................................................................ MEDICAL DIRECTOR	40.00 .......................				X		284,510	0	26,877
(51) PAUL SCHYVE........................................................................ SR ADVISOR-HEALTHCARE IMPROVEMENT	20.00 .......................					X	240,576	0	81,997
(52) ROBERT WISE........................................................................ MEDICAL ADVISOR-HQE	24.00 .......................					X	170,556	0	33,598

(A) Name and business address	(B) Description of services	(C) Compensation
AMERICAN HEART ASSOCIATION7272 GREENVILLE AVEDALLASTX75235	PROFESSIONAL SERVICES/CERTIFICATIONS	1,617,150
TEKSYSTEMS TELECOM INCP O 198568ATLANTAGA303848568	IT CONSULTING	734,434
INSTITUTE FOR MEDICAL QUALITY INC221 MAIN STREET SUITE 210SAN FRANCISCOCA94105	PROFESSIONAL SERVICES	716,930
EXPERIS IT SERVICES US LLCPO BOX 905378CHARLOTTENC282905378	IT SERVICES	669,253
GOLDMAN SACHS BANK USA85 BROADWAY STREET 26THNEW YORKNY10004	INTEREST RATE SWAP FEES	508,539
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 of compensation from the organization 52

Do not include amounts reported on lines 6b, 7b, 8b, 9b, and 10b of Part VIII.	(A) Total expenses	(B) Program service expenses	(C) Management and general expenses	(D) Fundraising expenses
1	Grants and other assistance to governments and organizations in the United States. See Part IV, line 21	0
2	Grants and other assistance to individuals in the United States. See Part IV, line 22	0
3	Grants and other assistance to governments, organizations, and individuals outside the United States. See Part IV, lines 15 and 16	0
4	Benefits paid to or for members	0
5	Compensation of current officers, directors, trustees, and key employees ....	6,911,581	2,304,727	4,606,854
6	Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) ....	0
7	Other salaries and wages	74,456,788	62,863,921	11,592,867
8	Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) ....	4,228,756	3,562,690	666,066
9	Other employee benefits .......	7,011,161	5,179,711	1,831,450
10	Payroll taxes ...........	5,412,425	4,468,357	944,068
11	Fees for services (non-employees):
a	Management ......	0
b	Legal .........	281,269	155,561	125,708
c	Accounting ...........	250,559	20,937	229,622
d	Lobbying ...........	195,437		195,437
e	Professional fundraising services. See Part IV, line 17	0
f	Investment management fees ......	676,048		676,048
g	Other (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O) ........	6,731,787	4,275,440	2,456,347	0
12	Advertising and promotion ....	1,242,813	949,544	293,269
13	Office expenses .......	283,611	133,367	150,244
14	Information technology ......	1,440,446	99,434	1,341,012
15	Royalties ..	0
16	Occupancy ...........	2,149,995	833,603	1,316,392
17	Travel ............	22,426,663	22,082,935	343,728
18	Payments of travel or entertainment expenses for any federal, state, or local public officials ......	0
19	Conferences, conventions, and meetings ....	1,126,080	838,452	287,628
20	Interest ...........	714,049	340,387	373,662
21	Payments to affiliates .......	0
22	Depreciation, depletion, and amortization .....	3,148,525	1,018,438	2,130,087
23	Insurance ..............	1,049,047	1,049,047
24	Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.)
a	TELEPHONE	932,271	771,292	160,979
b	EQUIPMENT RENTAL	799,564	14,172	785,392
c	POSTAGE & SHIPPING	226,852	98,309	128,543
d	RECRUITMENT	324,267	63,979	260,288
e	All other expenses	1,038,552	635,515	403,037	0
25	Total functional expenses. Add lines 1 through 24e	143,058,546	111,759,818	31,298,728	0
26	Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720).	0

Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X ..............
	1	Cash–non-interest-bearing .............		1
2	Savings and temporary cash investments .........	18,505,829	2	24,390,914
3	Pledges and grants receivable, net ...........		3
4	Accounts receivable, net .............	21,431,880	4	14,073,030
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
		0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
		0	6	0
7	Notes and loans receivable, net .............		7
8	Inventories for sale or use ..............	10,364	8	11,028
9	Prepaid expenses and deferred charges ..........	2,697,771	9	1,839,697
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	65,312,842
b	Less: accumulated depreciation .....	10b	40,686,305	24,983,198	10c	24,626,537
11	Investments—publicly traded securities ..........	56,311,380	11	112,636,136
12	Investments—other securities. See Part IV, line 11 .....	47,699,534	12	7,596,575
13	Investments—program-related. See Part IV, line 11 .....	0	13	0
14	Intangible assets ...............		14
15	Other assets. See Part IV, line 11 ...........	0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)......	171,639,956	16	185,173,917
	17	Accounts payable and accrued expenses .........	13,740,815	17	13,767,486
18	Grants payable .................		18
19	Deferred revenue ................	1,110,424	19	2,173,728
20	Tax-exempt bond liabilities .............	16,460,000	20	14,245,000
21	Escrow or custodial account liability. Complete Part IV of Schedule D..		21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........	0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..		23
24	Unsecured notes and loans payable to unrelated third parties ....		24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................	22,558,681	25	13,098,664
26	Total liabilities. Add lines 17 through 25.........	53,869,920	26	43,284,878
		Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............	117,770,036	27	141,889,039
28	Temporarily restricted net assets ...........		28
29	Permanently restricted net assets ...........		29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........		30
31	Paid-in or capital surplus, or land, building or equipment fund .....		31
32	Retained earnings, endowment, accumulated income, or other funds		32
33	Total net assets or fund balances ...........	117,770,036	33	141,889,039
34	Total liabilities and net assets/fund balances ........	171,639,956	34	185,173,917

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SCHEDULE A
(Form 990 or 990EZ)

Department of the Treasury
Internal Revenue Service

Public Charity Status and Public Support

Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust.

Attach to Form 990 or Form 990-EZ. right arrow

See separate instructions.
right arrow

Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Part I

Reason for Public Charity Status (All organizations must complete this part.) See instructions.

The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.)

A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i).

A school described in section 170(b)(1)(A)(ii). (Attach Schedule E.)

A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii).

A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state:

An organization operated for the benefit of a college or university owned or operated by a governmental unit described in

section 170(b)(1)(A)(iv). (Complete Part II.)

A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v).

An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.)

A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.)

An organization that normally receives: (1) more than 331/3% of its support from contributions, membership fees, and gross

receipts from activities related to its exempt functions—subject to certain exceptions, and (2) no more than 331/3% of

its support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses

acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.)

An organization organized and operated exclusively to test for public safety. See section 509(a)(4).

An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box that describes the type of supporting organization and complete lines 11e through 11h.

Type I

Type II

Type III - Functionally integrated

Type III - Non-functionally integrated

By checking this box, I certify that the organization is not controlled directly or indirectly by one or more disqualified persons other than foundation managers and other than one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2).

If the organization received a written determination from the IRS that it is a Type I, Type II, or Type III supporting organization, check this box ..................................................

Since August 17, 2006, has the organization accepted any gift or contribution from any of the
following persons?

(i) A person who directly or indirectly controls, either alone or together with persons described in (ii)

Yes

and (iii) below, the governing body of the supported organization? ................

11g(i)

(ii) A family member of a person described in (i) above? ......................

11g(ii)

(iii) A 35% controlled entity of a person described in (i) or (ii) above? ................

11g(iii)

Provide the following information about the supported organization(s).

(i) Name of supported organization	(ii) EIN	(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
(i) Name of supported organization	(ii) EIN	Yes	No	Yes	No	Yes	No	(vii) Amount of monetary support


Total

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990EZ.

Cat. No. 11285F

Schedule A (Form 990 or 990-EZ) 2013

Page 2

Part II

Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi)
(Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.)

Section A. Public Support

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	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.......
3	The value of services or facilities furnished by a governmental unit to the organization without charge..
4	Total. Add lines 1 through 3
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)..
6	Public support. Subtract line 5 from line 4.

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
7	Amounts from line 4..
8	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources...
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.)..
11	Total support (Add lines 7 through 10).

Gross receipts from related activities, etc. (see instructions) ..................

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization, check this box and stop here................................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2013 (line 6, column (f) divided by line 11, column (f)) .........

Public support percentage for 2012 Schedule A, Part II, line 14 ...............

16a

33 1/3% support test—2013. If the organization did not check the box on line 13, and line 14 is 33 1/3% or more, check this box
and stop here. The organization qualifies as a publicly supported organization ....................... right arrow

33 1/3% support test—2012. If the organization did not check a box on line 13 or 16a, and line 15 is 33 1/3% or more, check this
box and stop here. The organization qualifies as a publicly supported organization ..................... right arrow

17a

10%-facts-and-circumstances test—2013. If the organization did not check a box on line 13, 16a, or 16b, and line 14
is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain
in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported
organization ..................................................... right arrow

10%-facts-and-circumstances test—2012. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line
15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here.
Explain in Part IV how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly
supported organization ................................................ right arrow

Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see
instructions ..................................................... right arrow

Schedule A (Form 990 or 990-EZ) 2013

Page 3

Part III

Support Schedule for Organizations Described in Section 509(a)(2)
(Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.)

Section A. Public Support

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.") .	2,324,665	2,625,473	2,487,209	3,125,663	1,902,807	12,465,817
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......	115,797,728	119,131,593	127,333,477	137,010,728	142,545,602	641,819,128
3	Gross receipts from activities that are not an unrelated trade or business under section 513..						0
4	Tax revenues levied for the organization's benefit and either paid to or expended on its behalf...						0
5	The value of services or facilities furnished by a governmental unit to the organization without charge..						0
6	Total. Add lines 1 through 5.	118,122,393	121,757,066	129,820,686	140,136,391	144,448,409	654,284,945
7a	Amounts included on lines 1, 2, and 3 received from disqualified persons...	0	0	0	0	0	0
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.	0	0	0	0	0	0
c	Add lines 7a and 7b..	0	0	0	0	0	0
8	Public support (Subtract line 7c from line 6.)						654,284,945

Section B. Total Support

Calendar year (or fiscal year beginning in)		(a) 2009	(b) 2010	(c) 2011	(d) 2012	(e) 2013	(f) Total
9	Amounts from line 6...	118,122,393	121,757,066	129,820,686	140,136,391	144,448,409	654,284,945
10a	Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources..	3,567,554	3,648,455	3,849,715	3,452,041	3,781,039	18,298,804
b	Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975.	1,660	0	0	0		1,660
c	Add lines 10a and 10b.	3,569,214	3,648,455	3,849,715	3,452,041	3,781,039	18,300,464
11	Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on.						0
12	Other income. Do not include gain or loss from the sale of capital assets (Explain in Part IV.) ..	3,293,084	3,359,702	3,682,007	4,932,412	5,006,477	20,273,682
13	Total support. (Add lines 9, 10c, 11, and 12.)..	124,984,691	128,765,223	137,352,408	148,520,844	153,235,925	692,859,091

First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a 501(c)(3) organization,
check this box and stop here............................................. right arrow

Section C. Computation of Public Support Percentage

Public support percentage for 2013 (line 8, column (f) divided by line 13, column (f)) .........

94.430 %

Public support percentage from 2012 Schedule A, Part III, line 15 ...............

94.300 %

Section D. Computation of Investment Income Percentage

Investment income percentage for 2013 (line 10c, column (f) divided by line 13, column (f)) ......

2.640 %

Investment income percentage from 2012 Schedule A, Part III, line 17 .............

2.850 %

19a

33 1/3% support tests—2013. If the organization did not check the box on line 14, and line 15 is more than 33 1/3%, and line 17 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ........ right arrow

33 1/3% support tests—2012. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 33 1/3% and line 18 is not more than 33 1/3%, check this box and stop here. The organization qualifies as a publicly supported organization ..... right arrow

Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions ..... right arrow

Schedule A (Form 990 or 990-EZ) 2013

Page 4

Part IV

Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).

Facts And Circumstances Test

Explanation

Schedule A (Form 990 or 990-EZ) 2013

Additional Data

Software ID:	13000248
Software Version:	2013v3.1

- TIN:

Schedule B
(Form 990, 990-EZ,
or 990-PF)

Department of the Treasury
Internal Revenue Service

Schedule of Contributors

Attach to Form 990, 990-EZ, or 990-PF.

Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Name of the organization

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Organization type (check one):

Filers of:

Section:

Form 990 or 990-EZ

501(c)( ) (enter number) organization

4947(a)(1) nonexempt charitable trust not treated as a private foundation

527 political organization

Form 990-PF

501(c)(3) exempt private foundation

4947(a)(1) nonexempt charitable trust treated as a private foundation

501(c)(3) taxable private foundation

Check if your organization is covered by the General Rule or a Special Rule.
Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.

General Rule

For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, $5,000 or more (in money or
property) from any one contributor. Complete Parts I and II.

Special Rules

For a section 501(c)(3) organization filing Form 990 or 990-EZ that met the 33¹/3% support test of the regulations
under sections 509(a)(1) and 170(b)(1)(A)(vi) and received from any one contributor, during the year, a contribution of the
greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, total contributions of more than $1,000 for use exclusively for religious, charitable,
scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and
III.

For a section 501(c)(7), (8), or (10) organization filing Form 990 or 990-EZ that received from any one contributor,
during the year, contributions for use exclusively for religious, charitable, etc., purposes, but these contributions did
not total more than $1,000. If this box is checked, enter here the total contributions that were received during
the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule
applies to this organization because it received nonexclusively religious, charitable, etc., contributions of $5,000 or more
during the year ......................... Arrow Bullet

Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990,
990-EZ, or 990-PF), but it must answer “No” on Part IV, line 2, of its Form 990; or check the box on line H of its
Form 990-EZ or on its Form 990PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990,
990-EZ, or 990-PF).

For Paperwork Reduction Act Notice, see the Instructions
for Form 990, 990-EZ, or 990-PF.

Cat. No. 30613XSchedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 2

Name of organization JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Part I	Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
RESTRICTED	RESTRICTED RESTRICTED RESTRICTED RESTRICTED, RESTRICTEDRESTRICTED	$RESTRICTED	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
(a) No.	(b) Name, address, and ZIP + 4	(c) Total contributions	(d) Type of contribution
		$	Person Payroll Noncash (Complete Part II for noncash contributions.)
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 3

Name of organization JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Part II	Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
(a) No. from Part I	(b) Description of noncash property given	(c) FMV (or estimate) (see instructions)	(d) Date received
		$
Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Page 4

Name of organization
JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Part III

Exclusively religious, charitable, etc., individual contributions to section 501(c)(7), (8), or (10) organizations
that total more than $1,000 for the year. Complete columns (a) through (e) and the following line entry.
For organizations completing Part III, enter the total of exclusively religious, charitable, etc.,
contributions of $1,000 or less for the year. (Enter this information once. See instructions.) Arrow Bullet

$
Use duplicate copies of Part III if additional space is needed.

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

(a) No.
from
Part I

(b) Purpose of gift

(d) Description of how gift is held

(e) Transfer of gift
Transferee's name, address, and ZIP 4	Relationship of transferor to transferee

Schedule B (Form 990, 990-EZ, or 990-PF) (2013)

Additional Data

Software ID:	13000248
Software Version:	2013v3.1

- TIN:

SCHEDULE C
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Political Campaign and Lobbying Activities

For Organizations Exempt From Income Tax Under section 501(c) and section 527
SchCMd Bullet

Complete if the organization is described below. SchCMd Bullet

Attach to Form 990 or Form 990-EZ.
SchCMd Bullet

See separate instructions. SchCMd Bullet

Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

If the organization answered "Yes" to Form 990, Part IV, Line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then
Round Bullet

Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C.
Round Bullet

Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B.
Round Bullet

Section 527 organizations: Complete Part I-A only.
If the organization answered "Yes" to Form 990, Part IV, Line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then
Round Bullet

Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B.
Round Bullet

Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A.
If the organization answered "Yes" to Form 990, Part IV, Line 5 (Proxy Tax) or Form 990-EZ, Part V, line 35c (Proxy Tax), then
Round Bullet

Section 501(c)(4), (5), or (6) organizations: Complete Part III.

Name of the organization

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Part I-A

Complete if the organization is exempt under section 501(c) or is a section 527 organization.

Provide a description of the organization’s direct and indirect political campaign activities in Part IV.

Political expenditures .................................... SchCMd Bullet

Volunteer hours ........................................

Part I-B

Complete if the organization is exempt under section 501(c)(3).

Enter the amount of any excise tax incurred by the organization under section 4955 ......... SchCMd Bullet

Enter the amount of any excise tax incurred by organization managers under section 4955 ...... SchCMd Bullet

If the organization incurred a section 4955 tax, did it file Form 4720 for this year? ..............

Yes No

Was a correction made? .........................................

Yes No

If "Yes," describe in Part IV.

Part I-C

Complete if the organization is exempt under section 501(c), except section 501(c)(3).

Enter the amount directly expended by the filing organization for section 527 exempt function activities SchCMd Bullet

Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities ................................... SchCMd Bullet

Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b.. SchCMd Bullet

Did the filing organization file Form 1120-POL for this year? ..........................

Yes No

Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing
organization made payments. For each organization listed, enter the amount paid from the filing organization’s funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV.

(a) Name	(b) Address	(c) EIN	(d) Amount paid from filing organization's funds. If none, enter -0-.	(e) Amount of political contributions received and promptly and directly delivered to a separate political organization. If none, enter -0-.

For Paperwork Reduction Act Notice, see the instructions for Form 990 or 990-EZ.

Cat. No. 50084S

Schedule C (Form 990 or 990-EZ) 2013

Page 2

Part II-A

Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)).

A Check SchCMd Bullet

if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures).
B Check SchCMd Bullet

if the filing organization checked box A and "limited control" provisions apply.

Limits on Lobbying Expenditures (The term "expenditures" means amounts paid or incurred.)		(b) Affiliated group totals
1a	Total lobbying expenditures to influence public opinion (grass roots lobbying) ......
b	Total lobbying expenditures to influence a legislative body (direct lobbying) .......
c	Total lobbying expenditures (add lines 1a and 1b) ...................
d	Other exempt purpose expenditures ........................
e	Total exempt purpose expenditures (add lines 1c and 1d) ...............
f	Lobbying nontaxable amount. Enter the amount from the following table in both columns.
	If the amount on line 1e, column (a) or (b) is:The lobbying nontaxable amount is:
	Not over $500,00020% of the amount on line 1e.
	Over $500,000 but not over $1,000,000$100,000 plus 15% of the excess over $500,000.
	Over $1,000,000 but not over $1,500,000$175,000 plus 10% of the excess over $1,000,000.
	Over $1,500,000 but not over $17,000,000$225,000 plus 5% of the excess over $1,500,000.
	Over $17,000,000$1,000,000.

g	Grassroots nontaxable amount (enter 25% of line 1f) .................
h	Subtract line 1g from line 1a. If zero or less, enter -0-. ................
i	Subtract line 1f from line 1c. If zero or less, enter -0-. ................
j	If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? ......................................	Yes No

4-Year Averaging Period Under Section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the instructions for lines 2a through 2f on page 4.)
Lobbying Expenditures During 4-Year Averaging Period
	Calendar year (or fiscal year beginning in)	(a) 2010	(b) 2011	(c) 2012	(d) 2013	(e) Total

2a	Lobbying nontaxable amount

b	Lobbying ceiling amount (150% of line 2a, column(e))

c	Total lobbying expenditures

d	Grassroots nontaxable amount

e	Grassroots ceiling amount (150% of line 2d, column (e))

f	Grassroots lobbying expenditures

Schedule C (Form 990 or 990-EZ) 2013

Page 3

Part II-B

Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)).

For each "Yes" response to lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity.

(a)

Yes

(b)

Amount

During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of:

Volunteers? .........................................

Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? ....

Yes

Media advertisements? ....................................

Mailings to members, legislators, or the public? .........................

Publications, or published or broadcast statements? .......................

Grants to other organizations for lobbying purposes? .......................

Direct contact with legislators, their staffs, government officials, or a legislative body? ........

Yes

195,437

Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? ......

Other activities? ..........................

Total. Add lines 1c through 1i ...............................

195,437

Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? .....

If "Yes," enter the amount of any tax incurred under section 4912 .................

If "Yes," enter the amount of any tax incurred by organization managers under section 4912 .....

If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? .......

Part III-A

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6).

Yes

Were substantially all (90% or more) dues received nondeductible by members? ................

Did the organization make only in-house lobbying expenditures of $2,000 or less? ................

Did the organization agree to carry over lobbying and political expenditures from the prior year? ..........

Part III-B

Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No" OR (b) Part III-A, line 3, is answered “Yes."

Dues, assessments and similar amounts from members .....................

Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political
expenses for which the section 527(f) tax was paid).

Current year .........................................

Carryover from last year ....................................

Total ............................................

Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues .

If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? ................................

Taxable amount of lobbying and political expenditures (see instructions) ..............

Part IV

Supplemental Information

Provide the descriptions required for Part l-A, line 1; Part l-B, line 4; Part l-C, line 5; Part II-A (affiliated group list); Part II-A, line 2; and Part ll-B, line 1. Also, complete this part for any additional information.

Return Reference	Explanation
Schedule C, Part II-B, Line 1, Description of the activities reported on Lines 1a through 1i	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.

Schedule C (Form 990 or 990EZ) 2013

Additional Data

Software ID:	13000248
Software Version:	2013v3.1

- TIN:

SCHEDULE D
(Form 990)

Department of the Treasury
Internal Revenue Service

Supplemental Financial Statements

Complete if the organization answered "Yes," to Form 990,
Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b
SchDMd Bullet

Attach to Form 990. SchDMd Bullet

See separate instructions. SchDMd Bullet

Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Part I

Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" to Form 990, Part IV, line 6.

		(a) Donor advised funds	(b) Funds and other accounts
1	Total number at end of year .........
2	Aggregate contributions to (during year) ...
3	Aggregate grants from (during year) .....
4	Aggregate value at end of year ........

Did the organization inform all donors and donor advisors in writing that the assets held in donor advised
funds are the organization's property, subject to the organization's exclusive legal control? ............

Yes No

Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be
used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? ...................................

Yes No

Part II

Conservation Easements. Complete if the organization answered "Yes" to Form 990, Part IV, line 7.

Purpose(s) of conservation easements held by the organization (check all that apply).

Preservation of land for public use (e.g., recreation or education) Preservation of an historically important land area

Protection of natural habitat Preservation of a certified historic structure

Preservation of open space

Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year.


a	Total number of conservation easements .......................	2a
b	Total acreage restricted by conservation easements ..................	2b
c	Number of conservation easements on a certified historic structure included in (a) .....	2c
d	Number of conservation easements included in (c) acquired after 8/17/06, and not on a historic structure listed in the National Register ....................	2d

Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during
the tax year SchDMd Bullet

Number of states where property subject to conservation easement is located SchDMd Bullet

Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and
enforcement of the conservation easements it holds? .............................

Yes No

Staff and volunteer hours devoted to monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Amount of expenses incurred in monitoring, inspecting, and enforcing conservation easements during the year
SchDMd Bullet

Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? .......................................

Yes No

In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and
balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes
the organization’s accounting for conservation easements.

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets.
Complete if the organization answered "Yes" to Form 990, Part IV, line 8.

If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items.

If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items:

(i)

Revenues included in Form 990, Part VIII, line 1 ........................ SchDMd Bullet

(ii)

Assets included in Form 990, Part X .............................. SchDMd Bullet

If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the
following amounts required to be reported under SFAS 116 (ASC 958) relating to these items:

Revenues included in Form 990, Part VIII, line 1 .......................... SchDMd Bullet

Assets included in Form 990, Part X ............................... SchDMd Bullet

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 52283D

Schedule D (Form 990) 2013

Page 2

Part III

Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued)

Using the organization’s acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply):

Public exhibition

Loan or exchange programs

Scholarly research

Other

Preservation for future generations

Provide a description of the organization’s collections and explain how they further the organization’s exempt purpose in
Part XIII.

During the year, did the organization solicit or receive donations of art, historical treasures or other similar
assets to be sold to raise funds rather than to be maintained as part of the organization’s collection?........

Yes No

Part IV

Escrow and Custodial Arrangements. Complete if the organization answered "Yes" to Form 990,
Part IV, line 9, or reported an amount on Form 990, Part X, line 21.

Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not
included on Form 990, Part X? ....................................

Yes No

If "Yes," explain the arrangement in Part XIII and complete the following table:


c	Beginning balance .................................	1c
d	Additions during the year ..............................	1d
e	Distributions during the year .............................	1e
f	Ending balance ...................................	1f

Did the organization include an amount on Form 990, Part X, line 21? .....................

Yes No

If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided in Part XIII ........

Part V

Endowment Funds. Complete if the organization answered "Yes" to Form 990, Part IV, line 10.

		(a)Current year	(b)Prior year	b (c)Two years back	(d)Three years back	(e)Four years back
1a	Beginning of year balance ....
b	Contributions ........
c	Net investment earnings, gains, and losses
d	Grants or scholarships .....
e	Other expenditures for facilities and programs ........
f	Administrative expenses ....
g	End of year balance ......

Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as:

Board designated or quasi-endowment SchDMd Bullet

Permanent endowment SchDMd Bullet

Temporarily restricted endowment SchDMd Bullet

The percentages in lines 2a, 2b, and 2c should equal 100%.

Are there endowment funds not in the possession of the organization that are held and administered for the
organization by:

Yes

(i) unrelated organizations ........................

3a(i)

(ii) related organizations ........................

3a(ii)

If "Yes" to 3a(ii), are the related organizations listed as required on Schedule R? .........

Describe in Part XIII the intended uses of the organization's endowment funds.

Part VI

Land, Buildings, and Equipment. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11a. See Form 990, Part X, line 10.

Description of property		(b)Cost or other basis (other)	(c) Accumulated depreciation	(d) Book value
1a	Land .................	4,204,400		4,204,400
b	Buildings ................	28,495,133	15,869,082	12,626,051
c	Leasehold improvements ............	258,638	166,293	92,345
d	Equipment ................	7,186,443	4,244,458	2,941,985
e	Other .................	25,168,228	20,406,472	4,761,756
Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10(c).).......				24,626,537

Schedule D (Form 990) 2013

Page 3

Part VII

InvestmentsOther Securities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11b. See Form 990, Part X, line 12.

(a) Description of security or category (including name of security)		(b)Book value	(c) Method of valuation: Cost or end-of-year market value
(1)Financial derivatives
(2)Closely-held equity interests
Other








Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.)

Part VIII

InvestmentsProgram Related. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11c. See Form 990, Part X, line 13.

(a) Description of investment		(b) Book value	(c) Method of valuation: Cost or end-of-year market value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 13.)

Part IX

Other Assets. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11d. See Form 990, Part X, line 15.

(a) Description				(b) Book value









Total. (Column (b) must equal Form 990, Part X, col.(B) line 15.)...........

Part X

Other Liabilities. Complete if the organization answered 'Yes' to Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25.

1.(a) Description of liability		(b) Book value
Federal income taxes		0
DEFERRED SWAP		125,628
UNRESTRICTED OPERATING PLEDGE TO AFFILIATE		3,400,000
BOARD-DESIGNATED PLEDGE FUNDS FUNCTIONING AS ENDOWMENT TO AFFILIATE		5,000,000
FAIR VALUE OF HEDGE		1,082,559
ACCRUED PENSION LIABILITY		3,490,477




Total. (Column (b) must equal Form 990, Part X, col.(B) line 25.)		13,098,664
2. Liability for uncertain tax positions In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII ..................................................

Schedule D (Form 990) 2013

Page 4

Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total revenue, gains, and other support per audited financial statements .......			1	178,362,129
2	Amounts included on line 1 but not on Form 990, Part VIII, line 12:
a	Net unrealized gains on investments ..........	2a	9,648,158
b	Donated services and use of facilities .........	2b
c	Recoveries of prior year grants ...........	2c
d	Other (Describe in Part XIII.) ............	2d	11,612,810
e	Add lines 2a through 2d .....................			2e	21,260,968
3	Subtract line 2e from line 1.....................			3	157,101,161
4	Amounts included on Form 990, Part VIII, line 12, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b .	4a	244,762
b	Other (Describe in Part XIII.) ...........	4b	31,585
c	Add lines 4a and 4b.......................			4c	276,347
5	Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) ......			5	157,377,508

Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered 'Yes' to Form 990, Part IV, line 12a.
1	Total expenses and losses per audited financial statements ...........			1	154,243,126
2	Amounts included on line 1 but not on Form 990, Part IX, line 25:
a	Donated services and use of facilities ..........	2a
b	Prior year adjustments ..............	2b
c	Other losses ................	2c
d	Other (Describe in Part XIII.) ............	2d	11,460,927
e	Add lines 2a through 2d......................			2e	11,460,927
3	Subtract line 2e from line 1.....................			3	142,782,199
4	Amounts included on Form 990, Part IX, line 25, but not on line 1:
a	Investment expenses not included on Form 990, Part VIII, line 7b ..	4a	244,762
b	Other (Describe in Part XIII.) ............	4b	31,585
c	Add lines 4a and 4b.......................			4c	276,347
5	Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) ......			5	143,058,546

Part XIII

Supplemental Information

Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part lV, lines 1b and 2b;
Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information.

Return Reference	Explanation
Schedule D, Part X, Line 2, FIN 48 (ASC 740) footnote	THE INTERNAL REVENUE SERVICE HAS DETERMINED THAT THE JOINT COMMISSION AND ITS AFFILIATES ARE EXEMPT FROM FEDERAL INCOME TAXATION UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. THE JOINT COMMISSION AND ITS AFFILIATES ARE SUBJECT TO INCOME TAXES ON INCOME DETERMINED TO BE UNRELATED BUSINESS TAXABLE INCOME. AS OF JANUARY 2009, THE JOINT COMMISSION ADOPTED THE FINANCIAL ACCOUNTING STANDARDS BOARD (FASB) ACCOUNTING STANDARDS CODIFICATION (ASC) 740 10 (FORMERLY KNOWN AS FASB INTERPRETATION NO. 48, ACCOUNTING FOR UNCERTAINTY IN INCOME TAXES), WHICH PRESCRIBES A COMPREHENSIVE MODEL FOR HOW AN ORGANIZATION SHOULD MEASURE, RECOGNIZE, PRESENT, AND DISCLOSE IN ITS FINANCIAL STATEMENTS UNCERTAIN TAX POSITIONS THAT AN ORGANIZATION HAS TAKEN OR EXPECTS TO TAKE ON A TAX RETURN. THE JOINT COMMISSION HAS ANALYZED TAX POSITIONS TAKEN FOR FILING WITH THE INTERNAL REVENUE SERVICE AND ALL STATE JURISDICTIONS WHERE IT OPERATES. THE JOINT COMMISSION BELIEVES THAT INCOME TAX FILING POSITIONS WILL BE SUSTAINED UPON EXAMINATION AND DOES NOT ANTICIPATE ANY ADJUSTMENTS THAT WOULD RESULT IN A MATERIAL ADVERSE 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, 2013 FOR ITS UNITED STATES OPERATIONS.
Schedule D, Part XI, Line 2d, Other revenues in audited financial statements not in form 990	CHANGE IN FAIR VALUE OF HEDGE-INTEREST RATE SWAP - 528991; CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COSTS - 8025375; TRANSFER OF NET ASSETS FROM AFFILIATE - 3058444;
Schedule D, Part XI, Line 4b, Other revenues in form 990 not in audited financial statements	GAIN ON SALE OF FIXED ASSET - 31585;
Schedule D, Part XII, Line 2d, Other expenses in audited financial statements not in form 990	TRANSFER OF NET ASSETS TO AFFILIATE - 3060927; BOARD-DESIGNATED FUNDS FUNCTIONING AS ENDOWMENT - 5000000; OPERATING PLEDGE TO AFFILIATE DESIGNATED AS UNRESTRICTED - 3400000;
Schedule D, Part XII, Line 4b, Other expenses in form 990 not in audited financial statements	GAIN ON SALE OF FIXED ASSET - 31585;

Schedule D (Form 990) 2013

Additional Data

Software ID:	13000248
Software Version:	2013v3.1

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Schedule J
(Form 990)

Department of the Treasury
Internal Revenue Service

Compensation Information

For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
SchJMediumBullet

Complete if the organization answered "Yes" to Form 990, Part IV, line 23.
SchJMediumBullet

Attach to Form 990. SchJMediumBullet

See separate instructions.
SchJMediumBullet

Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Part I

Questions Regarding Compensation

Yes

Check the appropiate box(es) if the organization provided any of the following to or for a person listed in Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.

First-class or charter travel Housing allowance or residence for personal use

Travel for companions Payments for business use of personal residence

Tax idemnification and gross-up payments Health or social club dues or initiation fees

Discretionary spending account Personal services (e.g., maid, chauffeur, chef)

If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain....

Yes

Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a? ..

Yes

Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.

Compensation committee Written employment contract

Independent compensation consultant Compensation survey or study

Form 990 of other organizations Approval by the board or compensation committee

During the year, did any person listed in Form 990, Part VII, Section A, line 1a with respect to the filing organization or a related organization:

Receive a severance payment or change-of-control payment? ................

Participate in, or receive payment from, a supplemental nonqualified retirement plan? .........

Yes

Participate in, or receive payment from, an equity-based compensation arrangement? .........

If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.

Only 501(c)(3) and 501(c)(4) organizations only must complete lines 5-9.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:

The organization? ...........................

Yes

Any related organization? .........................

If "Yes," to line 5a or 5b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:

The organization? ...........................

Yes

Any related organization? .........................

Yes

If "Yes," to line 6a or 6b, describe in Part III.

For persons listed in Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed
payments not described in lines 5 and 6? If "Yes," describe in Part III ............

Were any amounts reported in Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III .............................

If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? .........................

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50053T

Schedule J (Form 990) 2013

Page 2

Part II

Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed.

For each individual whose compensation must be reported in Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note. The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.

(A) Name and Title		(B) Breakdown of W-2 and/or 1099-MISC compensation			(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(A) Name and Title		(i) Base compensation	(ii) Bonus & incentive compensation	(iii) Other reportable compensation	(C) Retirement and other deferred compensation	(D) Nontaxable benefits	(E) Total of columns (B)(i)-(D)	(F) Compensation reported as deferred in prior Form 990
(1)JOHN CULLINANDIRECTOR, DATA ANALYSIS & APPLICATIONS	(i) (ii)	175,883 0	2,000 0	716 0	21,772 0	18,439 0	218,810 0	0 0
(2)PAIGE RODGERSCHIEF FINANCIAL OFFICER	(i) (ii)	412,399 0	2,000 0	664 0	26,935 0	18,162 0	460,160 0	0 0
(3)PAUL SCHYVESR ADVISOR-HEALTHCARE IMPROVEMENT	(i) (ii)	234,076 0	1,000 0	5,500 0	43,716 0	38,281 0	322,573 0	0 0
(4)DANIEL CASTILLIOMEDICAL DIRECTOR	(i) (ii)	269,462 0	30,000 0	258 0	0 0	339 0	300,059 0	0 0
(5)JEROD LOEBEXECUTIVE VICE PRESIDENT	(i) (ii)	331,528 0	2,000 0	170,362 0	92,491 0	22,969 0	619,350 0	152,842 0
(6)DEBRA KIELDIRECTOR, STRATEGIC PLANNING IT	(i) (ii)	181,460 0	2,000 0	464 0	23,124 0	16,594 0	223,642 0	0 0
(7)MARK CHASSIN MD MPP MPHPRESIDENT/CEO	(i) (ii)	873,999 0	27,000 0	215,635 0	22,698 0	27,681 0	1,167,013 0	0 0
(8)JOHN MACHECHIEF INFORMATION OFFICER	(i) (ii)	301,252 0	2,000 0	1,299 0	60,744 0	27,501 0	392,796 0	0 0
(9)HAROLD BRESSLERGENERAL COUNSEL	(i) (ii)	285,199 0	2,000 0	75,808 0	95,562 0	26,278 0	484,847 0	60,648 0
(10)DAVID GILMARTINASSOCIATE GENERAL COUNSEL	(i) (ii)	221,515 0	2,550 0	804 0	19,783 0	19,144 0	263,796 0	0 0
(11)ANN SCOTT BLOUINEXECUTIVE VICE PRESIDENT	(i) (ii)	346,098 0	12,500 0	10,934 0	93,373 0	16,908 0	479,813 0	0 0
(12)ROBERT WISEMEDICAL ADVISOR-HQE	(i) (ii)	169,356 0	1,200 0	0 0	22,783 0	10,815 0	204,154 0	0 0
(13)ANNE MARIE BENEDICTOCHIEF OF STAFF/EXEC VP	(i) (ii)	318,706 0	2,000 0	7,969 0	40,105 0	24,975 0	393,755 0	0 0
(14)MARK PELLETIERCHIEF OPERATING OFFICER	(i) (ii)	350,215 0	2,000 0	1,453 0	78,005 0	781 0	432,454 0	0 0
(15)CHARLES MOWLLEXECUTIVE VICE PRESIDENT	(i) (ii)	324,112 0	11,906 0	92,524 0	103,973 0	24,772 0	557,287 0	80,797 0
(16)LYNN DRAGISICVICE PRESIDENT	(i) (ii)	250,406 0	2,000 0	82,191 0	89,751 0	25,563 0	449,911 0	60,827 0
(17)BARBARA BUTURUSISDIR. SURVEYOR MGMT & SUPPORT	(i) (ii)	166,920 0	2,000 0	1,025 0	9,652 0	26,353 0	205,950 0	0 0
(18)RONALD WYATTMEDICAL DIRECTOR	(i) (ii)	274,583 0	500 0	9,427 0	596 0	26,281 0	311,387 0	0 0
(19)MARION PANAGOPOULOSSR. DIR QUALITY EVALUATION & STRATEGY	(i) (ii)	185,808 0	2,000 0	265 0	17,533 0	24,874 0	230,480 0	0 0
(20)ANA PUJOLS MCKEEVP & CHIEF MEDICAL OFFICER	(i) (ii)	478,629 0	2,000 0	61,097 0	20,172 0	5,262 0	567,160 0	0 0
(21)MARGARET VAN AMRINGEEXECUTIVE VICE PRESIDENT	(i) (ii)	0 303,870	0 2,000	0 68,937	0 96,129	0 6,507	0 477,443	0 65,401

Schedule J (Form 990) 2013

Page 3

Part III

Supplemental Information

Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II.
Also complete this part for any additional information.

Return Reference	Explanation
Schedule J, Part I, Line 1a, First-class or charter travel	THE JOINT COMMISSION BOARD TRAVEL POLICY PERMITS REIMBURSEMENT FOR THE PURCHASE OF UPGRADE COUPONS FOR FIRST-CLASS AIR TRAVEL. THE JOINT COMMISSION'S STAFF TRAVEL POLICY PERMITS STAFF TO FLY BUSINESS CLASS ON INTERNATIONAL FLIGHTS, EXCLUDING EUROPE. FIRST CLASS TRAVEL BENEFITS ARE NOT TREATED AS TAXABLE COMPENSATION TO THE INTERESTED PERSON.
Schedule J, Part I, Line 1a, Personal services	CERTAIN OFFICERS ARE OFFERED AN ALLOWANCE FOR TAX PREPARATION AND FINANCIAL PLANNING SERVICES. NOT ALL OFFICERS ELIGIBLE FOR THE SERVICES UTILIZE THEM. THESE SERVICES ARE TREATED AS TAXABLE COMPENSATION AND REPORTED ON SCHEDULE J-2, PART I, COLUMN D AS REPORTABLE COMPENSATION.
Schedule J, Part I, Line 4b, Supplemental nonqualified retirement plan	ALL OFFICERS ARE ALLOWED TO PARTICIPATE IN A NONQUALIFIED SUPPLEMENTAL DEFINED BENEFIT RETIREMENT PLAN. THE INCREASES IN THE VALUE OF THE PLAN DURING THE YEAR ARE REFLECTED IN COLUMN C DEFERRED COMPENSATION ON SCHEDULE J.
Schedule J, Part I, Line 5a, Compensation contingent on revenues of the organization	THE JOINT COMMISSION'S HUMAN RESOURCES AND COMPENSATION COMMITTEE APPROVED THE 2012 AND 2013 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 2012 AND 2013 WERE CONTINGENT UPON WHETHER THE ACTUAL FINANCIAL RESULTS FOR THE JOINT COMMISSION EXCEEDED THE JOINT COMMISSION'S BUDGETED NET EARNINGS IN EXCESS OF 2% OVER BUDGET, THE ACTUAL FINANCIAL RESULTS MET OR EXCEEDED THE ORGANIZATION'S BUDGETED REVENUES, AND THE JOINT COMMISSION MET OR EXCEEDED A NET PROMOTOR SCORE RATING. INDIVIDUAL GAINSHARING AWARDS WERE CAPPED AT $3,000 FOR 2012 AND 2013, RESPECTIVELY. THE 2012 AWARDS WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2012 AND PAID OUT IN 2013. THE 2013 AWARDS WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2013 AND WILL BE PAID OUT IN 2014.
Schedule J, Part I, Line 6a, Compensation contingent on net earnings of the organization	THE JOINT COMMISSION'S HUMAN RESOURCES AND COMPENSATION COMMITTEE APPROVED THE 2012 AND 2013 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 2012 AND 2013 WERE CONTINGENT UPON WHETHER THE ACTUAL FINANCIAL RESULTS FOR THE JOINT COMMISSION EXCEEDED THE JOINT COMMISSION'S BUDGETED NET EARNINGS IN EXCESS OF 2% OVER BUDGET, THE ACTUAL FINANCIAL RESULTS MET OR EXCEEDED THE ORGANIZATION'S BUDGETED REVENUES, AND THE JOINT COMMISSION MET OR EXCEEDED A NET PROMOTOR SCORE RATING. INDIVIDUAL GAINSHARING AWARDS WERE CAPPED AT $3,000 FOR 2012 AND 2013, RESPECTIVELY. THE 2012 AWARDS WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2012 AND PAID OUT IN 2013. THE 2013 AWARDS WERE ACCRUED FOR IN THE YEAR ENDED DECEMBER 31, 2013 AND WILL BE PAID OUT IN 2014.
Schedule J, Part I, Line 6b, Compensation contingent on net earnings of a related organization	FOR THE CORPORATE GAINSHARING PLAN TO BE PAID, ALL AWARDS WERE CONTINGENT UPON WHETHER THE ACTUAL OPERATING MARGIN FINANCIAL RESULTS FOR THE ENTERPRISE EXCEEDED THE ENTERPRISE'S BUDGETED NET EARNINGS EXCESS OF 2% OVER BUDGET.

Schedule J (Form 990) 2013

Additional Data

Software ID:	13000248
Software Version:	2013v3.1

- TIN:

SCHEDULE O
(Form 990 or 990-EZ)

Department of the Treasury
Internal Revenue Service

Supplemental Information to Form 990 or 990-EZ

Complete to provide information for responses to specific questions on
Form 990 or to provide any additional information.
MediumBullet

Attach to Form 990 or 990-EZ.
MediumBullet

Information about Schedule O (Form 990 or 990-EZ) and its instructions is at
www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public
Inspection

Name of the organization

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Return Reference	Explanation
FORM 990, PART III, LINE 1, ORGANIZATION MISSION CONTINUED	(CONTINUATION FROM ABOVE) THESE ACCREDITATION SERVICES ARE PROVIDED FOR HOSPITALS, CLINICAL LABORATORIES, HOME CARE, LONG TERM CARE, BEHAVIORAL HEALTH CARE, AND AMBULATORY CARE ORGANIZATIONS. JOINT COMMISSION ACCREDITATION AND CERTIFICATION ARE RECOGNIZED NATIONWIDE AS A SYMBOL OF QUALITY THAT REFLECTS AN ORGANIZATION'S COMMITMENT TO MEETING OPTIMUM ACHIEVABLE PERFORMANCE STANDARDS. TO EARN AND MAINTAIN THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL, AN ORGANIZATION MUST UNDERGO AN ON-SITE SURVEY BY A JOINT COMMISSION SURVEY TEAM AT LEAST EVERY THREE YEARS. LABORATORIES MUST BE SURVEYED AT LEAST EVERY TWO YEARS. IN ORDER FOR A HEALTH CARE ORGANIZATION TO PARTICIPATE IN AND RECEIVE PAYMENT FROM THE MEDICARE OR MEDICAID PROGRAMS, IT MUST MEET ELIGIBILITY REQUIREMENTS FOR PROGRAM PARTICIPATION, INCLUDING A CERTIFICATION OF COMPLIANCE WITH THE CONDITIONS OF PARTICIPATION, SET FORTH IN FEDERAL REGULATIONS. THIS CERTIFICATION IS AVAILABLE ON THE BASIS OF SURVEYS CONDUCTED BY STATE AGENCIES ON BEHALF OF THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS). WHEN THE JOINT COMMISSION HAS 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, PRIMARY STROKE CARE, JOINT REPLACEMENT, SPINAL SURGERY PROGRAMS, AND PALLIATIVE CARE. AN ADVANCED CERTIFICATION IN DISEASE-SPECIFIC CARE PROGRAM IS ALSO OFFERED BY THE JOINT COMMISSION, WHICH ARE DEVELOPED IN COLLABORATION WITH INDUSTRY EXPERTS, IN VARIOUS AREAS SUCH AS: CHRONIC KIDNEY DISEASE, HEART FAILURE, PRIMARY STROKE CENTERS, COMPREHENSIVE STROKE CENTERS, VENTRICULAR ASSIST DEVICES, AND ETC. THE JOINT COMMISSION'S HEALTH CARE STAFFING SERVICES CERTIFICATION PROGRAM PROVIDES INDEPENDENT, THOROUGH EVALUATIONS OF THE ABILITY OF STAFFING FIRMS TO PROVIDE COMPETENT STAFFING SERVICES. THE JOINT COMMISSION DEVELOPED THIS CERTIFICATION PROGRAM TO MEET QUALITY OVERSIGHT NEEDS THAT HAVE ARISEN BECAUSE OF THE ONGOING SHORTAGES OF NURSES AND OTHER PROFESSIONAL PERSONNEL. THESE SHORTAGES FORCE HEALTH CARE ORGANIZATIONS TO FILL POSITIONS WITH TEMPORARY EMPLOYEES PROVIDED BY STAFFING FIRMS, WHICH ARE OFTEN NOT OTHERWISE SUBJECT TO ANY QUALITY OVERSIGHT MECHANISM. 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: (CONTINUATION BELOW)
FORM 990, PART III, LINE 1, ORGANIZATION MISSION CONTINUED	(CONTINUATION FROM ABOVE) AT THEIR HEART, ACCREDITATION AND CERTIFICATION ARE RISK-REDUCTION ACTIVITIES; COMPLIANCE WITH APPROPRIATE STANDARDS REDUCES THE RISK OF ADVERSE OUTCOMES. THE JOINT COMMISSION SPECIFICALLY TARGETS IMPROVEMENT IN PATIENT SAFETY THROUGH THE FOLLOWING EFFORTS: PATIENT SAFETY-RELATED STANDARDS JOINT COMMISSION STANDARDS ADDRESS PERFORMANCE OBJECTIVES AND EXPECTATIONS IN KEY FUNCTIONAL AREAS, SUCH AS PATIENT RIGHTS MEDICATION MANAGEMENT, AND INFECTION CONTROL. THE STANDARDS AND ON-SITE EVALUATION PROCESS FOCUS NOT SIMPLY ON AN ORGANIZATION'S ABILITY TO PROVIDE SAFE, HIGH QUALITY CARE, BUT ON ITS ACTUAL PERFORMANCE. ALL STANDARDS RELATE DIRECTLY OR INDIRECTLY TO SAFETY AND QUALITY-RELATED PATIENT OUTCOMES. THE JOINT COMMISSION DEVELOPS AND UPDATES ITS STANDARDS IN CONSULTATION WITH HEALTH CARE EXPERTS, PROVIDERS, PRACTITIONERS, MEASUREMENT EXPERTS, PURCHASERS AND CONSUMERS. OVER FIFTY PERCENT OF JOINT COMMISSION STANDARDS RELATE DIRECTLY TO PATIENT SAFETY, ADDRESSING A WIDE RANGE OF AREAS SUCH AS SURGERY AND ANESTHESIA, BLOOD TRANSFUSION, RESTRAINT AND SECLUSION, STAFFING AND STAFF COMPETENCE, FIRE SAFETY, MEDICAL EQUIPMENT MAINTENANCE, EMERGENCY MANAGEMENT, AND SECURITY. PATIENT SAFETY STANDARDS ADDRESS THE IMPLEMENTATION OF PATIENT SAFETY PROGRAMS; THE PREVENTION OF ACCIDENTAL HARM THROUGH THE PROSPECTIVE ANALYSIS AND REDESIGN OF VULNERABLE PATIENT SYSTEMS (E.G. THE ORDERING, PREPARATION, AND DISPENSING OF MEDICATIONS); AND THE ORGANIZATION'S RESPONSIBILITY TO TELL A PATIENT ABOUT ALL OUTCOMES OF THE CARE RESPECTING THAT PATIENT, WHETHER GOOD OR BAD. SENTINEL EVENT POLICY THE JOINT COMMISSION'S SENTINEL EVENT POLICY IS DESIGNED TO HELP HEALTH CARE ORGANIZATIONS TO IDENTIFY THE UNDERLYING CAUSES OF SENTINEL EVENTS AND TAKE ACTION TO PREVENT THEIR RECURRENCE. A SENTINEL EVENT IS AN UNEXPECTED OCCURRENCE INVOLVING DEATH OR SERIOUS PHYSICAL - INCLUDING LOSS OF LIMB OR FUNCTION - OR PSYCHOLOGICAL INJURY, OR THE RISK THEREOF. "RISK THEREOF" MEANS THAT, ALTHOUGH NO HARM OCCURRED ON THIS OCCASION, ANY RECURRENCE WOULD CREATE ANOTHER CHANCE FOR A SERIOUS ADVERSE OUTCOME. ANY TIME A SENTINEL EVENT OCCURS, THE HEALTH CARE ORGANIZATION IS EXPECTED TO COMPLETE A THOROUGH AND CREDIBLE ROOT CAUSE ANALYSIS, IMPLEMENT IMPROVEMENTS TO REDUCE RISK, AND MONITOR THE EFFECTIVENESS OF THOSE IMPROVEMENTS. THE ROOT CAUSE ANALYSIS IS EXPECTED TO DRILL DOWN TO EXAMINE ALL RELEVANT ORGANIZATION SYSTEMS AND PROCESSES THAT COULD HAVE CONTRIBUTED THE FAILURES LEADING TO THE OCCURRENCE. THIS EXAMINATION PROVIDES THE BASIS FOR RE-DESIGN OF SYSTEMS AND PROCESSES TO PREVENT RECURRENCE OF SIMILAR OCCURRENCES IN THE FUTURE. THE SENTINEL EVENT POLICY ALSO ENCOURAGES ORGANIZATIONS TO REPORT SENTINEL EVENTS, THEIR ASSOCIATED ROOT CAUSES AND RELATED PREVENTIVE ACTIONS TO THE JOINT COMMISSION SO THAT THE JOINT COMMISSION CAN SHARE WITH OTHER ORGANIZATIONS DE-IDENTIFIED, AGGREGATE INFORMATION ABOUT "LESSONS LEARNED", AND THEREBY REDUCE THE RISK OF FUTURE SENTINEL EVENT OCCURRENCES ACROSS THE DELIVERY SYSTEM. SENTINEL EVENT ALERTS A SENTINEL EVENT ALERT IS A PERIODIC NEWSLETTER OR WEBINAR THAT ADDRESSES SPECIFIC TYPES OF SENTINEL EVENTS, DESCRIBES THEIR COMMON UNDERLYING CAUSES, AND RECOMMENDS STEPS TO PREVENT FUTURE OCCURRENCES. INFORMATION FOR A SENTINEL EVENT ALERT IS DERIVED PRINCIPALLY FROM THE JOINT COMMISSION'S SENTINEL EVENT DATABASE. THE JOINT COMMISSION BEGAN PUBLISHING SENTINEL EVENT ALERTS IN 1998 TO REDEFINE THE PRINCIPAL PURPOSE OF ADVERSE EVENT REPORTING AS BEING FOR LEARNING. SENTINEL EVENT ALERT HAS RAISED AWARENESS IN THE HEALTH CARE COMMUNITY AND THE FEDERAL GOVERNMENT ABOUT THE OCCURRENCE OF ADVERSE EVENTS AND WAYS THAT THESE EVENTS CAN BE PREVENTED IN THE FUTURE. PAST ISSUES AND WEBINARS ARE AVAILABLE ON THE JOINT COMMISSION WEBSITE. TOPICS HAVE INCLUDED MEDICATION ERRORS, WRONG-SITE SURGERY, RESTRAINT-RELATED DEATHS, BLOOD TRANSFUSION ERRORS, INPATIENT SUICIDES, INFANT ABDUCTIONS, FATAL FALLS, OPERATIVE/POST-OPERATIVE COMPLICATIONS, HEALTH CARE WORKER FATIGUE, BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY, MATERNITY DEATHS AND INJURIES, INFECTION CONTROL, AND PREVENTING RETAINED FOREIGN OBJECTS. NATIONAL PATIENT SAFETY GOALS IN JULY 2002, THE JOINT COMMISSION ESTABLISHED ITS FIRST SET OF SIX NATIONAL PATIENT SAFETY GOALS (NPSGS) AND 11 RELATED SPECIFIC REQUIREMENTS FOR IMPROVING THE SAFETY OF PATIENT CARE IN HEALTH CARE ORGANIZATIONS. ALL JOINT COMMISSION ACCREDITED HEALTH CARE ORGANIZATIONS ARE REQUIRED TO IMPLEMENT GOAL-RELATED REQUIREMENTS-OR ACCEPTABLE ALTERNATIVES-THAT APPLY TO THEM. THE GOALS AND REQUIREMENTS ARE DRAWN FROM A "POOL" OF RECOMMENDATIONS IDENTIFIED BY THE PATIENT SAFETY ADVISORY GROUP AS EVIDENCE- OR CONSENSUS-BASED, COST-EFFECTIVE, AND FEASIBLE TO IMPLEMENT. EACH YEAR, RECOMMENDATIONS FROM SENTINEL EVENT ALERT PUBLISHED IN THE PREVIOUS YEAR AND FROM OTHER AUTHORITATIVE SOURCES ARE ADDED TO THE POOL. (CONTINUATION BELOW)
FORM 990, PART III, LINE 1, ORGANIZATION MISSION CONTINUED	(CONTINUATION FROM ABOVE) OFFICE OF QUALITY AND PATIENT SAFETY THE JOINT COMMISSION'S OFFICE OF QUALITY AND PATIENT SAFETY RECEIVES, EVALUATES, TRACKS, AND AS APPROPRIATE, RESPONDS TO COMPLAINTS AND REPORTS OF CONCERN ABOUT HEALTH CARE ORGANIZATIONS THAT RELATE TO SAFETY AND CARE ISSUES. THIS INFORMATION COMES FROM PATIENTS, THEIR FAMILIES, ORGANIZATION STAFF, PRACTITIONERS, GOVERNMENT AGENCIES, AND OTHERS. THE OFFICE MAINTAINS A TOLL FREE HOT LINE AND ALSO RECEIVES WRITTEN REPORTS BY MAIL OR E-MAIL. WHEN A REPORT IS SUBMITTED, THE JOINT COMMISSION REVIEWS ANY PAST REPORTS AND THE ORGANIZATION'S MOST RECENT ACCREDITATION DECISION. DEPENDING ON THE NATURE OF THE REPORTED CONCERN, THE JOINT COMMISSION WILL TAKE ONE OF THE FOLLOWING ACTIONS: * INCORPORATE THE REPORTED CONCERN INTO THE QUALITY MONITORING DATABASE THAT IS USED TO TRACK HEALTH CARE ORGANIZATIONS OVER TIME TO IDENTIFY TRENDS OR PATTERNS IN THEIR PERFORMANCE. * ASK THE ORGANIZATION TO PROVIDE A WRITTEN RESPONSE TO THE REPORTED CONCERN. * REVIEW THE REPORTED CONCERN AND COMPLIANCE WITH RELATED STANDARDS AT THE TIME OF THE ORGANIZATION'S NEXT ACCREDITATION SURVEY. * CONDUCT AN UNANNOUNCED ON-SITE EVALUATION OF THE ORGANIZATION IF THE REPORT RAISES SERIOUS CONCERNS ABOUT A CONTINUING THREAT TO PATIENT SAFETY OR CONTINUING FAILURE TO COMPLY WITH STANDARDS. INFECTION CONTROL INITIATIVES INFECTION PREVENTION AND CONTROL IS A CRITICAL COMPONENT OF SAFE, QUALITY HEALTH CARE. THE JOINT COMMISSION IS ADDRESSING THIS IMPORTANT ISSUE WITH A NUMBER OF INITIATIVES. * THE JOINT COMMISSION DEVELOPED "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 DEVELOPED "MEASURING HAND HYGIENE ADHERENCE: OVERCOMING THE CHALLENGES," TO HELP HEALTH CARE ORGANIZATIONS TARGET THEIR EFFORTS IN MEASURING HAND HYGIENE PERFORMANCE. THE FREE 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 DEVELOPED "TDAP VACCINATION STRATEGIES FOR ADOLESCENTS AND ADULTS, INCLUDING HEALTH CARE PERSONNEL: STRATEGIES FROM RESEARCH AND PRACTICE," A FREE MONOGRAPH, FOCUSING ON BARRIERS TO SUCCESSFUL TDAP VACCINATION PROGRAMS AND STRATEGIES FOR OVERCOMING THEM. * THE JOINT COMMISSION HAS TEAMED UP WITH THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) ON THE INITIATIVE TO INCREASE IMMUNIZATION RATES OF HEALTHCARE WORKERS FOR SEASONAL INFLUENZA. * THE JOINT COMMISSION, ALONG WITH THE AMERICAN HOSPITAL ASSOCIATION (AHA) AND THE ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY (APIC), PARTNERED WITH THE SOCIETY FOR HOSPITAL EPIDEMIOLOGY OF AMERICAN (SHEA) AND THE INFECTIOUS DISEASES SOCIETY OF AMERICA TO UPDATE THE "COMPENDIUM OF STRATEGIES TO PREVENT HEALTHCARE-ASSOCIATED INFECTIONS IN ACUTE CARE." THE COMPENDIUM, PREVIOUSLY PUBLISHED IN 2008, CONTAINED IMPLEMENTATION-FOCUSED STRATEGIES TO ADDRESS CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTION, VENTILATOR ASSOCIATED PNEUMONIA, CATHETER ASSOCIATED URINARY TRACT INFECTION, SURGICAL SITE INFECTION, METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS, AND CLOSTRIDIUM DIFFICILE INFECTION. NEWLY DEVELOPED AND PUBLISHED IN THE 2014 UPDATE WERE STRATEGIES TO PREVENT HEALTHCARE-ASSOCIATED INFECTIONS THROUGH HAND HYGIENE. * THE JOINT COMMISSION HAS DEVELOPED THE NURSING-SENSITIVE BLOOD STREAM INFECTION MEASURE, URINARY CATHETER-ASSOCIATED URINARY TRACT INFECTION FOR INTENSIVE CARE UNIT (ICU) PATIENTS MEASURE, AND VENTILATOR-ASSOCIATED PNEUMONIA FOR ICU PATIENTS MEASURE. * THE JOINT COMMISSION HAS TEAMED UP WITH THE CENTER FOR DISEASE CONTROL AND PREVENTION (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 AND PREVENTION (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. THIS MONOGRAPH IS EXPECTED TO BE PUBLISHED IN 4TH QUARTER OF 2014. * THE JOINT COMMISSION AND ITS AFFILIATES RECEIVED FUNDING FOR AN INTERNATIONAL PROJECT "PREVENTION OF CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS (CLABSI): PREFERRED PRACTICES AND USE OF TECHNOLOGY." THE PROJECT WAS DIVIDED INTO TWO PHASES. AS A RESULT OF PHASE ONE A FREE MONOGRAPH WAS PUBLISHED IN 2012 HIGHLIGHTING EVIDENCE-BASED PRACTICES KNOWN TO MINIMIZE AND PREVENT CLABSI. THE MONOGRAPH IS TITLED "PREVENTING CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS: A GLOBAL CHALLENGE, A GLOBAL PERSPECTIVE." AS A RESULT OF PHASE TWO, A TOOLKIT WAS DEVELOPED IN 2013 TO SUPPORT ORGANIZATIONAL SELF-ASSESSMENT RELATIVE TO RECOMMENDED PRACTICES AND TO PROVIDE GUIDANCE RESPECTING ACHIEVEMENT OF THE PREFERRED S THESE ACCREDITATION SERVICES ARE PROVIDED FOR HOSPITALS, CLINICAL LABORATORIES, HOME CARE, NURSING CARE CENTERS, 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, BREAST CANCER, BRAIN INJURY, DIABETES, HEART FAILURE, CORONARY ARTERY DISEASE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, SKIN AND WOUND MANAGEMENT, STROKE CARE, JOINT REPLACEMENT, SPINAL SURGERY PROGRAMS, HEALTH CARE STAFFING, AND PALLIATIVE CARE. AN ADVANCED CERTIFICATION IN DISEASE-SPECIFIC CARE PROGRAM IS ALSO OFFERED BY THE JOINT COMMISSION, WHICH ARE DEVELOPED IN COLLABORATION WITH INDUSTRY EXPERTS, IN VARIOUS AREAS SUCH AS: CHRONIC KIDNEY DISEASE, HEART FAILURE, PRIMARY STROKE CENTERS, COMPREHENSIVE STROKE CENTERS, VENTRICULAR ASSIST DEVICES, AND ETC. THE JOINT COMMISSION'S HEALTH CARE STAFFING SERVICES CERTIFICATION PROGRAM PROVIDES INDEPENDENT, THOROUGH EVALUATIONS OF THE ABILITY OF STAFFING FIRMS TO PROVIDE COMPETENT STAFFING SERVICES. THE JOINT COMMISSION DEVELOPED THIS CERTIFICATION PROGRAM TO MEET QUALITY OVERSIGHT NEEDS THAT HAVE ARISEN BECAUSE OF THE ONGOING SHORTAGES OF NURSES AND OTHER PROFESSIONAL PERSONNEL. THESE SHORTAGES FORCE HEALTH CARE ORGANIZATIONS TO FILL POSITIONS WITH TEMPORARY EMPLOYEES PROVIDED BY STAFFING FIRMS, WHICH ARE OFTEN NOT OTHERWISE SUBJECT TO ANY QUALITY OVERSIGHT MECHANISM. (CONTINUATION BELOW)
FORM 990, PART III, LINE 1, ORGANIZATION MISSION CONTINUED	(CONTINUATION FROM ABOVE) PATIENT SAFETY RESEARCH THE JOINT COMMISSION'S DIVISION OF HEALTHCARE QUALITY EVALUATION WORKS WITH EXTERNAL COLLABORATORS TO ADVANCE THE FIELD OF PATIENT SAFETY RESEARCH. JOINT COMMISSION RESEARCH INITIATIVES HAVE INCLUDED: * DEVELOPMENT OF A FIELD GUIDE ADVANCING EFFECTIVE COMMUNICATION, CULTURAL COMPETENCE, AND PATIENT- AND FAMILY-CENTERED CARE TO LESBIAN, GAY, BISEXUAL AND TRANSGENDER PATIENTS AND FAMILIES. * CREATION OF AN INTERNATIONAL, COLLABORATIVE LEARNING NETWORK THAT FOSTERS THE SHARING OF KNOWLEDGE AND EXPERIENCE IN IMPLEMENTING INNOVATIVE, STANDARDIZED OPERATING PROTOCOLS THAT ADDRESS PATIENT SAFETY. * DEVELOPMENT OF A MONOGRAPH ON THE OPPORTUNITIES FOR SYNERGY, COLLABORATION, AND INNOVATION BETWEEN PATIENT SAFETY AND WORKER SAFETY IN HEALTH CARE. * DEVELOPMENT OF A PROTOCOL DESIGNED TO HELP CLOSE THE GAPS IN IMPLEMENTATION OF THE UNIVERSAL PROTOCOL BY SYSTEMATICALLY ADDRESSING AND PREVENTING LAPSES IN IMPLEMENTATION. THE JOINT COMMISSION IS CURRENTLY TESTING THE PROTOCOL IN ONE HOSPITAL AS PART OF A RESEARCH PROJECT FUNDED BY THE AMERICAN SOCIETY FOR HEALTHCARE RISK MANAGEMENT. * COLLABORATION ON A PROJECT TO IMPLEMENT SOLUTIONS TO ADDRESS A RANGE OF ADVERSE EVENTS FOR THE CMS PARTNERSHIP FOR PATIENT SAFETY PROGRAM. THE GOAL OF THIS PROGRAM IS TO ACHIEVE A 40% REDUCTION IN HOSPITAL ADVERSE EVENTS AND A 20% REDUCTION IN HOSPITAL READMISSIONS. * WORK ON A PROJECT TO CREATE A VALIDATED INFORMED CONSENT TOOLKIT TO HELP HOSPITALS IMPROVE THEIR INFORMED CONSENT PROCESS. * WORK TO ESTABLISH A CREDIBLE AND MEANINGFUL PROCESS THAT CAN BE USED TO IDENTIFY, UNDERSTAND, DISSEMINATE AND EVENTUALLY HELP PREVENT SENTINEL EVENTS THAT ARE POTENTIALLY RELATED TO HEALTH INFORMATION TECHNOLOGY. THE JOINT COMMISSION IS MODIFYING ITS CURRENT SENTINEL EVENT DATABASE AND PROCESS AND HOPES TO ESTABLISH A DE-IDENTIFIED DATA SET SUITABLE FOR USE, AND TO EXPAND ITS CAPACITY TO INVESTIGATE HEALTH IT-RELATED EVENTS. * WORK WITH PFIZER INDEPENDENT GRANTS FOR LEARNING AND CHANGE (IGLC), PREVIOUSLY KNOWN AS THE PFIZER MEDICAL EDUCATION GROUP (PMEG), TO SUCCESSFULLY PILOT TEST A PARTNERSHIP WITH THE LONG-TERM GOAL TO SUPPORT AN ARRAY OF PROJECTS DESIGNED TO ACCELERATE THE ADOPTION OF EVIDENCE-BASED INNOVATIONS THAT IMPROVE PATIENT CARE. THIS COLLABORATION WAS DESIGNED TO UTILIZE THE REQUEST FOR PROPOSAL (RFP) PROCESS TO IDENTIFY, FUND AND OVERSEE PROJECTS RELATED TO SPECIFIC IMPROVEMENT OBJECTIVES THAT ALIGN THE MUTUAL INTERESTS OF PATIENTS, HEALTH CARE PROVIDERS AND THE TWO PARTNER ORGANIZATIONS. PHASE I OF THIS PROJECT FOCUSED ON PROVIDING A FUNDING OPPORTUNITY FOR ANTIMICROBIAL STEWARDSHIP AND PHASE II IS FOCUSED ON TRANSITIONS OF CARE. ACCREDITATION AND CERTIFICATION STANDARDS JOINT COMMISSION STANDARDS ARE DEVELOPED WITH INPUT FROM HEALTH CARE PROFESSIONALS, PROVIDERS, SUBJECT MATTER EXPERTS, CONSUMERS, GOVERNMENT AGENCIES (INCLUDING THE CENTERS FOR MEDICARE & MEDICAID SERVICES) AND EMPLOYERS. THEY ARE INFORMED BY SCIENTIFIC LITERATURE AND EXPERT CONSENSUS AND APPROVED BY THE BOARD OF COMMISSIONERS. NEW STANDARDS ARE ADDED ONLY IF THEY RELATE TO PATIENT SAFETY OR QUALITY OF CARE, HAVE A POSITIVE IMPACT ON HEALTH OUTCOMES, MEET OR SURPASS LAW AND REGULATION, AND CAN BE ACCURATELY AND READILY MEASURED. RECENT STANDARDS DEVELOPMENT ACTIVITIES HAVE INCLUDED: * WORK WITH THE AMERICAN HEART ASSOCIATION AND AMERICAN STROKE ASSOCIATION TO DEVELOP COMPREHENSIVE STROKE CENTER REQUIREMENTS TO IMPROVE THE QUALITY AND SAFETY OF CARE FOR COMPLEX STROKE PATIENTS. THE JOINT COMMISSION CONTINUES TO MONITOR THE RAPIDLY CHANGING SCIENCE IN THIS FIELD TO ASSURE REQUIREMENTS ALIGN WITH CURRENT SCIENCE. * WORK WITH EXPERTS IN THE DIAGNOSTIC IMAGING FIELD TO IMPLEMENT STANDARDS TO ENSURE THE SAFE DELIVERY OF DIAGNOSTIC IMAGING SERVICES TO PATIENTS RECEIVING COMPUTED TOMOGRAPHY (CT), NUCLEAR MEDICINE (NM), POSITRON EMISSION TOMOGRAPHY (PET), AND MAGNETIC RESONANCE IMAGING (MRI) SERVICES. THE JOINT COMMISSION IS CURRENTLY DEVELOPING STANDARDS ADDRESSING ADDITIONAL DIAGNOSTIC IMAGING TECHNOLOGIES. * THE CREATION OF EMERGENCY MANAGEMENT STANDARDS THAT OUTLINE A COMPREHENSIVE APPROACH TO PLANNING, PREPARING, TESTING, AND OTHER ESSENTIAL EMERGENCY MANAGEMENT ACTIVITIES, AS WELL AS LEADERSHIP-LEVEL OVERSIGHT AND ACCOUNTABILITY OF EMERGENCY MANAGEMENT. * DEVELOPMENT OF STANDARDS TO ENHANCE PATIENT SAFETY BY ADDRESSING PATIENT FLOW THROUGH THE EMERGENCY DEPARTMENT AS A HOSPITAL-WIDE CONCERN, AND THE SAFE PROVISION OF CARE FOR PATIENTS (SHOULD BOARDING OCCUR), PARTICULARLY FOR PATIENTS WITH PSYCHIATRIC EMERGENCIES. THE SPEAK UP INITIATIVES IN MARCH 2002, THE JOINT COMMISSION, TOGETHER WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS), LAUNCHED A NATIONAL SPEAK UP PROGRAM TO URGE PATIENTS TO TAKE AN ACTIVE ROLE IN PREVENTING HEALTH CARE ERRORS BY BECOMING INVOLVED AND INFORMED PARTICIPANTS ON THE HEALTH CARE TEAM. THE SPEAK UP PROGRAM FEATURES BROCHURES, POSTERS AND BUTTONS ON A VARIETY OF PATIENT SAFETY TOPICS INCLUDING: * HELP PREVENT ERRORS IN YOUR CARE * HELP AVOID MISTAKES IN YOUR SURGERY * TIPS FOR YOUR DOCTOR'S VISIT * INFORMATION FOR LIVING ORGAN DONORS * FIVE THINGS YOU CAN DO TO PREVENT INFECTION * HELP AVOID MISTAKES WITH YOUR MEDICINE * WHAT YOU SHOULD KNOW ABOUT RESEARCH STUDIES * PLANNING YOUR FOLLOW-UP CARE * HELP PREVENT MEDICAL TEST MISTAKES * KNOW YOUR RIGHTS * UNDERSTANDING YOUR DOCTORS AND OTHER CAREGIVERS * PREVENT ERROR'S IN YOUR CHILD'S CARE * WHAT YOU SHOULD KNOW ABOUT PAIN MANAGEMENT * REDUCE YOUR RISK OF FALLING * DIALYSIS - FIVE WAYS TO BE ACTIVE IN YOUR CARE AT THE HOSPITAL * DIABETES - FIVE WAYS TO BE ACTIVE IN YOUR CARE AT THE HOSPITAL * WHAT YOU NEED TO KNOW ABOUT BREASTFEEDING * WHAT YOU SHOULD KNOW ABOUT STROKE * WHAT YOU SHOULD KNOW ABOUT MEMORY PROBLEMS & DEMENTIA * WHAT YOU SHOULD KNOW ABOUT ADULT DEPRESSION * ASK YOUR ADVOCATE TO SPEAK UP * SPEAK UP: AT HOME; KID POWER, & AT THE DOCTOR'S OFFICE * WHAT YOU SHOULD KNOW ABOUT YOUR SERIOUS ILLNESS & PALLIATIVE CARE SPEAK UP BROCHURES ARE AVAILABLE TO THE GENERAL PUBLIC AT NO COST ON THE JOINT COMMISSION'S WEBSITE. THE JOINT COMMISSION HAS ALSO DEVELOPED A SERIES OF ANIMATED SPEAK UP VIDEOS TO ENCOURAGE PATIENTS TO SPEAK UP AND BE ACTIVE PARTICIPANTS IN THEIR HEALTH CARE. PRODUCED BY THE JOINT COMMISSION, THESE ENTERTAINING 60-SECOND VIDEOS ARE INTENDED AS PUBLIC SERVICE ANNOUNCEMENTS AND AIR ON THE JOINT COMMISSION'S YOUTUBE CHANNEL, ON THE JOINT COMMISSION WEBSITE, AND IN OTHER VENUES. THE CAST OF CHARACTERS INTRODUCED IN THE VIDEOS ENCOUNTER EVERYDAY SITUATIONS WHERE THEY HAVE TO READ INSTRUCTIONS, INSPECT LABELS, AND "SPEAK UP" TO ASK THEIR DOCTORS AND CAREGIVERS QUESTIONS. THE VIDEOS POINT OUT THAT YOU SHOULD BE JUST AS COMFORTABLE SPEAKING UP ABOUT YOUR HEALTH CARE WHETHER IN A DOCTOR'S OFFICE OR AT THE HOSPITAL. THE VIDEOS HAVE PROVEN TO BE WIDELY POPULAR WITH AUDIENCES ALL OVER THE WORLD, AND HAVE BEEN DOWNLOADED BY ORGANIZATIONS IN MORE THAN 35 COUNTRIES. QUALITY CHECK AND QUALITY REPORTS QUALITY CHECK OFFERS A COMPREHENSIVE COMPENDIUM OF QUALITY AND SAFETY-RELATED PERFORMANCE INFORMATION ON THE NEARLY 23,000 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. 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.
Form 990, Part VI, Sec A, Line 4, Significant changes to organizational documents	THE AMENDMENTS TO THE BYLAWS INCLUDE THE FOLLOWING. THROUGHOUT BYLAWS, THE CHAIRMAN AND VICE CHAIRMAN WILL NOW BE REFERRED TO AS CHAIR AND VICE CHAIR. ARTICLE VII. SECTION 1 OFFICERS -OFFICERS OF THE BOARD OF COMMISSIONERS WERE CHANGED TO RESTATE THAT THE CHIEF OPERATING OFFICER, CHIEF INFORMATION OFFICER, AND GENERAL COUNSEL WILL BE REFERRED TO AS SUCH OTHER OFFICERS AS MAY BE AUTHORIZED BY THE BOARD OF COMMISSIONERS OR THE PRESIDENT. FURTHERMORE, THE SECRETARY AND TREASURER ARE NO LONGER REFERRED TO AS ELECTED BOARD OF COMMISSIONERS BUT AS OTHER OFFICERS. ARTICLE VII. SECTION 2 SELECTION - ONLY THE CHAIR AND VICE CHAIR WILL BE ELECTED OFFICIALS AND ALL OTHER OFFICERS WILL BE APPOINTED BY THE PRESIDENT. ARTICLE VII SECTION 10 TREASURER - ALL DUTIES OF THE TREASURER WILL BE ASSUMED BY THE CHIEF FINANCIAL OFFICER. ARTICLE VII SECTION 11 TREASURER - THIS SECTION WAS ADDED AND STATES THAT DUTIES OF THE TREASURER WILL BE AS ASSIGNED BY THE CHIEF FINANCIAL OFFICER AND THE TREASURER WILL BE APPOINTED BY THE PRESIDENT. ARTICLE VIII SECTION 1 EXECUTIVE COMMITTEE - THIS SECTION WAS RESTATED TO SPECIFY THAT TWO OF THE EXECUTIVE COMMITTEE MEMBERS MUST BE THE THEN CURRENT ELECTED CHAIR AND VICE CHAIR OF THE CORPORATION, AND ONE MUST BE THE CHAIR OF THE FINANCE COMMITTEE. ARTICLE VIII SECTION 3 & 4 - THE FINANCE & AUDIT COMMITTEE HAS BEEN SUBDIVIDED INTO TWO COMMITTEES: FINANCE COMMITTEE AND THE AUDIT & FIREWALL OVERSIGHT COMMITTEE.
Form 990, Part VI, Sec A, Line 6, Classes of members or stockholders	THE JOINT COMMISSION HAS CORPORATE MEMBERS AS NOTED IN THEIR BYLAWS. EACH MEMBER IS GRANTED A CERTAIN NUMBER OF VOTES WHEN VOTING ON ISSUES BROUGHT UP DURING MEMBER MEETINGS. THE FOLLOWING CORPORATIONS ARE MEMBERS OF THE JOINT COMMISSION: AMERICAN COLLEGE OF PHYSICIANS, THREE VOTES; AMERICAN COLLEGE OF SURGEONS, THREE VOTES; AMERICAN DENTAL ASSOCIATION, ONE VOTE; AMERICAN HOSPITAL ASSOCIATION, SEVEN VOTES; AND AMERICAN MEDICAL ASSOCIATION, SEVEN VOTES. THE NUMBER OF VOTES TO WHICH ANY ADDITIONAL MEMBERS SHALL BE ENTITLED SHALL BE ESTABLISHED BY AMENDMENT TO THE BYLAWS
Form 990, Part VI, Sec A, Line 7a, Members or stockholders electing members of governing body	SEE NARRATIVE FOR LINE 6
Form 990, Part VI, Sec A, Line 7b, Decisions requiring approval by members or stockholders	SEE NARRATIVE FOR LINE 6
Form 990, Part VI, Sec B, Line 11b, Review of form 990 by governing body	THE JOINT COMMISSION'S MANAGEMENT, INCLUDING THE CEO, CFO, CORPORATE COMPLIANCE & PRIVACY OFFICER, AND LEGAL COUNSEL PERFORMED A DETAILED REVIEW OF THE FORM 990 WITH THE PAID TAX PREPARER. ONCE THIS LEVEL OF REVIEW WAS PERFORMED, A THOROUGH WALK THROUGH OF FORM 990 WAS DONE WITH THE FINANCE COMMITTEE PRIOR TO FILING. A COPY OF THE FORM 990 WAS PROVIDED TO THE ENTIRE BOARD OF COMMISSIONERS PRIOR TO FILING. A FINAL FILED COPY OF THE RETURN WILL BE PLACED ON THE ORGANIZATION'S WEBSITE FOR THE PUBLIC ONCE ACCEPTED BY THE IRS.
Form 990, Part VI, Sec B, Line 12c, Conflict of interest policy	THE POLICY STATES THAT ANY DECISION THAT COULD RESULT IN AN ACTUAL OR PERCEIVED CONFLICT OF INTEREST MUST BE AVOIDED. ALL STAFF AND BOARD MEMBERS REVIEW THE POLICY ON AN ANNUAL BASIS AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EACH YEAR, WHICH IS DESIGNED TO IDENTIFY INTERESTS THAT COULD GIVE RISE TO POSSIBLE CONFLICTS. ALTHOUGH MANY SUCH POTENTIAL CONFLICTS ARE AND WILL BE DEEMED INCONSEQUENTIAL, EVERY INDIVIDUAL OF THE ORGANIZATION HAS AN ONGOING RESPONSIBILITY TO DISCLOSE SITUATIONS THAT INVOLVE PERSONAL, FAMILIAR, OR BUSINESS RELATIONSHIPS THAT COULD BE PERCEIVED AS A CONFLICT OF INTEREST. THE INTERESTS IDENTIFIED ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AND MANAGER AND APPROPRIATELY MANAGED. ALL DISCLOSURES ARE PURSUED UNTIL 100% COMPLETED. THE BOARD IS REQUIRED TO DISCLOSE A CONFLICT OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER DURING A MEETING AND THEN NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING REFLECTS THAT A DISCLOSURE WAS MADE AND THE MEMBER ABSTAINED FROM VOTING. THE COMPLIANCE OFFICER MONITORS AND REVIEWS THE CONFLICT OF INTEREST POLICY AS WELL AS THE RESPONSES TO THE QUESTIONNAIRES ON AN ANNUAL BASIS. THE ORGANIZATION ALSO HAS AVAILABLE AN INDEPENDENT HOTLINE NUMBER FOR STAFF TO REPORT ANY POTENTIAL CONFLICTS DURING THE YEAR ANONYMOUSLY.
Form 990, Part VI, Sec B, Line 15a, Process to establish compensation of top management official	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.
Form 990, Part VI, Sec B, Line 15b, Process to establish compensation of other employees	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.
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, CODE OF CONDUCT, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC.
Form 990 , Part XI, Line 9, Other changes in net assets or fund balances	CHANGE IN FAIR VALUE OF HEDGE - INTEREST RATE SWAP - 528991; TRANSFER OF NET ASSETS TO PARENT CO CY - 3058444; TRANSFER OF NET ASSETS TO AFFILIATE - PY ADJUSTMENT - -3060927; TRANSFER OF NET ASSETS TO AFFILIATE - OPERATING - -3400000; BOARD-DESIGNATED FUNDS FUNCTIONING AS ENDOWMENT - -5000000; CHANGE IN UNRECOGNIZED NET DEFINED BENEFIT PLAN COSTS NOT YET RECOGNIZED IN NET PERIODIC BENEFIT COST - 8025375;

For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ.

Cat. No. 51056K

Schedule O (Form 990 or 990-EZ) 2013

Additional Data

Software ID:	13000248
Software Version:	2013v3.1

- TIN:

SCHEDULE R
(Form 990)

Department of the Treasury
Internal Revenue Service

Related Organizations and Unrelated Partnerships

Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37.
MediumBullet

Attach to Form 990. MediumBullet

See separate instructions.
MediumBullet

Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990.

OMB No. 1545-0047

2013

Open to Public Inspection

Name of the organization

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

Employer identification number

36-2229255

Part I

Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.

(a) Name, address, and EIN (if applicable) of disregarded entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Total income	(e) End-of-year assets	(f) Direct controlling entity

Part II

Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related tax-exempt organizations during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	(g) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Exempt Code section	(e) Public charity status (if section 501(c)(3))	(f) Direct controlling entity	Yes	No
(1) JOINT COMMISSION RESOURCES INC 1515 WEST 22ND STREET STE 1300W OAKBROOK,IL60523 36-3521721	HEALTHCARE	IL	501(C)(3)	9	JOINT COMMISSION	Yes
(2) JOINT COMMISSION CENTER FOR TRANSFORMING HLTCR ONE RENAISSANCE BLVD OAKBROOK TERRACE,IL60181 26-3020947	HEALTHCARE	IL	501(C)(3)	9	JOINT COMMISSION	Yes
(3) JCAHO SURVEYOR & QHR CONSULTANT CORP ONE RENAISSANCE BLVD OAKBROOK TERRACE,IL60181 36-3673595	HEALTHCARE	IL	501(C)(3)	11	JOINT COMMISSION	Yes

For Paperwork Reduction Act Notice, see the Instructions for Form 990.

Cat. No. 50135Y

Schedule R (Form 990) 2013

Page 2

Part III

Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V-UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Part IV

Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year.

(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	(i) Section 512(b)(13) controlled entity?
(a) Name, address, and EIN of related organization	(b) Primary activity	(c) Legal domicile (state or foreign country)	(d) Direct controlling entity	(e) Type of entity (C corp, S corp, or trust)	(f) Share of total income	(g) Share of end-of-year assets	Yes	No

Schedule R (Form 990) 2013

Page 3

Part V

Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.

Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule.

Yes

1 During the tax year, did the orgranization engage in any of the following transactions with one or more related organizations listed in Parts II-IV?

a Receipt of (i) interest (ii) annuities (iii) royalties or (iv) rent from a controlled entity . . . . . . . . . . . . . . . . . . . . . . .

Yes

b Gift, grant, or capital contribution to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

c Gift, grant, or capital contribution from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

d Loans or loan guarantees to or for related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e Loans or loan guarantees by related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f Dividends from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

g Sale of assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

h Purchase of assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

i Exchange of assets with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

j Lease of facilities, equipment, or other assets to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . .

k Lease of facilities, equipment, or other assets from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . .

l Performance of services or membership or fundraising solicitations for related organization(s) . . . . . . . . . . . . . . . . . . . .

Yes

m Performance of services or membership or fundraising solicitations by related organization(s) . . . . . . . . . . . . . . . . . . . .

n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) . . . . . . . . . . . . . . . . . . . . .

Yes

o Sharing of paid employees with related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

p Reimbursement paid to related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

q Reimbursement paid by related organization(s) for expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

r Other transfer of cash or property to related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

s Other transfer of cash or property from related organization(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds.

(a) Name of related organization	(b) Transaction type (a-s)	(c) Amount involved	(d) Method of determining amount involved
(1) JOINT COMMISSION RESOURCES INC	Q	13,690,709	ACTUAL
(2) JOINT COMMISSION RESOURCES INC	S	3,058,444	CONTRACTUAL
(3) JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE	Q	974,940	ACTUAL
(4) JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE	R	8,400,000	CONTRACTUAL
(5) JOINT COMMISSION RESOURCES INC	L	3,967,693	CONTRACTUAL
(6) JOINT COMMISSION RESOURCES INC	A	947,026	ACTUAL
(7) JOINT COMMISSION CENTER FOR TRANSFORMING HEALTHCARE	L	1,038,784	CONTRACTUAL
(8) JOINT COMMISSION RESOURCES INC	L	575,940	ACTUAL

Schedule R (Form 990) 2013

Page 4

Part VI

Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37.

Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships.

(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	(e) Are all partners section 501(c)(3) organizations?		(f) Share of total income	(g) Share of end-of-year assets	(h) Disproprtionate allocations?		(i) Code V?UBI amount in box 20 of Schedule K-1 (Form 1065)	(j) General or managing partner?
(a) Name, address, and EIN of entity	(b) Primary activity	(c) Legal domicile (state or foreign country)	Yes	No	(f) Share of total income	(g) Share of end-of-year assets	Yes	No	(i) Code V?UBI amount in box 20 of Schedule K-1 (Form 1065)	Yes	No

Schedule R (Form 990) 2013

Page 5

Part VII

Supplemental Information

Provide additional information for responses to questions on Schedule R (see instructions).

Return Reference	Explanation

Schedule R (Form 990) 2013

Additional Data

Software ID:	13000248
Software Version:	2013v3.1

1	Briefly describe the organization’s mission or most significant activities: 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.
2	Check this box
3	Number of voting members of the governing body (Part VI, line 1a) ........	3	29
4	Number of independent voting members of the governing body (Part VI, line 1b) .....	4	27
5	Total number of individuals employed in calendar year 2013 (Part V, line 2a) ......	5	511
6	Total number of volunteers (estimate if necessary) .............	6	32
7a	Total unrelated business revenue from Part VIII, column (C), line 12 ........	7a	0
b	Net unrelated business taxable income from Form 990-T, line 34 .........	7b	0

		Prior Year	Current Year
8	Contributions and grants (Part VIII, line 1h) .........	3,125,663	1,902,807
9	Program service revenue (Part VIII, line 2g) .........	137,010,728	142,545,602
10	Investment income (Part VIII, column (A), lines 3, 4, and 7d ) ....	4,194,525	6,975,596
11	Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e)	5,784,665	5,953,503
12	Total revenue—add lines 8 through 11 (must equal Part VIII, column (A), line 12)...................	150,115,581	157,377,508
13	Grants and similar amounts paid (Part IX, column (A), lines 1–3 )...	0	0
14	Benefits paid to or for members (Part IX, column (A), line 4).....	0	0
15	Salaries, other compensation, employee benefits (Part IX, column (A), lines 5–10)	92,807,458	98,020,711
16a	Professional fundraising fees (Part IX, column (A), line 11e).....	0	0
b	Total fundraising expenses (Part IX, column (D), line 25) 0
17	Other expenses (Part IX, column (A), lines 11a–11d, 11f–24e)....	42,578,962	45,037,835
18	Total expenses. Add lines 13–17 (must equal Part IX, column (A), line 25)	135,386,420	143,058,546
19	Revenue less expenses. Subtract line 18 from line 12.......	14,729,161	14,318,962
		Beginning of Current Year	End of Year
20	Total assets (Part X, line 16).............	171,639,956	185,173,917
21	Total liabilities (Part X, line 26).............	53,869,920	43,284,878
22	Net assets or fund balances. Subtract line 21 from line 20.....	117,770,036	141,889,039

Sign Here

	Signature of officer	Date

	Type or print name and title


4a	(Code: ) (Expenses $ 109,521,061 including grants of $ ) (Revenue $ 139,361,877 )
	SURVEY AND CERTIFICATION FEES ARE GENERATED AS A CONSEQUENCE OF PERFORMING ACCREDITATION SURVEYS THAT ARE DESIGNED TO EVALUATE AN ORGANIZATION'S COMPLIANCE WITH STATE-OF-THE-ART STANDARDS AND THEIR ACCREDITATION REQUIREMENTS. ABOUT 12,065 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 20,700 ORGANIZATIONS WERE ENROLLED IN 2013 FOR A SUBSCRIPTION FEE PLAN.

4b	(Code: ) (Expenses $ 2,238,757 including grants of $ ) (Revenue $ 3,183,725 )
	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.

4c	(Code: ) (Expenses $ including grants of $ ) (Revenue $ )












4d	Other program services (Describe in Schedule O.)
	(Expenses $ including grants of $ ) (Revenue $ )
4e	Total program service expenses111,759,818

1b	Sub-Total................
c	Total from continuation sheets to Part VII, Section A....
d	Total (add lines 1b and 1c)............	7,052,970	374,807	1,387,376

				(A) Total revenue	(B) Related or exempt function revenue	(C) Unrelated business revenue	(D) Revenue excluded from tax under sections 512-514
1a	Federated campaigns..1a
b	Membership dues....1b
c	Fundraising events....1c
d	Related organizations...1d
e	Government grants (contributions)1e		1,510,939

f	All other contributions, gifts, grants, and similar amounts not included above1f		391,868

g	Noncash contributions included in lines 1a-1f:$
h	Total. Add lines 1a-1f.......			1,902,807
			Business Code
2a	SURVEY FEES		900099	66,614,339	66,614,339
b	ANNUAL SUBSCRIPTION FEES		900099	72,249,562	72,249,562
c	PERFORMANCE MEASUREMENT & RELATED ACTIVITIES		900099	3,183,725	3,183,725
d	HONORARIUM FEES		900099	74,908	74,908
e	OTHER REVENUE		532000	423,068	423,068
f	All other program service revenue .			0	0	0	0
g	Total. Add lines 2a–2f........			142,545,602
3	Investment income (including dividends, interest, and other similar amounts).......			2,834,013			2,834,013
4	Income from investment of tax-exempt bond proceeds..			0
5	Royalties...........			947,026			947,026
		(i) Real	(ii) Personal
6a	Gross rents
b	Less: rental expenses
c	Rental income or (loss)	0	0
d	Net rental income or (loss).......			0
		(i) Securities	(ii) Other
7a	Gross amount from sales of assets other than inventory	57,212,132	31,585
b	Less: cost or other basis and sales expenses	53,102,134	0
c	Gain or (loss)	4,109,998	31,585
d	Net gain or (loss)..........			4,141,583			4,141,583
8a	Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 ..
	a
b	Less: direct expenses ...b
c	Net income or (loss) from fundraising events..			0
9a	Gross income from gaming activities. See Part IV, line 19 ...
	a
b	Less: direct expenses ...b
c	Net income or (loss) from gaming activities...			0
10a	Gross sales of inventory, less returns and allowances .
	a
b	Less: cost of goods sold ..b
c	Net income or (loss) from sales of inventory..			0
Miscellaneous Revenue			Business Code
11a	FEE FOR SERVICE FROM RELATED TAX EXEMPT ORGANIZATIONS		900099	5,006,477	5,006,477
b				0
c				0
d	All other revenue ....			0	0	0	0
e	Total. Add lines 11a–11d ......			5,006,477
12	Total revenue. See Instructions......			157,377,508	147,552,079	0	7,922,622


				(A) Beginning of year		(B) End of year
1	Cash–non-interest-bearing .............				1
2	Savings and temporary cash investments .........			18,505,829	2	24,390,914
3	Pledges and grants receivable, net ...........				3
4	Accounts receivable, net .............			21,431,880	4	14,073,030
5	Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L ..................
				0	5	0
6	Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions) Complete Part II of Schedule L
				0	6	0
7	Notes and loans receivable, net .............				7
8	Inventories for sale or use ..............			10,364	8	11,028
9	Prepaid expenses and deferred charges ..........			2,697,771	9	1,839,697
10a	Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D	10a	65,312,842
b	Less: accumulated depreciation .....	10b	40,686,305	24,983,198	10c	24,626,537
11	Investments—publicly traded securities ..........			56,311,380	11	112,636,136
12	Investments—other securities. See Part IV, line 11 .....			47,699,534	12	7,596,575
13	Investments—program-related. See Part IV, line 11 .....			0	13	0
14	Intangible assets ...............				14
15	Other assets. See Part IV, line 11 ...........			0	15	0
16	Total assets. Add lines 1 through 15 (must equal line 34)......			171,639,956	16	185,173,917
17	Accounts payable and accrued expenses .........			13,740,815	17	13,767,486
18	Grants payable .................				18
19	Deferred revenue ................			1,110,424	19	2,173,728
20	Tax-exempt bond liabilities .............			16,460,000	20	14,245,000
21	Escrow or custodial account liability. Complete Part IV of Schedule D..				21
22	Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified
	persons. Complete Part II of Schedule L..........			0	22	0
23	Secured mortgages and notes payable to unrelated third parties ..				23
24	Unsecured notes and loans payable to unrelated third parties ....				24
25	Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D....................			22,558,681	25	13,098,664
26	Total liabilities. Add lines 17 through 25.........			53,869,920	26	43,284,878
	Organizations that follow SFAS 117 (ASC 958), check here and complete lines 27 through 29, and lines 33 and 34.
27	Unrestricted net assets ..............			117,770,036	27	141,889,039
28	Temporarily restricted net assets ...........				28
29	Permanently restricted net assets ...........				29
	Organizations that do not follow SFAS 117 (ASC 958), check here and complete lines 30 through 34.
30	Capital stock or trust principal, or current funds ........				30
31	Paid-in or capital surplus, or land, building or equipment fund .....				31
32	Retained earnings, endowment, accumulated income, or other funds				32
33	Total net assets or fund balances ...........			117,770,036	33	141,889,039
34	Total liabilities and net assets/fund balances ........			171,639,956	34	185,173,917