Attach to Form 990 or Form 990-EZ.
Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990.
| (i)Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 9 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| Total | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (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 VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10. | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | 2,487,209 | 3,125,663 | 1,902,807 | 1,154,242 | 1,510,988 | 10,180,909 |
| 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...... | 127,333,477 | 137,010,728 | 142,545,602 | 139,684,281 | 145,954,509 | 692,528,597 |
| 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. | 129,820,686 | 140,136,391 | 144,448,409 | 140,838,523 | 147,465,497 | 702,709,506 |
| 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.) | 702,709,506 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2011 | (b) 2012 | (c) 2013 | (d) 2014 | (e) 2015 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | 129,820,686 | 140,136,391 | 144,448,409 | 140,838,523 | 147,465,497 | 702,709,506 |
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | 3,849,715 | 3,452,041 | 3,781,039 | 2,742,699 | 3,471,863 | 17,297,357 |
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | 0 | 0 | 0 | 0 | 0 | 0 |
| c | Add lines 10a and 10b. | 3,849,715 | 3,452,041 | 3,781,039 | 2,742,699 | 3,471,863 | 17,297,357 |
| 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 VI.) .. | 3,682,007 | 4,932,412 | 5,006,477 | 5,437,147 | 5,763,104 | 24,821,147 |
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | 137,352,408 | 148,520,844 | 153,235,925 | 149,018,369 | 156,700,464 | 744,828,010 |
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2015 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2015 |
(iii) Distributable Amount for 2015 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2015 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2015 (reasonable cause required--see instructions) |
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| 3 Excess distributions carryover, if any, to 2015: | ||||
| a | ||||
| b | ||||
| c | ||||
| d From 2013....... | ||||
| e From 2014....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2015 distributable amount | ||||
|
i
Carryover from 2010 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2015 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2015 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions) |
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|
6
Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions) |
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|
7 Excess distributions carryover to 2016. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a | ||||
| b | ||||
| c Excess from 2013....... | ||||
| d From 2014....... | ||||
| e From 2015....... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| Schedule A, Part III, Line 12 Other Income | DESCRIPTION - FEES FROM RELATED ORGANIZATIONS, COLUMN A - 3682007.0, COLUMN B - 4932412.0, COLUMN C - 5006477.0, COLUMN D - 5437147.0, COLUMN E - 5763104.0, COLUMN F - 24821147.0; |
| Software ID: | 15000238 |
| Software Version: | 2015v2.1 |
Attach to Form 990 or 990-EZ.
Information about Schedule O (Form 990 or 990-EZ) and its instructions is at| Return Reference | Explanation |
|---|---|
| Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED | (CONTINUATION FROM ABOVE) THESE ACCREDITATION SERVICES ARE PROVIDED FOR HOSPITALS, CLINICAL LABORATORIES, HOME CARE, LONG TERM CARE, BEHAVIORAL HEALTH CARE, AND AMBULATORY CARE ORGANIZATIONS. JOINT COMMISSION ACCREDITATION AND CERTIFICATION ARE RECOGNIZED NATIONWIDE AS A SYMBOL OF QUALITY THAT REFLECTS AN ORGANIZATION'S COMMITMENT TO MEETING OPTIMUM ACHIEVABLE PERFORMANCE STANDARDS. TO EARN AND MAINTAIN THE JOINT COMMISSION'S GOLD SEAL OF APPROVAL, AN ORGANIZATION MUST UNDERGO AN ON-SITE SURVEY BY A JOINT COMMISSION SURVEY TEAM AT LEAST EVERY THREE YEARS. LABORATORIES MUST BE SURVEYED AT LEAST EVERY TWO YEARS. IN ORDER FOR A HEALTH CARE ORGANIZATION TO PARTICIPATE IN AND RECEIVE PAYMENT FROM THE MEDICARE OR MEDICAID PROGRAMS, IT MUST MEET ELIGIBILITY REQUIREMENTS FOR PROGRAM PARTICIPATION, INCLUDING A CERTIFICATION OF COMPLIANCE WITH THE CONDITIONS OF PARTICIPATION, SET FORTH IN FEDERAL REGULATIONS. THIS CERTIFICATION IS AVAILABLE ON THE BASIS OF SURVEYS CONDUCTED BY STATE AGENCIES ON BEHALF OF THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS). WHEN THE JOINT COMMISSION HAS DEVELOPED AND ENFORCES STANDARDS AND SURVEY PROCEDURES THAT MEET OR EXCEED THE FEDERAL CONDITIONS OF PARTICIPATION, CMS MAY GRANT THE JOINT COMMISSION "DEEMING" AUTHORITY AND DEEM EACH ACCREDITED HEALTH CARE ORGANIZATION AS MEETING MEDICARE AND MEDICAID CERTIFICATION REQUIREMENTS. IN FACT, FEDERAL AND STATE AGENCIES OFTEN RELY ON THE EXPERTISE AND STANDARDS OF THE JOINT COMMISSION. FEDERAL DEEMED STATUS OPTIONS ARE CURRENTLY AVAILABLE FOR AMBULATORY CARE SURGICAL CENTERS, CLINICAL LABORATORIES, CRITICAL ACCESS HOSPITALS, HOME HEALTH AGENCIES, PSYCHIATRIC HOSPITALS, HOSPICES AND HOSPITALS. TO CONDUCT ITS ACCREDITATION SURVEYS, THE JOINT COMMISSION EMPLOYS AN EXPERIENCED, TRAINED CADRE OF APPROXIMATELY 500 SURVEYORS THAT INCLUDE LIFE SAFETY SPECIALISTS. BEYOND BASIC EDUCATION IN THE ACCREDITATION PROCESS, SURVEYORS RECEIVE EDUCATION IN SYSTEMS THEORY, ORGANIZATION BEHAVIOR, AND EVALUATION TECHNIQUES, AND ROBUST PROCESS IMPROVEMENT METHODS AND TOOLS. THE JOINT COMMISSION 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, PALLIATIVE CARE, PERINATAL, INTEGRATED, AND PATIENT BLOOD MANAGEMENT. ADVANCED CERTIFICATION DISEASE-SPECIFIC CARE PROGRAMS ARE 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 AND COMPREHENSIVE STROKE, VENTRICULAR ASSIST DEVICES, DIABETES DISEASE, AND CHRONIC PULMONARY DISEASE. THE JOINT COMMISSION'S HEALTH CARE STAFFING SERVICES CERTIFICATION PROGRAM PROVIDES INDEPENDENT, THOROUGH EVALUATIONS OF THE ABILITY OF STAFFING FIRMS TO PROVIDE COMPETENT STAFFING SERVICES. THE JOINT COMMISSION DEVELOPED THIS CERTIFICATION PROGRAM TO MEET QUALITY OVERSIGHT NEEDS THAT HAVE ARISEN BECAUSE OF THE ONGOING SHORTAGES OF NURSES AND OTHER PROFESSIONAL PERSONNEL. THESE SHORTAGES FORCE HEALTH CARE ORGANIZATIONS TO FILL POSITIONS WITH TEMPORARY EMPLOYEES PROVIDED BY STAFFING FIRMS, WHICH ARE OFTEN NOT OTHERWISE SUBJECT TO ANY QUALITY OVERSIGHT MECHANISM. (CONTINUATION BELOW) |
| Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED | (CONTINUATION FROM ABOVE) AT THEIR HEART, ACCREDITATION AND CERTIFICATION ARE RISK-REDUCTION ACTIVITIES; COMPLIANCE WITH APPROPRIATE STANDARDS REDUCES THE RISK OF ADVERSE OUTCOMES. THE JOINT COMMISSION SPECIFICALLY TARGETS IMPROVEMENT IN PATIENT SAFETY THROUGH THE FOLLOWING EFFORTS: PATIENT SAFETY-RELATED STANDARDS JOINT COMMISSION STANDARDS ADDRESS PERFORMANCE OBJECTIVES AND EXPECTATIONS IN KEY FUNCTIONAL AREAS, SUCH AS PATIENT RIGHTS MEDICATION MANAGEMENT, AND INFECTION CONTROL. THE STANDARDS AND ON-SITE EVALUATION PROCESS FOCUS NOT SIMPLY ON AN ORGANIZATION'S ABILITY TO PROVIDE SAFE, HIGH QUALITY CARE, BUT ON ITS ACTUAL PERFORMANCE. ALL STANDARDS RELATE DIRECTLY OR INDIRECTLY TO SAFETY AND QUALITY-RELATED PATIENT OUTCOMES. THE JOINT COMMISSION DEVELOPS AND UPDATES ITS STANDARDS IN CONSULTATION WITH HEALTH CARE EXPERTS, PROVIDERS, PRACTITIONERS, MEASUREMENT EXPERTS, PURCHASERS AND CONSUMERS. OVER FIFTY PERCENT OF JOINT COMMISSION STANDARDS RELATE DIRECTLY TO PATIENT SAFETY, ADDRESSING A WIDE RANGE OF AREAS SUCH AS SURGERY AND ANESTHESIA, BLOOD TRANSFUSION, RESTRAINT AND SECLUSION, STAFFING AND STAFF COMPETENCE, FIRE SAFETY, MEDICAL EQUIPMENT MAINTENANCE, EMERGENCY MANAGEMENT, AND SECURITY. PATIENT SAFETY STANDARDS ADDRESS THE IMPLEMENTATION OF PATIENT SAFETY PROGRAMS; THE PREVENTION OF ACCIDENTAL HARM THROUGH THE PROSPECTIVE ANALYSIS AND REDESIGN OF VULNERABLE PATIENT SYSTEMS (E.G. THE ORDERING, PREPARATION, AND DISPENSING OF MEDICATIONS); AND THE ORGANIZATION'S RESPONSIBILITY TO TELL A PATIENT ABOUT ALL OUTCOMES OF THE CARE RESPECTING THAT PATIENT, WHETHER GOOD OR BAD. SENTINEL EVENT POLICY THE JOINT COMMISSION'S SENTINEL EVENT POLICY IS DESIGNED TO HELP HEALTH CARE ORGANIZATIONS TO IDENTIFY THE UNDERLYING CAUSES OF SENTINEL EVENTS AND TAKE ACTION TO PREVENT THEIR RECURRENCE. A SENTINEL EVENT IS AN UNEXPECTED OCCURRENCE INVOLVING DEATH OR SERIOUS PHYSICAL - INCLUDING LOSS OF LIMB OR FUNCTION - OR PSYCHOLOGICAL INJURY, OR THE RISK THEREOF. "RISK THEREOF" MEANS THAT, ALTHOUGH NO HARM OCCURRED ON THIS OCCASION, ANY RECURRENCE WOULD CREATE ANOTHER CHANCE FOR A SERIOUS ADVERSE OUTCOME. ANY TIME A SENTINEL EVENT OCCURS, THE HEALTH CARE ORGANIZATION IS EXPECTED TO COMPLETE A THOROUGH AND CREDIBLE ROOT CAUSE ANALYSIS, IMPLEMENT IMPROVEMENTS TO REDUCE RISK, AND MONITOR THE EFFECTIVENESS OF THOSE IMPROVEMENTS. THE ROOT CAUSE ANALYSIS IS EXPECTED TO DRILL DOWN TO EXAMINE ALL RELEVANT ORGANIZATION SYSTEMS AND PROCESSES THAT COULD HAVE CONTRIBUTED THE FAILURES LEADING TO THE OCCURRENCE. THIS EXAMINATION PROVIDES THE BASIS FOR RE-DESIGN OF SYSTEMS AND PROCESSES TO PREVENT RECURRENCE OF SIMILAR OCCURRENCES IN THE FUTURE. THE SENTINEL EVENT POLICY ALSO ENCOURAGES ORGANIZATIONS TO REPORT SENTINEL EVENTS, THEIR ASSOCIATED ROOT CAUSES AND RELATED PREVENTIVE ACTIONS TO THE JOINT COMMISSION SO THAT THE JOINT COMMISSION CAN SHARE WITH OTHER ORGANIZATIONS DE-IDENTIFIED, AGGREGATE INFORMATION ABOUT "LESSONS LEARNED", AND THEREBY REDUCE THE RISK OF FUTURE SENTINEL EVENT OCCURRENCES ACROSS THE DELIVERY SYSTEM. SENTINEL EVENT ALERTS A SENTINEL EVENT ALERT IS A PERIODIC NEWSLETTER OR WEBINAR THAT ADDRESSES SPECIFIC TYPES OF SENTINEL EVENTS, DESCRIBES THEIR COMMON UNDERLYING CAUSES, AND RECOMMENDS STEPS TO PREVENT FUTURE OCCURRENCES. INFORMATION FOR A SENTINEL EVENT ALERT IS DERIVED PRINCIPALLY FROM THE JOINT COMMISSION'S SENTINEL EVENT DATABASE. THE JOINT COMMISSION BEGAN PUBLISHING SENTINEL EVENT ALERTS IN 1998 TO REDEFINE THE PRINCIPAL PURPOSE OF ADVERSE EVENT REPORTING AS BEING FOR LEARNING. SENTINEL EVENT ALERT HAS RAISED AWARENESS IN THE HEALTH CARE COMMUNITY AND THE FEDERAL GOVERNMENT ABOUT THE OCCURRENCE OF ADVERSE EVENTS AND WAYS THAT THESE EVENTS CAN BE PREVENTED IN THE FUTURE. PAST ISSUES AND WEBINARS ARE AVAILABLE ON THE JOINT COMMISSION WEBSITE. TOPICS HAVE INCLUDED MEDICATION ERRORS, WRONG-SITE SURGERY, RESTRAINT-RELATED DEATHS, BLOOD TRANSFUSION ERRORS, INPATIENT SUICIDES, INFANT ABDUCTIONS, FATAL FALLS, OPERATIVE/POST-OPERATIVE COMPLICATIONS, HEALTH CARE WORKER FATIGUE, BEHAVIORS THAT UNDERMINE A CULTURE OF SAFETY, MATERNITY DEATHS AND INJURIES, INFECTION CONTROL, AND PREVENTING RETAINED FOREIGN OBJECTS. NATIONAL PATIENT SAFETY GOALS IN JULY 2002, THE JOINT COMMISSION ESTABLISHED ITS FIRST SET OF SIX NATIONAL PATIENT SAFETY GOALS (NPSGS) AND 11 RELATED SPECIFIC REQUIREMENTS FOR IMPROVING THE SAFETY OF PATIENT CARE IN HEALTH CARE ORGANIZATIONS. ALL JOINT COMMISSION ACCREDITED HEALTH CARE ORGANIZATIONS ARE REQUIRED TO IMPLEMENT GOAL-RELATED REQUIREMENTS-OR ACCEPTABLE ALTERNATIVES-THAT APPLY TO THEM. THE GOALS AND REQUIREMENTS ARE DRAWN FROM A "POOL" OF RECOMMENDATIONS IDENTIFIED BY THE PATIENT SAFETY ADVISORY GROUP AS EVIDENCE- OR CONSENSUS-BASED, COST-EFFECTIVE, AND FEASIBLE TO IMPLEMENT. EACH YEAR, RECOMMENDATIONS FROM SENTINEL EVENT ALERT PUBLISHED IN THE PREVIOUS YEAR AND FROM OTHER AUTHORITATIVE SOURCES ARE ADDED TO THE POOL. (CONTINUATION BELOW) |
| Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED | (CONTINUATION FROM ABOVE) OFFICE OF QUALITY AND PATIENT SAFETY THE JOINT COMMISSION'S OFFICE OF QUALITY AND PATIENT SAFETY RECEIVES, EVALUATES, TRACKS, AND AS APPROPRIATE, RESPONDS TO COMPLAINTS AND REPORTS OF CONCERN ABOUT HEALTH CARE ORGANIZATIONS THAT RELATE TO SAFETY AND CARE ISSUES. THIS INFORMATION COMES FROM PATIENTS, THEIR FAMILIES, ORGANIZATION STAFF, PRACTITIONERS, GOVERNMENT AGENCIES, AND OTHERS. THE OFFICE MAINTAINS A TOLL FREE HOT LINE AND ALSO RECEIVES WRITTEN REPORTS BY MAIL OR E-MAIL. WHEN A REPORT IS SUBMITTED, THE JOINT COMMISSION REVIEWS ANY PAST REPORTS AND THE ORGANIZATION'S MOST RECENT ACCREDITATION DECISION. DEPENDING ON THE NATURE OF THE REPORTED CONCERN, THE JOINT COMMISSION WILL TAKE ONE OF THE FOLLOWING ACTIONS: * INCORPORATE THE REPORTED CONCERN INTO THE QUALITY MONITORING DATABASE THAT IS USED TO TRACK HEALTH CARE ORGANIZATIONS OVER TIME TO IDENTIFY TRENDS OR PATTERNS IN THEIR PERFORMANCE. * ASK THE ORGANIZATION TO PROVIDE A WRITTEN RESPONSE TO THE REPORTED CONCERN. * REVIEW THE REPORTED CONCERN AND COMPLIANCE WITH RELATED STANDARDS AT THE TIME OF THE ORGANIZATION'S NEXT ACCREDITATION SURVEY. * CONDUCT AN UNANNOUNCED ON-SITE EVALUATION OF THE ORGANIZATION IF THE REPORT RAISES SERIOUS CONCERNS ABOUT A CONTINUING THREAT TO PATIENT SAFETY OR CONTINUING FAILURE TO COMPLY WITH STANDARDS. INFECTION CONTROL INITIATIVES INFECTION PREVENTION AND CONTROL IS A CRITICAL COMPONENT OF SAFE, QUALITY HEALTH CARE. THE JOINT COMMISSION IS ADDRESSING THIS IMPORTANT ISSUE WITH A NUMBER OF INITIATIVES AND PRODUCTS. * The Joint Commission conducted a project to determine the effectiveness of universal glove and gowning procedures in reducing HAI rates in the ICU. * The Joint Commission conducted a project to determine whether a pre-operative antibiotic prophylaxis algorithm that includes the use of antibiotics shown to be effective against resistant gram-positive organisms is effective in reducing the number of SSIs attributable to resistant gram-positive organisms. * The Joint Commission conducted a project (through a CDC cooperative agreement) to develop an educational on-line course for care providers regarding the use of Rapid Influenza Diagnostic Testing (RIDTs) in ambulatory settings. The Joint Commission continues to host, promote, and update course to educate clinicians about the appropriate use of RIDTs within the context of circulating influenza types and prevalence. In addition, another course was developed focusing on influenza pandemic preparedness. * The Joint Commission conducted a project to identify how high reliability practices can be applied in facility-based long term care settings to reduce transmission of infection. Two products resulted from this project: an online, easy-to-use, engaging 50-minute e-learning module designed for the long term care (nursing home, assisted living) settings, which has been disseminated internationally; and, a searchable index of related resources, derived from a scoping literature review, that is intended to identify effective practices that improve reliability and reduce transmission of infections in nursing homes and assisted living facilities. Both products are available at no charge. * The Joint Commission continually works closely with CDC, SHEA, APIC, IDSA and other groups to help ensure coordination and collaboration among organizations working to reduce the burden of infections. The Joint Commission's comprehensive accreditation standards and national patient safety goals specific to infection prevention and control have facilitated broader implementation of CDC practice recommendations. These standards emphasize infection prevention, continuous strategic surveillance for infection and infection-related risks, and timely interventions to address identified problems. * The Joint Commission collaborated with CDC/NIOSH/NPPTL to develop an educational monograph designed to assist hospitals in addressing common challenges and barriers in the implementation of respiratory protection programs. The monograph, "Implementing Hospital Respiratory Protection Programs: Strategies from the Field," features case study examples, strategies, and new resources. The Joint Commission embarkED on expanded dissemination of this monograph TO INCLUDE PRESENTATIONS AT NATIONAL FORUMS AND AN EDUCATIONAL WEBINAR HOSTED BY NIOSH IN SEPTEMBER OF 2015. * In September of 2015, The Joint Commission received funding from CDC to embark on a three-year funded project titled, "Adaptation and Dissemination of Outpatient Infection Prevention (ADOPT) Guidance." This project is designed to prevent healthcare associated infections in ambulatory settings by identifying gaps and inconsistencies in current infection control materials for outpatient settings and adapting materials to better meet the needs of outpatient settings. * The Joint Commission collaborated with SHEA on a National hospital survey to estimate costs and benefits associated with measures required to prepare for handling Ebola patients. (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 MONOGRAPH ON THE OPPORTUNITIES FOR SYNERGY, COLLABORATION, AND INNOVATION BETWEEN PATIENT SAFETY AND WORKER SAFETY IN HEALTH CARE. * Work on a project to create and pilot test an Informed Consent toolkit to help hospitals improve their informed consent process. * Work with the Office of the National Coordinator to analyze Sentinel Event data associated with Health IT and development of a free online course (providing CE credit), titled "Investigating and Preventing Health Information Technology-Related Patient Safety Events" to teach staff how to identify, report and address health IT-related safety concerns in health care organizations. * Work with Pfizer Independent Grants for Learning and Change (IGLC), previously known as the Pfizer Medical Education Group (PMEG), to successfully pilot test a partnership with the long-term goal to support an array of projects designed to accelerate the adoption of evidence-based innovations that improve patient care. This collaboration was designed to utilize the Request for Proposal (RFP) process to identify, fund and oversee projects related to specific improvement objectives that align the mutual interests of patients, health care providers and the two partner organizations. Phase II is focused on projects related to transitions of care (TOC) among a defined venous thromboembolism patient population. Five awards were issued for two year research projects starting in 2016. * WORK ON A PROJECT WITH AHA'S HEALTH RESEARCH AND EDUCATIONAL TRUST (HRET) TO IMPLEMENT A COMPREHENSIVE UNIT-BASED SAFETY PROGRAM (CUSP) TO REDUCT CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI) IN LONG TERM CARE FACILITIES. * WORK ON A PROJECT FUNDED BY BMS/PFIZER TO DETERMINE WHETHER OR NOT COMPREHENSIVE PATIENT EDUCATION OR DISCHARGE MATERIALS ARE AVAILABLE FOR VENOUS THROMBOEMBOLISM (VTE) PATIENTS BEING DISCHARGED ON ANTICOAGULANTS OTHER THAN WARFARIN. 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 ACUTE STOKE-READY REQUIREMENTS RELEASED IN JULY 2015 TO IMPROVE THE QUALITY AND SAFETY OF CARE FOR 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. * WORK WITH EXPERTS TO DEVELOP A perinatal care (PNC) CERTIFICATION PROGRAM RELEASED IN JULY 2015 that focus on achieving integrated, coordinated, patient-centered care that starts with prenatal care through postpartum care. This certification focuses on the essential, high-value requirements that will improve perinatal outcomes for mothers and newborns who have been assessed as clinically uncomplicated. * EXPANSION OF THE integrated care certification (ICC) program TO INCLUDE EVALUATION OF INPATIENT, OUTPATIENT AND NOW, POST-ACUTE CLINICAL CARE PARTNERS TO DO THE following: A. Establish AND MAINTAIN a strong foundation for care coordination and clinical integration B. Decrease variation in the management of chronic disease and increase adherence to well-researched, evidence-based clinical practices C. Create and demonstrate the capacity to efficiently coordinate and integrate patient care, treatment, and services D. Build upon what these providers are already doing independently for patient care, treatment, and services and strengthen their capacities to support patients as they move among providers and home. (CONTINUATION BELOW) |
| Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED | (CONTINUATION FROM ABOVE) * Research on telehealth issues across health care settings. Existing standards are being evaluated and modified as necessary to reflect contemporary practices. * Develop a Total Hip and Total Knee Replacement (THKR) Certification program for patients undergoing total hip and total knee replacement procedures. This is an optional certification that is open to accredited organizations that provide total hip and total knee replacement procedures. The requirements will support quality, consistency, and safety throughout the pre-operative, intra-operative, and post-operative phases of care. It will address transitions that occur within each of those phases. The program will apply to surgeries performed in inpatient, hospital-based outpatient, and ambulatory surgery settings. * Develop a Community Based Palliative Care (CBPC) Certification program for the Home Care program. This is an optional Certification that is open to accredited Home Health and Hospice organizations that provide palliative care services to patients and families in their homes. CBPC is provided by an interdisciplinary team of doctors, nurses, social workers, chaplains, and other home care providers who work together to coordinate care, treatment, and services for the patient. The CBPC standards and elements of performance (EPs) are based on the 2013 Clinical Practice Guidelines for Quality Palliative Care, 3rd ed; the National Hospice and Palliative Care Organization's Standards of Practice for Pediatric Palliative Care and Hospice (2010); and other current palliative care professional literature. * Development of a Comprehensive Cardiac Center Certification program for Joint Commission- accredited hospitals. This is an optional certification program to recognize hospitals that demonstrate they deliver excellence in comprehensive cardiac care through a combination of standards compliance, clinical performance on targeted metrics, and achievement and/or maintenance of required Advanced Disease-Specific Care requirements. THE SPEAK UP INITIATIVES SINCE 2002, THE JOINT COMMISSION, TOGETHER WITH THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS), CONTINUE TO DEVELOP MATIERALS WITH 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 THOSE LISTED BELOW. SPEAK UP BROCHURES ARE AVAILABLE TO THE GENERAL PUBLIC AT NO COST ON THE JOINT COMMISSION'S WEBSITE. * 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 YOUR 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: RIGHT ID, RIGHT CARE 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 40 COUNTRIES. (CONTINUATION BELOW) |
| Form 990, Part III, Line 1 ORGANIZATION MISSION CONTINUED | (CONTINUATION FROM ABOVE) QUALITY CHECK AND QUALITY REPORTS QUALITY CHECK OFFERS A COMPREHENSIVE COMPENDIUM OF QUALITY AND SAFETY-RELATED PERFORMANCE INFORMATION ON THE NEARLY 21,000 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. THE JOINT COMMISSION ESTABLISHED THE PHYSICIAN ENVIRONMENT PORTAL DURING 2014. THE PURPOSE OF THE PORTAL IS TO PROVIDE GUIDANCE AND EDUCATION SPECIFIC TO FREQUENTLY IDENTIFIED STANDARDS AND ELEMENTS OF PERFORMANCE (EP). THE JOINT COMMISSION HAS IDENTIFIED SEVERAL STANDARDS THAT HAVE BEEN CITED DURING SURVEY ACTIVITY OVER THE YEARS. THE PORTAL WILL PROVIDE INFORMATION TO REDUCE THE FINDINGS OF NON-COMPLIANCE IMPROVING PATIENT SAFETY WITH BEST PRACTICES AND ENSURING COMPLIANCE. ALL INFORMATION ON THE SITE IS AVAILABLE FREE TO THE PUBLIC. THE JOINT COMMISSION ALSO HAS A PORTAL FOR TRANSITIONS OF CARE. THE PORTAL IS A VALUABLE SOURCE OF INFORMATION FROM THE JOINT COMMISSION AND OTHER HEALTH CARE ORGANIZATIONS RELATED TO TOPICS OF TRANSITIONS OF CARE OR THE MOVEMENT OF PATIENTS BETWEEN VARIOUS HEALTH CARE SETTINGS. |
| Form 990, Part VI, Line 15b PROCESS TO ESTABLISH COMPENSATION OF OTHER EMPLOYEES | OTHER OFFICERS: THE OTHER OFFICERS' COMPENSATION ARRANGEMENT IS SUBJECT TO AN INDEPENDENT BOARD COMMITTEE REVIEW AND APPROVAL REFERRED TO AS THE HUMAN RESOURCES AND COMPENSATION COMMITTEE. THE JOINT COMMISSION ENGAGED AN INDEPENDENT COMPENSATION CONSULTANT TO ASSIST IN DETERMINING COMPENSATION OF ITS OTHER OFFICERS. IN SETTING THE OTHER OFFICERS' COMPENSATION, THE ORGANIZATIONS' HUMAN RESOURCES AND COMPENSATION COMMITTEES RELY ON RECENT COMPENSATION STUDIES THAT PROVIDE COMPENSATION DATA FOR COMPARABLE POSITIONS IN OTHER ORGANIZATIONS TO SUPPORT ITS DECISION-MAKING PROCESS. THE HUMAN RESOURCES AND COMPENSATION COMMITTEES ADEQUATELY DOCUMENTED ITS COMPENSATION DETERMINATIONS AND DELIBERATIONS REGARDING COMPENSATION IN ITS COMMITTEE MINUTES ON A TIMELY BASIS. EACH VOTING COMMITTEE MEMBER HAS BEEN DETERMINED TO BE INDEPENDENT IN ACCORDANCE WITH INTERMEDIATE SANCTIONS REGULATIONS AND SIGNS THE BOARD'S CONFLICT OF INTEREST POLICY ANNUALLY TO ENSURE THAT HE OR SHE IS INDEPENDENT. The process for determining the organizations' top management officials' compensation is undertaken annually FOR: dr. mark chassin - president, david baker - vp, anne marie benedicto - vp, ann scott Blouin - vp, Harold Bressler - vp, brian Enochs - vp, john mache - vp, ana pujols mckee - vp, Charles mowll - vp, mark pelletier - vp, paige rodgers - cfo, Lisa Diehl Vandecaveye - vp, and Margaret Van Amringe - vp. KEY EMPLOYEES: THE JOINT COMMISSION ENGAGES ITS HUMAN RESOURCES DEPARTMENT TO ASSIST IN DETERMINING COMPENSATION OF ITS KEY EMPLOYEES. IN SETTING THE KEY EMPLOYEES' COMPENSATION, THE HUMAN RESOURCES DEPARTMENT RELIES ON INDEPENDENT SURVEY AND COMPENSATION DATA FOR COMPARABLE POSITIONS IN OTHER ORGANIZATIONS AND/OR ON THE INTERNAL JOB EVALUATION SYSTEM TO SUPPORT ITS DECISIONMAKING PROCESS. THE KEY EMPLOYEES' COMPENSATION AGREEMENT IS SUBJECT TO A REVIEW AND APPROVAL BY THE CHIEF HUMAN RESOURCES OFFICER. INCENTIVE COMPENSATION FOR KEY EMPLOYEES IS ALSO REVIEWED AND APPROVED BY THE ORGANIZATION'S HUMAN RESOURCES AND COMPENSATION COMMITTEES. THE PROCESS FOR DETERMINING THE ORGANIZATION'S KEY EMPLOYEES' COMPENSATION IS UNDERTAKEN ANNUALLY FOR ALL KEY EMPLOYEES. |
| Form 990, Part VI, Line 6 Classes of members or stockholders | THE JOINT COMMISSION HAS CORPORATE MEMBERS AS NOTED IN THEIR BYLAWS. EACH MEMBER IS GRANTED A CERTAIN NUMBER OF VOTES WHEN VOTING ON ISSUES BROUGHT UP DURING MEMBER MEETINGS. THE FOLLOWING CORPORATIONS ARE MEMBERS OF THE JOINT COMMISSION: AMERICAN COLLEGE OF PHYSICIANS, THREE VOTES; AMERICAN COLLEGE OF SURGEONS, THREE VOTES; AMERICAN DENTAL ASSOCIATION, ONE VOTE; AMERICAN HOSPITAL ASSOCIATION, SEVEN VOTES; AND AMERICAN MEDICAL ASSOCIATION, SEVEN VOTES. THE NUMBER OF VOTES TO WHICH ANY ADDITIONAL MEMBERS SHALL BE ENTITLED SHALL BE ESTABLISHED BY AMENDMENT TO THE BYLAWS |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | SEE NARRATIVE FOR LINE 6 |
| Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders | SEE NARRATIVE FOR LINE 6 |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | The Joint Commission's management, including the CEO, CFO, Corporate Compliance & Privacy Officer, and Legal Counsel performed a detailed review of the Form 990 with the paid tax preparer. Once this level of review was performed, a thorough walk through of Form 990 was done with the Finance Committee prior to filing. A copy of the Form 990 was provided to the entire Board of Commissioners prior to filing. A final filed copy of the return will be placed on the Organization's website for the public once accepted by the IRS. |
| Form 990, Part VI, Line 12c Conflict of interest policy | THE POLICY STATES THAT ANY DECISION THAT COULD RESULT IN AN ACTUAL OR PERCEIVED CONFLICT OF INTEREST MUST BE AVOIDED. ALL STAFF AND BOARD MEMBERS REVIEW THE POLICY ON AN ANNUAL BASIS AND COMPLETE A CONFLICT OF INTEREST QUESTIONNAIRE EACH YEAR, WHICH IS DESIGNED TO IDENTIFY INTERESTS THAT COULD GIVE RISE TO POSSIBLE CONFLICTS. ALTHOUGH MANY SUCH POTENTIAL CONFLICTS ARE AND WILL BE DEEMED INCONSEQUENTIAL, EVERY INDIVIDUAL OF THE ORGANIZATION HAS AN ONGOING RESPONSIBILITY TO DISCLOSE SITUATIONS THAT INVOLVE PERSONAL, FAMILIAR, OR BUSINESS RELATIONSHIPS THAT COULD BE PERCEIVED AS A CONFLICT OF INTEREST. THE INTERESTS IDENTIFIED ARE REVIEWED BY THE CORPORATE COMPLIANCE OFFICER AND MANAGER AND APPROPRIATELY MANAGED. ALL DISCLOSURES ARE PURSUED UNTIL 100% COMPLETED. THE BOARD IS REQUIRED TO DISCLOSE A CONFLICT OF INTEREST OR POSSIBLE CONFLICT OF INTEREST ON ANY MATTER DURING A MEETING AND THEN NOT VOTE OR USE PERSONAL INFLUENCE ON THE MATTER. THE MINUTES OF THE MEETING REFLECTS THAT A DISCLOSURE WAS MADE AND THE MEMBER ABSTAINED FROM VOTING. THE COMPLIANCE OFFICER MONITORS AND REVIEWS THE CONFLICT OF INTEREST POLICY AS WELL AS THE RESPONSES TO THE QUESTIONNAIRES ON AN ANNUAL BASIS. THE ORGANIZATION ALSO HAS AVAILABLE AN INDEPENDENT HOTLINE NUMBER FOR STAFF TO REPORT ANONYMOUSLY ANY POTENTIAL CONFLICTS DURING THE YEAR. |
| Form 990, Part VI, Line 15a Process to establish compensation of top management official | The ceo's compensation arrangement is subject to an independent Board committee review and approval referred to as the human resources and compensation committee. The joint commission engaged an independent compensation consultant to assist in determining compensation of its ceo. In setting the ceo's compensation, the organization's human resources and compensation committee Relies on recent compensation studies that provide compensation data for comparable position in other organizations to support its decision-making process. The human resources and compensation committee adequately Documents its compensation determinations and deliberations regarding compensation in its committee minutes on a timely basis. Each voting committee member has been determined to be independent in Accordance with intermediate sanctions regulations and signs the Board's conflict of interest policy annually to ensure that he or she Is independent. The process for determining the ceo's compensation is undertaken annually. |
| Form 990, Part VI, Line 15b Process to establish compensation of other employees | See narrative for Part VI, line 15b |
| Form 990, Part VI, Line 19 Required documents available to the public | THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AND IN ACCORDANCE WITH APPLICABLE LAWS. THE CONFLICT OF INTEREST POLICY, CODE OF CONDUCT, AND FINANCIAL STATEMENTS ARE MADE AVAILABLE TO THE PUBLIC. |
| Form 990, Part XI, Line 9 Other changes in net assets or fund balances | Change in fair value of hedge - interest rate swap - 294694; Transfer of net assets to Parent Co - 1776063; Transfer of net assets to Affiliate - Operating - -2000000; Change in unrecognized net defined benefit plan costs not yet recognized in net periodic benefit cost - -2431523; |
| Software ID: | 15000238 |
| Software Version: | 2015v2.1 |