The Joint Commission Center for Transforming Healthcare

“All center staff and board members follow the joint commission whistleblower policy.”

“All center staff and board members follow the joint commission records retention policy.”

“The center for transforming healthcare relies on the process of the joint commission (a related organization) for approval of top management officials' compensation. The top management officials' 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 top management officials. In setting the top management officials' 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 joint commission's human resources and compensation committees adequately document its compensation determinations and deliberations regarding compensation in its committee minutes on a timely basis. Each 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 compensation of the top management official, dr. Jonathan perlin - president, of the center is determined and paid for by a related organization and is undertaken annually.”

“ALL BOARD COMMITTEES DOCUMENT THEIR MEETINGS AND ACTIONS TAKEN. HOWEVER, NO BOARD COMMITTEES HAS AUTHORITY TO ACT ON BEHALF OF GOVERNING BOARD EXCEPT BY BOARD RESOLUTION. THE SOLE MEMBER OF THE FILING ORGANIZATION, THE JOINT COMMISSION, A RELATED TAX-EXEMPT ORGANIZATION, HAS BROAD AUTHORITY TO ACT ON BEHALF OF THE GOVERNING BODY. If the Joint Commission were to act on behalf of the governing body, the related meeting or actions are contemporaneously documented.”

“As the sole member of the filing organization, the joint commission, a related tax exempt organization, has broad authority to act on behalf of the governing body. Please see the narratives for part vi, lines 6, 7a and 7b for a description of such authority.”

“The Organization has one sole member, The Joint Commission. The Joint Commission has the power to: 1) Appoint all directors to the board of directors and remove them, with or without cause. 2) Approve the election of the Chairman and the Treasurer of the Organization and remove them, with or without cause, provided that an individual so removed may have a claim for compensation if the removal breaches any contract approved by the Organization. 3) Approve amendments to the articles of incorporation and bylaws. 4) Approve all mission and/or vision statements and all strategic or long-term plans of the organization. 5) Approve all creations of subsidiaries or controlled affiliates, mergers, consolidations, permanent or long-term affiliations and all joint ventures of the organization involving capital investments in excess of $250,000. 6) Approve the sale of encumbrance of all or substantially all the assets of the Organization and all long-term debt in excess of $250,000. 7) Approve the organization's annual operating and capital budgets and material amendments thereto. 8) Approve the dissolution of and all liquidations from the organization.”

“See response to Line 6”

“See response to Line 6”

“The management of The Joint Commission, including the CFO, Controller, Corporate Compliance & Privacy Officer, and General Counsel performed a detailed review of the Form 990 with the paid tax preparer. Once this level of review was performed, a walk-through of Form 990 was done with The Joint Commission's governing body prior to filing. A copy of the return will be available upon request once accepted by the IRS.”

“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, family, or business relationships that could be perceived as a conflict of interest. The interests identified are reviewed by the corporate compliance officer , general counsel, and governance committee and appropriately managed. All disclosures are pursued until 100% completed. Prior to any board or committee meeting, a member 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. At the beginning of each board or committee meeting a request is made to disclose any potential conflict of interest. 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.”

“The organization makes its governing documents and form 990 available to the public upon request and in accordance with applicable laws. The conflict of interest policy and financial statements are available to the public on The Joint Commission's website.”

“The joint commission center for transforming healthcare relies on the processes of the joint commission for determining other officers' compensation. The other officers' compensation arrangement is subject to an independent board committee review and approval referred to as the human resources and executive 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 executive 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 executive 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 board engages in an active review of the compensation recommended by the committee. In addition, an annual performance evaluation of the officers is conducted. The process for determining the organizations' other officers' compensation is undertaken annually for: paige rodgers - treasurer & cfo, and lisa vandecaveye- secretary & general counsel.”

“The center for transforming healthcare (the center) was established to solve the most pressing quality and safety problems in health care. These problems threaten lives and increase costs. Working with a cadre of leading hospitals and health systems, the center helps develop solutions to these problems through the application of methods such as lean six sigma and formal change management. The leading hospitals and health systems in the center's network has significant expertise in the application of these methods and tools to health care. Ultimately, the goal of the center is to transform health care into a high reliability industry. Once solutions are developed through this collaborative method, they are made publicly available. Solutions for specific unsafe conditions are also available through the targeted solutions tool (tst). The tst, a web-based tool, helps joint commission-accredited health care organizations measure their own performance and customize solutions to address the contributing factors that underlie their own breakdowns in quality and safety. The center operates five tsts: on hand hygiene, improving hand-off communications, safe surgery, preventing falls with injury and reducing sepsis mortality. The tsts are based on the center project work, described in more detail below. Hand hygiene hand hygiene is critically important to safe, high quality patient care. Unfortunately, many infections are transmitted by health care personnel due to poor hand hygiene. The tst provides the foundation and framework of an improvement method that, if implemented well, will improve an organization's hand hygiene compliance and contribute substantially to its efforts to reduce the frequency of health care-associated infections. The organizations who implemented the hand hygiene solutions from the center's work have achieved and continue to show major and sustained gains in hand hygiene compliance. Since the tool's deployment in 2010, over 1000 healthcare organizations have used the tst. The combined estimated impact of this tool is over 100,000 healthcare associated infections prevented. Safe surgery across the perioperative process, there are many opportunities for even tiny slips, lapses and mistakes that can heighten the risk of a wrong-site surgery. By identifying these risk points, the center's safe surgery project resulted in a deeper understanding of the many contributing factors that can result in a wrong-site surgery. The center's project identified many risk factors for wrong-site surgeries that occurred during scheduling, in pre-op/holding, in the operating room, or which stemmed from the organizational culture. Organizations who have used the safe surgery tst have been able to reduce the number of cases with risks by 56 percent in the scheduling area, by 24 percent in pre-op, and by 48 percent in the operating room. Hand-off communications ineffective hand-off communications have been a primary contributing factor in adverse events. The center's hand-off communications project is to focus on the quality of patient information that is communicated between "senders "receivers" when the care of the patient is being handed off to another caregiver. During the measure phase of the project, participating hospitals found that hand-offs were defective and didn't allow the receiver to safely care for patients 37 percent of the time on average. Senders were dissatisfied with the quality of the hand-off 21 percent of the time. By using solutions targeted to the specific causes of an inadequate hand-off, organizations that fully implemented the solutions achieved more than a 50 percent reduction in defective hand-offs on average. Using the tst and the solutions from the original project, senders have seen a 53 percent relative reduction in defective hand-offs while receivers have experienced a 53 percent relative reduction. Prevention of falls tens of thousands of patients fall in health care facilities every year, and many of”

“PREVENTION OF PATIENT HARM THE CENTER'S PROJECT WAS DESIGNED TO OPTIMIZE BEHAVIORS AND PRACTICES TO FOSTER AN IMPROVED SAFETY CULTURE THAT REINFORCES AND SUPPORTS THE PREVENTION OF PATIENT HARM. A SAFETY CULTURE ENABLES TRUST. IT EMPOWERS STAFF TO SPEAK UP ABOUT RISKS TO PATIENTS AND REPORT ERRORS AND NEAR MISSES, ALL OF WHICH DRIVE IMPROVEMENT. A SAFETY CULTURE WITHIN HEALTH CARE CAN BE DEFINED AS THE SUMMARY OF KNOWLEDGE, ATTITUDES, BEHAVIORS, AND BELIEFS THAT STAFF SHARE ABOUT THE PRIMARY IMPORTANCE OF THE WELL-BEING AND CARE OF THE PATIENTS THEY SERVE, SUPPORTED BY SYSTEMS AND STRUCTURES THAT REINFORCE THE FOCUS ON PATIENT SAFETY. THE CENTER'S SAFETY CULTURE PROJECT FOCUSED ON A KEY DYNAMIC THAT CAN IMPACT TRUST, NAMELY TO RESPONSIVENESS OF ORGANIZATIONAL LEADERSHIP TO REPORTS OF ADVERSE EVENTS OR UNSAFE CONDITIONS. TRUST IS IMPROVED WHEN THESE REPORTS ARE ACTED UPON AND THE ACTIONS TAKEN THEN COMMUNICATED BACK TO STAFF. THE PROJECT FOCUSED ON THE BARRIERS TO CLOSING THE LOOP AND THE DEVELOPMENT OF SOLUTIONS TO THESE BARRIERS. REDUCTION OF SEPSIS MORTALITY THE PROJECT AIMS TO REDUCE SEPSIS MORTALITY. SEPSIS IS THE BODY'S LIFE-THREATENING INFLAMMATORY RESPONSE TO AN INFECTION. THE LEADING CAUSE OF DEATH IN HOSPITALIZED PATIENTS, SEPSIS HAS A MORTALITY RATE ESTIMATED BETWEEN 25 AND 50 PERCENT. IN ADDITION, SEPSIS IS THE MOST EXPENSIVE DISEASE TO TREAT IN THE HOSPITAL, COSTING APPROXIMATELY $17 BILLION DOLLARS ANNUALLY. EARLY DETECTION AND APPROPRIATE TREATMENT OF SEPSIS CAN IMPROVE PATIENT OUTCOMES, DECREASE THE LENGTH OF STAY IN HOSPITALS, AND DECREASE MORTALITY. DURING PILOT TESTING, THE PARTICIPATING HOSPITALS REDUCED SEPSIS MORTALITY RATES BY ABOUT 23 PERCENT AND SUSTAINED THOSE IMPROVEMENTS FOR MORE THAN A YEAR. THE CENTER DEVELOPED ITS FIFTH TST FOCUSING ON THE REDUCTION OF SEPSIS MORTALITY WHICH WAS COMPLETED IN OCTOBER 2019. IN 2021, 29 UNIQUE ORGANIZATIONS HAVE UTILIZED THE SEPSIS TST TO REDUCE SEPSIS MORTALITY SINCE ITS LAUNCH. INSULIN-RELATED THIS PROJECT AIMS TO REDUCE INSULIN-RELATED MEDICATION ERRORS IN THE HOSPITAL SETTING. HOSPITALIZED PATIENTS WITH DIABETES WHO ARE TAKING INSULIN MAY BE UNABLE TO MANAGE THEIR GLUCOSE READINGS AND INSULIN ADMINISTRATION, AND STAFF MAY NOT BE TRAINED OR AVAILABLE TO HELP WITH THESE CRITICAL TASKS. GLYCEMIC CONTROL IS NOT ONLY FUNDAMENTAL TO THE MANAGEMENT OF DIABETES BUT IS ALSO ESSENTIAL TO HELP PREVENT HYPERGLYCEMIC EVENTS. SAFE USE OF INSULIN TO ACHIEVE OPTIMAL BLOOD GLUCOSE HAS BEEN DIRECTLY ASSOCIATED WITH IMPROVED PATIENT OUTCOMES. THE CENTERS FOR MEDICARE & MEDICAID SERVICES INCLUDED POOR GLYCEMIC MANAGEMENT ON ITS 2013 LIST OF 15 HOSPITAL-ACQUIRED CONDITIONS AND WILL NO LONGER REIMBURSE HOSPITALS FOR ADDITIONAL COSTS ASSOCIATED WITH THESE PREVENTABLE MEDICAL ERRORS. THE OCCURRENCE OF THESE PREVENTABLE ADVERSE DRUG REACTIONS AND EVENTS CAN BE REDUCED, AND INSULIN CAN BE USED SAFELY TO ACHIEVE OPTIMAL GLYCEMIC CONTROL FOR HOSPITALIZED PATIENTS. THIS EFFORT LED TO A REDUCTION IN THEIR EXTREME HYPERGLYCEMIA TEST RESULTS BY 29.75 PERCENT AND A REDUCTION IN THEIR HYPOGLYCEMIA TEST RESULTS BY 9.18 PERCENT. Reduction of CDI THE PROJECT AIMS TO REDUCE THE FREQUENCY OF CLOSTRIDIUM DIFFICILE-RELATED INFECTIONS (CDI). THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) ESTIMATES THAT THERE WERE APPROXIMATELY 337,000 HOSPITALIZATIONS RELATED TO CDI DURING 2009. THIS REPRESENTS A 300 PERCENT INCREASE IN THESE RATES FROM 1993. THE CENTERS FOR DISEASE CONTROL AND PREVENTION ESTIMATED THAT CDI-RELATED DIARRHEA IS LINKED TO APPROXIMATELY 14,000 DEATHS PER YEAR. THE FINANCIAL IMPACT OF CDI IS ALSO STAGGERING. ACCORDING TO JAMA INTERNAL MEDICINE THE CURRENT RATES OF CDI ADD AN ADDITIONAL $1.5 BILLION ANNUALLY TO THE COST OF HEALTH CARE. SINCE CDI DISPROPORTIONATELY AFFECTS OLDER PATIENTS, MEDICARE PAYS FOR 68 PERCENT OF ALL CDI-RELATED HOSPITAL STAYS. CDI RATES AND MORTALITY CAN BE REDUCED THROUGH A FOCUS ON A WIDE RANGE OF PATIENT CARE ASPECTS THAT INCLUDE EARLY IDENTIFICATION, ANTIBIO”

“The center also fulfills its mission to transform healthcare into a high reliability industry by offering the oro 2.0 high reliability organizational assessment (oro 2.0). Oro 2.0 is a web-based self-assessment that helps hospitals reflect on areas of performance that are critical aspects of the high reliability journey in the areas of leadership, safety culture, and robust process improvement. Oro 2.0 allows senior leaders in a hospital to self-assess their stage of maturity in 14 areas of performance that are critical for advancing from low to high reliability and the goal of zero preventable harm. Organizational leaders are able to understand areas of opportunities and strengths through a series of comprehensive reports that provide important information next steps, and target areas. In 2016 the center began an initiative to offer additional resources to healthcare organizations seeking to mature in the high reliability areas of leadership, safety culture, and performance improvement: high reliability training programs. These programs range in scope from webinars and other small education events to multi-year training programs with hospitals looking to build the infrastructure that supports organization-wide sustainable improvement. Work with organizations focus on building and strengthening the high reliability domains of leadership and performance improvement through (1) engagement with leadership and staff; (2) intensive training in robust process improvement (rpi); and (3) implementation of organization-wide programs, initiatives, and expectations that reinforce the organization's focus on zero harm, patient and employee safety, quality, and the patient experience. The center has seen significant improvements made by the health care organizations that purchased robust process improvement (rpi) training and partnered with the center for training and program development for a self-sustaining rpi program. As part of the training, the trainees apply the tools and concepts that they learn in class to an actual project. Between 2014-2021, center trainers have trained and mentored 1,700 individuals in rpi. These rpi-trained individuals have led improvement efforts within their organizations. To date, 97.4% of the training projects achieved the goals that were set at the beginning of the project work. Some of the improvements include: * 58% improvement in effective hand-offs * 54% reductioion in ssi rates for all procedures * 81% improvement in the discharge time rates * 52% reduction in medication delays * 84% improvement in compliance with active treatment hours * 55% improvement with patients leaving without being seen in the emergency department”

“The Center was dissolved as of October 3, 2022. The Center was originally conceived in 2008 as a place where the Center could partner with other institutions or providers that were able to apply lean six sigma and high reliability concepts in an effort to address the problems in the U.S. healthcare system. In June 2022, The Center's Board of Directors determined that the administration and operation of The Center had become impractical because of the Endowment's small size. Also, The Center's lack of ability to become self-sustaining prevented the Center from fulfilling its charitable purposes. Pursuant to the resolution adopted by The Center's Board of Directors, most of the Center's assets were distributed to The Joint Commission. All revenue producing products were transferred to Joint Commission Resources, Inc.”

“Professional Fees & Services - Total Expense: 8346, Program Service Expense: 4228, Management and General Expenses: 4118, Fundraising Expenses: ; Shared Services Fee - Total Expense: 623838, Program Service Expense: 378953, Management and General Expenses: 244885, Fundraising Expenses: ;”

“Undesignated Net Assets transferred to Parent Co - The Joint Commission on Accreditation of Healthcare Organizations EIN 36-2229255 - -2624553; Board-Designated Net Assets transferred to Parent Co - The Joint Commission on Accreditation of Healthcare Organizations EIN 36-2229255 - -21089202; Donor-Restricted Endowment Net assets transferred to Parent Co - The Joint Commission on Accreditation of Healthcare Organizations EIN 36-2229255 - -9139978;”

“The organization was subject to the Section 4960 excise tax on renumeration paid during the 2022 calendar year. In October 2022, the organization dissolved. As a result of the dissolution, the applicable excise tax on excess executive compensation, in accordance with section 4960, was paid by the successor organization, The JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS, a related tax-exempt organization. The successor organization has also completed the accompanying Form 4720, Return of Certain Excise Taxes on Charities and Other Persons Under Chapters 41 and 42 of the Internal Revenue, on behalf of the filing organization.”