Jcaho Surveyor & Qhr Consultant Corp

“All staff and board members are obligated to follow the joint commission whistleblower policy.”

“All staff and board members are obligated to follow the joint commission records retention policy.”

“The compensation of the top management official of the joint commission surveyor and qhr consultant corporation is determined and paid for by a related organization. See explanation on schedule j, part i, line 3 arrangement used to establish the top management official's compensation.”

“Any changes, amendments, repeals or new bylaws may be adopted by the Board of Directors which shall become effective when approved by the President of the Joint Commission, a related tax-exempt organization, unless disapproved by the Board of Commissioners of the Joint Commission. If any such action by the Board of Directors is disapproved by the Board of Commissioners, the action shall be referred back to the Board of Directors for reconsideration and possible resubmission to the Board of Commissioners.”

“The Joint Commission's management, including the CFO, Controller, 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 the Form 990 was done with the Board prior to filing.”

“All staff and board members are obligated to follow The Joint Commission on Accreditation of Healthcare Organizations' conflict of interest policy. The policy states that any decision that could result in an actual or perceived conflict of interest must be avoided. All staff and board members review the policy on an annual basis and complete a conflict of interest questionnaire each year, which is designed to identify interests that could give rise to possible conflicts. Although many such potential conflicts are and will be deemed inconsequential, every individual of the organization has an ongoing responsibility to disclose situations that involve personal, familiar, or business relationships that could be perceived as a conflict of interest. The interests identified are reviewed by the corporate compliance officer and manager and appropriately managed. All disclosures are pursued until 100% completed. The board is required to disclose a conflict of interest or possible conflict of interest on any matter during a meeting and then not vote or use personal influence on the matter. The minutes of the meeting reflects that a disclosure was made and the member abstained from voting. The compliance officer monitors and reviews the conflict of interest policy as well as the responses to the questionnaires on an annual basis. The organization also has available an independent hot-line number for staff to anonymously report any potential conflicts during the year.”

“The Joint Commission Surveyor and QHR Consultant Corporation relies on the processes of the Joint Commission and Joint Commission Resources, Inc. for determining other officers and key employees' compensation. 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 AND JOINT COMMISSION RESOURCES 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: margaret van amringe- vp, and anne marie benedicto - vp. KEY EMPLOYEES: THE JOINT COMMISSION AND JOINT COMMISSION RESOURCES 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.”

“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 the Joint Commission Consolidated financial statements are made available to the public on the Joint Commission website.”