11. Resubmission

Topics Covered in this section:

Purpose of Resubmission
FAQs Resubmission of data
How to Resubmit data

Purpose of Resubmission

The Joint Commission believes that performance measures are essential to the credibility of any health care organization, and as such, includes submission of performance measurement data as a condition of participation for accreditation with The Joint Commission.

The purpose of resubmission is to allow organizations to resubmit incorrectly entered or incorrectly omitted measure data so feedback/public reporting is accurate/reflective of performance. Additionally:

Resubmission of data allows The Joint Commission to use the most complete and accurate data possible in our analysis of the patient care provided by an HCO. This includes:
- Ensuring we calculate the most accurate comparative rates (e.g., national, state).
  - One HCO’s incorrect and/or missing data can impact how other organizations compare against TJC’s national and state rates
In the healthcare field, The Joint Commission is viewed as a leader in performance measurement. For this reason, other entities that desire performance measurement data will utilize Joint Commission Dashboard Reports when provided to them by the HCO. Therefore, allowing resubmission of data is a value-add to the HCOs that need to ensure their data is as complete and accurate as possible.
Organizations should be aware that allowance of resubmission has the potential to change organization’s rates of performance over time

Note: The intent of resubmission is not to “extend” data submission deadlines for chart-abstracted measures. Organizations that frequently or consistently use the resubmission functionality to submit data due because of missing deadlines will be assessed for compliance to APR.04.01.01.

Data updated via the resubmission functionality will be reflected in analysis and reports the following submission deadline. This includes all comparative analysis including The Joint Commission’s National and State rates.

FAQs Resubmission of data

Can HCOs resubmit Chart-Abstracted data to The Joint Commission?

Yes, beginning in 2024, organizations are able to resubmit chart-abstracted data via the DDSP on a continuous rolling cycle, effective CY2023 data.

What is the timeframe for resubmission?

HCOs have three quarters to resubmit chart-abstracted measure data. For example:

If the 1Q CAM deadline = 6/30, the resubmission window opens approximately two weeks later & closes the following calendar year on 3/31
If the 2Q CAM deadline = 9/30, the resubmission window opens approximately two weeks later & closes the following calendar year on 6/30
If the 3Q CAM deadline = 12/31, the resubmission window opens approximately two weeks later & closes on 9/30
If the 4Q CAM deadline = 3/31, the resubmission window opens approximately two weeks later & closes on 12/31

For additional information on the data submission timeline, refer to the ORYX Performance Measurement Timeline: https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257

What is the purpose of resubmitting Chart-Abstracted data to The Joint Commission?

Resubmission of chart-abstracted data allows organizations to correct data that may have been inadvertently submitted incorrectly or erroneously omitted. Chart-abstracted measures that are part of the National Patient Safety Goals and National Quality Improvement Goals are publicly reported on Quality Check and are reflective an an organization’s performance on key metrics. External entities and consumers may use publicly reported data to make decisions about healthcare entities.

PLEASE NOTE: the intent of resubmission is not to “extend” data submission deadlines for chart-abstracted measures. Organizations that frequently or consistently use the resubmission functionality to enter missing data outside established timelines will be assessed for compliance to APR.04.01.01 and may receive a requirement for improvement at the time of survey.

How often is Quality Check updated?

Quality Check refreshes on a rolling 4 quarter (current quarter plus most recent three quarters).

Can HCOs resubmit eCQM data to The Joint Commission?

No, there is no process at this time to resubmit eCQM data to The Joint Commission.

How are the Social Drivers of Health (SDOH) resubmitted since data can only be submitted during 4Q for these measures?

The SDOH measures will fall within the resubmission cycle for 4Q data, e.g. if the 4Q CAM deadline = 3/31, the resubmission window opens approximately two weeks later & closes on 12/31

How to Resubmit data

Open a measure by clicking the ‘Open’ button in the Measure List on the right. This opens the data entry tool for the selected measure.
Click Edit, then under each quarter click on the toggle button “Enable to Submit data”.
Enter the updated data and click Submit.
1. It is crucial for organizations resubmitting data to save a submission report for all resubmitted data! The Accelerate PI and trends and benchmark reports have delays in updating and will indicate gaps in submission or incorrect data during the resubmission timeframe; the submission report is the only evidence of correct/compliant data until these reports are refreshed.
The re-transmission deadlines are denoted under each quarter.

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