MIPS - Improvement Activities

Quality Measures
Advancing Care Information Measures
Choosing Improvement Activities


Measure ID Title Description Weight Subcategory ID
IA_PSPA_1 Participation in an AHRQ-listed patient safety organization. Participation in an AHRQ-listed patient safety organization. medium patientSafetyAndPracticeAssessment
IA_PSPA_10 Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine. medium patientSafetyAndPracticeAssessment
IA_PSPA_11 Participation in CAHPS or other supplemental questionnaire Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets). high patientSafetyAndPracticeAssessment
IA_PSPA_12 Participation in private payer CPIA Participation in designated private payer clinical practice improvement activities. medium patientSafetyAndPracticeAssessment
IA_PSPA_13 Participation in Joint Commission Evaluation Initiative Participation in Joint Commission Ongoing Professional Practice Evaluation initiative medium patientSafetyAndPracticeAssessment
IA_PSPA_14 Participation in Bridges to Excellence or other similar program Participation in other quality improvement programs such as Bridges to Excellence medium patientSafetyAndPracticeAssessment
IA_PSPA_15 Implementation of antibiotic stewardship program Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics medium patientSafetyAndPracticeAssessment
IA_PSPA_16 Use of decision support and standardized treatment protocols Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs. medium patientSafetyAndPracticeAssessment
IA_PSPA_17 Implementation of analytic capabilities to manage total cost of care for practice population Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following: Train appropriate staff on interpretation of cost and utilization information; and/or Use available data regularly to analyze opportunities to reduce cost through improved care. medium patientSafetyAndPracticeAssessment
IA_PSPA_18 Measurement and improvement at the practice and panel level Measure and improve quality at the practice and panel level that could include one or more of the following: Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level. medium patientSafetyAndPracticeAssessment
IA_PSPA_19 Implementation of formal quality improvement methods, practice changes or other practice improvement processes Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following: Train all staff in quality improvement methods; Integrate practice change/quality improvement into staff duties; Engage all staff in identifying and testing practices changes; Designate regular team meetings to review data and plan improvement cycles; Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families. medium patientSafetyAndPracticeAssessment
IA_PSPA_2 Participation in MOC Part IV Participation in Maintenance of Certification (MOC) Part IV for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results. medium patientSafetyAndPracticeAssessment

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