Index

MIPS - Improvement Activities

Quality Measures
Advancing Care Information Measures
Choosing Improvement Activities

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Measure ID Title Description Weight Subcategory ID
IA_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance. medium patientSafetyAndPracticeAssessment
IA_PSPA_21 Implementation of fall screening and assessment programs Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk). medium patientSafetyAndPracticeAssessment
IA_PSPA_3 Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity. For eligible professionals not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) medium patientSafetyAndPracticeAssessment
IA_PSPA_4 Administration of the AHRQ Survey of Patient Safety Culture Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html) medium patientSafetyAndPracticeAssessment
IA_PSPA_5 Annual registration in the Prescription Drug Monitoring Program Annual registration by eligible clinician or group in the prescription drug monitoring program of the state where they practice. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups must participate for a minimum of 6 months. medium patientSafetyAndPracticeAssessment
IA_PSPA_6 Consultation of the Prescription Drug Monitoring program Clinicians would attest that, 60 percent for first year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days. high patientSafetyAndPracticeAssessment
IA_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements Use of QCDR data, for ongoing practice assessment and improvements in patient safety. medium patientSafetyAndPracticeAssessment
IA_PSPA_8 Use of patient safety tools Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator. medium patientSafetyAndPracticeAssessment
IA_PSPA_9 Completion of the AMA STEPS Forward program Completion of the American Medical Association's STEPS Forward program. medium patientSafetyAndPracticeAssessment

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