Details

MIPS - Improvement Activities - Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes

Improvement Activities Measures Hints for Choosing Improvement Activities

Measure ID IA_PSPA_20
Category IA
Title Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
Description 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.
eMeasure ID
First Performance Year 2017
Last Performance Year
Metric Type boolean
Weight medium
Sub-category ID Patient Safety And Practice Assessment
CEHRT Eligibility
Bonus under ACI
Varidation Functionality of leadership engagement in regular guidance and demonstrated commitment for implementing improvements
Suggested Documentation 1) Clinical and Administrative Leadership Role Descriptions - Documentation of clinical and administrative leadership role descriptions include responsibility for practice improvement change (e.g. position description); or; 2) Time for Leadership in Improvement Activities - Documentation of allocated time for clinical and administrative leadership participating in improvement efforts, e.g. regular team meeting agendas and post meeting summary; or; 3) Population Health, Quality, and Health Experience Incorporated into Performance Reviews - Documentation of population health, quality and health experience metrics incorporated into regular practice performance reviews, e.g., reports, agendas, analytics, meeting notes
Registry Measure Spec
Web Interface Measure Spec
Claims Measure Spec

Back to List