Index

MIPS - Improvement Activities

Quality Measures
Advancing Care Information Measures
Hints for Choosing Improvement Activities

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Measure ID Title Description Weight Subcategory ID
IA_PSPA_13 Participation in Joint Commission Evaluation Initiative Participation in Joint Commission Ongoing Professional Practice Evaluation initiative Medium Patient Safety And Practice Assessment
IA_PSPA_14 Participation in Bridges to Excellence or other similar program Participation in other quality improvement programs such as Bridges to Excellence Medium Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment
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 Patient Safety And Practice Assessment

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