| 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 |
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 |
|
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 |
Patient Safety And Practice Assessment |
|
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 |
Patient Safety And Practice Assessment |
|
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 |
Patient Safety And Practice Assessment |
|
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 |
Patient Safety And Practice Assessment |
|
IA_PSPA_9
|
Completion of the AMA STEPS Forward program
|
Completion of the American Medical Association's STEPS Forward program.
|
Medium |
Patient Safety And Practice Assessment |