IA Measures

Improvement activities breakdown

Patient Safety & Practice Asses

Activity Weighting
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#IA_PSPA_4 Administration of the AHRQ Survey of Patient Safety Culture

Description :

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)
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_5 Annual registration in the Prescription Drug Monitoring Program

Description :

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
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_9 Completion of the AMA STEPS Forward program

Description :

Completion of the American Medical Association’s STEPS Forward program
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_10 Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments

Description :

Completion of training and obtaining an approved waiver for provision of medication-assisted treatment of opioid use disorders using buprenorphine.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_6 Consultation of the Prescription Drug Monitoring program

Description :

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.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    High

#IA_PSPA_17 Implementation of analytic capabilities to manage total cost of care for practice population

Description :

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.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_15 Implementation of antibiotic stewardship program

Description :

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
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_21 Implementation of fall screening and assessment programs

Description :

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).
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_19 Implementation of formal quality improvement methods, practice changes or other practice improvement processes

Description :

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.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_20 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.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_18 Measurement and improvement at the practice and panel level

Description :

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.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_3 Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.

Description :

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)
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_1 Participation in an AHRQ-listed patient safety organization

Description :

Participation in an AHRQ-listed patient safety organization.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_14 Participation in Bridges to Excellence or other similar program

Description :

Participation in other quality improvement programs such as Bridges to Excellence
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_11 Participation in CAHPS or other supplemental questionnaire

Description :

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).
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    High

#IA_PSPA_13 Participation in Joint Commission Evaluation Initiative

Description :

Participation in Joint Commission Ongoing Professional Practice Evaluation initiative
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_2 Participation in MOC Part IV

Description :

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.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_12 Participation in private payer CPIA

Description :

Participation in designated private payer clinical practice improvement activities.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_16 Use of decision support and standardized treatment protocols

Description :

Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_8 Use of patient safety tools

Description :

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.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium

#IA_PSPA_7 Use of QCDR data for ongoing practice assessment and improvements

Description :

Use of QCDR data, for ongoing practice assessment and improvements in patient safety.
  • Subcatagory Name :

    Patient Safety & Practice Assessment
  • Activity Weighting :

    Medium