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2020 MIPS IA_PSPA_18: Measurement and improvement at the practice and panel level

Activity ID

IA_PSPA_18

Activity Weighting

Medium

Subcategory Name

Patient Safety and Practice Assessment

Activity Description

Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards, 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.

Validation

Measure and improve quality at the practice and panel level. Practice and panel performance benchmarks and goals may also include benchmarks/goals for specific populations (for example, racial and ethnic minorities, individuals with disabilities, sexual and gender minorities, individuals in rural areas) to drive overall improvements, and individuals with certain chronic conditions or risk factors

Suggested Documentation

1) Quality Improvement Program/Plan at Practice and Panel Level - Copy of a quality improvement program/plan or review of quality, utilization, patient satisfaction (surveys should be administered by a third party survey administrator/vendor) and other measures to improve one or more elements of this activity; or
2) Review of and Progress on Measures - Report showing progress on selected measures, including benchmarks and goals for performance using relevant data sources at the practice and panel level.

Examples of Additional Activities that Qualify for Attestation

Completing these alternate activities can fulfill the requirements of this Improvement Activity; and Notes

Sub-IA-1: Obtain diagnostic Imaging Center of Excellence (DICOE) designation;
Sub-IA-2: Participate in Endoscopy Unit Recognition Program (EURP);
Sub-IA-3: Participate in Simulation Education Courses approved by the ASA Simulation Education Network

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