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2020 MIPS IA_PSPA_19: Implementation of formal quality improvement methods, practice changes or other practice improvement processes

Activity ID

IA_PSPA_19

Activity Weighting

Medium

Subcategory Name

Patient Safety and Practice Assessment

Activity 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, such as:

  • Participation in multisource feedback;
  • 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;
  • Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;
  • Participation in Bridges to Excellence;
  • Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.

Validation

Documentation/Evidence of the implementation of a formal model for quality improvement and creation of a culture in which staff actively participates in one or more improvement activities (e.g., formal QI models are used by clinicians to develop systems, tools, and interventional strategies to improve processes of care for their patient population. An example of a formal QI model would be the "Model for Improvement:" http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx, which requires a Plan, Do, Study, Act (PDSA) approach to improvement to promote change.

Suggested Documentation

1) Adopt Formal Quality Improvement Model and Create Culture of Improvement - Documentation of adoption of a formal model for quality improvement and creation of a culture in which staff actively participate in improvement activities; and
2) Staff Participation - Documentation of staff participation in one or more of the six identified; including, training, integration into staff duties, identifying and testing practice changes, regular team meetings to review data and plan improvement cycles, share practice and panel level quality of care, patient experience and utilization data with staff, or share practice level quality of care, patient experience and utilization data with patients and families.

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: Participate in Peer Review (MSF-360)process;
Sub-IA-2: Participate in a psychometrically scored clinical peer review program in medical imaging and interventional procedures;
Sub-IA-3: Conduct technical image quality review, with documentation of all imaging views;
Sub-IA-4: Use a clinical peer review tool to assess and accelerate quality improvement processes

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