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2020 MIPS IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program

Activity ID

IA_PSPA_28

Activity Weighting

Medium

Subcategory Name

Patient Safety and Practice Assessment

Activity Description

Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:

  • The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;
  • The activity must have specific, measurable aim(s) for improvement;
  • The activity must include interventions intended to result in improvement;
  • The activity must include data collection and analysis of performance data to assess the impact of the interventions; and
  • The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information. An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).

Validation

Documentation/Evidence of the completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement (e.g., http://www.astho.org/Accreditation-and-Performance/Accreditation-Readiness-and-Performance-Improvement-Technical-Assistance-to-States/)

Suggested Documentation

Documentation that the activity addresses a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of a needs assessment as part of the activity;

  • The activity must have specific, measurable aim(s) for improvement;
  • The activity must include interventions intended to result in improvement;
  • The activity must include data collection and analysis of performance data to assess the impact of the interventions; and
  • The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements and provide participant completion information.

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: Completion of a Performance Improvement Module, such as Asthma IQ: Patient Management and Outcomes; Asthma IQ: Patient Assessment; PI Pro: Food Allergy; Self-Directed Practice Improvement Module;
Sub-IA-2: Participate in Accredited Continuing Medical Education (CME) or continuing nurse education activities;
Sub-IA-3: Participate in simulation to develop technical and procedural skills;
Sub-IA-4: Participate in Micrographic Surgery & Dermatologic Oncology (Mohs) Fellowship Program;
Sub-IA-5: Participation in voluntary surveillance activity;
Sub-IA-6: Participate in ASGE Skills Training Assessment Reinforcement (STAR) Certificate Program;
Sub-IA-7: Participate in the ASCO Quality Training Program;
Sub-IA-8: Teach students, residents, and allied health professionals in accredited programs;
Sub-IA-9: Demonstrate strengthening Systems and Team‐Based Quality of Care;
Sub-IA-10: Tackling Community Level Diabetes: Overcoming Local Challenges to Patient Health; Using Community-Based Resources to Address Diabetes;
Sub-IA-11: Engage Patient and Stakeholder Partners using Guidance from the PCORI Engagement Rubric;
Sub-IA-12: Participate in AHRQ's Making Informed Consent an Informed Choice: Training for Health Care Professionals

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