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2021 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.

Objective

Enhance the measurement of the quality of care, making quality data relevant at practice and panel levels, and use those data to implement effective quality improvement activities.

Suggested Documentation

Evidence of quality measurement and improvement at the practice and panel level. Include one or more of the following elements:

1) Performance benchmarks and goals – Performance benchmarks and goals for populations at practice and panel levels, or for specific populations (e.g., racial and ethnic minorities, individuals with disabilities, sexual and gender minorities, individuals with certain chronic conditions/risk factors, or individuals in rural areas) to drive overall improvements; OR
2) 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
3) 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.

Example/Information

• Obtain diagnostic Imaging Center of Excellence (DICOE) designation.
• Participate in Endoscopy Unit Recognition Program (EURP).
• Participate in Simulation Education Courses approved by the American Society of Anesthesiologist's Simulation Education Network.

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