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2021 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.

Objective

Expand and formalize quality improvement (QI) activities across the practice, ultimately leading to improvements in the quality of care and fostering a culture of participation among staff.

Suggested Documentation

Evidence of the implementation of a formal plan for QI and creation of a culture in which staff actively participates in one or more applicable QI activities. Include both of the following elements:

1) Adopt formal quality improvement plan and create culture of improvement – Documentation of adoption of a formal model for QI and creation of a culture in which staff actively participate in QI activities. Formal QI models are used by eligible clinicians to develop systems, tools, and interventional strategies to improve processes of care for their patient population; AND
2) Staff participation – Documentation of staff participation in one or more of the 6 key areas for improvement*: a) training; b) integration into staff duties; c) identifying and testing practice changes; d) regular team meetings to review data and plan improvement cycles; e) share practice and panel level quality of care; f) patient experience and utilization data with staff; or g) share practice level quality of care, patient experience and utilization data with patients and families.

Example/Information

• *Report from the Institute of Medicine identifies 6 key areas for focus in healthcare quality improvement: http://www.ihi.org/resources/Pages/Publications/CrossingtheQualityChasmA...
• The Institute for Healthcare Improvement’s (IHI) "Model for Improvement" supports creation of a plan for improvement that is focused on the needs of the eligible clinician or practice and their population of patients: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
• The American Academy of Dermatology (AAD) Quality Innovation Center Collaborative.

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