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2021 MIPS IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes

Activity ID

IA_PSPA_20

Activity Weighting

Medium

Subcategory Name

Patient Safety and Practice Assessment

Activity Description

Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following:   

  • Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; 
  • Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or
  • Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.

Objective

Institutionalize quality improvement within the practice by making it an explicit component of leadership’s roles and responsibilities, thus strengthening the commitment to care quality across the practice.

Suggested Documentation

Evidence of clinical and administrative leadership engagement in regular guidance and demonstrated commitment for implementing improvements. Include at least one of the following elements:

1) Clinical and administrative leadership role descriptions – Documentation of clinical and administrative leadership role descriptions that include responsibility for practice improvement change (e.g., position description); OR
2) Time for leadership in improvement efforts – Documentation of allocated time for clinical and administrative leadership participating in improvement efforts (e.g., regular team meeting agendas and post meeting summaries); OR
3) Population health, quality, and health experience incorporated into performance reviews – Documentation of population health, quality, and health experience metrics incorporated into regular practice performance reviews (e.g., reports, agendas, analytics, meeting notes).

Example/Information

• A large group of eligible emergency clinicians determines that a more structured approach to quality improvement is needed. They appoint the medical director of the group and another eligible clinician to administer the program, and they ensure both have time allocated and are compensated for this work. The program has two components: 1) Traditional Peer Review with a formal process for identifying cases. A group of eligible clinicians is identified who commit to meeting on a regularly scheduled basis reviewing all peer review cases. Further, specified team members follow-up with group and individual eligible clinicians for cases that are educational; and 2) Data Review component that allows the Medical Director and the Quality Administrative clinician to identify an area of practice for review. For example, a decision is made to collect data on all intubations for the subsequent 4 months to identify variability in approach. The data could be used as part of education that will roll out in support of standardizing intubation processes within the emergency department.
• Institute of Healthcare Improvement’s “Model for Improvement”: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx.

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