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2021 MIPS IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements

Activity ID

IA_PSPA_7

Activity Weighting

Medium

Subcategory Name

Patient Safety and Practice Assessment

Activity Description

Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:

  • Performance of activities that promote use of standard practices, tools and processes for quality improvement (for example, documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups);
  • Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);
  • Use of standardized processes for screening for social determinants of health such as food security, employment, and housing;
  • Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or
  • Use of QCDR data for quality improvement such as comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcomes.

Objective

Use qualified clinical data registry (QCDR) data for practice assessment and improvement with primary goal of addressing patient safety for targeted populations.

Suggested Documentation

Documented use of QCDR data for ongoing practice assessment and improvements in patient safety. Include both of the following elements:

1) Use of QCDR for assessment – Feedback reports provided by the QCDR that demonstrate ongoing practice assessments in patient safety; AND
2) Use of QCDR for improvement – Documentation of how the practice is using QCDR data and documentation of intended improvements in patient safety for the specific populations targeted (e.g., documentation of standard tools, processes for screening, use of standard questionnaires, or use of QCDR data that are used for quality improvement, such as population-level analysis to assess for adverse outcomes).

Example/Information

An anesthesia group is supported by a QCDR for quality improvement and MIPS reporting. The QCDR provides routine data feedback reports to the eligible clinicians as part of the engagement. In one of the areas of review, the anesthesiologists realize, through the provided data, that they are inconsistently providing appropriately timed dosing of neuromuscular blocker recovery medication. This creates significant potential for complications at the time of extubation following the procedure. As a result, the anesthesiology group develops a plan that includes checklists to prevent this problem moving forward and they successfully eliminate the safety risk.

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