2023 MIPS IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements

Activity ID


Activity Weighting


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 preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians 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 drivers of health, such as food security, housing stability, and transportation accessibility;
  • Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;
  • Use of processes and tools that engage patients to improve adherence to treatment plans;
  • Implementation of patient self-action plans;
  • Implementation of shared clinical decision-making capabilities;
  • Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;
  • Promotion of collaborative learning network opportunities that are interactive;
  • 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 of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.


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).


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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