2024 MIPS IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways

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Activity Description

Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.

Create a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:

  • Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;
  • Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;
  • Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;
  • Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; or
  • Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.

Optional activities related to this activity (but do not count towards completion of this IA) include the following:

  • Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; and
  • Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.


To create a transparent quality improvement initiative within your practice that engages all staff and/or patients and families that results in a culture that fosters a collaborative team approach.

Suggested Documentation

Evidence of a quality improvement initiative that involves a minimum of three quality measures within a specific MVP that is characterized by all of the following:

1) Within an eligible clinician’s chosen MVP, identify 3 quality measures that will be used for MIPS reporting and develop a quality improvement initiative focused on those measures; AND

2) Identify and collect data at the outset of the quality improvement initiative (with specific goals set for improvement) and at its completion; AND

3) Actively work to develop a culture of quality improvement in the practice: involve all appropriate staff in the initiative, include non-clinical staff if they are in a position to support this quality improvement effort, document training/education of involved staff (e.g., training-session meeting minutes), and incorporate quality improvement updates into team meetings and other communications (e.g., updates, reminders).

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