2024 MIPS IA_PSPA_28: Completion of an Accredited Safety or Quality Improvement Program

Activity ID


Activity Weighting


Subcategory Name

Patient Safety and Practice Assessment

Activity Description

Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:

  • The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;
  • The activity must have specific, measurable aim(s) for improvement;
  • The activity must include interventions intended to result in improvement;
  • The activity must include data collection and analysis of performance data to assess the impact of the interventions; and
  • The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.

An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).


Complete an accredited performance improvement continuing medical education (CME) program, ultimately applying program content to address a specific quality or safety gap.

Suggested Documentation

Documented completion of an accredited performance improvement program that includes active individual participation in the completion of a performance improvement project. Include all of the following elements:

1) Documentation/report of the performance improvement project completed – Documentation to include: a) the specific quality or safety gap and measurable improvement goal; b) the interventions used to result in improvement; and c) data with analysis demonstrating the improvement; AND

2) Confirmation of participation – Documented confirmation of participation and completion in accredited performance improvement program; AND

3) Program details – Details of accredited program must include: a) definition of meaningful eligible clinician participation in their activity; and b) description of the mechanism for identifying eligible clinicians who meet the requirements.


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