2024 MIPS IA_PSPA_8: Use of Patient Safety Tools

Activity ID


Activity Weighting


Subcategory Name

Patient Safety and Practice Assessment

Activity Description

In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.

Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.


Improve the number of patients tracked and the precision of measurement for patient safety measures, thus allowing specialists to make evidencebased decisions about improving safety for their patients.

Suggested Documentation

Documented use of patient safety tools implemented for tracking specific patient safety and practice assessment measures that are meaningful to the eligible clinician or group (e.g., tracking HbA1c would be meaningful to an endocrinologist whereas tracking intraocular pressure would be more meaningful to an ophthalmologist). Include both of the following elements:

1) Evidence of safety tools used – Documentation of the use of patient safety tools that assist in tracking patient safety measures (e.g., practice policy or protocol, workflow diagram, screenshot); AND

2) Evidence of measures tracked – Documentation of specific patient safety measures tracked via use of tool (e.g., quality measure report, dashboard, screenshot).


  • Surgical risk calculator
  • Opiate risk tool
  • The Centers for Disease Control and Prevention (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms
  • Use of clinical assessment modalities and diagnostic screening tools in specialty medicine (e.g., World Health Organization’s Fracture Risk Assessment (FRAX) Tool)
  • Use American College of Cardiology Surviving myocardial infarction (MI)
  • Use American College of Physicians (ACP) Practice Advisor; ACP Quality Connect
  • Implement American Gastroenterological Association Clinical Guidelines Mobile App
  • Participate in public health emergency disease outbreak control efforts
  • Participate in voluntary surveillance activity;
  • Use of American Urological Association Symptom Index to increase patient engagement
  • Provide leadership of Infection Prevention and Control Program
  • Conduct therapeutic drug monitoring for inflammatory bowel disease patients that are on antitumor necrosis factor (TNF) therapies
  • Deploy predictive analytical models to manage chronic disease in patients
  • Perform review of Enhanced Recovery after Surgery protocol and implement improvement plan.
  • Document the use of quality measures, evidencebased instruments, and other metrics that contribute to assessing the performance of co-management models, including those focused on
    • patient outcomes (e.g., Risk-adjusted proportion of patients with all cause hospital admissions within the 6-month episode (ID: Oncology Care Model (OCM)– 1), etc.)
    • provider satisfaction (e.g., reliable and valid instruments such as the Satisfaction of Employees in Health Care Survey)
    • patient satisfaction (e.g., Consumer Assessment of Healthcare Providers & Systems® (CAHPS) Cancer Care Survey)
    • cost-effectiveness (e.g., Total Per Capita Cost (TPCC_1))
    • quality of care provided (e.g., Closing the Referral Loop: Receipt of Specialist Report ((ID: 133)).
  • Write policies around performance benchmarks and goals and plans for how providers and clinical practices will reach and implement these goals.

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