2025 MIPS Improvement Activities

Evidence of the creation and implementation of standardized processes for providing telehealth services. Telehealth services may include care provided over the phone, online, etc., and are not limited to the Medicare-reimbursed telehealth service criteria. Include both of the following elements:

1) Standardized processes – Creation of standardized processes for the provision of telehealth services. Examples of documentation include a) description of standardized telehealth processes in an eligible clinician or practice procedures manual; b) workflow diagrams depicting standardized telehealth processes used regularly by an eligible clinician or practice; AND

2) Implementation documentation – Implementation of standardized processes for providing telehealth services. Examples of documentation include a) claims adjudication (may use G-codes to validate); b) electronic health record (EHR); or c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient in accordance with standardized processes.

Develop an improvement plan informed by patient experience and satisfaction data, including any differences across demographic groups, so that eligible clinicians can use data-driven approaches to improve patient access and quality of care.

Evidence of documented improvement plan for access to care and quality based on collected and stratified patient experience and satisfaction data. The goals for improvement can be defined broadly or within certain population strata. CMS examples of stratification may include patient demographics such as race/ethnicity, disability status, sexual orientation, sex, gender identity, or geography. (It is acknowledged that some stratification data may not be available). Include both of the following elements:

1) Patient experience and satisfaction data on access to care – Data collected through a patient experience survey for a population defined by the eligible clinician. For example, eligible clinicians could give the survey to all patients seen within a defined study period. Data can be prepared in any useful format, or as they were collected; AND

2) Improvement plan – Documentation of an improvement plan, which should include specific activities, goals, and outcomes for addressing access to care. For example, an eligible clinician may observe that non-English-speaking patients were not confident in their interactions with eligible clinicians because of language barriers. A possible plan could include using translators, remote translation services, or language training. The improvement plan would include details regarding who would be trained with timelines for completion.

Use learnings from engagement with Quality Innovation Network-Quality Improvement Organization (QIN-QIO) technical assistance to design, plan, and initiate implementation of new activities, ultimately improving access to services or care coordination.

Evidence of implementation of newly added processes, practices, resources, or technology to improve access to services or improve care coordination as a result of receiving QIN-QIO technical assistance. Include both of the following elements:

1) Relationship with QIN-QIO technical assistance – Confirmation of technical assistance and documentation of relationship with QIN-QIO (e.g., signed letter of agreement, email exchange); AND

2) Activities – Documentation of planned and/or tested activities that improve access or improve care coordination, including support for newly offered services.

Help CMS improve the content provided on the Quality Payment Program (QPP) website.

Evidence of user participation and implementation of website testing for the QPP. Eligible clinicians must be verified on CMS User/Tester list and be able to share at least one of the following elements:

1) Improvement input – Documentation of specific input to improve the CMS QPP website through product user-testing aimed at enhancing system and program accessibility, readability, and responsiveness (e.g., saved emails, Word document with notes); OR

2) Tool/guidance development feedback – Documentation of specific feedback for developing tools and guidance for a more efficient and accessible clinician and practice QPP website experience (e.g., saved emails, Word document with notes).

Improve quality of care and patient outcomes by ensuring clear and culturally relevant communication with patients with limited English proficiency.

Evidence of a practice-wide review and implementation of a plan to language access. Include all of the following elements:

1) Review - Documentation of a practice-wide review of existing tools and policies; AND

2) Gap analysis memo - Completion of a memo comparing the results of the above review with the four standards on communication and language assistance stipulated in the National CLAS Standards; AND

3) Plan to improve language access - A new or updated plan, which includes information on patient needs (i.e., common languages spoken, percent of practice’s population that has low English proficiency), defines how interpretation will be provided, outlines how patients and families will be notified about interpretation services, and specifies staff training; AND

4) Plan Implementation - Report comparing the results from implementing the new or updated language access plan with the four standards on communication and language assistance stipulated in the National CLAS Standards and documenting where gaps have been closed or still remain.

Improve patient understanding and adherence while reducing the risk of medication errors and adverse drug events.

Evidence of participation by patients who have anti-coagulation medication prescriptions in one or more of the clinical practice improvement activities listed in the Activity Description. Include all of the following elements:

1) Patients receiving anti-coagulation medications – Total number of outpatients prescribed oral Vitamin K antagonist therapy (e.g., claims, electronic health record report); AND

2) Percentage of that total being managed by one of the methods of care in the Activity Description – Number of outpatients prescribed oral Vitamin K antagonist therapy and who are being managed by one or more of the four activities in the Activity Description; AND

3) Patient-centered plan – Documentation that the plan addresses patients' language and communication needs, literacy level, and cognitive and functional limitations.

Improve quality of care and formal quality improvement and reporting for Native Americans, Alaskan Natives, populations served by Rural Health Clinics (RHC), and Federally Qualified Health Centers (FQHC).

Evidence of quality improvement activity participation as part of RHC, Indian Health Service (HIS), or FQHC participation. By vulnerable populations/patients, CMS is referring to racial and ethnic minorities, refugees, those who are elderly, financially disadvantaged, or without health insurance, and those who have a disability or medical condition which are associated with disparities in outcomes across populations. Include both of the following elements:

1) Name of RHC, IHS or FQHC – Identified name of RHC, IHS, or FQHC in which the eligible clinician participates in ongoing engagement activities; AND

2) Continuous quality improvement activities - Documented continuous quality improvement activities aimed at services provided to RHC, IHS, or FQHC patients. To the extent possible, these quality improvement activities should contribute to more formal quality reporting, and should include receiving quality data back for broader quality and benchmarking improvement (e.g., data reports or dashboards tied to quality improvement projects).

Improve diabetes care by defining and documenting individualize glycemic control goals.

Evidence of report identifying diabetic patients who are taking diabetes medication and have documented glycemic treatment goals based on patient-specific factors. Include all of the following elements:

1) Diabetic patients prescribed antidiabetic agents – Total number of outpatients who are diabetic and prescribed antidiabetic agents; AND

2) Percentage of that total with glycemic treatment goals – Percentage of outpatient Medicare beneficiaries, who are diabetic and prescribed antidiabetic agents, with documented glycemic treatment goals. The goals must encompass patientspecific factors, including at least: a) age, b) comorbidities, and c) risk for hypoglycemia; AND

3) Annual assessment – Documented evidence of annual assessment for patients receiving glycemic treatment services (e.g., list of patients flagged for reassessment the following year, dated chart notes in an electronic health record).

Improve specific chronic condition health outcomes for community populations served by an eligible clinician or practice by implementing evidencebased practices and partnership with a Quality Improvement Organization (QIO).

Evidence of implementation of activity to improve specific chronic condition (e.g., diabetes, chronic kidney disease, hypertension) for specific identified population within the community. Include both of the following elements:

1) Documentation of partnership in the community – Screenshot of QIO website or other correspondence that identifies your organization as one of the key partners and stakeholders and that lists the activity that will be implemented, with details on the specific chronic condition and population targeted; AND

2) Plan for improving community health – QIO report, document, or correspondence detailing steps being taken to satisfy the activity. May include: timeline, purpose, anticipated outcome(s), and relevant tools (e.g., Population Health Toolkit).

Decrease healthcare inequities and improve health status in underserved communities.

Evidence of activity to decrease healthcare inequities. Include both of the following elements:

1) Population health data analysis resources used – Documentation of resources used to identify health inequities in the practice’s population and to assess options for intervention; AND

2) Implementation report – Report with action plan for implementing the selected intervention (including the health inequity targeted, detailed plan for improvement, and the specific outcomes targeted for improvement), and results from its implementation.

Improve understanding of targeted populations’ unique needs to tailor clinical treatments, address structural inequities, and better utilize community resources.

Evidence of participation in identification and reviews of targeted patient population needs. Include all of the following elements:

1) Targeted patient population identification – Documentation of method/s for identification and ongoing monitoring of a targeted patient population (e.g., policy or protocol), including stratification of patient data by demographic characteristics and, as needed, health-related social needs to appropriately identify differences among populations and assess drivers of gaps and inequities, as well as identifying interventions appropriate for the needs the targeted population; AND

2) Review of targeted population’s unique characteristics and needs – Report that compiles information on the unique characteristics of the targeted patient population, including inequities in relevant outcomes; ways to tailor clinical treatments to meet needs and reduce inequities (e.g., clinicians treating Black men, who have a higher incidence of prostate cancer, may choose to evaluate that population for consistency of screening); and lists of community resources that can further support patients with these needs outside of the clinical setting; AND

3) Implementation Report – Report with action plan detailing steps the practice has taken to address the results of its targeted population identification and needs assessment.

Strengthen patient-clinician relationships, making it possible to provide comprehensive, patientcentered primary care.

Evidence of patient population empanelment including use of panels for health management. Include both of the following elements:

1) Active population empanelment – Identification and selected operational definition of "active population" of the practice with empanelment and assignment confirmation linking patients to eligible clinician or care team (e.g., electronic health record report, Excel document); AND

2) Process for updating panel – Documented policy and/or process for review and update of panel assignments (e.g., detailed policy about frequency of review, stepwise guidance document for how to empanel new patients or reassign existing patients).

Improve effectiveness, efficiency, and patient-centeredness of preventive and chronic care provided to empaneled patients.

Evidence of chronic and preventative care management for empaneled patients via an individualized plan of care as appropriate to age and health status, including a) health risk appraisal; b) gender, age, and conditionspecific preventive care services (e.g., managing cardiovascular risk in patients with diabetes); and c) plan of care for chronic conditions (could use electronic health record [EHR] or medical records). Include at least one of the following elements:

1) Individualized plan of care – Documented indication of annual opportunity for development and/or adjustment of an individualized plan of care appropriate to age and health status (e.g., EHR alert or dated medical record note). Plan of care may include disease-specific services, such as Diabetes SelfManagement Education and Support (DSME/S) services and Medical Nutrition Therapy (MNT); OR

2) Condition-specific pathways – Documented use of evidenced-based condition-specific pathways for chronic conditions (e.g., hypertension, diabetes, depression, asthma, heart failure). These might include, but are not limited to, the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP); OR

3) Pre-visit planning – Use of pre-visit planning to optimize preventive care and team management (e.g., workflow indicating pre-visit planning process); OR

4) Panel support tools – Use of panel support tools (e.g., registry or other technology) to identify services that are due in patient records; OR 

5) Reminders and outreach – Use of reminders and outreach (e.g., phone calls, emails, postcards, patient portals) to alert and educate patients about services due and/or routine medication reconciliation (e.g., workflow indicating reminder and outreach process, outreach language, screenshot of reminders); OR

6) Risk prediction report – Documentation of the predictive analytical models used to predict risk, onset, and progression of chronic diseases for patient population.

Improve health outcomes and patientcenteredness of care for patients at high-risk for adverse health outcomes or harm.

Evidence of longitudinal, or relationship-based, care management of patients at high-risk for adverse health outcomes as defined by the eligible clinician. Include both of the following elements:

1) List of high-risk patients – Identification of patients at high-risk for adverse health outcome or harm; AND

2) Use of longitudinal care management – Documented use of longitudinal care management methods including at least one of the following: a) empaneled patient risk assignment and risk stratification into actionable risk cohorts; b) personalized care plans for patients at high risk for adverse health outcome or harm; or c) evidence of use of care managers to monitor and coordinate care for highest risk cohorts.

Use episodic care management to improve quality of care and communication across referrals and transitions of care.

Evidence of episodic care management practice improvements. Include at least one of the following elements:

1) Follow-up on hospitalizations, emergency department (ED), or other visits, and medication management – Routine and timely follow-up to hospitalizations, ED, or other institutional visits, and medication reconciliation and management (e.g., documented in medical record or electronic health record [EHR]); OR

2) New diagnoses, injuries and exacerbations – Intensive care management at time of new diagnoses, injuries, and exacerbations of illness documented in medical record or EHR.

Maximize the efficiency, effectiveness, and safety of care across settings by strengthening medication management.

Evidence of newly implemented medication management practice improvements. Eligible clinicians should include all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements a patient is currently taking within the purview of the medication management process. Include at least one of the following elements:

1) Documented medication reconciliation – Patient medical records demonstrating periodic structured medication reviews or reconciliation, which includes updating, reviewing, or obtaining each medication’s name, dosage, frequency, and administered route; OR

2) Integrated pharmacist – Evidence of pharmacist integrated into care team; OR

3) Reconciliation across transitions – Patient medical record demonstrating medication reconciliation at the time of the transition. For example, when a patient is being discharged from hospital to home, the reconciliation would be completed at discharge from a hospital by the discharging eligible clinician and at follow-up by the outpatient and/or primary eligible clinician; OR

4) Medication management improvement plan – Report detailing medication management practice improvement plan, and outcomes, if available. For example, the "Agency for Healthcare Research and Quality (AHRQ) Create a Safe Medicine List Together" strategy could be implemented.

Contribute to the development of evidencebased interventions, tools, or processes for improving health outcomes.

Evidence supporting participation in a federally and/or privately funded research initiative to identify systems, tools, or strategies that improve patient outcomes for a targeted population. Include both of the following elements:

1) Confirmed participation – Documentation of participation in a federally and/or privately funded research initiative; AND

2) Research intervention details – List of the interventions, tools, or processes used in the research including identified population(s) and health outcomes targeted.

Help patients and families access the right community resources for improving/maintaining health, education, and self-sufficiency with support from community health workers.

Evidence of engagement with community health workers to provide a comprehensive link to community resources and family-based services with an emphasis on improving health, education, and self-sufficiency. Include all of the following elements:

1) Community health worker engagement – Documentation of active engagement with community health workers to collaborate in helping patients served by the practice address risk factors related to social determinants of health (e.g., electronic health records referencing community health worker engagement, paperwork related to engagement of community health workers); AND

2) Coordination and patient engagement – Documentation of coordination with primary care and other eligible clinicians to engage and support patients (e.g., use of health information technology); AND

3) Measure and monitoring – Evidence of use of quality measurement and improvement processes (e.g., National Committee for Quality Assurance’s Patient-Centered Connected Care [PCCC] Recognition Program or similar programs) to continuously improve engagement and coordination with community health workers and other clinicians in an effort to improve patient wellbeing and health (e.g., dashboards, reports).

Screen more patients at risk for diabetes.

Evidence demonstrating the implementation of an abnormal blood glucose screening program focused on at-risk populations. The population/s for this activity are to be defined by the eligible clinician and might include (but are not limited to): patients over a certain Body Mass Index, patients with a family history of diabetes, or patients of an atrisk race or ethnicity. Include both of the following elements:

1) At-risk population identified – Total stratified number of Medicare patients at risk for abnormal blood glucose; AND

2) Percent of population screened – Total number and percentage of at-risk population screened for abnormal blood glucose as outlined by the US Preventive Services Task Force and/or American Diabetes Association guidelines.

Refer more patients with pre-diabetes to a recognized preventive program to help prevent or slow disease progression.

Evidence demonstrating the implementation of a comprehensive approach for screening for prediabetes. Include both of the following elements:

1) Identified Medicare patients at-risk – Total stratified number of Medicare patients at risk for abnormal blood glucose as outlined by the US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines; AND

2) Percentage of patients receiving diabetes prevention program referral – Total number and percentage of the at-risk population receiving referral to a Centers for Disease Control and Prevention recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.

Increase the frequency and quality of advanced care planning and documentation.

Evidence supporting implementation of practices/processes to improve advance care planning. Include all of the following elements:

1) Documentation approach – Standardized approach to documenting advance care plan or living will within the medical record (e.g., a medical record template or other defined, standardized method to include specific attributes defined by the eligible clinician) and storage of any relevant copies of patient documents when appropriate; AND

2) Patient identification – Identification of the population of patients, as defined by the eligible clinician (e.g., all patients over 65, patients with specific diagnoses, all patients) who would be subject to the eligible clinician’s practices/processes for encouraging advance care planning; AND

3) Eligible clinician education on advance care planning – Documentation of eligible clinician education (e.g., training curriculum or agenda, training materials) on approaches to advance care planning at the level of the individual patient.

Narrow gaps and inequities in care related to HIV prevention in clinical practice, and highlight HIV prevention guidelines, including recommendations to enhance prevention screening and PrEP awareness and use.

Evidence supporting HIV prevention screening and linkage to appropriate prevention resources. Include all of the following elements:

1) Identification of patients at HIV risk – Standardized approach to identifying patients (ages 13 and 64) at risk for HIV as recommended by Centers for Disease Control (CDC) with documentation of risk in patient records; AND

2) Percentage of patients receiving PrEP information – Information provided to all sexually active adult and adolescent patients about HIV pre-exposure prophylaxis (PrEP), and recommending PrEP as an effective HIV prevention strategy; AND

3) Follow-up – Documentation of follow-up processes for patients who have been screened for HIV, including documentation of discussion/s with clinician/s and decisions made, in patient records.

Help eligible clinicians align cervical cancer screening and management with up-to-date, evidencebased standards and guidelines as part of routine care.

Documented integration of the CCSM CDS tool into EHR and use of the tool. Include both of the following elements:

1) Integration of the CCSM CDS tool into EHR – Documentation (e.g., screenshot) demonstrating implementation of the CCSM CDS tool into an eligible clinician's or practice's EHR.

2) Use of the CCSM CDS tool to help clinicians evaluate patients' clinical data against existing guidance and make patient-specific recommendations – Documentation (e.g., screenshot) demonstrating ongoing use of the CCSM CDS tool in relevant patient populations in eligible clinicians’ practice.

Improve clinician-to-clinician communication to prevent delayed and/or inappropriate treatment while increasing patient satisfaction and adherence to treatment.

Evidence that relevant records from patient/consultant (internal or external specialist) interactions are sent to the referring eligible clinician. Include one of the following elements:

1) Report – Evidence that the consultant always sends a report to the referring eligible clinician; OR

2) Process for capturing referral information – Evidence that the referring eligible clinician has a defined method for capturing reports in the medical record (e.g., a) reports transmitted between electronic health records [EHRs]; b) documents that are electronically scanned and linked to the patient’s EHR; or c) chart documentation of the relevant details of the consultant patient interaction such as notes written into a progress note).

Reduce risk of patient harm that occurs when abnormal test results are not delivered in a timely way.

Evidence of a process that reduces the time needed before communicating test results to the patient. The eligible clinician may define the population of patients within their practice for the improvement based on specific test ordered, patient diagnosis, or another factor. Include all of the following elements:

1) Population identified – Characteristics of the population targeted and methods for capturing the entire population within your practice; AND

2) Documentation of method/s of communication and benchmark for timeliness of communication – The benchmark for timeliness of communication can be determined and measured in a variety of ways and should be defined by the eligible clinician in a way that will best meet the goals of the activity (e.g., actual times from an electronic health record or improvements in customer service reviews); AND

3) Improvement strategies – The strategies used to improve timeliness are defined and must be documented by the eligible clinician.

Utilize preferred practice patterns within your practice to improve care coordination.

Evidence of participation in/implementation of regular care coordination training within the attestation period. Include the following element:

1) Care coordination training – Examples include availability of care coordination training curriculum/training materials and attendance or training certification registers/documents

Develop and utilize processes that improve care coordination outcomes.

The eligible clinician identifies an area within their practice in which improved care coordination will improve an outcome. The area(s) for improvement, intervention strategies, and the outcome goals are to be defined by the eligible clinicians involved. Evidence of newly implemented processes and practices to improve care coordination, including both of the following elements:

1) Care coordination process documentation – Documentation of the implementation of practices/processes that document care coordination activities (e.g., record of meeting minutes to discuss changes, swim lane workflow diagram, agenda noting training on new practices/processes for staff, copy of old and new practices/processes on documenting care coordination activities); AND

2) Care coordination outcomes – Documentation of, or ability to demonstrate evidence of, the outcomes from newly implemented practices/processes.

Develop, maintain, and share personalized care plans with at-risk patients to promote patientcentered care and improve patient experience.

Evidence of processes for developing and updating individual care plans for atrisk patients and sharing them with beneficiary and/or caregiver. Areas of focus and consideration might include social determinants of health, language and communication preferences, physical or cognitive limitations, as well as desired outcomes of care. Include both of the following elements:

1) Individual care plans for at-risk patients – Documentation of process for developing individual care plans for clinician-defined at-risk patients (e.g., template care plan, standardized type of note in the health record); AND

2) Use of care plan with beneficiary – Patient medical records demonstrating the documentation of the care plan using a standardized approach.

Define and implement a standardized process for transitions of care that are relevant to the eligible clinician’s patient population.

Evidence of processes for preparing and implementing patient-centered care transition plans for the first 30 days following a discharge. Include at least two of the following elements:

1) Patient-centered care transition action plans – Documented plans to include out-patient follow-up, medication reconciliation, and post-discharge support. May include: a) patient communications and language preferences; b) available supports and services (medication availability and travel capability); c) patient’s discharge environment, or d) out-patient follow-up plan; OR

2) Implementation of action plan within first 30 days of discharge – May include: a) documentation of staff involved in the care transition; b) records of real-time communication between eligible primary care clinicians and consulting eligible clinicians; or c) records of eligible primary care clinicians included on specialist follow-up transition communication, etc.; OR

3) Patient communication and delivery of support services according to patient preferences within first 30 days of discharge – Examples from patient records that demonstrate conformity with patient preferences. May include: a) patient-preferred communication activities such as phone calls conducted in support of transition; b) accompaniments of patient to appointments or other navigation actions; c) home visits; patients’ access to their medical records; or d) translated discharge materials, etc.; OR

4) Processes for care transition planning – Documentation that defines the steps the eligible clinician will take to prepare and implement the patient-centered care transition plan with every patient.

Enhance communication during care transitions to improve patient outcomes by establishing standard operations, or preferred practice patterns, for transition communications.

Evidence of information flow during transitions of care. Include at least one of the following elements:

1) Communication lines with local settings – Documentation of standardized lines of communication to manage transitions of care between settings. Communication can occur in whatever format is most useful based on the circumstances of the eligible clinicians; OR

2) Partnership with community or hospital-based transitional care services – Documentation showing partnership with community or hospital-based transitional care services (e.g., written agreement, workflow documentation).

Improve processes for care coordination and active referral management, thus making care more effective and efficient, preventing risky delays and under-treatment, and increasing patient satisfaction and adherence to treatment.

Evidence of care coordination and referral management. Include at least one of the following elements:

1) Care coordination agreements – Documentation of care coordination agreements that establish flow of information and provide patients with information to set consistent expectations; OR

2) Tracking of patient referrals to specialists – Medical record or electronic health record documentation demonstrating tracking of patients referred to specialists through the entire process; OR

3) Referral information integrated into the plan of care – Samples of specialist referral information systematically integrated into the plan of care.

Utilize a program or process that provides an open exchange of necessary patient information between care teams and patients to guide patient care.

Evidence of full access to patient information (between care team and patient) to guide patient care. Required clinical documentation from a medical record available in a patient portal using United States Core Data for Interoperability (USCDI) standards, including consultation, as relevant to each patient. Medical records that are not required to be available include psychotherapy notes that are separated from the rest of the individual’s medical record and information compiled in reasonable anticipation of, or use in a civil, criminal, or administrative action or proceeding.

Participate in a Perioperative Surgical Home (PSH) model to improve coordination of patient care through the acute-care episode, recovery, and postacute care.

Evidence of participation in a PSH model that provides a patient-centered, clinician-led, interdisciplinary, and team-based system of coordinated patient care. Include at least one of the following elements:

1) Coordination with care managers/navigators in preoperative clinic – Documented conversations with care managers/navigators (e.g., electronic health record note) to plan and implement comprehensive post-discharge plan of care that could take into account patients' post-discharge environment and support system out of the hospital; OR

2) Perioperative care process improvements – Documentation of evidence-informed perioperative clinic and care processes implemented to standardize care across the spectrum of surgical patients (e.g., workflow diagrams, word document of written policies and procedures); OR

3) Patient education and improvement – Implement processes to ensure effective communication of and education on patients' discharge instructions, taking into account patients' literacy level, language and communication preferences, and cognitive or functional impairments.

Improve whole-person care by establishing bidirectional communication between eligible primary care clinicians and behavioral health practices for shared patients.

Evidence of collaboration and bidirectional flow of patient information between eligible primary care clinician(s) and behavioral health practice/s where electronic health records (EHRs) share common patients. Include the following element:

1) Communication exchange – Documentation of established bidirectional communication and information-sharing between primary care and behavioral health practices that share common patients or use the same EHR systems.

Reduce avoidable hospital readmissions and make hospital stays less stressful and recovery periods more supportive for patients.

Evidence of participation in a Patient Navigator Program (PNP) designed to meet this activity’s objective. Include all of the following elements:

1) PNP participation – Confirmation of participation in PNP. PNP should take into account patients' language and communication preferences, literacy level, and cognitive and physical disabilities; AND

2) Documentation of tools to reduce avoidable hospital readmissions – Tools should be evidencebased whenever possible; AND

3) Quality improvement strategies – Implementation of systems, tools, and strategies as part of the PNP that aim to achieve the objective of this activity. May include workflows and approaches that assist patients with communicating with eligible healthcare clinicians regarding their questions, obtaining information about their procedures/treatments, and arranging for test or appointments.

Improve quality of patient-clinician communication and interaction by attending training on relationship-centered care and communication techniques.

Evidence that the eligible clinician spent a minimum of eight hours of training focused on relationship-centered care. Include both of the following elements:

1) Certificate of completion – Documentation of completing 8 hours of training with patient-centered care training title, eligible clinician's name, and date of completion (e.g., certificate of completion, screenshot of module completion). The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills listed in the activity description, or didactic instructions on how to a) implement improvement action plans; b) monitor progress; and c) promote stability around improved clinician communication; AND

2) Details on patient-centered care training – Provide details on patient-centered care training components. Training should include such topics as: a) making effective open-ended inquires; b) eliciting patient stories and perspectives; c) listening and responding with empathy; d) using a specific technique such as ART (ask, respond, tell) to engage patients; or e) developing a shared care plan.

Increase the utilization of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) patient relationship codes (PRC) using the applicable Healthcare Common Procedure Coding System (HCPCS) modifiers on Medicare claims. Using PRC ensure that appropriate attribution is assigned to the appropriate eligible clinician. For example, it would be inappropriate to attribute the cost of an aortic aneurysm repair to the ophthalmologist who performed a cataract surgery in the same calendar year.

Documentation that MIPS eligible clinician(s) reported MACRA PRC using the applicable HCPCS modifiers on 50% or more of their Medicare claims MACRA patient relationship codes articulate the relationship and responsibility of an eligible clinician with a patient at the time of furnishing an item or service, thereby facilitating the attribution of patients and episodes to one or more eligible clinicians for purposes of cost measurement. Include the following element:

1) MACRA PRC HCPCS modifiers on 50% of Medicare claims – Documentation could be captured in the patient chart or electronic health record; note that the eligible clinician reported MACRA PRC using the applicable HCPCS modifiers on 50% or more of their Medicare claims for a continuous 90-day minimum reporting period within the performance year.

Improve patient engagement through patient/clinician review of patient collected information or through assessment of a patient’s understanding, confidence, and ability to perform selfcare.

Evidence of patient reported data and/or outcomes in the certified electronic health record technology (CEHRT). Include the following element:

1) Patient reported outcomes/self-management – Documentation demonstrating use of one or more measures that assess patients’ involvement in their care or their understanding, confidence, and ability to care for oneself. The eligible clinician should incorporate the results of the assessment into the patient’s overall plan of care, as deemed most appropriate for their population. As necessary or helpful, also include patient’s data in the CEHRT.

Become more equipped to help patients self-manage their chronic conditions.

Evidence of Quality Innovation Network-Quality Improvement Organization (QIN-QIO) relationship to implement selfmanagement training programs. Include the following element:

1) QIN-QIO engagement – Documentation from QINQIO of eligible clinician or group's engagement and use of services (e.g., email exchange, participation letter, listed on QIN-QIO website as partner) to assist with participation in self-management training program(s) such as the Diabetes Self-Management Program (DSMP).

Increase patient engagement, adherence to treatment plans, and self-management of chronic conditions through the availability of a patient portal within the electronic health record (EHR).

Evidence of a functioning patient portal that includes patient interactive features or up-to-date information on disease or symptom management. Include at least one of the following elements:

1) Enhanced patient portal screenshots – Documentation through screenshots of an enhanced patient portal that displays at least one of the following functions or features: a) bidirectional communication between patient and eligible clinician or care team (e.g., messaging for questions, medication refills, appointment scheduling); or b) availability of health information and education regarding the patient’s conditions; OR

2) Patient portal use reports – Reports of patient portal engagement detailing patient use of interactive functions (e.g., bidirectional communication between patient and eligible clinician or care team about medication changes and adherence).

Ensure eligible clinicians' website content and tools more accessible to people with disabilities

Evidence that updated practice website/tools are compliant with Section 508 and thus provide improved access for patients with disabilities. Include both of the following elements:

1) Regular updates and Section 508 compliance process – Documentation of a process for regular updates and ensuring Section 508 compliance for the eligible clinician's patient portal or website; AND

2) Compliant website/tools – Screenshots or hard copies of the practice's website/tools demonstrating key aspects of Section 508 compliance.

Improve patients' experience of and satisfaction with care by gathering and applying learnings from relevant data to make care more patient-centered.

Evidence that patient experience and satisfaction data are collected, and that follow-up occurs through an improvement plan. Include at least two of the following elements:

1) Report of patient experience and satisfaction – Report including collected data on patient experience and satisfaction (e.g., survey results). Report may include description of effort to implement patient surveys in multiple languages based on the needs of the patient population. The eligible clinician or practice may use a third-party administrator; AND/OR

2) Follow-up on patient experience and satisfaction – Documentation that the eligible clinician’s practice has implemented changes based on the results of the patient experience and satisfaction data gathered and analyzed (e.g., specific improvements made to practices/processes in response to survey results); AND/OR

3) Patient experience and satisfaction improvement plan – Documentation of a patient experience and satisfaction improvement plan.

Increase use of evidence-based decision aids to encourage shared decision-making with beneficiaries.

Documented use of evidence-based decision aids to support shared decision-making, a collaborative process aimed at improving beneficiary-clinician communication and informed consent in healthcare. Include the following element:

1) Use of decision-aids – Documentation (e.g., checklist, algorithms, tools, screenshots) showing the use of evidence-based decision aids (e.g., https://decisionaid.ohri.ca/AZlist.html and https://shareddecisions.mayoclinic.org/decision-aidinformation/decision-aids-for-chronic-disease/) to support shared decision-making with beneficiary.

Use active devices and platforms to allow the patient and the clinical care team to share information on a patient's status, adherence, comprehension, and indicators of clinical concern in a timely manner.

Evidence of engagement with patients and families by using digital tools for ongoing guidance and assessments outside the encounter. Include both of the following elements:

1) Use of digital tool or platform – Documentation of the practice’s adoption of an endorsed clinical tool or platform for digital collection and use of patient data that can create an active feedback loop between patient and clinical care team (e.g., license for tool/platform); AND

2) Collection of patient-generated health data (PGHD) and participation in active feedback loop with patients – Documentation of PGHD submission in realor near-real-time to the care team, or reports generating clinically endorsed real- or near-real-time automated feedback to the patient, including patient reported outcomes (PROs); may be used for patients and families who need additional support because of disability or plans to improve their quality of life or return to work.

Increase engagement with patients, family, and caregivers and ensure care provided aligns with their priorities and needs.

Evidence of inclusion of patients, family, and caregivers in developing plan of care with prioritization of goals for action, as documented in the electronic health record (EHR). The eligible clinician will identify the patient population that will participate in this activity. Include the following element:

1) Patient, family, and caregiver involvement – Report or screenshot from the EHR showing the plan of care and prioritized goals for action with notes from engagement of patients and/or their families and caregivers. May use another electronic platform to systematically capture patient preferences/value through a validated patient experience measure instrument.

Improve health outcomes by helping patients improve self-management.

Documented use of culturally and linguistically tailored evidence-based techniques to promote self-management into usual care. Include both of the following elements:

1) Patient literacy and language capture – Documentation of patient literacy level and/or anguage preference captured in the medical record (e.g., screenshot, electronic health record [EHR] report); AND

2) Provision of appropriate self-management care techniques – Documented use of evidence-based techniques to promote self-management into usual care (e.g., eligible clinicians' completed office visit checklist, electronic health record report of completed checklist, copies of goal-setting tools or techniques, motivational interviewing script/questions, action planning tool with patient feedback, record of condition-specific self-management coaching). Materials must be provided in a format appropriate for the patient's literacy and/or language preference.

Give patients with common chronic conditions opportunities to learn about selfmanagement topics and discuss shared concerns while improving efficiency in the delivery of quality care.

Documented use of group visits for chronic conditions. Could be supported by claims. Include the following element:

1) Provision of group visit(s) – Medical claims or referrals showing group visit and chronic condition codes in conjunction with care provided.

Increase the efficiency and effectiveness of visit time with patients, and promote patient engagement and satisfaction with care.

Evidence that a pre-visit agenda was shared and/or developed with patients prior to visit. Include at least one of the following elements:

1) Pre-visit communication with patient – Documentation of communication with patient (letter, email, discussion, portal screenshot, etc.) that shows a pre-visit agenda was shared with and/or developed with the patient; OR

2) Patient engagement workflow – Documentation of the practice's patient engagement workflow clearly showing pre-visit agenda sharing process (e.g., staff responsible, timing, method of sharing); OR

3) Co-creation of visit agenda – Documented strategies to engage patients and their family members to co-create a visit agenda (e.g., workflow diagram, policy or process document).

Provide additional direct support to patients in achieving their goals, thus improving patient satisfaction, adherence to plans, and health outcomes.

Documented use of coaching provided between visits with follow-up on care plan and goals, for a population of the eligible clinician’s choosing (e.g., patients with a specific condition). Include the population identified for this activity and at least one of the following elements:

1) Use of coaching codes – Medical claims with codes for coaching provided between visits; OR

2) Coaching plan and goals – Copy of documentation provided to patients (e.g., letter, email, portal screenshot) that includes coaching on care plan and goals; OR

3) Coaching tools used – Examples of coaching tools used by staff (e.g., coaching scripts, tools, materials).

Help patients navigate the stress and risks associated with paying for healthcare, and, when relevant, help them explore alternative options that address their holistic needs.

Demonstration that the practice provides patients with estimates of the costs of the types of healthcare services it will furnish in advance (for services that can be scheduled in advance) and financial counseling to patients or their caregivers about payment options. Financial counseling may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate. Include both of the following elements:

1) Estimated cost of care provided – Documentation that an estimate of the cost to the patient of the types of healthcare services to be furnished by the eligible clinician(s) was provided to patient in advance (for services that can be scheduled in advance); AND

2) Financial counseling provided – Documentation of financial counseling provided to patients and/or their caregivers about costs of care with evidence that different payment options were provided.

Help patients navigate the stress and risks associated with paying for healthcare by providing information on the patients’ share of the costs for medications in the drug formulary; help patients explore alternative options that address their holistic needs.

Documented provision of counseling to patients and/or their caregivers regarding the costs of medications using the Real-Time Benefit Tool (RTBT). Include both of the following elements:

1) Use of RTBT – Evidence of RTBT used in practice (e.g., workflow diagram, screenshot of tool) to provide real-time patient-specific formulary and benefit information for medications, including cost-sharing for a beneficiary and counselling on medication costs; AND

2) Discussion of alternative medications and assistance programs – Documentation (e.g., EHR or medical record note) of discussion/counseling with patients about the availability of any alternative medications (such as generics) and the patients’ eligibility for patient assistance programs that provide free medications for patients who are unable to afford to buy their medicine. For this activity, patient assistance programs pertain to patients who require assistance to purchase necessary medications

Adopt and implement Patient Safety Organization (PSO) methodologies through data collection, analysis, reporting, and education to promote the quantifiable reduction of avoidable medical errors and deficiencies identified in the quality of care provided.

Evidence of participation in an Agency for Healthcare Research and Quality (AHRQ)-listed PSO. Include the following element:

1) Confirmation of participation – Documentation from an AHRQ-listed PSO confirming the eligible clinician or group's participation with the PSO (e.g., welcome email or other communication).

Maintain certifications with a Maintenance of Certification (MOC)-approved specialty board to increase/update knowledge and apply it to practice and safety improvements.

Evidence of participation in MOC Part IV. Include the following element:

1) Confirmation of participation – Documentation of participation in MOC Part IV.

Obtain a Maintenance of Certification (MOC)-approved specialty board certification or other similar program to increase/update knowledge and apply it to practice and safety improvements.

Evidence of participation in Institute for Healthcare Improvement (IHI) Training/Forum Event: National Academy of Medicine, AHRQ Team STEPPS®, or other similar activity. Include the following element:

1) Certificate of participation – Certificate or letter of participation from an IHI Training/Forum Event: National Academy of Medicine, AHRQ Team STEPPS®, or the American Board of Family Medicine Performance in Practice Modules, or other similar activity, for eligible clinicians or groups not participating in MOC Part IV.

Create the opportunity to i) Raise staff awareness about patient safety; ii) Elucidate and assess the current status of patient safety culture; iii) Identify strengths and areas for patient safety culture improvement; iv) Evaluate trends in patient safety culture change over time; and v) Evaluate the cultural impact of patient safety initiatives and interventions (from https://www.ahrq.gov/sops/about/faq.html#Q1).

Evidence of administration of the Agency for Healthcare Research and Quality (AHRQ) survey of Patient Safety Culture and submission of data to the comparative database. Include the following element:

1) Survey results data submission – Survey results from the AHRQ Survey of Patient Safety Culture, including proof of administration and submission.

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

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).

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.

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).

Gain the knowledge to "improve practice efficiency and ultimately enhance patient care, physician satisfaction and practice sustainability" (from https://edhub.ama-assn.org/stepsforward/pages/About).

Evidence of completion of American Medical Association’s (AMA’s) STEPS Forward program. Include at least one of the following elements:

1) Certificate of completion – Certificate of completion from at least one AMA’s STEPS Forward program module; OR

2) Evidence of implementation – Documentation of newly implemented care processes based on completion of AMA’s STEPS Forward module.

Improve the quality of care provided, and health outcomes for patients, by participating in improvement activities designated by private payers.

Evidence of participation in private payer clinical practice improvement activities. Include the following element:

1) Confirmation of participation – Documents showing participation in private payer clinical practice improvement activities (e.g., quality measure documentation or feedback reports, practice workflow redesign tools developed for or with the payer as part of practice improvement).

Implement the Joint Commission’s Ongoing Professional Practice Evaluation with goal of identifying negative practice trends earlier.

Evidence of participation in the Joint Commission’s Ongoing Professional Practice Evaluation (OPPE) initiative. Include the following element:

1) Confirmation of participation – Documentation from Joint Commission's OPPE initiative confirming participation in its improvement program(s) (e.g., email or other communication).

Reduce inappropriate use of antimicrobials, thus playing a critical role in reducing microbial resistance and the incidence of antimicrobial-caused adverse drug reactions, all of which will help improve patient outcomes and the efficiency of spending.

Evidence of leadership of an Antimicrobial Stewardship Program (ASP) that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics. Include at least one of the following elements:

1) Antibiogram and report – Documented facilityspecific antibiogram and report of findings and specific action plan aligned with overall facility or practice strategic plan; OR

2) ASP patient care and safety protocols – Documentation of the development, implementation, and monitoring of patient care and safety protocols as a result of the process of operating the ASP (e.g., email communication, meeting agendas with eligible clinician’s name, staff confirmation); OR

3) ASP evaluation – Documentation of the on-going evaluation and monitoring of the management structure and workflow of ASP processes and involvement therein (e.g., email communication, meeting agendas with eligible clinician’s name, reports, staff confirmation); OR

4) ASP education and training – Records of presentation of ASP education and training including curriculum and presentation dates with eligible clinician named as one of the facilitators or presenters; OR

5) ASP policies or practices for high-priority conditions – Documentation of involvement in selecting and implementing evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions; OR

6) ASP protocols and decision supports – Documentation of developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections; OR

7) Alignment with CDC Core Elements of Outpatient Antibiotic Stewardship guidance – Documentation of involvement in the alignment of evidence-based protocols with recommendations in the Centers for Disease Control and Prevention’s (CDC’s) Core Elements of Outpatient Antibiotic Stewardship guidance.

Help eligible clinicians align diagnoses and treatment plans with up-to-date, evidence-based standards and guidelines as part of routine care, thus improving the appropriateness of the care they provide and the health outcomes of their patients.

Documented use of decision support and standardized treatment protocols and/or platform-agnostic, interoperable clinical decision support (CDS) tools to manage team workflows to meet patient needs. Include the following element:

1) Use of decision support and standardized treatment protocols and/or platform-agnostic, interoperable clinical decision support (CDS) tools – Documentation (e.g., checklist, order set, algorithm, screenshot) demonstrating use of decision support and standardized treatment protocols and/or platform-agnostic, interoperable clinical decision support (CDS) tools to manage team workflows to meet patient needs. May include use of artificial intelligence/machine learning.

Create opportunities to assess total cost of care and identify ways to reduce unnecessary costs.

Evidence of use or building of analytic capabilities to manage the total cost of care for the practice population. Include at least one of the following elements:

1) Staff training – Documentation of staff training on interpretation of cost and utilization information (e.g., training documentation); OR

2) Cost/resource use data – Availability of cost/resource use data for the practice population that the practice uses regularly to analyze opportunities to reduce cost; OR

3) Participation in regional Total Cost of Care efforts – Engage with local Regional Health Improvement Collaborative (RHIC) to measure and utilize Total Cost of Care (TCoC) to identify opportunities for practice improvement, create a practice improvement plan(s), and execute on the plan(s). Documentation may include communication with RHIC (e.g., email) or a copy of TCoC report(s).

Enhance the measurement of the quality of care, making quality data relevant at practice and panel levels, and use those data to implement effective quality improvement activities.

Evidence of quality measurement and improvement for populations at the practice and panel level or for specific populations (e.g., racial and ethnic minorities, individuals with disabilities, sexual and gender minorities, individuals with certain chronic conditions/risk factors, or individuals in rural areas). Include at least one of the following elements:

1) Performance benchmarks and goals – Performance benchmarks and goals to drive overall improvements; OR

2) Quality improvement program/plan at practice and panel level – Copy of a quality improvement program/plan or review of quality, utilization, patient satisfaction (surveys should be administered by a third-party survey administrator/vendor), and other measures to improve one or more elements of this activity; OR

3) Review of and progress on measures – Report showing progress on selected measures, including benchmarks and goals for performance using relevant data sources at the practice and panel level.

Expand and formalize quality improvement (QI) activities across the practice, ultimately leading to improvements in the quality of care and fostering a culture of participation among staff, including leadership.

Evidence of the implementation of a formal plan for QI and creation of a culture in which staff actively participates in one or more applicable QI activities. This activity allows MIPS clinicians to build the foundations for other activities they pursue in the future. Include both of the following elements:

1) Adopt formal quality improvement plan and create culture of improvement – Documentation of adoption of a formal model for QI and creation of a culture in which staff actively participate in QI activities. Formal QI models are used by eligible clinicians to develop systems, tools, and interventional strategies to improve processes of care for their patient population; AND

2) Staff participation – Documentation of staff participation in one or more of the 6 key areas for improvement*: a) training; b) integration into staff duties; c) identifying and testing practice changes; d) regular team meetings to review data and plan improvement cycles; e) share practice and panel level quality of care; f) patient experience and utilization data with staff; or g) share practice level quality of care, patient experience and utilization data with patients and families.

The following elements are suggested regarding the essential engagement of leadership in quality improvement:

1) Time for leadership in improvement efforts – Documentation of allocated time for clinical and administrative leadership participating in improvement efforts (e.g., regular team meeting agendas and post meeting summaries); OR

2) Clinical and administrative leadership role descriptions – Documentation of clinical and administrative leadership role descriptions that include responsibility for practice improvement change (e.g., position description)

Improve identification of patients who are at risk of falling; then reduce their risk and improve their health outcome, independence, and satisfaction with care.

Documented implementation of fall screening and assessment programs. Include at least one of the following elements:

1) Implementation of a falls screening and assessment program – Documentation of newly implemented falls screening and assessment program that uses valid and reliable tools to identify patients at risk for falls and address modifiable risk factors (e.g., clinical decision support (CDS)/prompts in the electronic health record (EHR) that help manage the use of medications, such as benzodiazepines, that increase fall risk). The program population should be defined by the eligible clinicians (e.g., all patients over a certain age); OR

2) Implementation progress – Documentation of follow-up after falls screening and assessment with focus on improvement in risk factors. Documentation of follow-up may include: follow-up screening, notes or medication list demonstrating mitigation of the risk or other health record data demonstrating follow-up, etc.

Become better equipped to improve prescription practices and thus help reduce patients' risks of addiction and overdose.

Documented completion with a passing score for all applicable modules available during the performance year of the Centers for Disease Control and Prevention’s (CDC’s) course "Applying CDC's Clinical Practice Guideline for Prescribing Opioids for Pain" that reviews the 2016/2022 "Clinical Practice Guideline for Prescribing Opioids for Pain." Include the following element:

1) Record of completion and passing score – Documented participation in and completion of (e.g., certificate of completion, screenshot) the CDC’s course "Applying CDC's Clinical Practice Guideline for Prescribing Opioids for Pain" that reviews the 2016/2022 "Clinical Practice Guideline for Prescribing Opioids for Pain."

Reduce inappropriate use of antimicrobials to help reduce microbial resistance and the incidence of antimicrobial-caused adverse drug reactions, all of which will help improve patient outcomes and the efficiency of spending.

Documented completion with a passing score of all available modules of the Centers for Disease Control and Prevention’s (CDC) antibiotic stewardship course. Include the following element:

1) Record of completion and passing score – Documented participation in and completion (e.g., certificate of completion, screenshot) of all available modules of the CDC antibiotic stewardship course.

Help eligible ordering clinicians easily obtain information on the cost of laboratory and radiography orders, allowing them to manage their costs strategically.

Demonstration of cost transparency by displaying costs for laboratory and radiography at the point-of-order for ordering clinicians. Include the following element:

1) Cost display for laboratory and radiographic orders – Documentation (e.g., screenshot, report from the electronic health record, written display procedure) of laboratory and radiographic costs at the point-oforder.

Allow primary care doctors to immediately tailor plans of care for patients to prevent further medication errors and achieve better outcomes in the future.

Documentation of communication regarding clinically significant adverse drug events from the eligible clinician providing unscheduled care to the primary care clinician within 48 hours. Unscheduled care includes emergency room visit, urgent care, or other unplanned encounter. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supra-therapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment or hospitalization. Include all of the following elements:

1) Documentation of the process for capturing adverse drug events; AND

2) Details of clinically significant adverse drug event – Documentation (e.g., medical record, chart note) of clinically significant adverse event; AND

3) Communication of event within 48 hours – Documentation of communication of the event to the patient's primary care clinician within 48 hours of the unscheduled event (e.g., Health Information Exchange, other Health Information Technology, secure email). Communication to include both details about the unscheduled event and the nature of the adverse drug event.

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

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.

Educate patients regarding the risks of concurrent opioid and benzodiazepine use, thus reducing their risk of overdose.

Evidence of both written and verbal education regarding the risks of concurrent opioid and benzodiazepine use provided to patients who are prescribed both benzodiazepines and opioids. Include both of the following elements:

1) Examples of education provided – Copies of written education (e.g., pamphlets, patient portal screenshot) and verbal education (e.g., scripts/descriptions of what must be said) provided; AND

2) Education provided to patients co-prescribed – Education must be completed for at least 75% of qualifying patients and occur a) at the time of initial co-prescribing and again following greater than 6 months of co-prescribing of benzodiazepines and opioids; or b) at least once per MIPS performance period for patients taking concurrent opioid and benzodiazepine therapy.

Make Centers for Disease Control (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain via clinical decision support (CDS) part of eligible clinicians' workflow, thus improving prescription practices, protecting patients at risk for addition and/or overdose, and helping to address the opioid epidemic.

Evidence of eligible clinicians utilizing the CDC Clinical Practice Guideline for Prescribing Opioids for Pain via CDS. Include all of the following elements:

1) CDC Clinical Practice Guideline for Prescribing Opioids for Pain via CDS within eligible clinicians’ workflow – Evidence that the CDC Clinical Practice Guideline for Prescribing Opioids for Pain is available to eligible clinician(s) via CDS, and that the guideline is incorporated into eligible clinicians’ workflow. May include: electronic health record-based prescribing prompts, chronic pain order sets with opiate prescribing based on CDC Guidelines, or prompts requiring review of guidelines before a subsequent action can be taken in the record; AND

2) Use of Guideline in CDS – Documentation of use of CDC guideline during patient care during the 90 day or year-long attestation period.

Improve health outcomes for patients with Lyme disease by leveraging clinical decision support (CDS) and training tools.

Evidence of eligible clinicians utilizing the Centers for Disease Control and Prevention’s (CDC’s) Training for Healthcare Providers on Lyme Disease via CDS. Include the following element:

1) CDC Training for Healthcare Providers on Lyme Disease via CDS within eligible clinicians’ workflow – Evidence that guidance from the CDC's training is available to eligible clinician(s) via CDS, and that guidance from the training is incorporated into eligible clinicians’ workflow. May include: electronic health record-based prescribing prompts and/or Lyme Disease specific order sets, order sets that require review of training guidance, and prompts requiring review of guidelines before a subsequent action can be taken.

Ensure timely treatment of patients from underserved populations, to help them achieve improved health outcomes.

Evidence of eligible clinicians tracking and improving timeliness of care delivered to patients from underserved populations, including those with Medicaid, through analysis and intervention. Include both of the following elements:

1) Analysis of time-to-treat data – Report documenting analysis of trends and inequities in timeto-treat data, disaggregated by beneficiary type (to compare those with and without Medicaid benefits) and by other patient demographics such as race/ethnicity, disability status, sexual orientation, sex, gender identity, or geography. Report should include possible explanations for the trends and inequities identified; AND

2) Implementation Plan and Results – Documentation of plans for activities to address inadequacies in timeto-treat performance, and the outcomes of those activities. Activities may address barriers facing patients (e.g., lack of access to affordable transportation) or barriers presented by the eligible clinician (e.g., appointment availability does not align with needs of those who lack sick leave).

Make it possible to use Patient Reported Outcomes (PRO) data as part of routine care, thus increasing patient engagement and health outcomes for all populations.

Demonstrated performance of activities to promote use of PRO tools and corresponding collection of PRO data. Include both of the following elements:

1) Promotion of PRO tools – Evidence that eligible clinicians are promoting use of PRO tools with their patients (e.g., documented notes in electronic health record, PRO materials); AND

2) PRO data collection – Feedback reports demonstrating use of PRO tools and corresponding collection of PRO data

Encourage clinicians to minimize disparities in healthcare access, care quality, affordability, or outcomes by contributing to new and improved tools, research, or processes, which may include addressing health-related social needs.

Evidence of leadership in clinical trials, research alliances, or community-based participatory research (CPBR), focused on minimizing disparities in healthcare access, care quality, affordability, or outcomes. Include the following element:

1) Evidence of research leadership about disparities – Documentation of participation and leadership by eligible clinicians in clinical trials, research alliances, or CBPR focused on addressing disparities to improve healthcare access, care quality, affordability, or outcomes. This research may include developing evidence about the influence of health-related social needs on disparities in health outcomes, and effective strategies for addressing HRSN.

Provide clinicians-in-training with diverse experiences, allowing them to gain deep understanding of the challenges facing eligible clinicians and patients in small practices or in underserved or rural areas.

Evidence of participation as a preceptor for clinicians-in-training and accepting clinical rotations in community practices in small underserved or rural areas. Include all of the following elements:

1) Proof of preceptor role – Documentation of participation as a preceptor for eligible clinicians-intraining (e.g., contract or communications with an academic-based health care organization). Any eligible clinician can serve as a preceptor; AND

2) Specific clinical rotations – Evidence of clinical rotation assignments in community practices in small, underserved, or rural areas. The 2019 CMS Final Rule defines small, underserved, or rural areas by ZIP codes designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data set.

Improve eye health of underserved and/or high-risk populations, and empower patients in these populations to become more educated consumers of eye care.

Evidence that eligible clinicians help underserved and/or high-risk populations understand the importance of their eye health and provide support to access comprehensive eye exams. Include all of the following elements:

1) Proof of eligible clinician/group type – Evidence that the attesting eligible clinicians are either: a providing literature and/or resources on the topic of comprehensive eye exam importance; a) nonophthalmologists or optometrist who refer patients to an ophthalmologist/optometrist; b) ophthalmologists/optometrist caring for underserved patients at no cost; or c) eligible clinicians; AND

2) Promotion of comprehensive eye exam – Documentation that literature and/or conversation about the importance of comprehensive eye exams were provided to targeted underserved and/or highrisk populations (e.g., visit note made in medical record; copy of literature provided); AND

3) Referrals to no-cost eye exams – Documentation of patient referrals made to resources providing no-cost eye exams (e.g., American Academy of Ophthalmology's EyeCare America, American Optometric Association's VISION USA) for targeted underserved and/or high-risk populations.

Begin to address inequities in health outcomes by creating and implementing an antiracism plan.

Evidence of a practice-wide review and implementation of an anti-racism plan. Please note that, although the CMS Disparities Statement does not mention racism, it can be effectively used to facilitate the completion of the requirements of this activity. Include all of the following elements:

1) Review – Documentation of a practice-wide review of existing tools and policies; AND

2) Assessment memo – Completion of an assessment memo summarizing the results of the above review; AND

3) Anti-Racism Plan – A new or updated anti-racism plan, which includes actions, intended outcomes, and timeline for completion for the eligible clinician’s practice; this plan must identify ways in which issues and gaps identified in the review can be addressed and should include target goals and milestones, and the eligible clinician or practice should also consider including training on anti-racism to support identifying explicit and implicit biases in patient care and addressing historic health inequities experienced by people of color; AND

4) Plan Implementation – Report with results from implementing the new or updated anti-racism plan.

Reduce food insecurity and improve nutritional outcomes for at-risk patients.

Evidence of screening for food insecurity and malnutrition risk and implementing protocols to support patients who are identified as at risk. Include both of the following:

1) Protocols for identifying at-risk patients created or improved – Documentation of screening tools— preferably standardized tools that have been tested in underserved communities—applied within clinician workflow and information stored within health information systems; AND

2) Implementation Plan and Results – Documentation of the plan to advance support to patients who have been identified as having the greatest risk for food insecurity and/or malnutrition, with specific rationale for the interventions selected and documentation of the results achieved. Example: A practice selects and adapts two standardized tools for screening patients for food insecurity and malnutrition into their electronic health record (EHR) system and begins screening all new patients and existing patients each year. The Quality Improvement team at the practice also establishes a new process whereby, during the visit when the screening occurs, the practice provides those identified as having risk of food insecurity or malnutrition with a) information and counseling about the national Supplemental Nutrition Assistance Program (SNAP) enrollment and b) an information sheet with referrals to food pantries and other community resources in the area. The Quality Improvement group also establishes protocols for calling patients who received counselling and information 3 weeks after their visit to follow-up. At the end of the year, the Quality Improvement group documents within their EHR an increase in SNAP enrollment among their patient population.

To promote the adoption of technology certified to the Security tags-summary of care send and Security tags-summary of care receive criteria at 45 CFR 170.315(b)(7) and (b)(8) in the ONC Health IT Certification Program.

Evidence of eligible clinician's practice working with their EHR vendor to implement technology meeting the security tags criteria at 45 CFR 170.315 (b)(7) and (b)(8) in practice systems and clinic workflows. Documentation can include the following elements:

1) Screen shots of the EHR including security tag technology meeting the certification criteria; OR

2) EHR-vendor documentation of the addition of security tagging certified health IT in the practice's systems; AND/OR

3) Practice policies & procedures manual and/or training materials related to security tagging technology meeting the certified health IT criteria in the EHR; AND/OR

4) Submission of a CMS EHR Certification ID for the certified health IT used by the eligible clinician which includes health IT certified to 45 CFR 170.315(b)(7) and (b)(8)

Begin to address disparities in health care and health outcomes for LGBTQ+ people by creating and implementing a plan to improve care for lesbian, gay, bisexual, transgender, and queer patients.

Evidence of a practice-wide review and implementation of a plan to improve care for LGBTQ+ patients. Include the following:

1) Review - Documentation of a practice-wide review of existing tools and policies; AND

2) Assessment memo - Completion of an assessment memo summarizing the results of the above review; AND

3) Plan to Improve Care for LGBTQ+ patients - A new or updated plan, which includes actions, intended outcomes, and timeline for completion for the eligible clinician's practice; this plan must identify ways in which issues and gaps identified in the review can be addressed and should include target goals and milestones, and the eligible clinician or practice should also consider including training on sexual orientation and gender identity; AND

4) Plan Implementation - Report with results from implementing the new or updated plan for improving care for LGBTQ+ patients.

Improve the screening and documentation of drivers of health needs using evidence-based tools.

Evidence of screening for the drivers of health, specified by the MIPS eligible clinician for this activity, and documentation of actions taken to address any identified needs. In addition to the drivers of health listed in the activity description, drivers of health prioritized by the MIPS eligible clinician may include others (e.g., transportation accessibility; interpersonal safety; legal challenges; and environmental exposures). Include the first element and one of the following elements:

1) Use of a validated patient drivers of health screening tool – Copy of implemented screening tool (e.g., completed survey or completed verbal assessment) used to identify patients with one or more specified. If feasible, the screening tool should be electronically enabled and include standards-based, coded question(s)/field(s) for the capture of data; AND

2) Provision of community resource guides – Medical record note/field indicating provision of a guide to community resources to meet specified drivers of health needs to patients with those identified needs. The MIPS eligible clinician should update this guide, or obtain an updated guide from community partners, at least once during the performance year; OR

3) Community referrals – Evidence (e.g., email, Memorandum of Understanding, meeting minutes, data sharing agreement) demonstrating formal relationships with established referral processes between the MIPS eligible clinician and one or more community-based organizations; OR

4) Electronic Health Record (EHR)/registry data analysis – Record of analysis of EHR or registry data that identifies patients with an need related to drivers of health and documents follow-up with identified patient(s).

Provide sustained support to communities facing the impact of disasters, filling immediate needs, and contributing to a faster, better recovery.

Evidence of participation in Disaster Medical Assistance Team or Community Emergency Responder Team for at least 6 months as a volunteer. Include the following element:

1) Details and confirmation of participation – Documentation of participation in Disaster Medical Assistance or Community Emergency Responder Teams for at least 6 months including registration and active participation (e.g., attendance at training, onsite participation).

Provide sustained support to communities across the globe that need humanitarian volunteer support, thus helping to alleviate suffering, save lives, and maintain human dignity.

Evidence of participation in domestic or international humanitarian volunteer work for at least a continuous 60 day duration. Include the following element:

1) Details and confirmation of participation – Documentation of participation in domestic or international humanitarian volunteer work for at least a continuous 60 day duration including registration and active participation (e.g., identification of location of volunteer work, timeframe, and confirmation from humanitarian organization).

Contribute to the development of clinically proven treatments for COVID-19.

Evidence of participation in the COVID-19 clinical trial. Include both of the following elements:

1) Clinical trial details – Details to verify participation in an acceptable COVID-19 clinical trial. The type of clinical trial could include designs ranging from the traditional double-blinded placebo-controlled trial to an adaptive design or pragmatic design that flexes to workflow and clinical practice context. It may be conducted in large organized clinical trials led by academic medical centers or healthcare systems. In addition, we intend for this activity to be applicable to eligible clinicians who are reporting their COVID-19 related patient data to a clinical data repository, such as Oracle’s COVID-19 Therapeutic Learning System (https://covid19.oracle.com/); AND

2) Clinical data submission – Evidence of submission of clinical data to the clinical data repository or registry supporting the COVID-19 clinical trial (e.g., screenshot from the participating clinical data repository or clinical data registry).

Improve rates of screening for patients with schizophrenia or bipolar disorder, who have higher risk or higher prevalence of diabetes relative to the general population, thus increasing eligible clinicians' ability to detect and respond early to positive diagnoses, potentially reducing the burden and complications of the disease.

Demonstration of diabetes screening for patients with schizophrenia or bipolar disease who are using antipsychotic medication. Include both of the following elements:

1) Identification of patients – Evidence of regular identification of patients with schizophrenia or bipolar disease who are using antipsychotic medication and who should receive diabetes screening (e.g., report from the electronic health record [EHR], flag or note in the EHR or medical chart, registry, other population health management tracking report); AND

2) Documented diabetes screenings – Percentage of patients identified in element “1)” (for example, annually) who receive a diabetes screening, with supporting documentation from EHR reports, medical charts, or claims.

Help patients at high risk for tobacco dependence and with behavioral or mental conditions to avoid or end addiction to tobacco.v

Demonstration of regular engagement in integrated prevention and treatment interventions including tobacco use screening and cessation interventions for patients with a diagnosis of behavioral or mental health disorders with risk factors for tobacco dependence. Include all of the following elements:

1) Identification of patients with behavioral or mental health conditions and tobacco dependence risk factors – Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry, or other system demonstrating that the eligible clinician tracks patients with conditions of behavioral health or mental health with risk factors for tobacco dependence; AND

2) Evidence of screening – Report from EHR, QCDR, clinical registry, or documentation from medical charts showing regular practice of tobacco screening for patients with conditions of behavioral or mental health with risk factors for tobacco dependence; AND

3) Evidence of cessation interventions – Report from EHR, QCDR, clinical registry, or documentation from medical charts showing regular practice of tobacco cessation interventions for patients with behavioral or mental health disorders with risk factors for tobacco dependence.

Improve the identification of depression among patients with behavioral or mental health conditions and sustain patient-centered support and treatment for those diagnosed with depression.

Demonstration of regular engagement in integrated prevention and treatment interventions including depression screening and follow-up plan for patients diagnosed with behavioral or mental health disorders. Include all of the following elements:

1) Identification of patients with behavioral or mental health conditions and depression risk factors – Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry, or other system demonstrating that the eligible clinician tracks patients with conditions of behavioral health or mental health and with risk factors for depression; AND

2) Evidence of depression screening – Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry, or documentation from medical charts showing regular practice for depression screening for patients with diagnosed behavioral or mental health disorders; AND

3) Evidence of depression follow-up – Report from EHR, QCDR, clinical registry, or documentation from medical charts showing depression follow-up plan for patients with positive screen.

Increase patient-centered support and treatment for patients with conditions of behavioral or mental health conditions to prevent severe depression and suicide.

Demonstration of regular engagement in prevention and treatment interventions including suicide risk assessment for mental health patients with conditions of behavioral or mental health. Include all of the following elements:

1) Identification of patients with behavioral or mental health conditions and depression risk factors – Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry or other system demonstrating that the eligible clinician tracks patients with conditions of behavioral health or mental health and with risk factors for depression; AND

2) Evidence of screening – Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry, or documentation from medical charts showing regular practice for screening, including suicide risk assessment for mental health patients with behavioral or mental health disorders; AND

3) Evidence of prevention and treatment – Report from EHR, QCDR, clinical registry, or documentation from medical charts showing patients receiving prevention and/or treatment services based on screening results.

Support patients with behavioral health needs and poorly controlled chronic illnesses though integrated behavioral health services and the use of evidence-based tools or other initiatives.

Evidence of integrated behavioral health services to support patients with behavioral health needs and poorly controlled chronic conditions (may use certified electronic health records (EHR), qualified clinical data registry (QCDR), clinical registry, or medical records). Include at least one of the following elements:

1) Use of evidence-based tools – Documented use of evidence-based tools (e.g., treatment protocols, screening tools); OR

2) Communication between primary care and behavioral health – Documentation could include EHR note that shows that the patient saw a behavioral health professional who communicated with the eligible primary care clinician or practice team, a record of a referral by the eligible primary care clinician to a behavioral health specialist, or documentation of staffing or behavioral health colocated in the primary care practice; OR

3) Behavioral health integration in primary care – Documented integration of behavioral health services with primary care to support patients with behavioral health needs (e.g., dementia) and poorly controlled chronic conditions (e.g., hypertension, diabetes, chronic kidney disease); OR

4) Active care management and outreach – Use of a clinical registry or certified EHR to support active care management and outreach to patients receiving treatment; OR

5) Participation in a relevant program or initiative – Participation in a program or initiative with a multidimensional approach to support patients with behavioral health needs and poorly controlled chronic conditions (e.g., National Partnership to Improve Dementia Care in Nursing Homes).

Continually improve the care provided to behavioral health populations through evidence-based interventions and the use of electronic health record technology (EHR).

Documented use of EHR to capture data on behavioral health populations and use data to inform clinical decision-making. Include both of the following elements:

1) Screenshots of data capture – Screenshots from EHR or from other software/tools integrated with the EHR displaying behavioral health data capture (e.g., capture of additional behavioral health data results in additional depression screening for at risk patient not previously identified); AND

2) Data reports – Reports showing how additional behavioral health data are captured and used for decision-making (e.g., dashboards, improvement plans).

Help patients better manage or overcome their alcohol and/or other substance abuse challenges through screenings and counseling.

Evidence of regular integrated prevention and treatment interventions with documented screening and brief counseling for patients with diagnosed coexistence of a mental health disorder and substance abuse. Include both of the following elements:

1) Documented screening and brief counseling – Screenshots from electronic health record (EHR) or from other software/tools demonstrating integrated prevention and treatment interventions (e.g., evidence of screening and brief counseling for patients with mental health and substance abuse disorders); AND

2) Evidence of percent of patients screened – 75% of ambulatory care patients are screened for unhealthy alcohol use.

Develop strategies to improve integration of behavioral health into primary care practices, ultimately improving patient-centeredness of care and health outcomes for mental health patients.

Documented completion of a collaborative care management training program such as the American Psychological Association Collaborative Care Model training program. Include at least one of the following elements:

1) Certificate of completion – Eligible clinicians and groups must provide authentic documentation of collaborative care management training program completion (electronic or paper); OR

2) Implementation of approach – Documented implementation of a collaborative care management approach that provides comprehensive training in the integration of behavioral health into the primary care practice (e.g., a workflow diagram, listed staff and clinician roles and responsibilities, documented policies and procedures for approach).

Ensure delivery of responsive care for patients and clinicians who have experienced physical or mental trauma.

Documentation of an implemented plan for delivering care to patients who have experienced trauma, and for addressing needs of clinicians and staff who have experienced trauma. Include the first element and one of the following elements:

1) Implementation of a Trauma-Informed Care (TIC) plan – Documentation of the creation and implementation of a TIC plan; AND

2) Training materials – Documentation of materials on TIC integrated into new employee orientation or annual employee training; OR

3) TIC education materials – Documentation that materials on TIC are supplied to third-party partners, such as care management companies and billing services, to ensure a system-wide approach to TIC; OR

4) Adverse events screener – Copy of implemented survey tool or prompt in electronic health record is used to assess and identify if a patient has experienced one or more adverse events that may have caused trauma.

Improve the well-being of clinicians and the quality and safety of care they deliver.

Evidence of activities to improve clinician well-being, defined by Chari et al. (2019) as a “concept that characterizes quality of life with respect to an individual’s health and work-related environmental, organizational, and psychosocial factors. Well-being is the experience of positive perceptions and the presence of constructive conditions at work and beyond that enables workers to thrive and achieve their full potential.” Include one of the following first two elements and the third element:

1) Report on clinician well-being – Report including collected data on clinician well-being and resilience (e.g., survey results); OR

2) Staff training – Documentation of staff training on clinician well-being (e.g., training certificate, letter, training materials); AND

3) Implementation of a clinician well-being improvement plan – Documentation of a clinician well-being and resilience improvement plan, based on the results of the clinician well-being survey or staff training.

Improve outcomes by providing appropriate mood, anxiety and substance use disorder screenings and treatment during the perinatal and post-partum periods.

Evidence of documented screening for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and post-partum women with evidence of treatment and/or referral to appropriate social services and document in the care plan. Include the following elements:

1. Identification of perinatal and postpartum population - Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry or other system demonstrating the tracking of perinatal and post-partum women; AND

2. Evidence of perinatal mood and anxiety disorders (PMAD's) and substance use disorder (SUD) screening - Report from EHR, QCDR, clinical registry or documentation from medical record chart showing regular practice for screening for PMAD's and SUD; AND

3. Evidence of appropriate treatment and/or referral documented in care plan - Report from EHR, QCDR, clinical registry or documentation from medical chart showing appropriate treatment and/or referral for PMADs and SUD.

Some examples of screening tools can be found here:

https://www.acog.org/programs/perinatal-mentalhealth/implementing-perinatal-mental-healthscreening

Improve outcomes by providing appropriate mental health and substance abuse screening for older adults.

Evidence of documented screening for mental/behavioral health and substance abuse for older adults with evidence of treatment and/or referral to appropriate social services established in the care plan. Include the following elements:

1. Identification of older adult population with mental/ behavioral health and substance use concerns – Report from the electronic health record (EHR), qualified clinical data registry (QCDR), clinical registry, or other system demonstrating tracking of older adults with behavioral/mental health and or substance abuse; AND

2. Evidence of behavioral/mental health and substance use disorder (SUD) screening - Report from EHR, QCDR, clinical registry, or documentation from medical record chart showing regular practice for screening for behavioral/mental health and substance use disorder; AND

3. Evidence of appropriate treatment and/ or referral documented in care plan – Report from HER, QCDR, clinical registry, or documentation from a medical chart showing appropriate treatment and/ or referrals for behavioral/mental health concerns and substance use disorder.

Examples of screening tools:

- Patient Health Questionnaire (PHQ-9)

- Anxiety Disorder 7-item scale (GAD-7)

Obtaining Patient-Centered Medical Home™ certification drives significant and sustainable practice improvements including population care quality, efficiency, and improved patient satisfaction all directly linked to better health outcomes.

Evidence of meeting performance standards and expectations pertaining to the Patient-Centered Medical Home™ model. Include the following element:

1) Recognition certificate – Documented recognition as a Patient-Centered Medical Home™ from a regional or state program, private payer, or other body that certifies at least 500 or more practices for PatientCentered Medical Home™ accreditation or comparable specialty practice certification.

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.

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).