2021 MIPS Improvement Activity IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes

Activity Description

Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following, such as:

  • Participation in multisource feedback;
  • Train all staff in quality improvement methods;
  • Integrate practice change/quality improvement into staff duties;
  • Engage all staff in identifying and testing practices changes;
  • Designate regular team meetings to review data and plan improvement cycles;
  • Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;
  • Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;
  • Participation in Bridges to Excellence;
  • Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.
Activity ID Activity Weighting Sub-Category Name
IA_PSPA_19 Medium Patient Safety and Practice Assessment


IA_2021, Lab Medicine-2021, Pathology-2021, Speech Therapy-2021