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|
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.
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:
- 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
- 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.
Example(s): A cardiology or multi-specialty practice seeks to institute changes to improve the management of patients with elevated low-density lipoprotein cholesterol (LDL-C), which is associated with higher risk of heart disease. The practice develops and implements a formal quality improvement plan with the goals of appropriately identifying, engaging, treating, and monitoring patients with elevated cholesterol. To achieve these goals, the practice takes the following steps:
- Methodically identify patients who would benefit from initiating or intensifying lipid-lowering therapy
- Implement a systematic effort to increase the proportion of patients who reach threshold LDL-C levels defined in evidence-based guidelines—e.g. by implementing automated scheduling, enhanced use of office screening protocols, flags/alerts in the electronic health record system, clinical team reviews of health plan/patient care gaps
- Measure impact through routine follow-up visits and LDL-C testing