PSPA 19 - Implementation of Formal Quality Improvement Methods, Practice Changes, or Other Practice Improvement Processes

Activity Weighting: Medium

Subcategory Name: Patient Safety and Practice Assessment

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:

  • Multi-Source 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; and/or 
  • 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.

Supporting Documentation

  • Adopt Formal Quality Improvement Model and Create Culture of Improvement - Documentation of adoption of a formal model for quality improvement and creation of a culture in which staff actively participate in improvement activities; and 
  • Staff Participation - Documentation of staff participation in one or more of the six identified; including, training, integration into staff duties, identifying and testing practice changes, regular team meetings to review data and plan improvement cycles, share practice and panel level quality of care, patient experience and utilization data with staff, or share practice level quality of care, patient experience and utilization data with patients and families.

Resources

2018 Improvement Activities Requirements

2019 Improvement Activities Requirements

2018 MIPS Improvement Activities Fact Sheet

Scores for Improvement Activities for MIPS APMs in the 2018 Performance Period Fact Sheet

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