PSPA 20 - Leadership Engagement in Regular Guidance and Demonstrated Commitment for Implementing Practice Improvement Changes

Activity Weighting: Medium

Subcategory Name: Patient Safety and Practice Assessment

Description: Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following:

  • Make responsibility for guidance of practice change a component of clinical and administrative leadership roles;
  • Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or
  • Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.

Supporting Documentation

  1. Clinical and Administrative Leadership Role Descriptions - Documentation of clinical and administrative leadership role descriptions include responsibility for practice improvement change (e.g. position description); or
  2. Time for Leadership in Improvement Activities - Documentation of allocated time for clinical and administrative leadership participating in improvement efforts, e.g. regular team meeting agendas and post meeting summary; or
  3. Population Health, Quality, and Health Experience Incorporated into Performance Reviews - Documentation of population health, quality and health experience metrics incorporated into regular practice performance reviews, e.g., reports, agendas, analytics, meeting notes.


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

WebChart Documentation

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