Planning for MIPS Success – Improvement Activities

This is Part III of our series on MIPS.  See Quality Measures for Part I on the Quality Portion of MIPS and EHR Use (ACI) for Part on the Advancing Care Initiative/EHR Portion of MIPS.

As references in Part I and II, CMS has a good website on the overall MIPS program: https://qpp.cms.gov/

This week we will cover the Improvement Activities portion:

At only 15% of your overall MIPS score, Improvement Activities will impact your overall score (and 2019 Medicare bonus $s) less than Quality Reporting or Advancing Care Initiative (EHR).  However, if you’re participating in certified PCMH (http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh) you will automatically receive full credit for this portion of MIPS.

Also, while these activities make up a smaller portion of the MIPS score, you may find that they result in big gains in patient satisfaction and referrals.

Selecting Activities:

Rural and Professional Shortage Area clinics mat select 2 activities and all other clinics that are not part of an ACM (ACO) will need to select 4 activities.  The CMS site has a page (https://qpp.cms.gov/mips/improvement-activities ) to help you filter and select the most appropriate activities for your practice.  

Appendix B of this document also lists Activities: https://qpp.cms.gov/docs/QPP_ACI_Fact_Sheet.pdf

Planning is Key to Your Success:

  • Select 4+ possible Activities.  You may want to select more than the minimum as possible activities because you may find that some are easier to implement than others.
  • An EHR is not required for the Practice Activities as a whole.  However, some of the activities are best suited to an EHR or your EHR may help support the activity.  As such, check with your EHR on any support they may provide for your selected activities.
  • Work with your team to design/redesign your processes and workflows to implement the selected possible Activities.  
  • Choose your final 2 (if Rural or HSP) or 4 Activities.  

Execute Your Plan:

  • Document in a Process document the process for EACH Activity.  Include how and when the Activity will be measured to ensure it is in place.
  • Implement/adjust your process.  Hold at least one meeting per process with your staff to ensure the Activity is in place and working properly.  Document the meeting.
  • Schedule periodic reporting to check progress – share results with your staff and document.
  • Change/update the process as necessary to ensure your practice is correctly performing each Activity.  

Last but not least, consider implementing a patient survey to measure your before and after results.