2023 MIPS Improvement Activity IA_PSPA_18: Measurement and improvement at the practice and panel level

<h1>Activity Description</h1>
Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards that could include one or more of the following:
• Regularly review measures of quality, utilization, patient satisfaction and other measures; and/or
• Use relevant data sources to create benchmarks and goals for performance at the practice or panel levels.
MIPS eligible clinicians can apply the measurement and quality improvement to address inequities in quality and outcomes for underserved populations, including racial, ethnic, and/or gender minorities.
<th>Activity ID</th>
<th>Activity Weighting</th>
<th>Sub-Category Name</th>
<td>Patient Safety & Practice Assessment</td>
<h1>Objective & Validation Documentation</h1>
Objective: Enhance the measurement of the quality of care, making quality data relevant at practice and panel levels, and use those data to implement effective quality improvement activities.

Validation Documentation: Evidence of quality measurement and improvement for populations at the practice and panel level or for specific populations (e.g., racial and ethnic minorities, individuals with disabilities, sexual and gender minorities, individuals with certain chronic conditions/risk factors, or individuals in rural areas). Include at least one of the following elements:
1) Performance benchmarks and goals – Performance benchmarks and goals to drive overall improvements; OR
2) Quality improvement program/plan at practice and panel level – Copy of a quality improvement program/plan or review of quality, utilization, patient satisfaction (surveys should be administered by a third-party survey administrator/vendor), and other measures to improve one or more elements of this activity; OR
3) Review of and progress on measures – Report showing progress on selected measures, including benchmarks and goals for performance using relevant data sources at the practice and panel level.

• Obtain diagnostic Imaging Center of Excellence (DICOE) designation
• Participate in Endoscopy Unit Recognition Program (EURP)
• Participate in Simulation Education Courses approved by the American Society of Anesthesiologist’s Simulation Education Network
• Use the Centers for Medicare & Medicaid Services’ Disparities Impact Statement tool to fulfill this activity and address inequities in quality and outcomes for underserved and vulnerable populations

• Toolkit for implementing Culturally and Linguistically Appropriate Services Standards: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CLAS-Toolkit-12-7-16.pdf