As part of the MIPS program, practices must implement improvement activities. Each Improvement activity has a point value, High Weight Activities are worth 20 points and Medium Weight Activities are worth 10 points. Each practice must earn 40 improvement activity points.
Small practices get a bonus of having the point values DOUBLED for improvement activities, so for small practices High Weight activities are worth 40 points and Medium weight activities are worth 20 points.
In this article we will provide information on Medium Weight Activities that you can implement in your practice. For High Weight Activities see our previous article.
Medium Weight Activities (Worth 10 points for Large Practices, 20 points for small practices)
- • Advance Care Planning
- ○ This measure ties very nicely into Quality Measure 047 Advance Care Planning
- ○ Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.
- • COVID-19 Vaccine Achievement for Practice Staff
- ○ Demonstrate that the MIPS eligible clinician’s practice has maintained or achieved a rate of 100% of office staff staying up to date with COVID vaccines according to the Center for Disease Control and Prevention (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html). Please note that those who are determined to have a medical contraindication specified by CDC recommendations are excluded from this activity.
- • Implementation of a Personal Protective Equipment (PPE) Plan
- ○ This activity supports the OSHA requirements for the Blood Borne Pathogen Rule, This is something that needs to be in place to be compliant with OSHA
- ○ Implement a plan to acquire, store, maintain, and replenish supplies of personal protective equipment (PPE) for all clinicians or other staff who are in physical proximity to patients. In accordance with guidance from the Centers for Disease Control and Prevention (CDC) the PPE plan should address:• Conventional capacity: PPE controls that should be implemented in general infection prevention and control plans in healthcare settings, including training in proper PPE use.• Contingency capacity: actions that may be used temporarily during periods of expected PPE shortages.• Crisis capacity: strategies that may need to be considered during periods of known PPE shortages. The PPE plan should address all of the following types of PPE:• Standard precautions (e.g., hand hygiene, prevention of needle-stick or sharps injuries, safe waste management, cleaning and disinfection of the environment)• Eye protection• Gowns (including coveralls or aprons)• Gloves• Facemasks• Respirators (including N95 respirators)
- • Implementation of fall screening and assessment programs
- ○ This activity ties in very nicely with Quality Measure 155
- ○ Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).
- • Participation in MOC Part IV
- ○ In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or American Society of Anesthesiologists (ASA) Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE); American Psychiatric Association (APA) Performance in Practice modules.
- ○ Check with your specialty board to see if they have a Part IV MOC program
- • Tobacco use
- ○ This activity ties in very nicely with quality measure 226
- ○ Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.
- • Use of QCDR data for ongoing practice assessment and improvements
- ○ Regular meetings with your representative at Registry Clearinghouse to improve your practice can meet this measure
- ○ Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including: • Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups); • Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment); • Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility; • Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system; • Use of processes and tools that engage patients to improve adherence to treatment plans; • Implementation of patient self-action plans; • Implementation of shared clinical decision-making capabilities; • Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement; • Promotion of collaborative learning network opportunities that are interactive; • Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or • Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.
- • Use of telehealth services that expand practice access
- ○ Create and implement a standardized process for providing telehealth services to expand access to care.
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