Improvement Activities: Tips for Success
Improvement Activities are a crucial component of the MIPS program and by completing them, you'll automatically add 15 points to your overall score! Click here to get into the nitty-gritty details about Improvement Activities, like how many you need to complete and how to attest to their completion.
- Improvement Activities are practice-level initiatives that address a gap in quality OR an opportunity to enhance quality even more. Note: Improvement Activities are required.
- They must be conducted for at least 90 continuous calendar days.
- If your organization is participating as a group in 2021, then at least 50% of the clinicians must participate in the activity.
- A practice must complete improvement activities even if only one provider from the practice is participating in MIPS.
How do I complete an Improvement Activity (IA)?
Regardless of which activities you choose to complete, the following steps can help you get started.
- Define the problem or opportunity you want to address based on a topic area from the current year’s approved list of Improvement Activities.
- Describe the current state of this problem area in your organization. This may require the collection of baseline information to verify assumptions.
- Develop a plan to address the problem or opportunity based on what you know about where you are starting from (denote resources required, logistics, etc.).
- Implement the plan for a specified period of time.
- Measure your results. Did the activity have the impact you thought it would have?
- Describe what you will do in response to the results.
Example: IA_AHE_3 - Promote Use of Patient Reported Outcome Tools
This fictitious example is intended to illustrate how a practice could approach one of the improvement activities relevant to therapists. You should design your own project according to your practice needs and interests.
- A new physician practice group has opened up in town and has started referring patients with headaches to your practice. You notice that many of these patients also report sleep disruption.
- You decide to focus on this population and introduce two standardized patient-reported outcomes tools (PROs) to measure their response to treatment.
- You assign two of your PTs to research the evidence and identify the PROs you will implement.
- The therapists come back to the group with their results; after a review with all team members, you select two PROs (one for headache and one for sleep hygiene)
- You create a script for your front desk staff to use when introducing these PROs to appropriate patients during the first visit.
- The therapy team also develops standards for using the PRO information during goal-setting and progress reviews.
- The practice starts administering the new PROs on May 1 and continues using them for three months.
- The team reviews the survey results and discusses factors that may have influenced success (or failure) as well as any logistical challenges to implementing the PROs.
- Based on this discussion, you determine that a continuing education opportunity would benefit the staff, and you invite a speaker to come to the clinic at the end of the year.
IA Documentation on File
At a minimum, you should have the following information documented for each Improvement Activity.
- Start date and end date for attestation (in this example, March 1–September 30)
- A written summary that describes:
- The purpose of the activity
- The patient population that was the focus of the activity
- Who from the practice was involved, along with their roles
- Samples of the PROs implemented
- Data summary and/or minutes from meetings
- Follow-up plan