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.

Essential Elements

  • 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.

  1. Define the problem or opportunity you want to address based on a topic area from the current year’s approved list of Improvement Activities. 
  2. Describe the current state of this problem area in your organization. This may require the collection of baseline information to verify assumptions.
  3. 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.).
  4. Implement the plan for a specified period of time.
  5. Measure your results. Did the activity have the impact you thought it would have?
  6. 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