Under MIPS, the Improvement Activity category is one of four components designed to evaluate processes in clinical practice such as beneficiary engagement, patient safety, health equity, emergency preparedness, and expanded practice access.

For performance year 2019, CMS has removed, modified, and added new improvement activities. Now, MIPS clinicians have access to 100+ activities to select from to demonstrate their performance. In order to earn full credit (i.e. up to a maximum of 15% of your MIPS Score) in this category, a combination of either high-weighted (20 points) or medium weighted (10 points) activities are required for at least a continuous 90-day period up to a full calendar year. Providers in groups that are small practices (15 or less clinicians) only need to earn 20 points. All other practices with more than 15 providers need to earn 40 points.

To better guide you, first I would like to define improvement activities. Then, I will discuss how to choose and provide supporting documentation for the activity.

Improvement Activities

Improvement Activities are areas of intervention that organizations and stakeholders have identified as improving clinical practice or care delivery that are likely to result in improved outcomes. Why is this important? Better outcomes should result in healthier patients.

The simplest way to select Improvement Activities is to consider quality efforts that you are already doing or planning to implement within your practice. Take a closer look at some of your daily operations that impact patient care and safety such as accessing patient experience, timely communication of test results, or even correspondence of specialist reports back to referring providers. Each of these is listed as CMS approved Improvements Activities and essential to ensuring patients receive the best care.

Documentation

You are probably wondering what type of documentation is required to support improvement activities. CMS has developed a resource tool called Improvement Activities Data Validation Criteria, which provides guidance for how to fulfill each measure. After you have selected which activities to report, I recommend that you read the measure and decide how you are going to implement the measure and track it. Let’s look at an example. Perhaps you decide to report on timely communication of test results. According to the Data Validation Criteria, you will need to have EHR reports or medical records demonstrating timely communication of abnormal test results to a patient. One other activity that may spark your interest is evaluating patient experience by way of administering surveys. To report this activity, you must show documentation of collection and follow-up on patient experience and satisfaction of survey results which must be administered by an outside vendor. Since CMS has outlined over 100 activities, do not stress.

The purpose of the IA category is to transition providers toward coordinated and more patient-centered care. To be successful and earn full credit in this category, it is easier to find activities that are relevant to key functions you have in place and just build upon those. For additional insight, all Improvement Activities can be found on the Quality Payment Program website.

By being mindful of these important tips, I am confident that you will be able to decide what is right for you.

  • Choose measures that you are already working on or applicable to your practice.
  • Maintain and keep evidence of your work.
  • Document your starting point.
  • Print screens, time stamps, and hardcopies of policies and procedures are great examples of supporting documentation.

Remember, you will have to report on measures for a minimum of 90 consecutive days. So, get started early, decide how you will submit improvement activities either by group or as an individual, and establish your timeframe. As Nike would say, “Just do It.”

April Richardson
QI Advisor