What does it take to get an improvement activities performance category score of 100%? See “Improvement Activities: An Overview.”
Which improvement activities should you perform? The IRIS Registry supports reporting of 59 improvement activities—16 of those are high-weighted and 43 are medium-weighted.
Select your improvement activities carefully. To determine which improvement activities would be right for your practice, review the list below and click on activity titles for detailed activity descriptions and CMS documentation suggestions.
|
High-Weighted Activities
|
Activity ID#: Improvement Activity |
Notes |
Achieving Health Equity |
IA_AHE_1: Enhance engagement of Medicaid and other underserved populations |
No EHR required, high-weighted, substantive changes to measure description |
IA_AHE_3: Promote use of patient-reported outcome tools |
No EHR required, high-weighted |
IA_AHE_6: Provide education opportunities for new clinicians |
No EHR required, high-weighted |
Beneficiary Engagement |
IA_BE_6: Regularly assess patient experience of care and follow up on findings |
No EHR required, high-weighted, substantive changes to measure description |
IA_BE_14: Engage patients and families to guide improvement in the system of care |
No EHR required, high-weighted |
Care Coordination |
IA_CC_14: Practice improvements that engage community resources to support patient health goals |
No EHR required, high-weighted, substantive changes to measure description |
Emergency Response and Preparedness |
IA_ERP_2: Participation in a 60-day or greater effort to support domestic or international humanitarian needs |
No EHR required, high-weighted |
IA_ERP_3: COVID-19 clinical data reporting with or without clinical trial |
Facilitated by IRIS Registry-EHR integration, high-weighted |
Expanded Practice Access |
IA_EPA_1: Provide 24/7 access to MIPS eligible clinicians or groups who have real-time access to patient’s medical record |
No EHR required, high-weighted, substantive changes to measure description |
Patient Safety and Practice Assessment |
IA_PSPA_6: Consultation of the Prescription Drug Monitoring Program |
No EHR required, high-weighted, substantive changes to measure description |
IA_PSPA_22: CDC Training on CDC’s guideline for prescribing opioids for chronic pain* |
No EHR required, high-weighted |
IA_PSPA_23: Completion of CDC training on antibiotic stewardship* |
No EHR required, high-weighted |
IA_PSPA_31: Patient medication risk education |
No EHR required, high-weighted |
IA_PSPA_32: Use of CDC guideline for clinical decision support to prescribe opioids for chronic pain via clinical decision support |
High-weighted |
Population Management |
IA_PM_3: Rural Health Clinic (RHC), Indian Health Service Medium Management (HIS), or Federally Qualified Health Center (FQHC) quality improvement activities |
No EHR required, high-weighted |
IA_PM_7: Use of QCDR for feedback reports that incorporate population health |
Facilitated by IRIS Registry—EHR, high-weighted integration |
* You can only select IA_PSPA_22 once every four years. The same is true for IA_PSPA_23. |
Medium-Weighted Activities
|
Activity ID#: Improvement Activity |
Notes |
Achieving Health Equity |
IA_AHE_5: MIPS eligible clinician leadership in clinical trials or CBPR [community-based participatory research] |
No EHR required, medium-weighted, substantive changes to measure description |
IA_AHE_7: Comprehensive eye exams |
No EHR required, medium-weighted |
Beneficiary Engagement |
IA_BE_1: Use of certified EHR to capture patient reported outcomes |
Medium-weighted, substantive changes to measure description |
IA_BE_3: Engagement with QIN-QIO to implement self-management training programs [Quality Innovation Network-Quality Improvement Organization] |
No EHR required, medium-weighted |
IA_BE_4: Engagement of patients through implementation of improvements in patient portal |
Medium-weighted |
IA_BE_5: Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities |
No EHR required, medium-weighted |
IA_BE_12: Use evidence-based decision aids to support shared decision-making |
No EHR required, medium-weighted |
IA_BE_15: Engagement of patients, family, and caregivers in developing a plan of care |
Medium-weighted |
IA_BE_16: Promote self-management into usual care |
No EHR required, medium-weighted, substantive changes to measure description |
Care Coordination |
IA_CC_1: Implementation of use of specialist reports back to referring clinician or group to close referral loop |
No EHR required, medium-weighted |
IA_CC_2: Implementation of improvements that contribute to more timely communication of test results |
No EHR required, medium-weighted |
IA_CC_7: Regular training in care coordination |
No EHR required, medium-weighted |
IA_CC_8: Implementation of documentation improvements for practice/process improvements |
No EHR required, medium-weighted |
IA_CC_9: Implementation of practices/processes for developing regular individual care plans |
No EHR required, medium-weighted |
IA_CC_12: Care coordination agreements that promote improvements in patient tracking across settings |
No EHR required, medium-weighted |
IA_CC_13: Practice improvements for bilateral exchange of patient information |
Medium-weighted |
IA_CC_18: Relationship-centered communication |
No EHR required, medium-weighted |
Emergency Response and Preparedness |
IA_ERP_1: Participation on Disaster Medical Assistance Team, registered for 6 months |
No EHR required, medium-weighted |
Expanded Practice Access |
IA_EPA_2: Use of telehealth services that expand practice access |
No EHR required, medium-weighted, substantive changes to measure description |
IA_EPA_3: Collection and use of patient experience and satisfaction data on access |
No EHR required, medium-weighted |
IA_EPA_4: Additional improvements in access as a result of QIN/QIO TA [Quality Innovation Network-Quality Improvement Organization technical assistance] |
No EHR required, medium-weighted |
IA_EPA_5: Participation in user testing of the Quality Payment Program website (https://qpp.cms.gov) |
No EHR required, medium-weighted |
Patient Safety and Practice Assessment |
IA_PSPA_1: Participation in an AHRQ-listed patient safety organization |
Medium-weighted |
IA_PSPA_2: Participation in MOC Part IV |
No EHR required; IRIS Registry—EHR integration required for Academy/ABO option, medium-weighted |
IA_PSPA_4: Administration of the AHRQ Survey of Patient Safety Culture |
No EHR required, medium-weighted |
IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements |
Facilitated by IRIS Registry—EHR integration, medium-weighted |
IA_PSPA_8: Use of patient safety tools |
No EHR required, medium-weighted |
IA_PSPA_9: Completion of the AMA STEPS Forward program |
No EHR required, medium-weighted |
IA_PSPA_12: Participation in private payer CPIA [clinical practice improvement activities] |
No EHR required, medium-weighted |
IA_PSPA_13: Participation in Joint Commission Evaluation Initiative |
No EHR required, medium-weighted |
IA_PSPA_16: Use of decision support and standardized treatment protocols |
No EHR required, medium-weighted |
IA_PSPA_17: Implementation of analytic capabilities to manage total cost of care for practice population |
No EHR required, medium-weighted |
IA_PSPA_18: Measurement and improvement [of quality] at the practice and panel level |
No EHR required, medium-weighted, substantive changes to measure description |
IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes |
No EHR required, medium-weighted, substantive changes to measure description |
IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes |
No EHR required, medium-weighted |
IA_PSPA_21: Implementation of fall screening and assessment programs |
No EHR required, medium-weighted |
IA_PSPA_25: Cost display for laboratory and radiographic orders |
No EHR required, medium-weighted |
IA_PSPA_26: Communication of unscheduled visit for adverse drug event and nature of event |
No EHR required, medium-weighted |
IA_PSPA_28: Completion of an accredited safety or quality improvement program |
No EHR required, medium-weighted |
Population Management |
IA_PM_5: Engagement of community for health status improvement |
No EHR required, medium-weighted |
IA_PM_6: Use of toolsets or other resources to close healthcare disparities across communities |
No EHR required, medium-weighted, substantive changes to measure description |
IA_PM_11: Regular review practices in place on targeted patient population needs |
No EHR required, medium-weighted, substantive changes to measure description |
IA_PM_17: Participation in population health research |
No EHR required, medium-weighted |