FAQs

The criteria are:

• The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;
• The activity must have specific, measurable aim(s) for improvement;
• The activity must include interventions intended to result in improvement;
• The activity must include data collection and analysis of performance data to assess the impact of the interventions; and

The accredited program must define meaningful clinician participation in their activity and describe the mechanism for identifying clinicians who meet the requirements.

Yes. Any practice-based improvement work that learners participate in can be accredited CME, so long as it meets ACCME expectations for educational planning (Educational Needs, Designed to Change, Appropriate Formats, Competencies, and Analyzes Change).

Yes. In fact, the MIPS expectations for Completion of an Accredited Safety or Quality Improvement Program are the same as the expectations for Practice Assessment (Part IV) MOC for several medical specialty boards. For more information, see CME for MOC resources.

There are no additional requirements. Any accredited CME activity that meets MIPS expectations (i.e., addressing practice or quality improvement) can be offered as a MIPS Improvement Activity.

Here are some examples of accredited CME activities that meet the expectations for the “Completion of an Accredited Safety or Quality Improvement Program” MIPS Improvement Activity:

• Our clinicians complete a self-evaluation each year and we ask them to identify an area for growth. We use these accumulated reports to create small group collaborative activities to address these gaps. As clinicians complete these activities – focused on their quality objectives – we can issue them CME and Maintenance of certification (MOC) credits and tell them how to attest to meeting MIPS expectations.
• We’ve recently implemented an electronic health record (EHR) system in our small family practice. We created an opportunity for clinicians to conduct some simple improvement projects using data reports from the EHR as a way to both learn how to use the system and identify and address opportunities to improve diagnostic accuracy and our coordination with other services (e.g., physical therapy, nutrition, mental health). We have checked in with each clinician over a 6-week period to hear about their progress and support them with any additional training we can provide.

Our quality assurance committee tracks several quality measures for our dialysis center. Twice per month, we meet to review problem areas and create a short-term improvement action plan. In last week’s meeting, we observed a higher number of infections among a group of patients and identified that some staff were unclear about which protocol they should be using. We created an action plan to conduct additional training for staff and we’ll look back to the quality measures for the next few weeks to see if that helps to lower the number of infections.

Yes. MIPS-eligible clinicians include many health professions in addition to physicians. Both the ACCME and the Centers for Medicare and Medicaid Services (CMS) encourage participation by multiple health professions.

Yes.

For the accreditation process, there is no additional information that is required beyond what is required for any accredited CME activity. For reporting purposes, the Centers for Medicare and Medicaid Services (CMS) expects that accredited providers, “define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.”

Any accredited CME activity can be offered, so long as it meets the expectations for the Completion of an Accredited Safety or Quality Improvement Program. There are no format limitations on these improvement activities.

The Centers for Medicare and Medicaid Services (CMS) expects that Completion of an Accredited Safety or Quality Improvement Program “include data collection and analysis of performance data to assess the impact of the interventions.” As the accredited CME provider, you can determine what approaches you use to measure the impact of the activity. The expectation for performance data can fulfilled with quantitative and/or qualitative data.

No.

The “Completion of an Accredited Safety or Quality Improvement Program” is the activity that ACCME submitted and the Centers for Medicare and Medicaid Services (CMS) approved as a MIPS Improvement Activity. This MIPS Improvement Activity is listed on the QPP website as Activity ID IA_PSPA_28, Subcategory Name: Patient Safety And Practice Assessment, with an Activity Weighting of Medium.   

It is up to the accredited CME provider to determine how learners complete accredited CME activities that are being offered as a Merit-Based Incentive Payment System (MIPS) Improvement Activity: Completion of an Accredited Safety or Quality Improvement Program.

Accredited CME providers can support participation in QPP and MIPS through any of the following approaches:

• Offer training and consultation with organizational stakeholders (e.g., leadership, administrative staff, clinicians) to help them navigate participation in payment reform.
• Identify existing practice and quality improvement work that clinicians are already doing that count as both accredited CME and MIPS Improvement Activities.
• Provide training and administrative support to help clinicians submit their MIPS Improvement Activity participation data.

Collaborate with stakeholders to integrate accredited CME with other organizational initiatives related to QPP and MIPS (e.g., data registries, quality reporting).

No. Activities can be designed for a single clinician, a small team, a large group, or the entire membership of a professional society or community. 

Accredited providers can use ACCME's Program and Activity Reporting System (PARS) to indicate that a CME activity meets the requirements for the Completion of an Accredited Safety or Quality Improvement Program. Activities in PARS that are flagged as MIPS activities will then be displayed in CME Finder.

Any accredited CME activity can be an Improvement Activity if it:

• addresses a quality or safety gap;
• uncovers educational needs that—when addressed—can help close the gap;
• articulates what your participation in the activity seeks to improve;
• includes methods to help achieve that improvement; and
• evaluates the impact of the education on improving performance and/or quality

Can you give me some examples of CME Improvement Activities?

• Our clinicians complete a self-evaluation each year and we ask them to identify an area for growth. We use these accumulated reports to create small group collaborative activities to address these gaps. As clinicians complete these activities – focused on their quality objectives – we can issue them CME and MOC credits and tell them how to attest to meeting MIPS expectations.
• We’ve recently implemented an electronic health record (EHR) system in our small family practice. We created an opportunity for clinicians to conduct some simple improvement projects using data reports from the EHR as a way to both learn how to use the system and identify and address opportunities to improve diagnostic accuracy and our coordination with other services (e.g., physical therapy, nutrition, mental health). We have checked in with each clinician over a 6-week period to hear about their progress and support them with any additional training we can provide.
• Our quality assurance committee tracks several quality measures for our dialysis center. Twice per month, we meet to review problem areas and create a short-term improvement action plan. In last week’s meeting, we observed a higher number of infections among a group of patients and identified that some staff were unclear about which protocol they should be using. We created an action plan to conduct additional training for staff and we’ll look back to the quality measures for the next few weeks to see if that helps to lower the number of infections.

If your organization or practice is not using another mechanism to report MIPS participation data (e.g., CMS Web Interface, Qualified Clinical Data Registry, Electronic Health Record, Qualified Registry), individual clinicians, groups, virtual groups, and third-party intermediaries can log in and upload their improvement activities measure data in an approved file format on the Quality Payment Program (QPP) website. For more information, clinicians can check the QPP website Improvement Activities page.

Accredited CME providers can choose their own mechanism, intervention, or process to support their clinicians, and can choose the most relevant measure or outcome for their community.

Yes. Eligible clinicians are encouraged to retain documentation of their participation in Improvement Activities for six years as required by the Centers for Medicare and Medicaid Services (CMS) document retention policy. CME providers are already retaining this information for their accredited activities, per the ACCME CME Activity and Attendance Records Retention Policy and can fulfill this role for their participating learners. For more information, see the Improvement Activities Fact Sheet in the QPP Resource Library.

Yes. Activities that you already provide—such as improvement projects, weekly case conferences, quality committee meetings, personal learning plans, and self-assessment modules—can all meet the criteria for MIPS Improvement Activity: Completion of an Accredited Safety or Quality Improvement Program.

Yes. Clinicians can contact the Quality Payment Program at (866) 288-8292 [TTY (877) 715-6222] available Monday through Friday, 8:00 AM-8:00 PM Eastern or email at QPP@cms.hhs.gov.

Clinicians can determine their status in the Quality Payment Program (QPP) by entering their 10-digit National Provider Identifier (NPI) number in this CMS lookup tool.

Clinicians in organizations that are participating in Advanced Alternative Payment Models (Advanced APMs) or meeting MIPS requirements through other methods [e.g., Qualified Clinical Data Registry (QCDR), Qualified Registry, Electronic Health Record (EHR)] may not be required to participate in additional Improvement Activities. Consult with your office or system administrator to determine how your organization is participating in the MIPS program.