What are the expectations for the Merit-Based Incentive Payment System (MIPS) Improvement Activity: Completion of an Accredited Safety or Quality Improvement Program?
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.