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What is the basic framework for CME activities that count for Merit-based Incentive Payment System (MIPS) Improvement Activities?

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.