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), clinicians can attest to meeting Improvement Activities. For more information, clinicians can check the QPP website Improvement Activities page for information about PY2018 reporting for individuals. Clinicians should be reminded to login to the CMS web portal in the new year of 2019 to report their participation in 2018 improvement activities.
October 3, 2018 - CMS requires that clinicians attest to a minimum of 90 days participation in MIPS Improvement Activities. October 3, 2018, is therefore the final day to initiate engagement in an improvement activity for a 90-day minimum engagement period for Accredited CME Improvement Activities for 2018.
December 31, 2018 - 2018 MIPS performance period ends.
January 2 – March 31, 2019 - MIPS data submission period for the 2018 performance period. (Note the CMS Web Interface has an 8-week submission period within this timeframe.)
July 2019 - Performance feedback will be available to participating clinicians.
No. Accredited CME Improvement Activities can be designed for a single clinician, a small team, a large group, or the entire membership of a professional society/community.
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.
The QPP website does not yet include specific guidance on reporting Accredited CME Improvement Activities for Performance Year 2018. However, CMS is providing this fact sheet as a resource to identify which approaches your clinicians may take with regard to Improvement Activities. Consult with your office or system administrator to determine how your organization is participating in the MIPS program.
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 Accredited CME Improvement Activities that are required as part of MIPS expectations for clinicians.
Yes. Eligible clinicians are encouraged to retain documentation of their participation in Improvement Activities for six years as required by the 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 2018 MIPS Improvement Activities Fact Sheet.
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.
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.