FAQs

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.