PSPA 28 - Completion of an Accredited Safety or Quality Improvement Program

Activity Weighting: Medium
Subcategory Name: Patient Safety and Practice Assessment
Description: Completion of an accredited performance improvement continuing medical education program that addresses performance or quality improvement according to the following criteria:

• 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, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.

Supporting Documentation
Documentation that the activity addresses 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, describe the mechanism for identifying clinicians who meet the requirements and provide participant completion information.

Resources
2018 Improvement Activities Requirements
2019 Improvement Activities Requirements
2018 MIPS Improvement Activities Fact Sheet
Scores for Improvement Activities for MIPS APMs in the 2018 Performance Period Fact Sheet