MIPS Improvement Activities for year one of the QPP

By Bevin Rousopoulos posted 06-05-2018 12:45 PM


CMS TEP Report Posted: MIPS Improvement Activities for year one of the QPP

A Technical Expert Panel (TEP) was convened by CMS to review the 93 MIPS improvement activities (IAs) for the first year of the Quality Payment Program. Stephen Davidow, MBA-HCM, CPHQ, APR, Director, Quality Improvement, served on the panel representing PCPI. This CMS TEP provided feedback around the effectiveness and accuracy of the IAs included in the transition year of the QPP. It’s work focused on:

● The relevance of the current set of IAs to patients and caregivers

● Clarity

● Burden

● The weighting of the IAs category in MIPS scoring


The TEP performed a review of selected IAs, especially those for which the QPP Service Center received comments and questions. CMS seeks to engage program participants in the design of these IAs and solicited feedback with the goal of ensuring that the IAs are valid, weighted correctly and have the right set of qualifications for credit. Also discussed was the issue of burden for eligible clinicians to implement or participate in improvement activities. View the full report here.



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Downloadable Resources

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Closing the Referral Loop Tool Kit - Through participation in a quality improvement collaborative, dyads were able to increase the number of closed referrals from 40% to 70%, and significantly improve physician satisfaction with the referral process. Learn more and access the CRL tool kit here.

Common Clinical Registry Framework Domain Analysis Model - This Health Level Seven® International (HL7®) publication describes a general clinical registry from a data standards and interoperability perspective. Learn more and access the DAM here.

Measure specification resources - The PCPI Measurement Science team has created several internal, and collected several external resources, and made them available to you here.

PCPI-stewarded measures - PCPI stewards select measure(s) in several clinical conditions or topic areas. These measures are listed in order by condition or topic area here.

Qualified Clinical Data Registries in MACRA - This fact sheet explains the basics of the QCDR program and may be helpful to QCDR stewards in creating educational collateral for your participants. Learn more and access the QCDR fact sheet here.


Interested in learning more about our consulting services, education & training opportunities, and downloadable resources? Contact PCPI Membership Manager, Bevin Rousopoulos at bevin.rousopoulos@thepcpi.org.