IA_PSPA_7 · Use of QCDR data for ongoing practice assessment and improvements

Subcategory: Patient Safety and Practice Assessment

Activity Description: Participation in a Qualified Clinical Data Registry and use of QCDR data for ongoing practice assessment and improvements in patient safety, including one or more of the following:

• Performance of activities that promote use of standard practices, tools, and processes for quality improvement that can be shared across MIPS eligible clinicians or groups;
• Use of standard questionnaires for assessing improvements in functional health status;
• Use of standardized processes for screening for drivers of health;
• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes;
• Use of processes and tools that engage patients to improve adherence to treatment plans;
• Implementation of patient self-action plans;
• Implementation of shared clinical decision-making capabilities;
• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;
• Promotion of collaborative learning network opportunities that are interactive;
• Use of supporting QCDR modules that can be incorporated into certified EHR technology; or
• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.

Why we recommend it: If you are a Graphium QCDR client and you review your analytics, you are already performing this activity. The documentation burden is the lowest of any activity on this list. Retain your quarterly analytics reports and a short record of at least one change made in response to what the data showed.