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MIPS Improvement Activities for Non-Patient Facing Practices

Practice Improvement, also called Practice Transformation, has often been discussed in relation to primary care.  Step-by-step pathways to practice improvement, like the Patient Centered Medical Home model can be useful guides for those who fit into a family-practice model, but the current focus on finding ways to improve the quality of care we provide while reducing costs should not be limited to primary care. In addition, under MIPS and the Quality Payment Program, most clinicians must participate in the new Improvement Activities performance category.

What Does Practice Improvement Mean to Radiology and Pathology?

Non-patient facing practices, such as radiology and pathology, also have a responsibility to learn and adopt the skill set needed to improve and transform their own practices. This is essential as we move forward into nation-wide healthcare transformation in order for these practices to maintain autonomy and relevance in the ever-changing healthcare market and not be simply relegated to a commodity of referring practices.

The work of practice improvement has its own language and techniques, much like project management or other formal fields of work.  Although there are many formal paths to practice improvement that can be used by a non-patient facing group, the Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) process and the Plan Do Study Act (PDSA) cycle are two of the more common methodologies and both align well with a results-based practice.  Radiologists and Pathologists tend to find these methods reassuring as they discover that these are ways to apply the scientific method to the practice itself.

Most simply, what we are doing is:

  1. Becoming aware of our own practices’ current level of quality, safety, and cost by analyzing measurable data.
  2. Becoming accountable (both as an individual and at the group level) for that quality, safety, and cost without placing blame.
  3. Continually work to improve it by identifying the best changes to be made.
  4. And the final, crucial step is to re-analyze our practice again, this time to ensure that the change we made actually made a difference in our level of quality, safety, or cost.
Practice improvement opportunities for Radiology/Pathology Departments

Analyzing the routine processes that take place in a radiology or pathology department can offer the best opportunities for improvement.  Some of the more commonly used methods to gather data are environment walkabouts, surveys, process bottlenecks, peer review and error reporting, brainstorming sessions, and strength, weakness, opportunity, and threat (SWOT) analyses.

  • Environment Walkabouts help identify potential issues, safety equipment, or physical areas that do not meet guidelines and require intervention.  Working in the same area every day can lead us to no longer seeing potential safety hazards.  When we take the time to walk through our routine areas with a specific eye to safety or other concerns, we are much more likely to find areas of improvement.
  • Patient or staff surveys, including feedback from staff and referring providers, will allow you to compare/benchmark your performance against other practices and can highlight improvement opportunities.  There are many standardized survey questions, which allow for good comparison across multiple areas, but internally created surveys can be useful as well, especially when trying to determine the specific experiences of those who interact with our practice.
  • Process Bottlenecks which affect areas like scheduling, access to services, patient throughput, room turnover, and report turnaround time offer opportunities for further analysis and improvement of service.  Mapping the process in a visual way, using flowcharts/process maps can facilitate identification and allow for new decision points to be added.  Although it is easy to get ahead of ourselves and map out the post-change or ideal workflow, there is always quite a bit to be learned from mapping the current state workflows.
  • Peer Review/Error Reporting can provide insight into potential areas for clinical or technical improvement.  Performing a root cause analysis (RCA) of errors can help identify contributing factors.  Also, encouraging a Just Culture, in which staff members feel comfortable disclosing errors without fear of punitive actions is important.  Competent professionals make mistakes, and those mistakes can be an opportunity for the entire practice to learn, while still not tolerating disregard for patient risk or actual misconduct.  Performing the analysis of your department’s culture in regard to error reporting and patient safety is a good place to start practice improvement.
  • Brainstorming sessions allow staff to have their voices heard and thus participate in the quality improvement process.  We don’t often think of brainstorming as a formal piece of the improvement process, but it is essential for innovation and determining new interventions to combat any existing barriers or issues we find.
  • SWOT analyses allow a department or organization to identify major internal and external barriers as well as opportunities for improvement.  Each practice stakeholder has different experiences, and thus, different perspectives.  Encouraging them as a group to identify the department’s internal strengths and weaknesses as well as the external threats and opportunities can not only help with practice improvement but can help the leaders of the practice formulate a strong strategic plan.
Recommended MIPS Improvement Activities

This year under MIPS, non-patient facing practices will still need to attest to enough Improvement Activity measures to earn 40 points.  If your practice has at least 75% non-patient facing providers, the points you receive for the Improvement Activity category will be doubled.  This means that medium-weight activities are worth 20 points each and high-weight activities are worth 40.

Here is a list of recommended activities which may be applicable to your radiology or pathology practice:

  • IA_PSPA_19 – Medium:  Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
    This is a good starting measure for groups who are interested in learning more about practice improvement and how to go about it.  The measure requires the documentation of a formal quality improvement plan and staff participation in learning about that plan.  This is a great opportunity to teach staff the basics of quality improvement while helping manage expectations for improvement activities moving forward.
  • IA_PSPA_18 – Medium: Measure and improvement at the practice and panel level
    This is a measure which encourages practices to review their progress and set goals for their quality or other data.  If your practice is meeting regularly to discuss quality metrics, then this is one you should definitely attest to as it is wise to earn credit in this first year for the work you are already doing.  The measure requires that you save a copy of your quality improvement plan or show progress on your selected measures, including the benchmarks and goals you selected for the practice and panel levels.
  • IA_PSPA_20 – Medium: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
    This is a great measure where we are simply proving that leadership at our organization is taking practice improvement seriously as a part of their job.  Having leadership “buy-in” for practice improvement is one of the key strategies for actually getting the needle moved.  Work doesn’t get done unless it is prioritized.  Practice leaders can help us do that.  The measure requires one of the following: Documentation of clinical and administrative leadership role descriptions that include responsibility for practice improvement change, OR Documentation of allocated time for clinical and administrative leadership participating in improvement efforts (regular team meeting agendas or minutes), OR Documentation of population health, quality and health experience metrics incorporated into regular practice performance reviews.
  • IA_PSPA_17 – Medium: Implementation of analytic capabilities to manage total cost of care for practice population
    This is a measure which encourages discussion and education on the cost and utilization information available for your practice.  CMS offers a Quality and Resource Use Report (QRUR) which can be downloaded by the administrator and shared with the group.  The cost category is not scorable for this year, but it is likely to be for future years, making it an excellent topic for proactive practices.  This measure requires documentation of staff training regarding cost and utilization information OR availability of the cost/resource use data that is used to regularly analyze opportunities to reduce cost.
  • IA_ERP_1 – Medium: Participation on Disaster Medical Assistance Team, registered for 6 months
    This measure is another example of leveraging the work your clinicians may already be doing.  It is common for practitioners to already be serving as volunteers on their community first responder teams.  If your group has these individuals, attesting to this measure is a good way to spark discussion and perhaps encourage further community involvement.  This measure requires documentation of participation in Disaster Medical Assistance or Community Emergency Responder Teams for at least six months including registration and active participation.
  • IA_CC_7 – Medium: Implementation of regular care coordination training
    Coordination of care, especially through patient transitions from one area to another, including the communication necessary between providers is an essential part of healthcare improvement.  This measure requires documentation of implemented regular care coordination training within your practice.  This should include training materials, attendance lists, or training certification documents.
  • IA_PSPA_2 – Medium: Maintenance of Certification Part IV
    Many clinicians participate in the Maintenance of Certification (MOC) work, and part IV of this work includes practice improvement.  This activity is offered to acknowledge the transformative work already being done here.  The measure requires documentation of participation in MOC part IV from an American Board of Medical Specialties (ABMS) member board (and both the American Board of Pathology and the American Board of Radiology are ABMS members) including participation in a local, regional, or national outcomes registry or quality assessment program, AND documentation of monthly activities across the practice to assess performance by reviewing outcomes, addressing areas of improvement, and evaluation of results.
  • IA_CC_1 – Medium: Implementation of use of specialist reports back to the referring clinician or group to close the referral loop
    This activity is best for non-patient facing practices when the referring clinician/group has a formal referral to the radiology practice. Closing the referral loop simply means creating a report which goes back to the referring clinician, so they have a communication that the radiology exam was performed which includes the radiologist/pathologist’s assessment, result, and plan.  This measure requires that you save a sample of your reports used to communicate back to the referring clinician within the EHR or medical record.
  • IA_EPA_3 – Medium: Collection and use of patient experience and satisfaction data on access
    Although this measure is written with primary provider access to care in mind, it CAN be used for access to service by the non-patient facing departments if they own the workflow of patients coming to the department for the actual radiology exam process as well as interpretation.  This measure requires that the practice collect patient experience/satisfaction data on access to care AND create and implement an access improvement plan.
  • IA_PSPA_16 – Medium: Use of decision support and standardized treatment protocols
    This measure is good for radiology groups who have reached the optimization stage within their EHR.  Decision support is designed to assist with decision-making at the point of care.  If the practice has a checklist, algorithm, or standard treatment protocols in place, they can reach out to the EHR team to incorporate those into electronic decision support tools.  This measure requires that the practice document (most commonly through screenshots) the use of those tools to manage workflow in the team to meet patient needs.
  • Other measure options to consider include: BE_12, CC_7, PSPA_16, PSPA_17, PSPA_18, PSPA_19, and PSPA_2
Additional Resources

Six Sigma – The Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) methodology can be thought of as a roadmap for problem-solving and process improvement.  Each phase of the roadmap has well-defined steps and tools you can use to improve your practice/processes.

Plan Do Study Act (PDSA) – The PDSA cycle is a part of the Institute for Healthcare Improvement Model for Improvement, a simple tool for accelerating quality improvement.  It allows the team to set a goal and determine whether change leads to an improvement.

Radiology Support, Communications and Alignment Network (R-SCAN) – the CMS program Transforming Clinical Practice initiative (TCPI) is a collection of collaborative healthcare networks focused on supporting clinician practices through nationwide, peer-based learning that facilitates practice transformation.  R-SCAN is the TCPI program specific to the College of Radiology.

R-SCAN is a collaborative action plan that brings radiologists and referring clinicians together to improve imaging appropriateness based on a list of topics.  Participation in an R-SCAN project can potentially fulfill requirements for up to seven Improvement Activities including: BE_12, CC_7, PSPA_16, PSPA_17, PSPA_18, PSPA_19, and PSPA_2.  Radiology practices that feel they may benefit from peer-based assistance in practice transformation should consider registration and participation in R-SCAN.

Just Culture/Patient Safety Culture – Just Culture is an organizational approach that encourages individuals to report mistakes so the precursors to errors can be better understood in order to fix system issues.  It is believed that approaches which focus on punishing individuals provide incentives for people to report only the errors they cannot hide.

The Agency for Healthcare Research and Quality provides educational materials, toolkits, and surveys on patient safety culture.

What MIPS Improvement Activities are you undertaking for your practice?

Let us know in the comments! Have questions about your practice? Leave your question in the comments –the Mingle Team is here to help.

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