IA_PSPA_8Patient Safety and Practice Assessment

Use of Patient Safety Tools

2026 MIPS Improvement Activities

At a glance
Activity ID
IA_PSPA_8
Subcategory
Patient Safety and Practice Assessment
Category
Improvement Activities

Objective

Improve the number of patients tracked and the precision of measurement for patient safety measures, thus allowing specialists to make evidencebased decisions about improving safety for their patients.

Activity description

In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.

Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.

Suggested documentation

Documented use of patient safety tools implemented for tracking specific patient safety and practice assessment measures that are meaningful to the eligible clinician or group (e.g., tracking HbA1c would be meaningful to an endocrinologist whereas tracking intraocular pressure would be more meaningful to an ophthalmologist). Include both of the following elements:

1) Evidence of safety tools used – Documentation of the use of patient safety tools that assist in tracking patient safety measures (e.g., practice policy or protocol, workflow diagram, screenshot); AND

2) Evidence of measures tracked – Documentation of specific patient safety measures tracked via use of tool (e.g., quality measure report, dashboard, screenshot).

Improvement Activity details reference the CMS Quality Payment Program and change each performance year. Confirm requirements against the official CMS pages before attesting.