2026 MIPS Improvement Activity IA_PSPA_15: Implementation of an ASP
Written by Tucker Deyett, Dedicated Advisor, ReportingMD. Source data: CMS Quality Payment Program 2026 measure specifications and benchmark files.
Subcategory: Patient Safety and Practice Assessment
At a glance
IA_PSPA_15, Implementation of an ASP, is a 2026 MIPS improvement activity in the Patient Safety and Practice Assessment subcategory, included in 1 MVP. For PY2026 activities are not weighted: clinicians with small practice, rural, non-patient-facing, or HPSA status attest to one activity, all other Traditional MIPS participants attest to two, and MVP participants attest to one.
Activity description
Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include: • Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.• Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient). • Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.• Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws. • Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.• Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.• Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line. • Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions. • Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.• Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance.
Activity details
- Activity ID: IA_PSPA_15
- Subcategory: Patient Safety and Practice Assessment
- Programs: Traditional MIPS, APP, APP Plus
- First performance year: 2017
MVPs that include this activity
Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
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