2026 MIPS Improvement Activity IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
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_7, Use of QCDR data for ongoing practice assessment and improvements, is a 2026 MIPS improvement activity in the Patient Safety and Practice Assessment subcategory, included in 10 MVPs. 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
Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:
• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);
• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);
• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;
• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;
• 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 the 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.
Activity details
- Activity ID: IA_PSPA_7
- Subcategory: Patient Safety and Practice Assessment
- Programs: Traditional MIPS, APP, APP Plus
- First performance year: 2017
MVPs that include this activity
Advancing Care for Heart Disease; Adopting Best Practices and Promoting Patient Safety within Emergency Medicine; Improving Care for Lower Extremity Joint Repair; Patient Safety and Support of Positive Experiences with Anesthesia; Quality Care for the Treatment of Ear, Nose, and Throat Disorders; Complete Ophthalmologic Care; Optimal Care for Patients with Urologic Conditions; Surgical Care; Diagnostic Radiology; Podiatry
Need help with IA_PSPA_7?
ReportingMD is a CMS qualified registry and healthcare data pipe with a 100% submission rate since 2001. We confirm IA attestations and documentation with every client before submission. Talk to a ReportingMD advisor or browse the full 2026 MIPS directory.