MIPS Improvement Activities: Practical Ways to Increase Your Score

Written by Chirpy Bird contributor Shereese Maynard, MS, MBA She/Her

Healthcare is becoming more challenging; the climate is tricky, and finding time to work on new processes can feel burdensome. The Merit-based Incentive Payment System (MIPS) sets performance targets that may seem like extra work on top of a busy schedule. However, one area often gets overlooked, even though it can be easier to handle than many people realize: Improvement Activities (IA).

If you are part of a clinic, hospital, or other healthcare facility, Improvement Activities might seem like a small piece of MIPS. Yet, they can help you score higher without wasting as much time or money as other tasks. In this post, we will walk through what Improvement Activities are, why they matter, and how you can choose and complete them. By the end, you will have clear ideas you can practice immediately.

Understanding MIPS

Many healthcare professionals already know MIPS is a key part of Medicare’s Quality Payment Program, aimed at rewarding high-quality, cost-effective care. MIPS measures performance in four main areas:

1. Quality
2. Cost
3. Improvement Activities (IA)
4. Promoting Interoperability (PI)

Most people think of MIPS in terms of the Quality category. This makes sense because it often has the most measures to choose from. However, focusing solely on quality may leave other categories behind. Improvement Activities, for instance, can give you many points with less effort than expected.

Why Improvement Activities Matter

The Improvement Activities category represents a notable share of your total MIPS score. This category rewards providers for work that enhances care processes, patient involvement, and overall outcomes. You can pick from a list of recognized activities that range from improving care coordination to boosting patient education. The best part is that you often can build on workflows you already have.

Some examples of Improvement Activities might include:

• Performing medication reconciliation with patients at admission or discharge
• Setting up a process to follow up with patients after they go home
• Offering expanded patient access through telehealth services

These are tasks you are already doing. If so, you can score points by properly documenting these efforts. Even if some tasks require minor changes, they can offer a significant return regarding your MIPS score.

The Value of “Easy Wins” in IA

Why do Improvement Activities often get called an “easy win”? Simply put, they can be simpler to manage than collecting Quality data or meeting strict interoperability rules. The improvement tasks often align with the usual flow of patient care. For example, your practice may already have a weekly meeting on patient cases, so turning that meeting into a recognized improvement activity might take just a little extra record-keeping.

The Centers for Medicare & Medicaid Services (CMS) weights IAs differently (medium or high), but many are easier to manage than you would think. You may only have to do an activity for 90 days to get the credit. Also, many small practices with 15 or fewer clinicians get special scoring consideration. That means earning full credit in that category might take fewer or simpler IAs.

Key Steps to Choose the Right Improvement Activities

Step 1: Know Your Current Workflows Start by listing tasks your team already does. Do you have a patient education program? Do you check medications at each visit? Do you hold monthly meetings to discuss care transitions? These could fit IA options.

Step 2: Check the CMS IA Inventory. Each performance year, CMS publishes a list of approved Improvement Activities. Compare your list of current workflows to the official IA list. Mark any that seem to already match your work.

Step 3: Assess Time and Resources Not all Improvement Activities are equal. Some are “high-weighted,” and others are “medium-weighted.” High-weighted activities might take more time or resources, but they also yield more points. Check to see if your staff can handle bigger tasks. Small or solo practices might lean toward activities that demand less staff time.

Step 4: Plan a 90-Day Period. In most cases, you have to perform your chosen Improvement Activities for at least 90 days within the performance year. Plan out those 90 days. Who will track the activity? How will you record what you did? Answering these questions ahead of time helps you stay on top of deadlines. Chirpy Bird regularly publishes content on 90-day windows. Be sure to follow us to take advantage of the strategies.

Step 5: Maintain Good Documentation. It is imperative to keep track of what you do. Keep logs, meeting minutes, or system reports that show you completed the activity. If you are ever audited, you will want a paper trail showing your compliance.

Simple IAs for Small Practices

Smaller practices face unique challenges. Staff might be limited, and resources for data tracking may not be as sophisticated. Still, a few Improvement Activities can often be done with minimal disruption:

1. Medication Review During Transitions of Care (Often missed)
2. Patient Access and Communication
3. Regular Care Coordination Meetings
4. Basic Quality Improvement Training

Simple IAs for Large Practices

Large practices or hospital systems have more staff and often use advanced tools like EHR systems. This opens the door to more complex tasks, but there are still reasonably simple IAs that fit bigger groups:

1. Advanced Care Coordination Projects
2. Expanding Telehealth Services
3. Advanced Risk Stratification
4. Data Analytics and Reporting

The Role of Technology in MIPS IAs

Many Improvement Activities tie in with technology. For instance, you might have an EHR that allows you to receive CCDA files (Consolidated Clinical Document Architecture). If you are in the skilled nursing facility (SNF) space, you might use PointClickCare (PCC) or a similar system. These tools can import and reconcile patient records automatically. This can save you from manually typing in patient histories or medication lists.

Yet, we see a significant gap in how often people use these features. Many SNFs do not take advantage of the CCDA functionality or other readily available data exchange features. They end up spending time on manual data entry, which slows them down and raises the chance of mistakes. By tapping into EHR and data exchange features, you can complete a recognized Improvement Activity (like improving the efficiency of patient admission processes) while making your workflow smoother.

Why does this matter for MIPS? Streamlined data exchange can qualify as an Improvement Activity if it helps with things like care coordination or medication reconciliation. More importantly, it helps your staff save time and lowers the risk of missing essential patient details. Once you set up the process, you can gather evidence of its success—like fewer errors or quicker care transitions—and show that to CMS.

Documentation and Tracking

A key part of MIPS (and Improvement Activities in particular) is showing your work. If you do not have proof, you do not get credit. This proof can take many forms:

• Meeting Minutes: If your Improvement Activity involves team meetings, keep notes showing who attended, what topics were covered, and how these meetings improved care.
• Reports from EHR: If you set up an EHR-based system to track patient outreach, print or save those reports. They can show the tasks completed, the patients reached, and the time frame covered.
• Checklists and Logs: If your activity is medication reconciliation, keep a simple checklist for each patient that includes medication changes, the date, and the staff member responsible.

The point is to create an audit-friendly paper (or digital) trail. You do not need a giant binder full of documents, but you do need enough to prove you followed through. You can repeat or improve your activities with good documentation habits each year.

Common Pitfalls and How to Avoid Them

While Improvement Activities can be simpler than some other parts of MIPS, a few mistakes can cause problems:

1. Not Selecting the Right Activity
2. Inconsistent Execution
3. Poor Documentation
4. Ignoring the Tech Tools You Already Have

Tying IA Back to MIPS Success

Beyond Improvement Activities, you also have Quality, Cost, and Promoting Interoperability. A balanced approach will help you do well overall. Here is how Improvement Activities can support the other categories:

• Quality: Many IAs, such as medication reconciliation, can reduce errors. Lower errors can mean higher performance in specific Quality measures.
• Cost: Better care coordination often means fewer hospital readmissions. That can improve your performance in the Cost category.
• Promoting Interoperability: If you use EHR features to share data or let patients view their records, you might meet goals in the PI category.

By picking Improvement Activities that work across multiple MIPS areas, you can get more value from your efforts.

A Look at the Future

Value-based care is becoming more important every year. MIPS itself is part of a larger plan to encourage cost-effective, high-quality healthcare. Improvement Activities help providers focus on better communication, efficient processes, and patient-centered care. Over time, we may see an even bigger push for advanced data sharing and real-time tracking of care outcomes.

Many skilled nursing facilities have been slow to adopt advanced technology, especially when it comes to data exchange. If that describes your organization, this is a chance to stand out by getting ahead of the curve. By using features like CCDA ingestion or automated medication reconciliation, you can not only save time but also earn MIPS credit. This benefits your patients and your bottom line.

Action Steps You Can Take Today

1. Review the CMS IA List: Look for an activity you can match with current workflows.
2. Create a Simple Plan: Outline who will take part, how often tasks will occur, and how you will track them.
3. Test One Technology Feature: If you have an EHR system with advanced features, pick one you haven't tried yet. Learn how it works, then set it up in a pilot group.
4. Log Your Work: Set up a folder (preferably digital) to store proof of your work each day or week.
5. Evaluate Your Results: After a few weeks, check if the new process saves time or improves care. If it does, keep doing it. If not, adjust the plan.

Here's the thing . . .

Improvement Activities can offer a more straightforward path to boosting your MIPS score. Whether you are a small clinic or a large health system, there are many ways to fit these tasks into your routine without creating a huge burden. The secret is to pick activities that match what you already do or want to do. With precise planning, strong documentation, and a willingness to use tech tools, you can earn valuable points in MIPS while making your practice more efficient.

Think of it this way: each Improvement Activity is a chance to sharpen how you care for patients. And in the long run, that is what MIPS is all about—better outcomes, more innovative processes, and a system that rewards good care. If unsure where to begin, focus on what you do best. Start small, track your progress, and keep an open mind about trying new tools and ideas. As you grow more comfortable, you can branch out and tackle more ambitious Improvement Activities.

Your patients, your staff, and your practice will benefit. And you will also see the results in your MIPS score. That is a win worth aiming for. What are your small wins? Share your tips below. If you're looking for MIPS strategies or a team to help you capture those small and large wins, Chirpy Bird is here to help.