New Feature: SPSQ Low Score Comment Prompts

Low Score Comment Prompts

Better understand patient concerns with our low-score survey logic, now included on our Standard Patient Satisfaction Questionnaire (SPSQ). When patients select a score of a ‘1’ or ‘2’ on the five-point Likert scale for any standard survey question, they will be prompted to leave a comment describing their experience in that area.

The long-term use of this feature on our Anesthesia Patient Satisfaction Questionnaire (APSQ2) has been effective in helping providers to better understand trends and improvement opportunities in specific areas. These prompts encourage patients to include details about a specific part of their experience, providing deeper insights than often gained with generalized comment prompts at the end of a survey. Please note, there will be no change to the existing SPSQ comment questions with the addition of the low score prompts.

To gain even more insight from your patient feedback, use our sentiment analysis tool to review patient low score comments. This will help you to identify the most critical feedback quickly.

Have questions about this new feature or the SPSQ survey? Chat with us using the blue chat icon below, or reach out to your client account manager. Interested in learning more about SurveyVitals? Request a demo of the solution here.

December 16th, 2019 Categories: featured, Outpatient Practice, Patient Experience, Product Features

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Public Review Just Got Better! Boost Your Google Business Reviews with this New Feature

Nearly 90 percent of patients look to online reviews when choosing a physician, so increasing a positive presence online is more important than ever.

SurveyVitals’ Public Review feature helped healthcare providers and organizations proactively build their online reputation and improve their search rank in 2019. The feature drives verified patients to leave public reviews about their experiences on a page hosted by SurveyVitals and indexed by Google, allowing prospective patients to find you more easily online.

Since its launch this year, over 200,000 verified patients have posted online ratings using Public Review, and 98% of those reviews scored 4 out of 5 stars or higher. Using our composite scoring algorithm ensures patients’ public star ratings are more reflective of their visit, rather than a single aspect of their experience.

Public Review is an important tool that allows healthcare organizations and providers to build a brand on the web. However, we also want to help get you more positive reviews where they matter the most. Google accounts for 57.5% of all online reviews worldwide, far superseding other online review platforms. If you have only a handful of Google reviews, a one- or two-star rating can drag your overall rating down.

Public Review + Google

We’ve enhanced our Public Review feature to give you a two-pronged approach to building your online reputation. The newest expansion of the tool allows you to better incorporate your Google Business pages into your SEO strategy. Use Public Review to boost your volume of reviews by driving a percentage of your verified patients to your Google Business review pages.

Public Review plus Google

How it works

Setup is quick and easy. Add your Google Business review link to your Public Review settings within your SurveyVitals portal, and specify a percentage of your patients to route directly to this page upon completion of a survey. You can link to the Google Business reviews page for the whole organization or separate pages for each of your practice locations.

That’s it! To schedule a demo or learn more, chat with us using the blue chat icon below.

December 13th, 2019 Categories: featured, Patient Experience, Product Features, Reputation Management

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10 Million Surveys!

10 million patient experience surveys completed

Together with our clients, we reached 10 million surveys in the SurveyVitals comparative benchmark. Thank you for helping us achieve this incredible milestone!

SurveyVitals 10 million surveys completed

With over 16,000 clinicians across 85 specialties utilizing SurveyVitals at over 3,500 locations, we are excited to watch this benchmark continue to grow. Your partnership and each interaction with your patients strengthens the solution and continues to fuel our mission to improve care and the experiences of patients across the country every day.

Ten million surveys comes on the heels of several new feature releases in 2019. Check them out here:

Report Builder

Upgrades to our custom reporting tool increased its speed and ability to analyze higher volumes of data, and introduced more comparison options, diverse filtering, and deeper comment analysis.

Sentiment Analysis

Using a machine learning algorithm, the new sentiment analysis feature measures the overall tone of text comments to help identify the most positive and negative feedback. The addition of sentiment analysis made it easier and faster for users to gain deeper insights from hundreds and even thousands of comments.

Improvement Center

We launched the Improvement Center in our client portal to aid providers in targeting improvement in the areas where it is needed most. The Improvement Center houses over 120 short videos and articles organized by question group.

Provider Performance by Location

Enhancements to the Location & Provider Details tool optimized how organization and division-level users capture provider performance. The Provider Scorecard breaks down each provider’s performance across multiple locations, making comparison of individual performance at one location versus another fast and easy.

We look forward to continuing to enhance and grow our solution as we work toward the next 10 million surveys!

November 25th, 2019 Categories: featured, Patient Experience

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Provider Spotlight: Tina Eide, MD, Matrix Anesthesia

Provider Spotlight: Tina Eide

Tina Eide, a board certified anesthesiologist from Matrix Anesthesia, was one of the winners of our recent Patient Experience Week giveaway. We asked Tina about the best practices she follows to provide exceptional patient care, and we’re excited to share her responses.

Tina studied medicine at the University of Washington and trained at Virginia Mason Medical Center. Her primary areas of work interest include regional anesthesia, neuroanesthesia, lifestyle/behavior, and anti-aging medicine.

What best practices do you and the staff you work with follow that you attribute to your positive scores?

Tina Eide: [The] Overtake Hospital pre-operative setting includes private rooms for each patient, so interviews can be conducted with a closed door, and a quiet environment. This is instrumental in developing patient trust, explaining anesthetic choices, and creating a safe space for patients to voice anxieties or fears. Also, the pre-op nurses are excellent and gather information ahead of the anesthesiologist meeting the patient, so we don’t have to be entirely reiterative.

I always try to ask several specific questions about a patient. By knowing a few personal details, I can often begin talking about a familiar topic that helps put the patient at ease. I’ve even gotten three patients to sing for me recently!

Finally, I always offer my first name after I’ve introduced myself as Doctor Eide. I give my patient the choice of which to call me, and most prefer calling me Dr. Tina or just Tina. I am able to communicate through this that I am a professional but I am also a human.

What is one example of how you improved your relationship with your patients and/or the care you provide?

Tina Eide: When I first began, I was hesitant to explain all the risks that are inherent to anesthesia with patients. I felt this information might burden them or raise their anxiety prior to surgery. As I grew as a doctor and learned from my patients, I realized that patients are entitled to know the specifics of the care they will receive while under anesthesia. Some patients will decline a total explanation, and this is just fine. Other patients want to know each event that will occur and the possible up and downsides.

I learned that if I was upfront and explicit about the risk discussion, patients were extremely appreciative and their trust in me grew as well.

How do you best use your SurveyVitals data for your own personal improvement?

Tina Eide: I look for the specific comments that patients make about their experiences. Often we only hear general feedback like “great job” but when people relay a certain moment that touched them, or a particular action I did that helped them feel at ease, I am able to repeat that going forward.

I also accept any critical feedback with an open mind and heart. As a doctor, I hold myself to an exceptionally high standard to ‘do no harm’ which can sometimes translate in my mind as ‘make no mistakes.’ Clearly, as a human being, I have to accept that I will make a mistake now and again. If I can hear the critical feedback well enough to learn from it, however, I see it as a growth opportunity rather than something negative.

September 16th, 2019 Categories: Anesthesia, Best Practices, Client Spotlight, featured, Patient Experience

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Feature Highlight: Challenge Mode

Feature Highlight: Challenge Mode

Have you set up a challenge yet? Using Challenge Mode, you can create a competition between your providers to encourage improvement. Once the competition is live, you can monitor the results in real-time from your dashboard.

During Challenge Mode setup, choose questions or question areas you want to focus on. At the end of the challenge, the clinician with the highest scores in these categories is deemed the winner.

Challenge Mode Leaderboard

Note that you must be an administrative user with ‘Organization’ permissions to launch a challenge. From the ‘Challenge’ tab in your portal, you can view current challenges, leaderboards, and historical data.

Why create a challenge?

Challenges can create a bit of friendly competition among clinicians. Target questions or question areas where you would like to see improvement in patient experience scores. This can be a fun way to start some friendly competition and encourage provider engagement. Offer prizes or other incentives to encourage providers to achieve the highest possible scores.

Setting up a challenge

Ready to get started? Here’s how to set up a challenge:

Navigate to the Challenge page within your portal.

Challenge Mode

On the Challenge page, click “+Create” and follow the prompts as they appear in the pop-up menu.

Challenge Mode

Participants will receive an email notifying them of the challenge. Once enough surveys have been collected, results will automatically update in the leaderboard. Clinicians can check the rankings from their portal login.

More resources

For more information about Challenge Mode, check out the resources in the Help section, or contact your dedicated support team members.

September 9th, 2019 Categories: featured, Patient Experience, Product Features

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Surveys You Might Not Know SurveyVitals Offers

4 survey types you may not know SurveyVitals offers

SurveyVitals’ digital patient experience surveys help you gain a deeper understanding of your performance with immediate patient feedback. Did you know our solution includes many more surveys at no additional cost to help drive improvement from every angle of your practice?

1. Point of Care

Our Point of Care tool allows you to address patient concerns on the spot before the leave your facility. The survey is sent to patients on their own devices while they’re still onsite, giving you the opportunity to resolve concerns in real-time.

2. Outcomes Surveys
Global Surgical Outcomes Survey (GSOS)

The GSOS survey is sent to surgical patients post-visit to collect feedback about the recovery experience. GSOS works in sync with the Perioperative Surgical Home (PSH) model and ERAS guidelines to identify gaps in care and spot opportunities to improve outcomes.

Emergency Medicine Outcomes Survey (EMOS)

The EMOS survey is sent to patients following an Emergency Department visit. It collects patient feedback related to understanding the recovery plan and accessibility to follow-up care.

3. 360° Surveys

As a part of our 360° solution, we offer a variety of internal and stakeholder surveys to help you better understand the perceptions of employees, peers, surgeons, physicians, and third party groups who work with your organization.

Employee Satisfaction

The Employee Satisfaction survey collects feedback to help increase teamwork, reduce turnover, and keep your teams motivated. The survey assesses individual employee perceptions about the organization, professional interactions, performance, job duties, and more.


The Peer-to-Peer survey aims to increase accountability and awareness of workplace conflict. Employees rate their peers in a number of areas including attitude, communication, competency, responsibility, teamwork, and timeliness.

Physician Satisfaction

Intended to prevent physician burnout, the Physician Satisfaction survey gathers insights from physicians about their quality of life in the workplace. Drive positive change with candid feedback from your physicians in a number of areas.

Referring Physician

Maximize your referral opportunities with the Referring Physician survey. Receive feedback from referring physicians on reports, recommendations, and interpretations they receive.

Anesthesiologist Surgeon Satisfaction

The Anesthesiologist Surgeon Satisfaction Questionnaire gathers important input from surgeons who work alongside anesthesia providers. This survey gives anesthesia providers valuable insights to strengthen relationships and increase safety and efficiency.

Third Party Group Evaluation

Enhance your third party relationships with feedback from your hospital and facility partners about your care, safety, responsiveness, clinical competency, cost efficiency, support, and more.


SurveyVitals is certified by CMS to administer nine different CAHPS surveys. The transition to value-based care has made CAHPS surveys mandatory for many facilities. The CAHPS surveys we offer are:

Note: There may be an additional cost to administer CAHPS surveys.


Have questions about the SurveyVitals solution or any of the surveys we offer? Reach out to us today at or contact us using the blue chat icon below.

August 28th, 2019 Categories: Anesthesia, CAHPS Surveys, Emergency Medicine, featured, Outpatient Practice, Patient Experience

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5 Benefits of Higher Patient Experience Scores

patient experience benefits

Today, there’s a bigger emphasis on the patient experience than ever–and for good reason. Here are five reasons you should want to achieve higher patient experience scores.

1. A better patient experience often leads to better outcomes

Numerous studies have shown a correlation between positive patient experience and better health outcomes. The patient experience is measured by factors that reflect trust and understanding between patient and provider, such as communication, confidence, and sensitivity. More satisfied patients tend to comply with treatment and follow recommendations better than dissatisfied patients do (1, 2), leading to better outcomes and continuity of care.

2. Happier patients make for happier providers

Physician burnout affects almost half of U.S. physicians. Research shows physicians with more satisfied patients tend to be happier and experience less burnout. These providers are more likely to form a human connection to their patients, which contributes to the patient experience but also gives them a better sense of well-being and fulfillment.

3. Higher patient experience scores mean lower malpractice risk

A JAMA study found that physicians who score in the bottom one-third on patient satisfaction surveys have malpractice lawsuit rates 110% higher than physicians with top patient satisfaction ratings. Many of the concerns that lead to malpractice suits can be alleviated by understanding your patients’ perceptions of care and working to improve your scores in the most critical areas. Service recovery tools like ‘Contact Me’ also allow for timely follow up to mitigate any potential issues before they arise.

4. Patient experience is directly related to financial success

There are two ways in which patient experience impacts your organization’s financial success.

First, there is a direct link between higher patient experience scores and a healthcare organization’s bottom line. U.S. hospitals with top patient satisfaction scores are reported to have net margins 50 percent higher than those with average to poor scores.

Second, patient experience can affect federal reimbursement. From CAHPS surveys to MIPS measures, the patient experience is a determining factor in federal incentives and penalties. Did you know SurveyVitals can administer nine CAHPS surveys and help you meet certain MIPS measures?

5. A better patient experience gives you a competitive advantage

Eighty-eight percent of patients look online before choosing a physician. To attract new patients, it’s important to showcase your quality of care. One way to do this is by sharing your patient experience scores.

SurveyVitals makes it easy to share your scores in a variety of ways; to learn more, see this blog post.

Additionally, patient experience data can be used as an effective tool by physician services groups and organizations seeking contracts with hospital partners and other facilities.

Are you ready to start improving your patient experience scores? Talk to us today using the blue chat icon below!

August 20th, 2019 Categories: featured, Patient Experience

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Provider Spotlight: Clint Allred, CRNA, Anesthesia Associates of Boise

Provider Spotlight: Clint Allred

Clint Allred, a full-time CRNA for Anesthesia Associates of Boise, was the grand prize winner of our recent Patient Experience Week giveaway. He is performing in the top 25% of anesthesia providers nationally. We asked Clint about his best practices for providing exceptional patient care, and we’re excited to share his responses.

Clint completed his nursing education at Weber State University in 2006, and then attended the University of Tennessee for CRNA training. He has been practicing in Boise since 2011.

What best practices do you and the staff you work with follow that you attribute to your positive scores?

Clint Allred: There is a huge push in our profession to unite with our surgeon colleagues and work toward “enhanced recovery after surgery ” protocols. We have known that there are a lot of different ways to manage the anesthetic of a patient, and each patient requires a different anesthetic. The downside to this is the fact that everyone does something different so the continuity of care is sometimes lacking.

To correct this discrepancy, we created a quality committee within our group. This committee was tasked with reviewing literature along with some of the bigger medical institutes, and then sitting down with anesthesia providers from within our group and developing some protocols for the surgeries that we provide routinely. This initiative at least put all of us on the same page to start with. These protocols deal not only with the patient during surgery, but also some interventions before surgery to improve their outcomes. Since installing these protocols, it has been incredible to see the patient, surgeon, and nurse satisfaction elevate. Every anesthetic still needs to be tailored just right, but this has really helped us be proactive in our decision prep.

What is one example of how you improved your relationship with your patients and/or the care you provide?

Clint Allred: It has amazed me how a little bit of effort goes a long way in ensuring comfort for our patients. It can be something as simple as a warm blanket in the cold metal OR, or talking with the patient on their level trying to take time to explain things.

One thing that we have instituted is in our pediatric population. The inhalational anesthetics that we use have a pungent smell. Kids really hate inhaling that odorous gas. So, we bought a bunch of Lip Smacker chapsticks and then bring the mask to the kids and let them pick out a flavor. They paint the inside of the mask with the flavor they selected and it negates that bad smell when the mask is on their face. Little things like these efforts don’t really take a cumbersome amount of time or energy. They just require a little effort and can really improve the relationship with patients.

What is one thing you avoid doing in order to provide a better experience for your patients?

Clint Allred: The biggest thing I have had to make a conscious effort to try and avoid is just going through the motions with my patients preoperatively. I have always taken pride in the quality of anesthesia care that I provide, but I realized when my son had surgery, that I really needed to change my approach to patients before they even have anesthesia. The day of surgery for patients is an overwhelming experience. Even before you get to the surgery and recovery phase, so much is thrown at them. I found that because administering anesthesia is a routine part of my life, I was just doing the bare minimum to educate and put my patients at ease. We would then whisk them away and go provide anesthesia. My experience taught me that taking an extra five minutes to sit down and talk with the patients about what they were going to experience, both for them and their family members, went a long way to easing their anxiety.

How do you best use your SurveyVitals data for your own personal improvement?

Clint Allred: SurveyVitals definitely serves as a reminder to keep those goals and changes, instituted in my own personal practice, in the forefront of my mind daily. Obviously, I won’t make everyone happy all the time. I used to just shrug my shoulders and act like it didn’t matter. However, what I did find is that when I changed my attitudes and practice – all of a sudden the SurveyVitals data meant something to me. It is a way to drive and improve my practice. I still won’t make every patient happy all the time, but I can take pride in my work and raise the bar for my patients.

August 6th, 2019 Categories: Anesthesia, Best Practices, Client Spotlight, featured, Patient Experience

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CMS Releases 2020 MIPS Proposed Rule

CMS has released the final rule for MIPS 2020. Read the key takeaways here.

If you’re participating in MIPS, you’ll need to know about the changes to the program in 2020. This week, CMS released the Quality Payment Program proposed rule for the next performance year. While their goal is to maintain many of the requirements from the 2019 performance year, there are some updates to the MIPS track. Here are the highlights of the proposed changes.

Quality and Cost performance category weights

In 2020, the Quality performance category weight will be reduced from 45 percent to 40 percent. The Cost category weight will increase from 15 percent to 20 percent.

Payment adjustment

The maximum negative payment adjustment will increase from -7% to -9% in 2020. Positive payment adjustments (not including exceptional performance) will increase from 7% to up to 9%.

Performance threshold

The performance threshold–the minimum number of points to avoid a negative payment adjustment–will increase from 30 points in 2019 to 45 points in 2020. The exceptional performance threshold, which determines additional positive payment adjustments, will increase to 80 points in 2020.

A full breakdown of proposed MIPS changes can be found in the table below. CMS is accepting feedback on the proposed rule at through September 27, 2019 with the file code CMS-1715-P.

CMS has also proposed larger changes to the program starting in 2021. Click here to read our summary of their new proposed framework.

For more information on the current MIPS performance year and how SurveyVitals can help you fulfill your requirements, visit our MIPS page or chat with us using the blue chat icon below.

Policy Area Current Year 3 (Final Rule CY 2019) Year 4 (Proposed Rule CY 2020)
Performance Category Weights
  • Quality: 45%
  • Cost: 15%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
  • Quality: 40%
  • Cost: 20%
  • Promoting Interoperability: 25%
  • Improvement Activities: 15%
Quality Performance Category Data Completeness Requirements
  • Medicare Part B Claims measures: 60% of Medicare Part B patients for the performance period
  • QCDR measures, MIPS CQMs, and eCQMs: 60% of clinician’s or group’s patients across all payers for the performance period
Call for Measures
CMS seeks measures that are:
  • Applicable
  • Feasible
  • Reliable
  • Valid at the individual clinician level
  • Different from existing measures
Measure Removal
  • A quality measure may be considered for removal if the measure is no longer meaningful, such as measures that are topped out
  • A measure would be considered for removal if a measure steward is no longer able to maintain the quality measure
QCDR Measure Requirements
  • QCDR measures must be beyond the measure concept phase of development
  • CMS will show a preference for QCDR measures that are outcome-based rather than clinical process measures
  • Measures should address significant variation in performance
  • QCDR measures are approved for use in MIPS for a single performance period
Measure Removal
There is no formal policy for measure removal, as QCDR measures must be submitted for CMS approval on an annual basis as part of the self-nomination process.
Data Completeness Requirements
  • Medicare Part B claims measures: 70% sample of Medicare Part B patients for the performance period
  • QCDR measures, MIPS CQMs, and eCQMs: 70% sample of clinician’s or group’s patients across all payers for the performance period
  • Note: If quality data is submitted selectively such that the data are unrepresentative of a MIPS eligible clinician or group’s performance, any such adat would not be true, accurate, or complete
Call for Measures
In addition to current requirements:
  • Measures submitted in response to Call for Measures would be required to demonstrate a link to existing and related cost measures and improvement activities as appropriate and feasible
Measure Removal
In addition to current measure removal criteria:
  • MIPS quality measures that do not meet case minimum and reporting volumes required for benchmarking for 2 consecutive years would be removed
  • We may consider a MIPS quality measure for removal if we determine it is not available for MIPS Quality reporting by or on behalf of all MIPS eligible clinicians (including via third party intermediaries)
QCDR Measure Requirements
In instances in which multiple, similar QCDR measures exist that warrant approval, we may provisionally approve the individual QCDR measures for 1 year with the condition that QCDRs address certain areas of duplication with other approved QCDR measures in order to be considered for the program in subsequent years. Duplicative QCDR measures would not be approved if QCDRs do not elect to harmonize identified measures as requested by CMS within the allotted timeframe.

QCDR Measure Rejections
CMS is proposing the following guidelines to help QCDRs understand when a QCDR measure would likely be rejected during the annual self-nomination process:

  • QCDR measures that are duplicative of an existing measure or one that has been removed from MIPS or legacy programs
  • Existing QCDR measures that are “topped out” (though these may be resubmitted in future years)
  • QCDR measures that are process-based (consideration given to the impact on the number of measures available for a specific specialty) or have no actionable quality action
  • Considerations and evaluation of the measure’s performance data, to determine whether performance variance exists
  • QCDR measures that have the potential for unintended consequences
  • QCDR measures that split a single clinical practice/action into several measures or that focus on rare events
  • QCDR measures that are “check-box” with no actionable quality action
  • Existing QCDR measures that have been in MIPS for two years and have failed to reach benchmarking thresholds due to low adoption (unless a plan to improve adoption is submitted and approved)
  • Whether the existing approved QCDR measure is no longer considered robust, in instances where new QCDR measures are considered to have a more vigorous quality action, where CMS preference is to include the new QCDR measure rather than requesting QCDR measure harmonization
  • QCDR measures with clinician attribution issues, where the quality action is not under the direct control of the reporting clinician. (that is, the quality aspect being measured cannot be attributed to the clinician or is not under the direct control of the reporting clinician)
  • QCDR measures that focus on rare events or “never events” in the measurement period
Improvement Activities Performance Category Definition of Rural Area
Rural area means a ZIP code designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data set available.

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice must meet one of the following criteria:

  • The practice has received accreditation from one of four accreditation organizations that are nationally recognized:
    • The Accreditation Association for Ambulatory Healthcare
    • The National Committee for Quality Assurance (NCQA)
    • The Joint Commission
    • The Utilization Review Accreditation Commission (URAC); OR
  • The practice is participating in a Medicaid Medical Home Model or Medical Home Model; OR
  • The practice is a comparable specialty practice that has received the NCQA Patient Centered Specialty Recognition
Improvement Activities Inventory
  • Added 1 new criterion, “Include a public health emergency as determined by the Secretary”
  • Removed “Activities that may be considered for a Promoting Interoperability bonus”
CMS Study on Factors Associated with Reporting Quality Measures
MIPS eligible clinicians who successfully participate in the study receive full credit in the Improvement Activities performance category.

Removal of Improvement Activities
No formal policy but invited public comments on what criteria should be used to identify improvement activities for removal from the inventory.

Requirement for Improvement Activity Credit for Groups
Group or virtual group can attest to an improvement activity if at least one clinician in the TIN participates.

Definition of Rural Area
Rural area is proposed to mean a ZIP code designated as rural by the Federal Office of Rural Health Policy (FORHP) using the most recent FORHP Eligible ZIP Code file available.

Patient-Centered Medical Home Criteria
To be eligible for Patient-Centered Medical Home designation, the practice would need to meet one of the following criteria:

  • The practice has received accreditation from an accreditation organization that is nationally recognized
  • The practice is participating in a Medicaid Medical Home Model or Medical Home Model
  • The practice is a comparable specialty practice that has received recognition through a specialty recognition program offered through a nationally recognized accreditation organization; OR The practice has received accreditation from other certifying bodies that have certified a large number of medical organizations and meet national guidelines, as determined by the Secretary. The Secretary must determine that these certifying bodies must have 500 or more certified member practices, and require practices to include the following:
    1. Have a personal physician/clinician in a team-based practice
    2. Have a whole-person orientation
    3. Provide coordination or integrated care
    4. Focus on quality and safety
    5. Provide enhanced access
Improvement Activities Inventory
  • Addition of 2 new Improvement Activities
  • Modification of 7 existing Improvement Activities
  • Removal of 15 existing Improvement Activities

Please review Appendix 2 in the CY 2020 NPRM for a comprehensive look at the changes proposed to the inventory.

CMS Study on Factors Associated with Reporting Quality Measures
Study year 2019 (CY 2019) is the last year of the 3-year study, as stated in CY 2019 PFS final rule (83 FR 59776). CMS will not continue the study during the 2020 performance period. Final study results will be shared at a later date.

Removal of Improvement Activities
Establish factors to consider for removal of improvement activities from the Inventory. An activity would be considered for removal if:

  • It is duplicative of another activity
  • An alternative activity exists with stronger relationship to quality care or improvements in clinical practice
  • The activity does not align with current clinical guidelines or practice
  • The activity does not align with at least one meaningful measures area
  • The activity does not align with Quality, Cost, or Promoting Interoperability performance categories
  • There have been no attestations of the activity for 3 consecutive years
  • The activity is obsolete
Requirement for Improvement Activity Credit for Groups
  • Group or virtual group would be able to attest to an improvement activity when at least 50% of MIPS eligible clinicians (in the group or virtual group) participate in or perform the activity
  • At least 50% of a group’s NPIs must perform the same activity for the same continuous 90 days in the performance period
Promoting Interoperability Performance Category – Hospital-Based MIPS Eligible Clinicians in Groups

A group is identified as hospital-based and eligible for reweighting when 100% of the MIPS eligible clinicians in the group meet the definition of a hospital-based MIPS eligible clinician.

A group would be identified as hospital-based and eligible for reweighting if more than 75% of the NPIs in the group meet the definition of a hospital-based individual MIPS eligible clinician.

For non-patient facing groups (more than 75% of the MIPS-eligible clinicians in the group are classified as non-patient facing) we would automatically reweight the Promoting Interoperability performance category.

No change to definition of an individual hospital-based MIPS eligible clinician.

Promoting Interoperability Performance Category Objectives and Measures
  • One set of objectives and measures based on the 2015 Edition CEHRT
  • Four objectives: ePrescribing, Health Information Exchange, Provider to Patient Exchange, and Public Health and Clinical Data Exchange
  • Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is claimed
  • PTwo new measures for the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement as optional with bonus points available
Objectives and Measures
  • CMS would require a yes/no response for the Query of PDMP measure
  • CMS would redistribute the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Access to Their Health Information measure if an exclusion is claimed
Cost Performance Category Measures
  • Total Per Capita Cost (TPCC)
  • Medicare Spending Per Beneficiary (MSPB)
  • 8 episode-based measures
Case Minimums
  • 10 for procedural episodes
  • 20 for acute inpatient medical condition episodes
Measure Attribution
  • All measures are attributed at the TIN/NPI level for both individuals and groups
  • Plurality of primary care services rendered by the clinician to determine attribution for the total per capita cost measure
  • Plurality of Part B services billed during the index admission to determine attribution for the MSPB measure
  • For procedural episodes, we attribute episodes to each MIPS eligible clinician who renders a trigger service (identified by HCPCS/CPT procedure codes)
  • For acute inpatient medical condition episodes, we attribute episodes to each MIPS eligible clinician who bills inpatient evaluation and management (E&M) claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30% of the inpatient E&M claim lines in that hospitalization
  • TPCC measure (Revised)
  • MSPB-C (MSPB Clinician) measure (Name and specification Revised)
  • 8 existing episode-based measures
  • 10 new episode-based measures
Case Minimums
No changes.

Measure Attribution
  • Measure attribution would be different for individuals and groups and would be defined in the measure specifications
  • TPCC attribution would require E&M services to have an associated primary care service or a follow up E&M service from the same clinician group
  • TPCC attribution would exclude certain clinicians who primarily deliver certain non-primary care services (e.g. general surgery)
  • MSPB clinician attribution changes would have a different methodology for surgical and medical patients
  • No changes proposed for attribution in episode-based measures (existing and new)
Final Score Calculation: Performance Category Reweighting due to Data Integrity Issues
  • No policy to account for data integrity concerns
  • Several scenarios for reweighting have previously been finalized, including extreme and uncontrollable events (all performance categories) and hardship exemptions specific to the Promoting Interoperability performance category
  • We would reweight performance categories in rare events due to compromised data outside the control of the MIPS eligible clinician. MIPS eligible clinicians or third party intermediaries can inform CMS that they believe they are impacted by a relevant event by providing information on the event (CMS may also independently learn of qualifying events)
  • If we determine that reweighting for compromised data is appropriate, we would generally redistribute to the Promoting Interoperability performance category as well as the Quality performance category
  • In rare cases, we would redistribute to the Cost performance category
Performance Threshold / Additional Performance Threshold / Payment Adjustment
  • Performance Threshold is set at 30 points
  • Additional performance threshold set at 75 points for exceptional performance
  • As required by statute, the maximum negative payment adjustment is – 7%
  • Positive payment adjustments can be up to 7% (not including additional positive payment adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 7%
  • Performance Threshold would be set at 45 points
  • Additional performance threshold would be set at 80 points for exceptional performance
  • As required by statute, the maximum negative payment adjustment is -9%
  • Positive payment adjustments can be up to 9% (not including additional positive adjustments for exceptional performance) but are multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 9%
Targeted Review

MIPS eligible clinicians and groups may submit a targeted review request by September 30 following the release of the MIPS payment adjustment factor(s) with performance feedback.

All requests for targeted review would be required to be submitted within 60 days of the release of the MIPS payment adjustment factor(s) with performance feedback.

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July 30th, 2019 Categories: featured, MIPS Information, Patient Experience

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Breakout Provider Performance by Location

Provider Scorecard

SurveyVitals has enhanced the Location & Provider Details reporting feature to optimize how organization and division-level users capture provider performance.

Location & Provider Details allows organization and division-level users to quickly filter, sort, and rank division and provider performance for the whole organization. This time-saving tool eliminates the work of running custom reports and organizing data.

LAPD Sample

Based on client feedback, the Location & Provider Details data models have been updated to provide a more granular look at your organization’s data and individual provider performance across locations.

Provider Performance by Division

Organization-level users will continue to see all providers and their performance across all divisions where they practice. Division-level users will now see only the providers and their performance data for that particular division. At this level of granularity, the data becomes more pertinent by giving division leaders and clinicians a better sense of how providers interact with patients in different locations and settings.

Location codes and provider NPIs have also been added to the Location & Provider Details data. This information may be useful to match up providers and locations appropriately when downloading raw data.

Provider Scorecard

You can compare a provider’s individual performance across locations by viewing the new provider scorecard. Simply click the name of any provider in the report results to view this data.

The scorecard allows you to see how a provider is performing at one location versus another or overall. For example, the scorecard below shows the provider performing in the 100th percentile for some question groups at certain locations, but in the 1st and 3rd percentile for the same question groups at different locations.

Provider Scorecard


Organization, National, and Specialty benchmarks have been added to provide ease of use for users who want to see a breakdown of their provider or location performance and compare it to the national average and specialty benchmarks. These benchmarks can be added to division-level data as well as the provider scorecards.


Want to know more about Location & Provider Details? Contact our support team today or reach out to us. You can also always drop us a message using the blue chat icon below.

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July 25th, 2019 Categories: featured, Patient Experience, Product Features

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