Healthcare organizations are being asked to do more with less. Staffing shortages continue to strain clinical operations, reimbursement pressures are intensifying, and quality reporting expectations continue to evolve. At the same time, leaders are expected to maintain strong performance across multiple initiatives while ensuring documentation accurately reflects the care being delivered.
In this environment, many organizations participating in the Merit-based Incentive Payment System (MIPS) are asking a familiar question: Which measures should we report?
By 2026, however, measure selection is no longer the greatest challenge.
Most organizations have already identified the quality measures that best align with their patient populations and services. The more difficult task is maintaining consistent performance throughout the year as workflows, staffing, and documentation practices inevitably change.
CMS continues to refine the Quality Payment Program through measure additions, removals, modifications, and ongoing cost measure development. Staying current with these updates is important, but long-term success depends less on selecting the “right” measures and more on building reliable operational processes that support them every day.
Several common challenges can quietly erode MIPS performance over time:
- Provider turnover introduces variation in documentation and workflow adherence.
- Documentation inconsistencies among clinicians reduce measure capture and reporting accuracy.
- Workflow drift occurs as established processes gradually change without being recognized.
- EHR optimization gaps make it more difficult to identify performance issues before they affect reporting.
These issues rarely develop overnight. Instead, they accumulate gradually throughout the performance year, often remaining unnoticed until reporting deadlines are approaching and opportunities to improve performance have become limited.
One of the biggest mistakes organizations make is relying primarily on quarterly performance reviews. While quarterly reporting can identify broad trends, it often leaves little time to correct documentation gaps, reinforce workflows, or recover declining quality scores.
Monthly performance monitoring offers a more proactive approach. Regular reviews allow organizations to identify emerging risks earlier, reinforce documentation expectations, evaluate workflow consistency, and implement corrective actions while there is still time to influence year-end results.
As CMS continues to evolve the Quality Payment Program, successful organizations are treating MIPS as an ongoing operational strategy rather than an annual reporting requirement. Sustainable performance comes from consistent documentation, reliable workflows, and continuous monitoring—not simply selecting the right measures.
For organizations looking to strengthen their MIPS performance, an independent assessment can help identify opportunities before they become reporting challenges. BCA, Inc. partners with healthcare organizations through auditing, education, and consulting services that help improve documentation quality, reinforce compliant workflows, and support sustainable performance throughout the year. Whether you’re preparing for the next performance period or looking to strengthen your current processes, our team is here to help you turn performance goals into lasting operational success.
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