Understanding the 2024 MIPS SAFER Guides Requirements

To satisfy the MIPS requirement in 2024, the MIPS-eligible clinician must conduct an annual Self-Assessment of the High-Priority Practices Guide of the SAFER Guides. In previous years, clinicians could satisfy this measure by selecting “No” for the completion of the Self-Assessment.  Clinicians will now be required to select “Yes” to satisfy the measure.  The measure is not worth any points for the Promoting Interoperability category, but you will not be able to pass the category without completing the Self-Assessment.

The Self-Assessment consists of an 18-question checklist that should be filled out by a multidisciplinary team.  For each of the 18 questions, you will be asked how well the recommended practices are implemented.  You have three choices for implementation status: Fully in all areas, Partially in some areas, or Not implemented.

Source: https://www.healthit.gov/

After going through the checklist, you will need to review the detailed worksheets that correlate with each question. The worksheets provide guidance on implementing the recommended practices.  There is also an area on the worksheet to document any remediation or follow-up that may be needed.  The Self -Assessment must be completed by the end of the 2024 performance year to be able to attest “Yes” to completion.

CMS will not score your assessment. It is an internal document that you will need to save with your compliance records for the 2024 reporting year.  Also, it is important to note that the High-Priority Practices Guide of the SAFER Guides does not replace your yearly Security Risk Assessment.

Additional information regarding the SAFER Guides can be found at: https://www.healthit.gov/topic/safety/safer-guides