SWOT Analysis for Successful MIPS Reporting

SWOT Analysis is a strategic tool widely used by many industries, including healthcare. SWOT stands for Strengths, Weaknesses, Opportunities, and Threats. This analysis technique was developed by Albert Humphrey, a senior researcher at Stanford University in 1960s. He analyzed data from top companies with the goal of figuring out the reasons why corporate planning failed and ended up in creating a tool called SOFT which later became SWOT Analysis.

Now the question is – How is SWOT Analysis beneficial when thinking about Merit-based Incentive Payment System (MIPS) reporting?

  • Helps a practice to be successful in developing processes for data collection for MIPS reporting.
  • Has been shown to enable healthcare organizations to take a deep dive into current workflow, resource utilization rates, patient care gaps, delays in the communication and overall efficiency. It is imperative to understand the current pain points as well as strengths before reporting for MIPS.
  • Guides an organization in the MIPS measure selection process by allowing them to gain clarity and frame the MIPS decision making around current practice needs and priorities.
  • As practices begin to evaluate how they will be reporting for MIPS in the 2017 transition year, some have expressed uncertainty in how to proceed with selecting appropriate quality measures as well as improvement activities. In many cases, the practices have little information to assist them in determining appropriate measure sets that will align with the clinical and quality improvement activities that are currently underway in the practice.
  • Informs the organization about opportunities for future state of MIPS reporting and quality improvement within the practice.
  • Performing SWOT analysis can assist a practice in the rechanneling of resources towards workflow optimization or quality improvement activities that can lead to marked improvements in patient care and outcomes. This improvement further enables practices to both achieve higher levels of patient satisfaction and the ability to more efficiently report for a full year on MIPS required measures and activities.

The Elements of SWOT Analysis

Strengths (S) and Weaknesses (W) are often referred to as the internal factors of SWOT analysis and directly linked to the organizational goals and performance. Opportunities (O) and Threats (T) are considered to be external factors where the organization has little or no control over them.

Strengths (S) & Weaknesses (W)

  • Financial Resources
    • Various sources of income, investments, grants, funds
  • Human Resources
    • Staff, volunteers, members on various boards
  • Physical Resources
    • Location, equipment, building, inventory
  • Activities and past experiences
    • Programs currently undertaken, systems employed, reputation of the organization.

Opportunities (O) & Threats (T)

  • Economic factors
  • Demographic factors
  • Political factors

Let’s review an example

Below is an example of how to use SWOT analysis to evaluate an improvement activity and current state in the practice.

A practice is considering attesting to improvement activity IA_BE_4 (Engagement of patients through the implementation of improvements in patient portal) but quickly realizes that their utilization rates are lower than expected. Before making a decision on whether or not to proceed, the practice performs a SWOT analysis to determine what strengths, weakness, opportunities and threats may be present.

SWOT Analysis – Patient Portal



  • Easy check-in and check-out feature
  • Registration Kiosk in the waiting area with staff assistance
  • View health records/ reports
  • Easy to navigate
  • Appointment reminder features
  • Online request option for appointments
  • Strong marketing – brochures, display boards
  • Patients cannot download reports
  • No secure messaging or bidirectional communication option
  • No ‘alert’/ ‘send an email’ feature when new message comes
  • No online bill payments
  • Lack of motivation from patients
  • No prescription refill request feature
  • Delay in updating records



  • Shift in patient population – more younger people in the pool
  • Adopting mobile optimized portal / access portal from cell phone feature
  • 2 new practice sites
  • Management decision to invest in a new technology and revamping of the portal
  • Competition
  • Political and economic changes
  • Loss of experienced employees and associates

Final Thoughts

The organization should consider all the factors identified in the SWOT analysis and make an informed decision. SWOT analysis can be either performed by the leader or the entire team. It is not a perfect tool, but undoubtedly a valuable one to those practices struggling with MIPS measure selection and reporting.


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