QASP_MEDCOM_Case_Mgmt_10817085.pdf

Quality Assurance Surveillance Plan (QASP)

1.0 Background: The Department of Defense (DOD) TRICARE Management Activity (TMA) values all staff involved in the delivery of high-quality care to service members. In 2009, a

Medical Management Guide was issued by the Office of the Assistant Secretary of Defense for

Health Affairs (ASD [HA]) and TMA, Office of the Chief Medical Officer (OCMO), Population

Health and Medical Management Division (PHMMD). The Guide covers the components of a

Medical Management (MM) program, including applicable principles, implementation concepts, processes, and tools/databases for Utilization Management (UM), Case Management (CM), and

Disease Management (DM). It complements the 2001 DoD Population Health Improvement

Plan and Guide published by TMA and the Government Printing Office http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.

1.1 Under legislative mandates, the ASD (HA) submitted an annual report to Congress regarding healthcare delivery for Military Health System (MHS) beneficiaries. The 2009 report documented the MHS goal to providing high-quality care, improving performance through clinical and process outcomes, and increasing patients’ confidence in the care they receive. The

Guide describes crucial components of Medical Management within the MHS, including the link between MM and population health and the dynamics between Utilization Management, Case

Management and Disease Management in helping reduce unnecessary or inappropriate services and/or duplication of services. In the military setting, Case Management targets Active Duty

Service Members and beneficiaries with complex, multi-system healthcare needs who require care coordination or case management services.

1.1.1. Originally, Case Management almost exclusively targeted in-patients with catastrophic illnesses or injuries. However, a number of developments have served to change that strategy;

notably: - The emergence of the National Committee for Quality Assurance (NCQA):

http://www.ncqa.orgorg/ and the development of accreditation standards by the Utilization

Review Accreditation Commission (URAC): http://www.urac.org. While Case Management continues to focus on catastrophic illness or injury, Case Management practices are also intensely directed at addressing chronic conditions that are more prevalent in the general patient population. Case managers can affect patient outcomes through proactive interventions across multiple healthcare settings. Additionally, case managers are expected to engage community resources and facilitate ongoing and consistent patient education.

1.1.2 The MHS has three primary goals for Case Management:

- Improve the care, management, and transition of recovering Service members.

- Broaden the application of CM to include those with complex and at-risk needs before the

Soldier requires complex care.

- Evaluate the impact of case management on the quality of military health care.

The Army National Guard, recognizing the importance of Medical Readiness after several years of combat deployments, implemented the Case Manager Support Contract in August 2005 as a http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf http://www.ncqa.orgorg/ http://www.urac.org/ time and materials contract, not Firm Fixed Price (FFP) and Performance Statement of Work-based. The current contract was originally awarded August 2009 to Skyline Ultd (with 49% subcontract to Sterling Medical). At the end of FY09, case managers in 31 states were using the medical non-deployable module to manage their caseloads. During the period of August 2008 to

August 2009, 15,292 cases were put into the module; of these, 6734 were closed by return to duty, fit for duty, or forwarded for an MEB/PEB evaluation. Additionally, readiness increased from 35% fully-ready in FY08 to 44% in FY09. This success resulted from increased targeted funding and a concerted effort by the National Guard Bureau. On 29 March 2012, the ARNG achieved the Department of Defense (DOD) goal of 75% Fully Medically Ready (FMR) Soldiers per DoD Instruction (DoDI) 6025.19, Individual Medical Readiness (IMR). This monumental accomplishment marked the highest medical readiness percentage that the ARNG has achieved in documented history. Over the past year, ARNG readiness has continued to increase to over

80%. Continued utilization of medical case managers is essential to maintaining established medical readiness goals for the ARNG.

- Vision: Provide a healthy, resilient, ready and deployable force for federal, state and community missions

- Mission: To Provide a Responsive Medical Force and a Healthy Medically Ready Army

National Guard

- Support deployment of a healthy force – Soldiers

- Support deployment of the medical force – Units

- Facilitate Warriors in Transition and Family Care – Beneficiaries

2.0 Purpose: This Quality Assurance Surveillance Plan is a government-developed document used to determine if the contractor’s performance meets the performance standards contained in the contract. The QASP establishes procedures on how this assessment/inspection process will be conducted. It provides the detailed process for a continuous oversight process:

- What will be monitored

- How monitoring will take place

- Who will conduct the monitoring

- How monitoring efforts and results will be documented

2.1 The contractor is responsible for implementing and delivering performance that meets contract standards using its Quality Control Plan. The QASP provides the structure for the government’s surveillance of the contractor’s performance to assure that it meets contract standards. It is the government’s responsibility to be objective, fair and consistent in evaluating contractor performance.

2.2 The QASP is not part of the contract nor is it intended to duplicate the contractor’s quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

2.3 The government may provide a copy of the QASP to the contractor to facilitate open communication. In addition, the QASP should recognize that unforeseen or uncontrollable circumstances might occur that are outside the control of the contractor.

2.4 Bottom line, the QASP should ensure early identification and resolution of performance issues to minimize impact on mission performance.

2.4.1 Authority

Authority for issuance of this QASP is provided under Part 46 of the Federal Acquisition

Regulation, Inspection of Services clauses, which provide for inspection, acceptance and documentation of the service called for in the contract or order. This acceptance is to be executed by the contracting officer or a duly authorized representative.

2.4.2 Roles and Responsibilities

The following personnel shall oversee and coordinate surveillance activities.

2.4.2.1 Program/Project Manager (PM) – The PM (if the individual’s supervisor) nominates (or request the individual’s supervisory nominate the COR using VCE-COR or as directed by the

Contracting Officer based upon the dollar value of the action. The PM/Supervisor ensures the

COR is meets all COR training requirement outlined by the Contracting Office for the action before taking action regarding the nomination of the COR. The contract shall not be awarded until a qualified COR is appointed in writing by the Contracting Officer. The PM/Supervisor is not authorized to perform any COR duties but provides support to help the COR properly provide the necessary federal government oversight needed. The PM/Supervisor is required to include the performance of the COR in the COR/s annual performance rating. While the PM may serve as a direct conduit to provide Government guidance and feedback to thru the COR to the

Contractor on technical matters, they are not empowered to make any contractual commitments or any contract changes on the government’s behalf. It is highly recommended the

PM/Supervisor also nominate an alternate COR.

Assigned PM: TBD

Organization or Agency: TBD

Telephone: TBD

Email: TBD

2.4.2.2 Contracting Officer (KO) – The KO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The KO shall also ensure the contractor receives impartial, fair, and equitable treatment under this contract. Determine the final assessment of the contractor’s performance.

Assigned KO: TBD

2.4.2.3 Contracting Officer’s Representative (COR) – The COR is responsible for providing continuous technical oversight of the contractor’s performance. The COR uses the QASP to conduct the oversight/surveillance process. The COR shall keep a Quality Assurance file that accurately documents the contractor’s actual performance. If required to use VCE-COR by the

Contracting Officer, the COR will always make sure these records are accurately and timely uploaded to the VCE-COR system. The purpose is to ensure the contractor meets the performance standards contained in the contract. The COR is responsible for reporting early identification of performance problems to the KO. The COR is required to provide an annual performance assessment (or more frequently as directed by the Contracting Officer) to the KO which will be used in documenting past performance. The QASP is the primary tool for documenting contractor performance. The COR is not empowered to make any contractual commitments or to authorize any contractual change on the Government’s behalf. The COR shall meet with the KO periodically as directed (usually monthly or quarterly at a minimum) to discuss the CORs performance. These meeting are in addition to the progress and similar type meeting involving at a minimum the contractor, COR and KO. The COR and alternate as applicable should communicate frequently to ensure both are aware of the current on-going oversight status and contract performance status.

Assigned COR: TBD

2.5 Contractor Representatives

The following employees of the contractor serve as the contractor’s Program Manager and Task

Manager for this contract. (Complete this section after the contract award)

2.5.1 Program Manager - <upon award, enter name>

Telephone: <enter number>

Email: <enter address>

2.5.2 Task Manager - <upon award, enter name>

2.5.3 Other Key Contract Personnel - <upon award, enter name or delete these lines if not applicable>

Title: <enter title>

3.0 Government Contract Surveillance

The goal of the QASP is to ensure contractor performance is effectively monitored and documented. The COR is responsible for maintaining quality assurance surveillance for the federal government. The COR will ensure monthly quality assurance inspections are accomplished accurately and timely. All records shall be uploaded to VCE-COR as applicable.

4.0. Surveillance Matrix

The Surveillance Matrix (Attachment 1) is the list of performance objectives and standards that must be performed by the government. This matrix details the method of surveillance the COR will use to validate and inspect these performance elements. Inspection of each element will be documented in the COR file.

4.1 Performance Rating Definitions

In evaluating the quality of contractor’s performance, the following performance ratings may be used.

Performance objectives define the desired outcomes. Performance Standards define the level of service required under the contract to successfully meet the performance objective. The inspection methodology defines how, when, and what will be assessed in measuring performance. The Government performs surveillance, using this QASP, to determine the quality of the contractor’s performance as it relates to the performance element standards.

4.2 Corrective Action Report (CAR) (See attachment 2)

Used identify, document and resolve issues or performance concerns/failures.

Performance

Rating

Criteria

Excellent /

Outstanding

Performance meets contractual requirements and exceeds many to the government’s benefits. The contractual performance of the element or sub-element being assessed was accomplished with no problems and contractor actions were highly effective.

Very Good Performance meets contractual requirements and exceeds some to the government benefits. The contractual performance was accomplished with few minor problems for which corrective actions taken by the contractor were effective.

Good Performance meets contractual requirements. The contractual performance contains some minor problems for which corrective actions taken by the contractor were satisfactory.

Marginal Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear marginally effective or were not fully implemented.

Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

4.3 Customer Complaint Form (See attachment 3)

Provides a format for customers who are support by the contractor to report on the contractor’s performance (For Agency use – Remember customers do not know what the contract requirements are). CORs should use this as method to become aware of issues but these forms are not to be used to evaluate the contractor unless complaint is valid and applicable to the contract (consult with Contracting Office if there are any questions).

4.4 Performance Assessment Report

Monthly or as directed by the KO, assessments of the contract performance.

Attachment 1: Surveillance Matrix

Requirement Indicators Standards for

Acceptance

Minimum

AQL

Method of

Surveillance

Corrective

Actions

Performance

Rating

Quality Control

Plan Quality

Ensures contractor will maintain a high quality standard for completing the requirements of the contract

QCP will be submitted with proposal

Electronic

Systems Data

Entry within 96 hours of event

(PHA/SRP)

Completeness/

Timeliness

All Event critical referrals, are entered into the appropriate government electronic system

80% of initiated cases within a 30 calendar day period following event

MEDCHART

Contractor will evaluate entry omissions and provide remedial training

Follow-up MODS input from contracted events

(PHA/SRP)

Completeness/

Timeliness After 14 days

Within 30 days of contracted event

MODS

Contractor will provide

Performance/surv eillance reports to consist of number of open referrals/closed referrals/PDES packets forwarded into the IDES system.

Completeness/

Timeliness

Report turned in by the

10th of the month prior to the IPR and written according to Army standards.

Within a 3 month period no more than 1 late SITREP

MEDCHART

Contractor will contact

COR to submit performance/ surveillance report.

Medical Records

Administration Completeness

Received medical documentation (scanned into HRR and stamped accordingly) will be transmittal letter to SM’s medical record.

No less than monthly

Weekly or monthly dependent upon State’s workload

Contractor will provide

Credentialing/

Training Actions Quality

The contractor will ensure that all employees meet minimum standards set in the PWS pertaining to

RN/LPN state licensure.

No less than annual

Biannual review of

RN/LPN files to verify current licensure

Contractor will provide

Update data input on all UIC Task

Force for the State

Completeness/

Timeliness Weekly

No less than monthly

MEDCHART

Contractor will provide eCase records shall be reassigned within

5 working days of personnel changeover

Completeness All events leading to personnel changeover

No open and active eCase records will be left with case managers no longer employed by contractor

Monthly review of eCase records

Contractor will provide

Attachment 2: Corrective Action Report (CAR)

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE

DATE

6. CONTROL

NUMBER

7. DEFICIENCY MAJOR MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. QUALITY ASSURANCE PERSONNEL (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT

RECURRENCE

11. COR DETERMINATION

ACCEPTED REJECTED

12. CLOSE DATE

Attachment 3: Customer Complaint Record

CUSTOMER COMPLAINT RECORD

DATE/TIME OF

COMPLAINT

SOURCE OF COMPLAINT

ORGANIZATION

BUILDING

INDIVIDUAL

PHONE

NATURE OF COMPLAINT

CONTRACT REFERENCE

VALIDATION

DATE/TIME CONTRACTOR INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR