36C24419R0074-030.pdf

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Quality Assurance Surveillance Plan (QASP)

Outpatient Site of Care Service

The contractor shall be evaluated in accordance with the following:

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

• What will be monitored.

• How monitoring will take place.

• Who will conduct the monitoring?

• How monitoring efforts and results will be documented.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO 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 CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned CO: Mark Knorr

Assign CS: Brandi Shellhammer

Organization or Agency: Department of Veterans Affairs NC04/ Erie VAMC

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: TBD

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary:

Alternate:

4. PERFORMANCE STANDARDS

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The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of contractor performance in the elements defined.

To be paid the full capitated rate on the schedule, the contractor must provide services as required in the entire contract and to meet or exceed the acceptable quality level outlined in this section/sub-sections. If any portion of the requirement is not met and/or the acceptable quality level in any of the elements in this section/subsection are not maintained, the contractor will be notified by the contracting officer for response outlining the contractor’s proposed remedy. The Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming services per FAR 52.212-4.

Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the contractor on the contract.

5. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. 100% surveillance: method not applicable.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Data collected from I CARE cards, congressional and patient-initiated interactions.

d. RANDOM SAMPLING. Ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. Verification and/or documentation provided by Contractor.

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6. Measures

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template

As of: October 2018

METRIC PWS

Para

Performance

Requirement

Standard Acceptable

Quality Level

(tailor to meet your requirements)

Method of

Surveillance and frequency

Met

AQL/Did

Not Meet

AQL

(Add comment)

DOMAIN: ACCESS

New PC Appointments

Completed within 20

Days of Create Date

(pc18)

New Primary Care

Completed Appointments less than or equal to 20 days from create date

(See Performance Measure

Report for more information)

PWS

para.

4.9.1

Contractor shall provide completed appointments for new PC patients <=20 days from the create date

Contractor shall provide completed appointments for new PC patients <=20 days from the create date no less than 76% of the time

Contractor shall provide completed appointments for new PC patients <=20 days from the create date no less than 95% of the time.

VA will monitor progress quarterly by using data from the Performance

Measure Report.

Established PC Patient

Average Wait Time in

Days (pc17)

Established Primary Care

Completed Appointments less than or equal to 20 days from Patient

Indicated Date (patient desired date) or the clinically indicated date information)

PWS

para.

4.9.2

Contractor shall provide completed appointments for established

PC patients

<=20 days from the patient indicated date

Contractor shall provide completed appointments for established

PC patients

<=20 days from the patient indicated date no less than 97% of the time

Contractor shall provide completed appointments for established

PC patients

<=20 days from the patient indicated date no less than

97% of the time.

VA will monitor progress quarterly by using data from

PCMH SHEP Access

Composite

Composite % based on 3 questions from the

SHEP/PCMH report: 1)

Get an urgent care appointment as soon as needed, 2) Get a routine care appointment as soon

PWS

para.

4.9.3

Contractor shall provide: 1) urgent care appointments as soon as needed,

2) routine care appointments as soon as needed, and 3) same day answers to

Contractor’s

SHEP access composite score shall meet or exceed 51%

Contractor’s

SHEP access composite score shall meet or exceed

69%

VA will monitor progress quarterly by quarterly using data from

SHEP/PCMH

report.

http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

Version 6/20/2019 Page 4 of 12 as needed, and 3) Get same day answer to your medical question.

(See SHEP/PCMH Report for more information) patients’ medical questions

SHEP Question 7

In the last 6 months, how many days did you usually have to wait for an appointment when you needed care right away?

(Less is better)

PWS

para.

4.9.4

Contractor shall provide timely appointments when patients need care right away

Contractor’s

SHEP

question 7 score shall meet or exceed 41%

Contractor’s

SHEP question

7 score shall

41%.

by quarterly using data from

Same-Day

Appts w/ PCP

Measures the percent of requested same day appointments with PCP

(See PACT Compass for more information)

PWS

para.

4.9.5

Contractor shall provide same day appointments with primary care provider

Contractor’s same day appointments with PCP rate shall meet or exceed 60%

Contractor’s same day appointments with PCP rate shall meet or exceed 70% by using data from the PACT Compass.

Appointment

Cancellations

Cancelled by clinic rate for all active clinic stop codes (mop13)

(Lower is better) information)

PWS

para.

4.9.6

Contractor shall not unnecessarily cancel patient appointments

Contractor’s rate of appointments cancelled by clinic shall not exceed

9%

Contractor’s rate of appointments cancelled by clinic shall not exceed 9% by using data from

DOMAIN:

QUALITY OF CARE

Composite - Behavioral

Health Screening

Composite of mdd40 -- Vets screened annually for major depression dx.

ptsd51 -- PTSD screening using the PC-PTSD at required times

PWS

para.

4.9.7

Contractor shall complete all behavioral health screenings and follow-up evaluations

Contractor shall maintain a behavioral health composite score of at least 95%

Contractor shall maintain a behavioral health composite score of at least

95% the CBOC Report.

https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

Version 6/20/2019 Page 5 of 12 sa17 -- Vets screened for alcohol misuse w/ score

GE 5 w/ timely brief counselling sa7 -- Vets screened annually for alcohol misuse sre1 -- (mdd41 and ptsd52) aggregated scores for timely suicide evaluations

(See the CBOC Report for

Composite – Diabetes

Composite of dmg27h_ec DM: BP LT

140/90 ( eMeasure ) dmg34h_ec DM: Medical attention for nephropathy -

Renal Testing

(OP)(eMeasure) statn7_ec Statin therapy for patients with diabetes ( eMeasure )

PWS

para.

4.9.8

Contractor shall manage patients with diabetes in accordance with

VA standards

Contractor shall maintain a diabetes composite score of at least 79%

Contractor shall maintain a diabetes composite

79%

Composite - Ischemic

Heart

Composite of ihd53_ec and statn1_ec Statin

Therapy for patients with cardiovascular disease

(eMeasure)

PWS

para.

4.9.9

Contractor shall manage patients with ischemic heart disease in accordance with

VA standards

Contractor shall maintain an ischemic heart composite score of at least 78%

Contractor shall maintain an ischemic heart composite

78%

Composite – Prevention

Composite of dmg31h

DM: Retinal exam, timely by disease (OP) p61h Colorectal Cancer

Screening Ages 50-75 p42 Cervical Cancer

Screening Women age 21-

29y

PWS

para.

4.9.10

Contractor shall provide preventive health care in accordance with

VA standards

Contractor shall maintain a prevention composite score of at least 80%

Contractor shall maintain a prevention composite score of at least

80%

VA will monitor progress quarterly http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx

Version 6/20/2019 Page 6 of 12 p43h Cervical Cancer

Screening Women age 30-pvc11h Pneumococcal

Immunizations (OP) EPRP sample p32h Breast Cancer

Screening including tomography for Women

50-74y (OP) HEDIS

Composite – Tobacco

Composite of smg8 Pts using tobacco provided w/counsel (OP) smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds (OP)

PWS

para.

4.9.11

Contractor shall provide tobacco counseling and care in accordance with

VA standards

Contractor shall maintain a tobacco composite score of at least 94%

Contractor shall maintain a tobacco composite

94%

Clinical Reminders PWS para.

4.9.12

Contractor shall complete all clinical reminders as indicated in the

VA EHR.

Contractor shall complete no less than 90% of all clinical reminders as indicated in the VA EHR

Contractor shall complete no less than

90% of all clinical reminders as indicated in the

VA EHR

VA will monitor progress monthly by

Clinical supervisor will perform monthly chart audits.

Progress Notes and

Patient Care Encounter

(PCE) Module

Documentation

PWS

para.

4.9.13

Contractor shall complete workload and encounter documentation as defined in the

PWS within 2 business days.

Progress notes must be connected to the correct visit/encounter and location, entered into the

VA EHR on the same day as the visit/encounter, Contractor shall properly complete documentatio n for each patient encounter

100% of the time

Contractor shall properly complete documentation for each patient encounter

100% of the time progress monthly by

Clinical supervisor will perform monthly chart audits.

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PWS.

DOMAIN:

PANEL MANAGEMENT

Percent of Teams with

Core Teamlet Staffing

Ratio >=3

The total Core Primary

Care Support Staff

(clerical/administrative associate, RN care manager, and clinical associate) FTE divided by the total Primary Care

Provider FTE entered in the PCMM Web

Application.

(See mPACT Dashboard

PWS

para.

4.9.14

Contractor shall provide core teamlet staffing at a ratio of >=3

FTE core teamlet members (RN care manager, clinical associate, administrative associate) for each PCP FTE

100% of

Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

100% of

Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

VA will monitor progress quarterly by using data from the mPACT

Dashboard.

Percent of Women

Assigned to Women’s

Health PACT or

Designated Women’s

Health Provider

(WH1)

The total number of female patients assigned to a Women’s Health PACT

(identified by having

*WH* in the team name or a primary or secondary team focus of Women’s

Health) OR to a provider with a team role of

DESIGNATED WH

PROVIDER (WH-PCP)

divided by the total number of unique female patients assigned to

Primary Care Teams

PWS

para.

4.9.15

Contractor shall ensure that an appropriate number of WH-

PACTs or WH-

PCPs are available at site of care to ensure that all VHA access goals are met for women

Veterans who choose to be seen by a designated women’s health provider.

Contractor’s percent of women assigned to

Women’s

Health PACT or

Designated

Women’s

Health

Provider shall meet or exceed 77%

Contractor’s percent of women assigned to

Women’s

Health PACT or Designated

Women’s

Health Provider exceed 100% https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e97f10a0-94e2-4186-b157-3e30a33fb349|ispasFalse|reporta945bca6-c8d6-4239-9190-f20255341eb2|ws4|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render

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Percent Primary Care

Patients Enrolled in

Home Telehealth

Reflects the total number of unique PC patients enrolled in home telehealth (numerator) divided by the total number of unique patients assigned to primary care teams (denominator)

PWS

para.

4.9.16

Contractor shall offer and refer patients to home telehealth

Contractor shall exceed

1.6% of PC patients enrolled in Home

Telehealth

(HT)

Contractor shall exceed

1.6% of patients enrolled in Home

Telehealth

(HT)

Ratio of Non-Traditional

Encounters

This is the sum of all PC telephone encounters added to the sum of all PC group encounters added to the sum of all incoming and outgoing secure messages, and video as the numerator. The denominator is the total team assignments for the reporting period.

PWS

para.

4.9.17

Contractor shall provide telephone encounters, group encounters, and secure messaging

Contractor shall exceed

25% ratio of non-traditional encounters

Contractor shall exceed

20% ratio of non-traditional encounters

VETERAN SATISFACTION

Veteran Satisfaction

Overall rating of Primary

Care Provider on question

32 of the SHEP/PCMH survey

PWS

para.

4.9.18

The

Contractor’s

PCPs shall provide care that

Veterans rate as a 9 or 10 on question 32 of the

SHEP/PCMH

survey

Contractor’s

SHEP

question 32 score shall meet or exceed 69%

Contractor’s

SHEP question

32 score shall

69% by using data from http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue

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COORDINATION OF CARE

Post Discharge Contact by PACT Teamlet

The percent of assigned primary care patients discharged from any VA facility who have been contacted by PACT teamlet within two business days

PWS

para.

4.9.19

The

Contractor’s

PACT teamlets shall contact their assigned patients within 2 business days of discharge from any VA facility

Contractor’s rate of post discharge contact by

PACT

teamlet shall meet or exceed 60%

Contractor’s rate of post discharge contact by

PACT teamlet exceed 75%

PACT Compass.

ENVIRONMENT OF CARE (EOC)

Percentage of

Deficiencies Identified

During EOC Rounds that are Closed Timely

(e5eoc1)

Percentage of deficiencies identified during EOC rounds that are closed within 14-business days or have a documented Plan for Action (PFA) information)

PWS

para

4.9.20

Contractor shall address deficiencies identified in

EOC rounds within 14 business days or have a documented

Plan for Action

Contractor’s rate of EOC deficiencies that are closed within

14 business days or have a PFA shall meet or exceed 85%

Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA exceed 85% by using data from

DOMAIN: PHARMACY

Non-Formulary and

Restricted Drug

Requests

PWS

para.

4.9.21

Contractor shall submit non-formulary and restricted drug requests in the

VA EHR using the PBM consult option

Contractor shall submit non-formulary and restricted drug requests in the VA

EHR using the PBM consult option 100% of the time.

(Zero disapproval ratings for non-

Contractor shall submit non-formulary and restricted drug requests in the VA EHR using the PBM consult option

100% of the time. (No more than 10% disapproval ratings for non-formulary and restricted drug

COR will monitor performance monthly via electronic reports pulled from the VA

EHR.

https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

Version 6/20/2019 Page 10 of 12 formulary and restricted drug requests quarterly).

requests quarterly).

Pharmacy New Drug

Order Requests

PWS

para.

4.9.22

Contractor shall submit new drug orders through the VA EHR

The contractor shall ensure that 95% all new drug order requests follow all prescribing guidelines.

This is including but not limited to ensuring all appropriate labs have been previously ordered and that the order is not a non-formulary drug.

The contractor shall ensure that 95% all new drug order requests follow all prescribing guidelines.

This is including but not limited to ensuring all appropriate labs have been previously ordered and that the order is not a non-formulary drug.

COR will monitor performance quarterly via electronic reports pulled from the VA

EHR.

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7. Ratings:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

EXCEPTIONAL: Performance meets contractual requirements and exceeds many to the

Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However, a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified.

VERY GOOD:

Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also, there should have been NO significant weaknesses identified.

SATISFACTORY:

Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also, there should have been NO significant weaknesses identified.

MARGINAL:

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

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the

GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g., Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTORY:

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

Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental

Deficiency Reports, or letters).

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8. DOCUMENTING PERFORMANCE

a. The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. When the COR and the

CO determines, formal written communication is required, the COR shall prepare a Contract Discrepancy

Report (CDR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CDR in writing. The CDR will specify if the contractor is required to prepare a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the contractor must present this corrective action plan to the CO. The Government shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

The frequency of measurement is defined in the contract or otherwise in this document. The government

(COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting.

The COR shall communicate with the Contractor and will provide written reports to the Contracting

Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE