36C24719R0094-007.pdf

QASP

PERFORMANCE

REPORT DATE:

Measures

PWS

Reference

Performance Requirement

Standard Acceptabl e Quality Level

Surveillance Method

Met AQL/DID NOT MEET AQL-

CPAR RATING/ADD COMMENTS

1 -Provider Quality Performance

4.6.4.1 Providers provide

quality care for all services in accordance with standards outlined in PWS.

FPPE/OPPE

documentation for all (100%) staff providing services under the contract. All staff (100%) meet Standards.

Level:

100% meet Standards

Ongoing Provider Performance Evaluation (OPPE) data pertinent to care performed for each provider working under this contract.

Unfavorable contractor performance evaluation.

Removal from contract until such time as contract urology surgeon meets qualification standard.

Reduction of 2% off of monthly invoice

2 - Qualifications of Key Personnel

2.7;4.6.4.2 Contractor’s physician (s) shall have current board certified in accordance with PWS requirements.

All (100%) Contractor’s physician (s) are board certified.

100 % Random Inspection of qualification documents

Unfavorable contractor performance evaluation.

Removal from contract until such time as contract urology surgeon meets qualification standard

3 - Scope of Practice/Privileging

4.6.4.3 Contractor’s

physician (s) perform within their individual scopes of practice/privileging

All (100%) Contractor’s physician (s) perform within their scope of practice/privileges 100% of the time.

100 % Random Inspection of records.

Unfavorable contractor performance evaluation.

Removal from contract until such time as contract urology surgeon meets qualification standard

4- Patient Access

3.1;3.2;4.4.6.2;

4.6.4.4

Contractor’s physician (s) shall be available and in location as needed to properly perform tasks as specified.

All (100%) Contractor’s physician (s) are on time and available to perform services.

100 % Contractor’ s physician

(s) perform within their scope of practice/pri vileges 100% of the time..

Periodic Sampling of Time and Attendance Sheets

Unfavorable contractor performance evaluation.

Removal from contract until such time as contract urology surgeon meets qualification standard

5 - Patient Safety 4.4.7.4;4.6.4.4 Patient safety incidents shall to be reported using Patient Safety Report. All incidents reported immediately (within 24 hours.)

All (100%) of patient safety incidents are reported using Patient Safety Report within 24 hours of incident.

Contractor’ s physician reports incidents within 24 hours 95% of the time

Direct Observation Unfavorable contractor performance evaluation

Maintains licensing, registration, and certification

2.2.1;4.6.4.7 Updated Licensing, registration and certification shall be provided as they are renewed.

Licensing and registration information kept current

All (90%) licensing, registration(s) and certification(s) for contractor’s physician (s) shall be provided as they are renewed.

Licensing and registration information kept current.

Periodic Sampling and Random Sampling

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation.

Removal from contract until such time the contract physician (s) meet qualification standard.

Reduction of 2% off of monthly invoice.

Mandatory Training

6.3;4.6.4.8 Contractor shall complete all required training per VAMC policy

All (90%) of required training is complete on time by contractor’s physician (s) .

Periodic Sampling

Favorable contactor performance evaluation.

Suspension or termination of all physical and/or electronic access privileges and removal from contract until such time as the training is complete

Reduction of 2% off of monthly invoice.

Privacy, Confidentiality and HIPAA

4.4.2;4.6.4.9 Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality

All (100%) contractor’s physician (s) (s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

Contractor shall provide evidence of annual training required by

VAMC,

reports violations per VA Directive 6500.6.

Favorable contactor performance evaluation.

Immediate removal from contract

Timekeeping – Tour of Duty

The contractor will verify attendance via Outlook message at the start and end of the schedule shift;

these must correlate with all other timekeeping documents

The contractor shall have no deviation between timekeeping records

100% of all timekeeping documentation received is accurate

100% of all timekeeping documentation received is accurate

Outlook emails, periodic inspection

Favorable contactor performance evaluation

Invoice Rejection