S02_Attachment_1_-_QASP_-_CBOC_Marshall_County.docx

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: Kimberly S. Carson Organization or Agency: Department of Veterans Affairs (IDENTIFY YOUR DIVISION)

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: Kaylyn Sickmeier

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

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 52.212-1.

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. PERIODIC INSPECTION. Inspections scheduled monthly and/or quarterly and reported quarterly per COR delegation or as needed. Reports will be run monthly or as needed. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

b. Verification and/or documentation provided by Contractor. COR will verify documents submitted by contractor for accuracy.

36C24919R0003 – Attachment 1

DRAFT

6. Measures PACT CBOC QASP Template

Surveillance and frequency

4.9.1.1

Contractor shall provide completed appointments for new PC patients <=30 days from the create date

Contractor shall provide completed appointments for new PC patients <=30 days from the create date no less than 76% of the time

Contractor sall provide cmpleted apointments for new PC patients <30 days frm the ceate date noless than 99% of the time.

VA will monitor progress via SAIL or PACT COMPASS Reports on a monthly basis. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

4.9.1.2 Contractor shall provide completed appointments for established PC patients <=30 days from the patient indicated date.

Contractor shall provide completed appointmnts for establishd PC patients <=30 days from the patient indicated date no less than 97% of the time.

Contractor shall provide completed appointments for established PC patients <=30 days from the patient indicated date no less than 99% of the time.

VA will monitor progress monthly. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PCMHI PENTRATION (PACT15)

PWS para.

4.9.1.3

Contractor shall involve PCMHI staff in the care of patients with mental health needs.

Contractor’s PCMHI penetration rate shall meet or exceed 8%

Contractor’s PCMHI penetration rate shall meet or exceed 8%

VA will monitor progress quarterly, non-cumulative, by reviewing the PACT COMPASS Report. VA COR will send reports to the Contractor and CO quarterly to notify them of current performance.

4.9.1.4 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 patients’ medical questions

4.9.1.5 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 meet or exceed 41%

VA will monitor progress quarterly by reviewing SAIL results. VA COR will send reports to the Contractor and CO quarterly to notify them of current performance.

4.9.1.6 Contractor shall provide same day appointments with primary care provider

APPOINTMENT CANCELLATIONS

PWS para.

4.9.1.7

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%

VA will monitor progress utilizing the Performance Measures Report at the VSSC. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

BEHAVIORAL HEATH SCREENING

PWS para.

4.9.2.1 Contractor shall complete all behavioral health screening and follow-up evaluations

DIABETES

PWS para.

4.9.2.2 Contractor shall manage patients with diabetes in accordance with VA standards

4.9.2.4 Contractor shall provide preventive health care in accordance with VA standards

4.9.2.5 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 maintan a tobacco composite score of at least 94%

VA will monitor progress monthly. Ambulatory Care will provide this data utilizing local reports. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

CLINICAL REMINDERS

PWS para.

4.9.2.6

4.9.2.7

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 CPRS/VISTA on the same day as the visit/encounter, meet CMS guidelines, and include content as defined in PWS.

Contractor shall exceed 1.6% of PC patients enrolled in Home Telehelth (HT)

VA will monitor progress monthly utilizing the PACT Compass Report COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 60%

VA will monitor progress monthly by reviewing the PACT Compass Report which updates monthly. VA COR will send reports to the Contractor and CO monthly to notify them of current performance

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 business days or have a PFA shall meet or exceed 99%

VA will monitor progress as EOC Rounds deficiencies are identified. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Contractor shall submit non-formulary and restricted drug requests in CPRS/VISTA using the PBM consult option 100% of the time. (Zero disapproval ratings for non-formulary and restricted drug requests quarterly).

COR will monitor performance monthly via electronic reports pulled from CPRS/VISTA. COR will send monthly status reports to the CO and Contractor to notify them of current performance.

7. Ratings:

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

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.

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.

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.

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