S02 ATTACHMENT D.1 QASP.pdf

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.

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.

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: Billy Morris, billy.morris@va.gov / Contract Specialist Thomas Kovarovic, thomas.kovarovic@va.gov

Organization or Agency: Department of Veterans Affairs / Network Contracting Office 16

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: Keisha R. Isaac

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

mailto:thomas.kovarovic@va.gov

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. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. PATS-R, Congressional and White House Hotline submissions, VSIGNALS

d. RANDOM SAMPLING. Five (5) randomly selected patient files will be reviewed for each Contract physician per inspection period. Ten (10) randomly selected patient files will be reviewed for each Contract advanced practice provider per inspection period.

e. Verification and/or documentation provided by Contractor. Method not applicable.

6. MEASURES

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

As of: December 10, 2021

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

Calendar Days of Create Date

New Primary

Care Completed

Appointments less than or equal to 20 days from create date

(See the

Cube in

Pyramid

Analytics for more information)

PWS

para.

4.16.1.1

Contractor shall provide completed appointments for new PC patients

<=20 calendar days from the create date

Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date no less than 56% of the time

Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date no less than 75% of the time

VA will monitor progress quarterly using data from the

Power BI

Clinical

Practice

Management

Dashboard.

COR will send reports to the

Contractor and

CO quarterly to notify them of current performance.

Established PC

Patient

Average Wait

Time in Days

Established

Primary Care

Completed

Appointments less than or equal to 20 calendar days from Patient

Indicated Date

(patient desired date) or the clinically indicated date

(See the

PWS

para.

4.16.1.2

Contractor shall provide completed appointments for established PC patients <=20 calendar days from the patient indicated date

Contractor shall provide completed appointments for established

PC patients

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

92% of the time

Contractor shall provide completed appointments for established

PC patients

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

95% of the time progress quarterly using data from the

Power BI

Clinical

Practice

Management

Dashboard.

COR will send reports to the

Contractor and

CO quarterly notify them of https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258

Cube in

Pyramid

Analytics for more information)

PCMHI

Penetration

(PACT21)

The percent of assigned

Primary Care patients seen in

Primary Care-

Mental Health

Integration

(PCMHI)

(AS OF

OCTOBER 1,

2019 THIS

MEASURE

WILL APPLY

TO ALL SITES

REGARDLESS

OF THE

NUMBER OF

UNIQUE

PATIENTS

ASSIGNED).

(See PACT

Compass for more information)

PWS

para.

4.16.1.3

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 meets or exceeds 8%

VA will monitor progress quarterly using data from the

PACT Compass

(Percent of

Primary Care

Patients

Engaged in PC-

MHI – PACT

21. COR will send reports to the Contractor and CO quarterly to notify them of

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 as needed, and 3) Get same day answer to your medical question.

(See

SHEP/PCMH

PWS

para.

4.16.1.4

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

Contractor’s

SHEP access composite score shall meet or exceed

50%

Contractor’s

SHEP access composite score shall meet or exceed

51%.

VA will monitor progress quarterly using data from the

SHEP/PCMH

report. COR will send reports to the

Contractor and

CO quarterly to notify them of https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx

Report for more information)

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)

Report for more information)

PWS

para.

4.16.1.5

Contractor shall provide timely appointments when patients need care right away

Contractor’s

SHEP question

7 score shall meet or exceed

33%

Contractor’s

SHEP question

7 score shall meet or exceed

33%.

VA will monitor progress quarterly using data from the

SHEP report.

COR will send reports to the

Contractor and

CO quarterly to notify them of

Same-Day

Appts w/ PCP

Measures the percent of requested same day appointments with PCP

(See PACT

Compass for more information)

PWS

4.16.1.6 provide same day appointments with primary care provider

Contractor’s same day appointments with PCP rate shall meet or exceed 43%

Contractor’s same day appointments with PCP rate shall meet or exceed 50%.

VA will monitor progress quarterly using data from the

PACT Compass

(Percent of

Primary Care

Patients

Engaged in PC-

MHI – PACT

21. COR will send reports to the Contractor and CO quarterly to notify them of

Appointment

Cancellations

Cancelled by clinic rate for all active clinic stop codes

(mop13)

(Lower is better)

Performance

Measure Report for more information)

PWS

para.

4.16.1.7

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 10%.

VA will monitor progress quarterly using data from the

Power BI

Clinic Practice

Management

Dashboard (By

Facility). COR will send reports to the

Contractor and

CO quarterly to notify them of

DOMAIN:

QUALITY OF CARE

https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

Composite -

Behavioral

Health

Screening

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

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

PWS

4.16.2.1

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%

VA will monitor progress quarterly using data from the

CBOC Report

(Behavioral

Health

Screening

Composite).

COR will send reports to the

Contractor and

CO quarterly to notify them of

Composite –

Cardiovascula r Risk

Mananagemen t (eQM)

Composite measure monitors cardiovascular and diabetes patients for blood pressure management and statin prescribing. The eQM performance measures ihd53h, dmg27h_ec, statn1_ec, and statn7_ec are

PWS

para.

4.16.2.2

Contractor shall manage patients with diabetes and cardiovascular disease in accordance with

VA standards

Contractor shall maintain a cardiovascular risk management composite score of at least

72%

Contractor shall maintain a cardiovascular risk management composite score of at least 72%

VA will monitor progress quarterly using data from the

CBOC Report

(Cardiovascular

Risk

Management

Electronic

Composite).

COR will send reports to the

Contractor and

CO quarterly to notify them of http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx included in the composite with data collected and scored using electronic extraction from the CDW.

PRV90_EC_Pr evention dmg31h DM:

Retinal exam, timely by disease (OP) p61h

Colorectal

Cancer

Screening Ages

50-75 p42 Cervical

Cancer

Screening

Women age 21-

29y 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

4.16.2.3

Contractor shall provide preventive health care in accordance with

VA standards

Contractor shall maintain a prevention composite score of at least

62%

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

VA will monitor progress quarterly using data from the

CBOC Report

(Prevention

Composite).

COR will send reports to the

Contractor and

CO quarterly to notify them of

SMG90_1 -

Tobacco

PWS

para.

4.16.2.4

Contractor shall provide tobacco counseling and

Contractor shall maintain a tobacco

Contractor shall maintain a tobacco

VA will progress smg8 Pts using tobacco provided w/counsel (OP) smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds

(OP)

care in accordance with

VA standards composite score of at least

95% composite score of at least 98% quarterly using data from the

CBOC Report

(Tobacco

Composite).

COR will send reports to the

Contractor and

CO quarterly to notify them of current performance.

Composite

FLU90_EC –

Outpatient

Influenza

Immunization

PWS

para.

4.16.2.5

Contractor shall provide flu immunizations in accordance with

VA standards.

Contractor shall maintain an influenza immunization composite score of at least

29%

Contractor shall maintain an influenza immunization composite score of at least 35%

VA will monitor progress quarterly using data from the

CBOC Report

(Outpatient

Influenza

Immunization).

COR will send reports to the

Contractor and

CO quarterly to notify them of

Adult

Immunization

Status

PWS

para.

4.16.2.6

Contractor shall provide adult immunizations in accordance with

VA standards

Contractor shall maintain an adult immunization status composite score of at least

56%

Contractor shall maintain an adult immunization status composite score of at least 60%

VA will monitor progress quarterly using data from the

CBOC Report

(Adult

Immunization

Status). COR will send reports to the

Contractor and

CO quarterly to notify them of

Composite

DMG91_EC -

Diabetes

PWS

4.16.2.7

Clinical

Reminders

PWS

para.

4.16.2.8

Contractor shall complete all clinical reminders

Contractor shall complete no less than

90% of all

Contractor shall complete no less than

90% of all

VA will monitor progress monthly by as indicated in the

VA EHR.

clinical reminders as indicated in the

VA EHR

clinical reminders as indicated in the VA EHR using data from the Vista

Clinical

Reminders Due

Report. COR will send reports to the

Contractor and

CO monthly to notify them of current performance.

Progress Notes and Patient

Care

Encounter

(PCE) Module

Documentation

PWS

para.

4.16.2.9

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, meet CMS guidelines, and include content as defined in PWS.

Contractor shall properly complete documentation for each patient encounter

100% of the time

Contractor shall properly complete documentation for each patient encounter

100% of the time.

Contractor shall complete progress notes for encounters within 48 hours 95% of the time.

VA will monitor encounters daily using data from the

Corporate Data

Warehouse

(FY23

Incomplete

Encounters).

COR will send reports to the

Contractor and

CO daily as needed to notify them of any action required for incomplete encounters. VA will monitor progress notes quarterly using data from the

Vista

Performance

Monitor

Detailed

Report. COR will send reports to the

Contractor and

CO quarterly to notify them of

PANEL MANAGEMENT

Percent of

Teams with

Core Teamlet

Staffing Ratio

>=3

The total Core

Support Staff

PWS

para.

4.16.3.1

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

FTE core teamlet members (RN care manager, clinical associate, administrative

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 monthly using data from the

PACT Profile –

Summary. COR will send reports to the

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

Care Provider

FTE entered in the PCMM

Web

Application.

Compass Cube for more information) associate) for each PCP FTE

Contractor and

CO monthly to notify them of current performance.

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

Teams

4.16.3.2

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 88%

Contractor’s percent of women assigned to

Women’s

Health PACT or Designated

Women’s

Health

Provider shall meet or exceed

90%

VA will monitor progress quarterly using data from the

PACT Compass

(Percent of

Women

Assigned to

Women's

Health PACT or Designated

WH Provider -

WH1). COR

will send reports to the

Contractor and

CO quarterly to notify them of https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96 https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96 more

Percent

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)

4.16.3.3 offer and refer patients to home telehealth shall exceed

2% of PC patients enrolled in

Home

(HT)

shall exceed

2% of PC patients enrolled in

Home

(HT)

progress quarterly using data from the

PACT Compass

(Percent PC PT

Enrolled in

HT). COR will send reports to the Contractor and CO quarterly to notify them of

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 as the numerator. The denominator is the total team assignments for the reporting period.

4.16.3.4

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

Contractor shall exceed

44% ratio of non-traditional encounters

Contractor shall exceed

50% ratio of non-traditional encounters

VA will monitor progress quarterly using data from the

PACT Compass

(Ratio of Non-

Traditional

Encounters).

COR will send reports to the

Contractor and

CO quarterly to notify them of https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render 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 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://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render

VETERAN SATISFACTION

Veteran

Satisfaction

Overall rating of Primary Care

Provider on question 32 of the survey

Report for more information)

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

73%

Contractor’s

SHEP question

32 score shall meet or exceed

70%

VA will monitor progress quarterly using data from the

SHEP report.

COR will send reports to the

Contractor and

CO quarterly to notify them of

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 more information)

PWS

para.

4.16.5.1

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 shall meet or exceed 75%

VA will monitor progress quarterly using data from the

PACT Compass

(Team 2Day

Post DC

Contact Ratio).

COR will send reports to the

Contractor and

CO quarterly to notify them of

ENVIRONMENT OF CARE (EOC)

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render

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)

Performance

Measure Report for more para

4.16.6.1

Contractor shall address deficiencies identified in EOC rounds within 14 business days or have a documented Plan for Action (PFA).

Reference and guidance for EOC compliance requirements can be found here and in Document

NFPA 101,

included in the attachments section.

Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 91%

Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA shall meet or exceed 91%.

VA will monitor progress biannually through EOC rounds onsite in the CBOC.

COR will send deficiency reports to the

Contractor and

CO as indicated by EOC

Committee to notify them of current performance and any action required.

DOMAIN: PHARMACY

Medication

Storage Area

Inspections

PWS

para.

4.16.7.1

Contractor shall inspect medication storage areas monthly

The Contractor shall ensure that 100% of medication storage areas are inspected monthly and documented on

VA Form 10-

0053 (or local

VA medical center form).

Inspection documentation will be sent to the COR within

10 days of the end of each month. Any issues discovered shall be resolved by the

Contractor and reported to the

COR within 15 days of the inspection date.

The Contractor shall ensure that 100% of medication storage areas are inspected monthly and documented on VA Form

10-0053 (or local VA medical center form).

Inspection documentation will be sent to the COR within 10 days of the end of each month.

Any issues discovered are resolved by the Contractor and reported to the COR within 15 days of the

COR will monitor performance via receipt of

VA Form 10-

0053 (or local medical center form) and documented resolution of any issues discovered during inspections.

COR will send reports to the

Contractor and

CO quarterly to notify them of https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render inspection date.

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).

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:

Keisha R. Isaac DATE

Supervisory Administrative Officer

Primary Care Service

SIGNED:

CONTRACTOR NAME/TITLE DATE