36C25718R0842-080.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: Carlos Leon

Organization or Agency: Department of Veterans Affairs

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: Melinda Perez

Organization or Agency: Department of Veterans Affairs

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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 52.212-4.

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. Method not applicable

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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. VA will monitor progress at least quarterly using data from the SHEP/PCMH Report.

d. RANDOM SAMPLING. VA will monitor using electronic report using data from VA Vista/CPRS system. VA will monitor progress weekly thru automated verification and/or documentation provided by the Contractor, with a sampling of 10 patients records. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

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METRIC PWS Para Performance

Requirement Standard Acceptable Quality

Level

Method of

Surveillance and frequency

Met AQL/Did

Not Meet

AQL

DOMAIN: ACCESS

NEW PC

APPOINTMENTS

COMPLETED WITHIN

20 DAYS OF CREATE

DATE

New Primary Care

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

PWS para.

4.12.1

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 61% of the time

Contractor shall provide completed appointments for new PC patients

<=20 days from the create date no less than 85% of the time

COR will monitor progress quarterly using data from the

Appointments Cube.

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 days from Patient

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

4.12.2

Contractor shall provide completed appointment s 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 94% of the time

Contractor shall provide completed appointments for established PC patients <=20 days from the patient indicated date no less than 94% of the time using data from the

Appointments Cube.

COR will send reports to the

Contractor and CO quarterly to notify performance

PCMHI

PENETRATION

4.12.3 shall involve

PCMHI staff

Contractor’s

PCMHI penetration

Contractor’s PCMHI penetration rate meets or exceeds 8%

COR will monitor using data from the

Dec 2019 Page 5 of 16

The percent of assigned

Primary Care patients seen in Primary Care- Mental

Health Integration

(PCMHI)

in the care of patients with mental health needs rate shall meet or exceed 8%

PACT Compass.

COR will send reports to the

Contractor and CO quarterly to notify performance.

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.

4.12.4 shall provide: 1) urgent care appointment s as soon as needed, 2) routine care appointment s as soon as needed, and

3) same day answers to patients’ medical questions

Contractor’s SHEP access composite score shall meet or exceed 52%

Contractor’s SHEP access composite score shall meet or exceed 52% using data from

SHEP/PCMH report.

COR will send reports to the

Contractor and CO quarterly to notify

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)

(See SHEP/PCMH Report for more information)

4.12.5 shall provide timely appointment s when patients need care right away

Contractor’s SHEP question 7 score shall meet or exceed 40%

Contractor’s SHEP question 7 score shall meet or exceed

40%.

VA will monitor progress using data from the PCMG

SHEP Report and send reports to the

Contractor and CO quarterly to notify

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SAME-DAY

APPTS W/ PCP

Measures the percent of requested same day appointments with PCP

(See PACT Compass for more information)

4.12.6 shall provide same day appointment s with primary care provider

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

62%

Contractor’s same day appointments with PCP rate shall meet or exceed 62% using data from the

PACT Compass.

COR will send reports to the

Contractor and CO quarterly to notify performance. .

APPOINTMENT

CANCELLATIONS

Cancelled by clinic rate for all active clinic stop codes

(mop13)

(Lower is better)

(See Performance Measure

Report for more information)

4.12.7 shall not unnecessaril y cancel patient appointment s

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

7.5%

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

7.5% using data from the

Performance

Measure Report.

COR will send reports to the

Contractor and CO quarterly to notify

DOMAIN:

QUALITY OF CARE

COMPOSITE -

BEHAVIORAL

HEALTH SCREENING

4.12.8 shall complete all behavioral

Contractor shall maintain a behavioral health

Contractor shall maintain a behavioral health

COR will monitor progress quarterly

CBOC Report. COR

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(See the CBOC Report for health screenings and follow-up evaluations composite score of at least 96% composite score of at least 96% will send reports to the Contractor and

CO quarterly to notify them of current performance.

COMPOSITE –

DIABETES

4.12.9 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 least 79% using data from the

CBOC Report. COR will send reports to the Contractor and

CO quarterly to notify them of

COMPOSITE -

ISCHEMIC HEART

4.12.10 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 score of at least 78% using data from the

CBOC Report. COR will send reports to the Contractor and

CO quarterly to notify them of

PREVENTION

4.12.11 shall provide preventive health care in accordance with VA standards

Contractor shall maintain a prevention composite score of at least 78%

Contractor shall maintain a prevention least 78% using data from the

CBOC Report. COR will send reports to the Contractor and

CO quarterly to notify them of

TOBACCO

PWS para.

4.12.12

Contractor shall provide

Contractor shall maintain a tobacco

Contractor shall maintain a tobacco

Dec 2019 Page 8 of 16 tobacco counseling and care in accordance with VA standards composite score of at least 95% least 95%

CBOC Report. COR will send reports to the Contractor and

CO quarterly to notify them of current performance.

CLINICAL

REMINDERS

4.12.13 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

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

EHR

progress weekly using VA EHR reports. COR will send reports weekly to the Contractor and

CO to notify them of

PROGRESS NOTES

AND PATIENT CARE

ENCOUNTER (PCE)

MODULE

DOCUMENTATION

4.12.14 shall complete workload and encounter documentati on as defined in the PWS within 2 business days.

Progress notes must be connected to the correct visit/encount er and

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 progress weekly using VA EHR reports. COR will send reports weekly to the Contractor and

Dec 2019 Page 9 of 16 location, entered into the VA EHR on the same day as the visit/encount er, meet

CMS

guidelines, and include content as defined in

PWS.

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 for more information)

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

FTE core teamlet members

(RN care manager, clinical associate, administrati ve 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

COR will monitor progress monthly using data from the mPACT Dashboard.

COR will send reports monthly to the Contractor and

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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

4.12.16 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 80%

Contractor’s percent of women assigned to Women’s Health

PACT or Designated

Women’s Health

Provider shall meet or exceed 85% using data from the

PACT Compass.

COR will send reports to the

Contractor and CO quarterly to notify

PERCENT PRIMARY

CARE PATIENTS

ENROLLED IN HOME

TELEHEALTH

Reflects the

4.12.17 shall offer and refer patients to home telehealth exceed 1.3% of PC patients enrolled in Home Telehealth

(HT)

exceed .5% of patients enrolled in Home Telehealth

(HT)

using data from the

PACT Compass.

COR will send reports to the

Contractor and CO https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render

Dec 2019 Page 11 of 16 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) quarterly to notify them of current performance.

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.

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

Contractor shall exceed 26% ratio of non-traditional encounters

Contractor shall exceed 21% ratio of non-traditional encounters using data from the

PACT Compass.

COR will send reports to the

Contractor and CO quarterly to notify

VETERAN SATISFACTION

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

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VETERAN

SATISFACTION

Overall rating of

Primary Care

Provider on question

32 of the

SHEP/PCMH survey

4.12.19

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 70.5%

Contractor’s

SHEP question

32 score shall meet or exceed

65% using data from

SHEP/PCMH

report. COR will send reports to the

Contractor and CO quarterly to notify

COORDINATION OF CARE

POST

DISCHARGE

CONTACT BY

PACT TEAMLET

(See PACT Compass for more information)

4.12.20

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 60% using data from the

PACT Compass.

COR will send reports to the

Contractor and CO quarterly to notify https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render

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ENVIRONMENT OF CARE (EOC)

PERCENTAGE OF

DEFICIENCIES

IDENTIFIED

DURING EOC

ROUNDS THAT

ARE CLOSED

TIMELY

(E5EOC1)

(See Performance

Measure Report for

PWS para

4.12.21 address deficiencies identified in EOC rounds within 14 business days or have a documented

Plan for Action

(PFA)

Contractor’s rate of

EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 90%

Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA shall meet or exceed 90% using data from the

Performance

Measure Report.

COR will send reports to the

Contractor and CO quarterly to notify

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DOMAIN: PHARMACY

NON-

FORMULARY

AND

RESTRICTED

DRUG REQUESTS

4.12.22 submit non-formulary and restricted drug requests in the VA

EHR using the PBM consult option 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-formulary and restricted drug requests quarterly).

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

90% of the time. (No more than 10% disapproval ratings for non-formulary and restricted drug requests quarterly).

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

EHR. COR will send monthly status reports to the

CO and Contractor to notify them of current

PHARMACY NEW

DRUG ORDER

REQUESTS

4.12.23 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 monthly via electronic reports pulled from the VA

EHR. COR will send monthly status reports to the

CO and Contractor to notify them of current performance .

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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

COR NAME/TITLE DATE

CONTRACTOR NAME/TITLE DATE