D.01 FINAL QASP V17 Denton CBOC North TX VANCS.pdf

Attachment D.1

36C25722R0015

Quality Assurance Surveillance Plan (QASP)

Denton CBOC

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 Contracting Officer: Carlos Leon

Assigned Contract Specialist: Robert Moffett

Organization or Agency: Department of Veterans Affairs, VHA Procurement Center West

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: Teri Stewart

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.

36C25722R0015

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

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

c. VALIDATED USER/CUSTOMER COMPLAINTS.

d. RANDOM SAMPLING.

36C25722R001

6. Measures

9.2 PERFORMANCE STANDARDS AND

SURVEILLANCE: 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 (a).

DOMAIN: ACCESS

9.2.1 MEASURE: NEW PC APPOINTMENTS

COMPLETED WITHIN 20 DAYS OF CREATE DATE

Performance Requirement: Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date Standard: Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date no less than 71% of the time Acceptable Quality Level: Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date no less than 71% of the time Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the Appointments Cube. COR will send quarterly reports to Contractor and CO to notify them of current performance.

9.2.2 MEASURE: ESTABLISHED PC PATIENT AVERAGE WAIT

TIME IN DAYS.

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

Standard: Contractor shall provide completed appointments for established PC patients <=20 calendar days from the patient indicated date no less than 92% of the time.

Acceptable Quality Level: Contractor shall provide completed appointments for established PC patients <=20 calendar days from the patient indicated date no less than 91% of the time Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the Appointments Cube. COR will send quarterly reports to Contractor and CO to notify them of current performance.

9.2.3 MEASURE: PCMHI PENETRATION (PACT21).

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

Standard: Contractor’s PCMHI penetration rate shall meet or exceed 8% Acceptable Quality Level: Contractor’s PCMHI penetration rate meets or exceeds 8%

Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the PACT Compass Report. COR will send quarterly reports to Contractor and CO to notify them of current

9.2.4 MEASURE: PCMH SHEP ACCESS COMPOSITE

Performance Requirement: 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 Standard: Contractor’s SHEP access composite score shall meet or exceed 51% Acceptable Quality Level: Contractor’s SHEP access composite score shall meet or exceed 51% Surveillance Method and Frequency: COR will monitor progress at least quarterly using data from the SHEP/PSMH Report. COR will send

9.2.5 MEASURE: SHEP QUESTION 7

Performance Requirement: Contractor shall provide timely appointments when patients need care right away Standard: Contractor’s SHEP question 7 score shall meet or exceed 34% Acceptable Quality Level: Contractor’s SHEP question 7 score shall meet or exceed 34% Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the SHEP/PSMH Report. COR will send

9.2.6 MEASURE: SAME-DAY APPTS W/ PCP

Performance Requirement: Contractor shall provide same day appointments with primary care provider Standard: Contractor’s same day appointments with PCP rate shall meet or exceed 54% Acceptable Quality Level: Contractor’s same day appointments with PCP rate shall meet or exceed 54% Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the PACT Compass Report. COR will send quarterly reports to Contractor and CO quarterly to notify them of current performance

9.2.7 MEASURE: APPOINTMENT CANCELLATIONS

Performance Requirement: Contractor shall not unnecessarily cancel patient appointments Standard: Contractor’s rate of appointments cancelled by clinic shall not exceed 9% Acceptable Quality Level: Contractor’s rate of appointments cancelled by clinic shall not exceed 9% Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the Performance Measurement or VSCC No

Show and Cancellation Report. COR will send reports to quarterly Contractor and CO to notify them of current performance.

DOMAIN: QUALITY OF CARE

9.2.8 MEASURE: COMPOSITE - BEHAVIORAL HEALTH SCREENING

Performance Requirement: Contractor shall complete all behavioral health screening and follow-up evaluations Standard: Contractor shall maintain a behavioral health composite score of at least 92% Acceptable Quality Level: Contractor shall maintain a behavioral health composite score of at least 92% Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the CBOC Report. COR will send quarterly reports to Contractor and CO to notify them of current performance.

9.2.9 MEASURE: COMPOSITE – DIABETES

Performance Requirement: Contractor shall manage patients with diabetes in accordance with VA standards Standard: Contractor shall maintain a diabetes composite score of at least 74% Acceptable Quality Level: Contractor shall maintain a diabetes composite score of at least 74% Surveillance Method and Frequency: VA will monitor progress at least

9.2.10 MEASURE: COMPOSITE - ISCHEMIC HEART

Performance Requirement: Contractor shall manage patients with ischemic heart disease in accordance with VA standards Standard: Contractor shall maintain an ischemic heart composite score of at least 59% Acceptable Quality Level: Contractor shall maintain an ischemic heart composite score of at least 59% Surveillance Method and Frequency: VA will monitor progress at least

9.2.11 MEASURE: COMPOSITE – PREVENTION

Performance Requirement: Contractor shall provide preventive health care in accordance with VA standards Standard: Contractor shall maintain a prevention composite score of at least 80% Acceptable Quality Level: Contractor shall maintain a prevention composite score of at least 80% Surveillance Method and Frequency: VA will monitor progress at least

9.2.12 MEASURE: COMPOSITE – TOBACCO

Performance Requirement: Contractor shall provide tobacco counseling and care in accordance with VA standards Standard: Contractor shall maintain a tobacco composite score of at least 94% Acceptable Quality Level: Contractor shall maintain a tobacco composite score of at least 94% Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the CBOC Report. COR will send reports to Contractor and CO quarterly to notify them of current

9.2.13 MEASURE: CLINICAL REMINDERS

Performance Requirement: Contractor shall complete all clinical reminders as indicated in the VA EHR.

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

Acceptable Quality Level: Contractor shall complete no less than 90% of all clinical reminders as indicated in the VA EHR.

Surveillance Method and Frequency: VA will monitor progress at least monthly using data from the VA EHR Reports. COR will send quarterly

9.2.14 MEASURE: PROGRESS NOTES AND PATIENT CARE

ENCOUNTER (PCE) MODULE DOCUMENTATION

Performance Requirement: 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.

Standard: Contractor shall properly complete documentation for each patient encounter 100% of the time Acceptable Quality Level: Contractor shall properly complete documentation for each patient encounter 95% of the time.

Surveillance Method and Frequency: VA will monitor progress at least monthly using data from the VA EHR Reports. COR will send quarterly

DOMAIN: PANEL MANAGEMENT

9.2.15 MEASURE: PERCENT OF TEAMS WITH CORE TEAMLET STAFFING RATIO

>=3

Performance Requirement: 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 Standard: 100% of Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3 Acceptable Quality Level: 100% of Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the mPACT Dashboard Report. COR will send quarterly reports to Contractor and CO to notify them of current performance

9.2.16 MEASURE: PERCENT OF WOMEN ASSIGNED TO WOMEN’S HEALTH PACT

OR DESIGNATED WOMEN’S HEALTH PROVIDER (WH1)

Performance Requirement: 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.

Standard: Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 83% Acceptable Quality Level: Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 77%.

Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the PACT Compass Report. COR will send quarterly reports to Contractor and CO to notify them of current

9.2.17 MEASURE: PERCENT PRIMARY CARE PATIENTS

ENROLLED IN HOME TELEHEALTH

Performance Requirement: Contractor shall offer and refer patients to home telehealth Standard: Contractor shall exceed 1.1% of PC patients enrolled in Home Telehealth (HT) Acceptable Quality Level: Contractor shall exceed 1.1% of patients enrolled in Home Telehealth (HT Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the PACT Compass Report. COR will

9.2.18 MEASURE: RATIO OF NON-TRADITIONAL ENCOUNTERS

Performance Requirement: Contractor shall provide telephone encounters, group encounters, and secure messaging Standard: Contractor shall exceed 46% ratio of non-traditional encounters Acceptable Quality Level: Contractor shall exceed 46% ratio of non-traditional encounters Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the PACT Compass Report. COR will

DOMAIN: VETERAN SATISFACTION

9.2.19 MEASURE: VETERAN SATISFACTION

Performance Requirement: The Contractor’s PCPs shall provide care that Veterans rate as a 9 or 10 on question 32 of the SHEP/PCMH survey Standard: Contractor’s SHEP question 32 score shall meet or exceed 73% Acceptable Quality Level: Contractor’s SHEP question 32 score shall meet or exceed 73% Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the SHEP/PSMH Report. COR will send

DOMAIN: COORDINATION OF CARE

9.2.20 MEASURE: POST DISCHARGE CONTACT BY

PACT TEAMLET

Performance Requirement: The Contractor’s PACT teamlets shall contact their assigned patients within 2 business days of discharge from any VA facility Standard: Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 62% Acceptable Quality Level: Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 62% Surveillance Method and Frequency: VA will monitor progress at least quarterly using data from the PACT Compass Report. COR will send

9.2.21 MEASURE: PERCENTAGE OF DEFICIENCIES

IDENTIFIED DURING EOC ROUNDS THAT ARE CLOSED

TIMELY (e5eoc1)

Performance Requirement: Contractor shall address deficiencies identified in EOC rounds within 14 business days or have a documented Plan for Action (PFA) Standard: Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 90% Acceptable Quality Level: Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA shall meet or exceed 85% Surveillance Method and Frequency: VA will monitor progress at least semi-annually using data from the Performance Measurement Report.

COR will send semi-annual reports to Contractor and CO to notify them of

DOMAIN: ENVIRONMENT OF CARE (EOC)

9.4.21.1 MEASURE: PERCENTAGE OF DEFICIENCIES IDENTIFIED DURING EOC

ROUNDS THAT ARE CLOSED TIMELY (e5eoc1)

Performance Requirement: Contractor shall address deficiencies identified in EOC rounds within 14 business days or have a documented Plan for Action (PFA) Standard: Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 92% Acceptable Quality Level: Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA shall meet or exceed 92% Surveillance Method and Frequency: VA will monitor progress at least semi-annually using data from the Performance Measurement Report.

COR will send semi-annual reports to Contractor and CO to notify them of

DOMAIN: PHARMACY

9.2.22 MEASURE: MEDICATION STORAGE AREA INSPECTIONS

Performance Requirement: Contractor shall review medication storage areas monthly Standard: 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.

Acceptable Quality Level: 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 inspection date.

Surveillance Method and Frequency: VA 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 current performance

9.4.23 MEASURE: CLINICAL PHARMACY SPECIALIST (CPS) USE OF

PHARM D TOOL

Performance Requirement: The Contractor shall ensure CPSs utilize the Pharm D tool to document workload.

Standard: The Contractor shall ensure that CPS documents workload via the PharmD tool 100% of the time.

Acceptable Quality Level: The Contractor shall ensure that CPS documents workload via the PharmD tool 90% of the time.

Surveillance Method and Frequency: COR will monitor performance quarterly via

PBM Pharm D report found at

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 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