D.28 QUALITY ASSURANCE SURVEILLANCE PLAN.pdf

D.28 QUALITY ASSURANCE SURVEILLANCE PLAN

36C25922R0102

Quality Assurance Surveillance Plan

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:

Organization or Agency: Department of Veterans Affairs Network Contracting Office (NCO) 19

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:

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary:

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. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed by note reviews by Chief, Ambulatory Care Service on a daily, weekly, or quarterly basis. Inspection through various reporting avenues for data (PACT Compass, CBOC Report, Performance Measure Report, etc.).

b. VALIDATED USER/CUSTOMER COMPLAINTS. SHEP/PCMH Reports and PATS

6. MEASURES:

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

As of September 15, 2022

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 Patient

Appointments

Completed within 20

Calendar Days of

Create Date for new patients completed in less than or equal to 20 calendar days from create date

PWS

para.

4.13.1

Contractor shall provide completed appointments for new patients

<=20 calendar days from the create date

Contractor shall provide completed appointments for new patients <=20 calendar days from the create date no less than 71% of the time

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

85% of the time

COR will monitor performance quarterly using data from the

Appointments

Cube in

Pyramid

Analytics.

(See the

Cube in Pyramid

Analytics for more information)

Established PC

Patient Average

Wait Time in

Days for established patients completed in less than or equal to 20 calendar days from Patient

Indicated Date

(See the

Cube in Pyramid

Analytics for more information)

PWS

para.

4.13.2

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

Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date no less than

92% of the time

Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date no less than

95% of the performance quarterly by using data from

Appointments

Cube in

Pyramid

Analytics.

PCMHI

Penetration

(PACT21)

Percent of All

Primary Care

Patients engaged in Primary Care-

Mental Health

Integration (PC-

MHI)

(See PACT

Compass for

PWS

4.13.3

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% performance quarterly using data from the

PACT Compass.

https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258 https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258 https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258 https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258 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 more information)

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

Report for more information)

PWS

para.

4.13.4

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 51%

Contractor’s

SHEP access composite score shall meet or exceed 55% performance quarterly using data from

SHEP/PCMH

report.

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) information)

PWS

para.

4.13.5

Contractor shall provide timely appointments when patients need care right away

Contractor’s

SHEP question

7 score shall meet or exceed 34%

Contractor’s

SHEP question

7 score shall exceed 50%.

performance quarterly using data from

Same-Day

Appts w/ PCP

PWS

4.13.6 provide same

Contractor’s same day appointments

Contractor’s same day appointments

COR will performance https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx

Measures the percent of requested same day appointments with PCP more information) day appointments with primary care provider with PCP rate shall meet or exceed 54% with PCP rate shall meet or exceed 60% quarterly using

PACT Compass.

Appointment

Cancellations

Cancelled by clinic rate for all active clinic stop codes (mop13)

(Lower is better)

(See

Performance

Measure Report for more

4.13.7

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 8% performance quarterly using data from the

Performance

Measure

Report.

QUALITY OF

CARE

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

PWS

para.

4.13.8

Contractor shall complete all behavioral health screenings and follow-up evaluations

Contractor shall maintain a behavioral health composite score of at least 92%

Contractor shall maintain a behavioral health composite score of at least 96% performance quarterly using

CBOC Report.

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 alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened annually for alcohol misuse

(See the CBOC

Composite-

Cardiovascular

Risk

Management

(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 included in the composite with data collected and scored using electronic extraction from the CDW.

4.13.9 manage patients with diabetes and cardiovascular disease in accordance with

VA standards.

Contractor shall maintain a cardiovascular risk management composite score of at least 70%

Contractor shall maintain a cardiovascular risk management composite least 82% performance quarterly using http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx

Composite –

Prevention 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

4.13.1

Contractor shall provide preventive health care in accordance with

VA standards

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

Contractor shall maintain a prevention composite least 83% performance quarterly using

Composite –

Tobacco smg8 Pts using tobacco

PWS

para.

4.13.1

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 maintain a tobacco composite score of at least 94%

COR will monitor performance quarterly using provided w/counsel (OP) smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds (OP)

Clinical

Reminders

PWS

para.

4.13.1

Contractor 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.

Contractor shall complete no less than

100% of all clinical reminders as indicated in the VA EHR.

performance quarterly by using data from the

External Peer

Review and monitor ad hoc through note reviews.

Progress Notes and Patient Care

Encounter (PCE)

Module

Documentation

PWS

para.

4.13.1

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

Contractor shall properly complete documentatio n for each patient encounter

100% of the time

Contractor shall properly complete documentatio n for each patient encounter

100% of the performance weekly by using VSSC

Encounter reports.

guidelines, and include content as defined in

PWS.

PANEL

MANAGEMENT

Percent of

Teams with Core

Teamlet Staffing

Ratio >=3

The total Core

Support Staff

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

Care Provider

FTE entered in the PCMM Web

Application.

(See the PACT

Compass Cube for more information)

PWS

para.

4.13.1

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

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 performance quarterly using data from the

PACT Compass

Cube.

Percent of

Women

Assigned to

Women’s Health

PACT or

Designated

Women’s Health

Provider

(WH1)

4.13.1

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

Contractor’s percent of women assigned to

Women’s

Health PACT or

Designated

Women’s

Health

Provider shall

Contractor’s percent of women assigned to

Women’s

Health PACT or Designated

Women’s

Health

Provider shall

COR will monitor performance quarterly using https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96 https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96

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 goals are met for women

Veterans who choose to be seen by a designated women’s health provider.

exceed 83% exceed 100%

Percent Primary

Care Patients

Enrolled in

Home

Telehealth

Reflects the total number of unique PC patients enrolled in home telehealth

4.13.1 offer and refer patients to home telehealth shall exceed

1.1% of PC patients enrolled in Home

(HT)

shall exceed

1.2% of patients enrolled in Home

(HT)

performance quarterly using 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

(numerator) divided by the total number of unique patients assigned to primary care teams

(denominator) more information)

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.

4.13.1

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

Contractor shall exceed

46% ratio of non-traditional encounters

Contractor shall exceed

46% ratio of non-traditional encounters performance quarterly using 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?%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

Provider on question 32 of the SHEP/PCMH survey information)

PWS

para.

4.13.1

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 exceed 75% performance quarterly using data from

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.

4.13.1

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 62%

Contractor’s rate of post discharge contact by

PACT teamlet exceed 65% performance quarterly using 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

ENVIRONMENT

OF CARE (EOC)

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)

(See

Performance

Measure Report for more para

4.13.2

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

Plan for Action

Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 92%

Contractor’s rate of EOC deficiencies that are closed within

14 days or have a PFA exceed 95% performance quarterly using data from the

Performance

Measure

Report.

PHARMACY

Medication

Storage Area

Inspections

PWS

para.

4.13.2

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

The

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

COR will monitor performance via receipt of

VA Form 10-

0053 (or local medical center form) and documented resolution 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

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.

local VA medical center form).

Inspection documentatio n 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.

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

Inspection documentatio n 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.

any issues discovered during inspections.

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:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE