D.22 Quality Assurance Surveillance Plan - McCurtain CBOC.pdf

D.22 QUALITY ASSURANCE SURVEILLANCE PLAN

36C25923R0040

QUALITY ASSURANCE SURVEILLANCE PLAN

Outpatient Site of Care Service

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: Yomika Brock

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: Leon Langguth

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. 100% surveillance: (if this method is used, define how surveillance will be accomplished.)

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. (Define what and how often it will be inspected. For example, 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. If this method is used, explain how data will be collected and reported.

d. RANDOM SAMPLING. If this method is used, what and how often it will be sampled. (For example, ten

(10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

e. Verification and/or documentation provided by Contractor. Review PWS and if this method of surveillance is selected, define how documentation will be verified and how assessment will be conducted.

6. Measures

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

METRIC PWS

Para

Performance

Requirement

Standard Acceptable

Quality Level

Method of

Surveillance and frequency

Met AQL/Did

Not Meet AQL

(Add comment)

DOMAIN:

ACCESS

New Patient

Appointments

Completed within 20

PWS

para.

4.13.

Contractor shall provide completed appointments for new patients <=20

Contractor shall provide completed appointments for new

Contractor shall provide completed appointments for new

VA will monitor performance quarterly using data from the

Calendar Days of Reference

Date (RD) for new patients completed in less than or equal to 20 calendar days from reference date

(See the

Cube in

Pyramid

Analytics for more information) calendar days from the reference date patients <=20 calendar days from the reference date no less than

56% of the time patients <=20 calendar days from the reference date no less than 56% of the time

Appointments

Cube in

Pyramid

Analytics.

COR will send reports to the

Contractor and

CO quarterly to notify them of current performance.

Established PC Patient Appointments Completed within 20 calendar days of Patient Indicated Date

(PID)

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

Indicated Date

(See the

Appointments

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

92% of the time

VA will monitor performance quarterly by using data from

Appointments

Cube in

Pyramid

Analytics. COR will send reports to the

Contractor and

CO quarterly to 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)

Percent of All

Primary Care

Patients engaged in

Primary Care-

Mental Health

Integration

(PC-MHI)

(See PACT

Compass for more information)

PWS

para.

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%

VA will monitor performance quarterly using data from the

PACT Compass.

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

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 50%

Contractor’s

SHEP access composite score shall meet or exceed 50%

VA will monitor performance quarterly using data from

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 medical question.

(See

SHEP/PCMH

Report for

SHEP Question

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.

4.13.

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 performance quarterly using data from

SHEP/PCMH

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 more information)

PWS

para.

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 43%

VA will monitor performance quarterly using data from the

PACT Compass.

COR will send reports to the

Contractor and

CO quarterly to notify them of

Appointment

Cancellations

PWS

para.

Contractor shall not unnecessarily

Contractor’s rate of

Contractor’s rate of

VA will monitor 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

Cancelled by clinic rate for all active clinic stop codes

(mop13)

(Lower is better)

Performance

Measure

Report for more information)

4.13.

7.

cancel patient appointments appointments cancelled by clinic shall not exceed 9% appointments cancelled by clinic shall not exceed 9% performance quarterly using data from the

Performance

Measure

Report. COR will send reports to the

Contractor and

CO quarterly to notify them of

QUALITY OF

CARE

Composite –

BH90 Behavioral

Health

Screening

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

ptsd51 -- PTSD screening sa17 -- Vets screened for alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened

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 95%

Contractor shall maintain a behavioral health composite score of at least 95%

VA will monitor progress quarterly using data from the

Outpatient

Sites of Care

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?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render annually for alcohol misuse

CSSRS1--Annual

Suicide Risk

Screen

Outpatient Sites of Care Report for more

Composite-

CVRM90_EC

Cardiovascular/

Diabetes Risk

Management eQM dmg27h_ec

(DM: BP LT

140/90 ( eMeasure )) ihd53h_ec

(Controlling High

Blood Pressure ( eMeasure )) statn1_ec (Statin

Therapy for patients with cardiovascular disease ( eMeasure )) statn7_ec (Statin therapy for patients with diabetes ( eMeasure )) of Care Report for more information)

PWS

para.

9.

manage patients with diabetes and cardiovascular disease in accordance with

VA standards.

Contractor shall maintain a cardiovascular

/diabetes 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

Outpatient

Sites of Care

Report. COR will send reports to the

Contractor and

CO quarterly to notify them of

PRV90_EC

Prevention bcs01_ec (Breast

Cancer

Screening for

Women 50-74y

(Electronic)) ccs01_ec

(Cervical Cancer

Screening

(eMeasure)) col01_ec

(Colorectal

Cancer

Screening Ages

45-75

(eMeasure)) psa1_ec (Non-

Recommended

PSA-Based

Screening ( eMeasure )) of Care Report for more information)

PWS

para.

4.13.

10.

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 62%

VA will monitor progress quarterly using data from the

Outpatient

Sites of Care

Report. COR will send reports to the

Contractor and

CO quarterly to notify them of

SMG90_1

Tobacco Use and Cessation

Composite of p7

(Tobacco Use -

Screened for Use

- NEXUS (Outpt)) smg10 (Tobacco

Use Cessation -

Discussed

Cessation

Medications

(Outpt)) smg8

(Tobacco Use

PWS

para.

4.13.

11.

Contractor shall provide tobacco counseling and care in accordance with VA standards

Contractor shall maintain a tobacco use and cessation composite score of at least 95%

Contractor shall maintain a tobacco use and cessation composite score of at least 95%

VA will monitor progress quarterly using data from the

Outpatient

Sites of Care

Report. COR will send reports to the

Contractor and

CO quarterly to notify them of

Cessation -

Advised to Quit

(Outpt)) smg9

(Tobacco Use

Cessation -

Discussed

Cessation

Strategies

(Outpt)) of Care Report

Composite - PWS para.

4.13.

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 29%

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report.

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

FLU90_EC

Outpatient Influenza Immunization p28h_ec (Influenza Immunizations 66 years of age and older (eMeasure)) p29h_ec (Influenza Immunization 19-65 years of age (eMeasure))

Sites of Care Report for

Adult Immunization Status

PWS

para.

4.13.

Contractor shall provide adult immunizations in

Contractor shall maintain an adult

Contractor shall maintain an adult immunization

VA will monitor progress quarterly using https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true ais01_ec Pneumococcal Immunization (eMeasure) ais10td_ec Tdap Immunization (eMeasure) ais20zos_ec Zoster Immunization (eMeasure)

Sites of Care Report for more information) accordance with

VA standards immunization status composite score of at least 56% status composite score of at least 56% data from the Outpatient Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of

Composite – PWS

4.13.

Contractor shall provide diabetes care in accordance with VA standards

Contractor shall maintain a diabetes composite score of at least 68%

Contractor shall maintain a diabetes composite score of at least 68%

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of

DMG91_EC

Diabetes

Composite of dmg23h_ec (DM: HbA1c poor control ( eMeasure )) dmg31h_ec (Diabetes Mellitus - Outpatient - Retinal exam, timely by disease (eMeasure)) ked01_ec (Kidney Health Evaluation for Patients With Diabetes (eMeasure)) https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true

Sites of Care Report for

Clinical PWS Contractor shall Contractor Contractor VA will

Reminders para. complete all shall complete shall monitor

4.13. clinical reminders no less than complete no progress

15. as indicated in the 90% of all less than 90% quarterly by

VA EHR. clinical of all clinical using data reminders as reminders as from the indicated in indicated in External Peer the VA EHR. the VA EHR. Review and monitor ad hoc through note reviews. COR will send reports to the

Contractor and

CO quarterly to notify them of current performance.

Progress Notes PWS Contractor shall Contractor Contractor VA will and Patient para. complete workload shall properly shall properly monitor

Care 4.13. and encounter complete complete performance

Encounter 16 documentation as documentatio documentatio weekly by

(PCE) Module defined in the PWS n for each n for each using VSSC

Documentatio within 2 business patient patient Encounter n days. Progress encounter encounter reports. COR notes must be 100% of the 100% of the will send connected to the time time reports to the correct Contractor and visit/encounter CO quarterly to and location, notify them of entered into the current

VA EHR on the performance.

same day as the visit/encounter, meet CMS guidelines, and https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs%3AEmbed=true include content as defined in PWS.

PANEL

MANAGEMEN

T

Percent of

Teams with

Core Teamlet

Staffing Ratio

>=3 (PACT 22)

The total Core

Support Staff

(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.

PWS

para.

4.13.

17.

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

99% of

Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

VA will monitor progress quarterly using data from the

PACT Compass

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

(See the PACT

Compass Cube

Percent of PWS Contractor shall Contractor’s Contractor’s VA will

Women para. ensure that an percent of percent of monitor

Assigned to 4.13. appropriate women women performance

Women’s 18. number of WH- assigned to assigned to quarterly using

Health PACT or PACTs or WH-PCPs Women’s Women’s data from the

Designated are available at site Health PACT or Health PACT PACT COR will

Women’s of care to ensure Designated or Designated send reports to

Health that all VHA access Women’s Women’s the Contractor

Provider goals are met for Health Health and CO https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96 https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96

(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 more information) women Veterans who choose to be seen by a designated women’s health provider.

Provider shall meet or exceed 88%

Provider shall meet or exceed 88% quarterly to notify them of current

Compass.

Percent

Patients

Enrolled in

Home

Telehealth

Reflects the

PWS

19.

offer and refer patients to home telehealth

Contractor shall exceed

2% of PC patients enrolled in Home

(HT)

Contractor shall exceed

2% of patients enrolled in Home

(HT)

VA will monitor performance quarterly using data from the

PACT Compass.

COR will send reports to the 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%2BReports%2fMeasure%2BManagement%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance%2BReports%2fMeasure%2BManagement%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance%2BReports%2fMeasure%2BManagement%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance%2BReports%2fMeasure%2BManagement%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance%2BReports%2fMeasure%2BManagement%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance%2BReports%2fMeasure%2BManagement%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed 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) more information)

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

PWS

para.

4.13.

20.

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

Contractor shall exceed

44% ratio of non-traditional encounters

Contractor shall exceed

44% ratio of non-traditional encounters

VA will monitor performance quarterly using data from the

PACT Compass.

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 reporting period.

VETERAN

SATISFACTION

Veteran

Satisfaction

Overall rating of Primary Care

Provider on question 32 of the survey

Report for more information)

PWS

para.

4.13.

21.

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 73%

VA will monitor performance quarterly using data from

SHEP/PCMH

report. COR will send reports to the

Contractor and

CO quarterly to notify them of

COORDINATIO

N OF CARE

Post Discharge

Contact by

PACT Teamlet

The percent of assigned primary care patients discharged from any VA facility who

PWS

para.

4.13.

22.

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%

VA will monitor performance quarterly using data from the

PACT Compass.

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 have been contacted by

PACT teamlet within two business days more information)

ENVIRONMEN

T 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)

Performance

Measure

Report for more information)

PWS

para

4.13.

23.

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 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 performance quarterly using data from the

Performance

Measure

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://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render

PHARMACY

Medication

Storage Area

Inspections

PWS

para.

4.13.

24.

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 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.

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 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.

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

7. Ratings:

Metrics and methods are designed to determine rating for a given standard and acceptable qualitylevel. 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 actionstaken 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 wasaccomplished 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 theelement 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 forwhich the contractor has not yet identified corrective actions. The contractor’s proposedactions 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 appearor 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 apart of the supporting documentation for any contractual action and preparing annual past performanceusing 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

DiscrepancyReport (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 contractorreceives 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 workbeing 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