36C26119R0001-002.docx

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Yreka VA Community Based Outpatient Clinic (CBOC)

Contract Number:

Contract Description: The facility shall provide complete Primary Care services in a hospital or clinic environment to include professional and technical fees, injections, routine spirometry, pulse oximetry at rest/exercise, blood sugar monitoring, and EKGs as clinically indicated and specified within the contract.

Contractor’s name:

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

· What will be monitored.

· How monitoring will take place.

· Who will conduct the monitoring.

· How monitoring efforts and results will be documented.

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

This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

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: Tracy Worrell Organization or Agency: VISN 21 Consolidated Contracting Authority

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: Candi Tucker

c. Other Key Government Personnel – Redding VA Outpatient Managers, Nursing, Lab, Pharmacy, BDMS, Mental Health, Physician Manager

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager –

b. Other Contractor Personnel - Title: Medical Director/Primary Care Provider-

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Performance Requirements Summary Matrix in the PWS includes performance measures. The Government shall use these measures to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

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.

(tailor to meet your requirements) Method of Surveillance and frequency Met AQL/Did Not Meet AQL (Add comment)

DOMAIN: ACCESS

New PC Appointments Completed within 30 Days of Create Date (pc18)

New Primary Care Completed Appointments less than or equal to 30 days from create date

(See Performance Measure Report for more information) PWS para.

4.9.28.2

VA will monitor progress quarterly by SAIL reports

Established PC Patient Average Wait Time in Days (pc17)

Established Primary Care Completed Appointments less than or equal to 30 days from Patient Indicated Date (patient desired date) or the clinically indicated date

PWS para.

4.9.28.3

VA will monitor progress periodically by VA Scheduling Report

PCMHI

Penetration (PACT15)

The percent of assigned Primary Care patients seen in Primary Care- Mental Health Integration (PCMHI)

(Only required divisions – those with 5,000 or more unique patients – are included in this measure).

(See PACT Compass for more information) PWS para.

4.9.28.4

Contractor shall involve PCMHI staff in the care of patients with mental health needs

VA will monitor progress quarterly by the Performance Measure Report

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.

4.9.28.5

VA will monitor progress quarterly by SHEP reports

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)

PWS para.

4.9.28.6

VA will monitor progress quarterly by SHEP report

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP

(See PACT Compass for more information) PWS para.

4.9.28.7

Contractor shall provide same day appointments with primary care provider

VA will monitor progress periodically by Performance Measure report and PACT Dashboard

Appointment Cancellations

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

PWS para.

4.9.28.8

VA will monitor progress periodicallyby PACT dashboard

DOMAIN:

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 alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened annually for alcohol misuse sre1 -- (mdd41 and ptsd52) aggregated scores for timely suicide evaluations

(See the CBOC Report for more information)

PWS para.

4.9.29.2

VA will monitor progress periodically by PACT dashboard

Composite – Diabetes dmg27h_ec DM: BP LT 140/90 ( eMeasure ) dmg34h_ec DM: Medical attention for nephropathy - Renal Testing (OP)(eMeasure) statn7_ec Statin therapy for patients with diabetes ( eMeasure )

(See the CBOC Report for more information)

PWS para.

4.9.29.3

Contractor shall manage patients with diabetes in accordance with VA standards

VA will monitor progress periodically by PACT dashboard

Composite - Ischemic Heart ihd53_ec and statn1_ec Statin Therapy for patients with cardiovascular disease ( eMeasure )

(See the CBOC Report for more information)

PWS para.

4.9.29.4

VA will monitor progress periodicallyby PACT Dashboard

Composite – Prevention

Composite of 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 30-64 pvc11h Pneumococcal Immunizations (OP) EPRP sample p32h Breast Cancer Screening including tomography for Women 50-74y (OP) HEDIS

(See the CBOC Report for more information)

PWS para.

4.9.29.5

VA will monitor progress periodically by PACT Dashboard

Composite – Tobacco

Composite of smg8 Pts using tobacco provided w/counsel (OP) smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds (OP)

(See the CBOC Report for more information)

PWS para.

4.9.29.6

VA will monitor progress periodically by PACT Dashboard

4.9.29.7

Contractor shall complete no less than 81% of all clinical reminders as indicated in the VA EHR.

VA will monitor progress periodically by PACT Dashboard

4.9.29.8 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.

VA will monitor progress monthly by EARR report

DOMAIN:

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) PWS para.

4.9.30.

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

(See PACT Compass for more information)

PWS para.

4.9.30.3 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.

VA will monitor progress annually by PCMM report

Percent Primary Care Patients Enrolled in Home Telehealth

Reflects the total number of unique PC patients enrolled in home telehealth (numerator) divided by the total number of unique patients assigned to primary care teams (denominator)

PWS para.

4.9.30.4

Contractor shall offer and refer patients to home telehealth

Contractor shall exceed 1.6% of PC patients enrolled in Home Telehealth (HT)

Contractor shall exceed 0.80% of patients enrolled in Home Telehealth (HT)

VA will monitor progress periodically by PCMM and VistA reports

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.

PWS para.

4.9.30.5

VA will monitor progress monthly by Vista Workload reports

DOMAIN:

VETERAN SATISFACTION

Veteran Satisfaction

Overall rating of Primary Care Provider on question 32 of the SHEP/PCMH survey

(See SHEP/PCMH Report for more information)

VA will monitor progress quarterly by SHEP report

DOMAIN:

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

PWS para.

4.9.32.2

VA will monitor progress periodic review via CPRS

DOMAIN:

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 information) PWS para 4.9.33.2

VA will monitor progress quarterly via EOC Deficiency Reports

DOMAIN: PHARMACY

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

COR will monitor performance quarterly 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.

Pharmacy New Drug Order Requests

PWS para.

4.9.34.3

COR will monitor performance quarterly via electronic reports pulled from the VA EHR. COR will send quarterly status reports to the CO and Contractor to notify them of current performance.

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. (Can be performed periodically or through 100% surveillance.)

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

c. USER SURVEY. (Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. May also generate inspections and sampling.)

d. VALIDATED USER/CUSTOMER COMPLAINTS. (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.)

e. PERIODIC SAMPLING. (Variation of random sampling. However, sample is only taken when a problem/deficiency is suspected. Sample results are applicable only for the specific work inspected. Since sample is not entirely random, it cannot be applied to total activity performance.)

f. Analysis of contractor's progress reports, peer review, and contractor documentation. (Evaluate cost, schedule, etc.)

6. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

Ratings will be based on a 5 level rating scale including; Outstanding= 100%, Above Average= 80%, Average= 75%, Below Average= 65%, and Unsatisfactory= 60% or less.

Any marks below average could result in a negative performance outcome.

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the CO determines formal written communication is required, the CO shall prepare a Contract Discrepancy Report (CDR), and present it to the contractor's program manager.

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 has to present this corrective action plan to the COR. The Government shall review the contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COTR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COTR shall meet with the contractor annually to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative