QASP - Physical Therapy.pdf

Page 1 of 7 Original Date: 09/25/2024

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 Contracting Officer (CO): Please see COR Nomination Memo

• Organization or Agency: U.S. Department of Veterans Affairs, Northern California Health Care

System

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(S): Julie Cabral, (916) 841-4234; Samantha Adkins, (916) 213-3723

c. Other Key Government Personnel: Chief, Physical Therapy Section, TBD

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – TBD

b. Other Contractor Personnel – TBD

Page 2 of 7 Original Date: 09/25/2024

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.

QUALITY ASSURANCE SURVEILLANCE PLAN

Physical Therapy Section, VA NCHCS

No. Paragraph in PWS

Indicator/Performance Standard

Standard for Quality Level

Acceptable Quality Level

Method of Surveillance

Incentive

1 4.5.1.1.1 Review patient medical records to assess for appropriateness of PT intervention

100% 100% Periodic Reviews and spot checks

Positive past performance rating

2 4.5.1.1.2 Perform and document comprehensive evaluations with using standard and nonstandard methods for evaluating complex patients with an emphasis on assessing a patient’s medical status.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

3 4.5.1.1.3 Evaluate to address rehabilitation potential, behavior, motor skills and psychosocial at an age-appropriate level. Identify barriers to learning.

Develop and implement strategies to overcome them to ensure accurate patient evaluation.

100% 95% Periodic Reviews and spot checks

Positive past performance rating

4 4.5.1.1.4 Independently develop appropriate treatment plans and goals with emphasis on subacute and long term medical rehabilitation; performs a full range of PT treatment procedures, modifying the treatment according to the patient’s response to PT intervention.

100% 100% Periodic reviews

Positive past performance rating

5 4.5.1.1.5 Recognize adverse reactions to treatment and initiates effective action immediately.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

6 4.5.1.1.6 Modify treatment plan according to patient response to best meet established goals.

Documents progression and/or modifications according to Departmental and Medical

100% 100% Periodic Reviews and spot checks

Positive past performance rating

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Center Standards.

7 4.5.1.1.7 Discuss patient performance in PT, current status, and continuing goals regularly with physicians and other team members. Work effectively with treatment team members and other health care providers in coordinating the patient’s total care.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

8 4.5.1.1.8 Ensure appropriate patient referrals and discharge planning in concert with the Physical Therapy and Medical Center staff.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

9 4.5.1.1.9 Measure, fit and instruct patients for the use of complex adaptive equipment and assistive devices. Justify medical need for all adaptive equipment and assistive device requests.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

10 4.5.1.1.10 Practice all infection control and safety standards.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

11 4.5.1.2.1 Maintain and submit productivity and other required reports in a timely manner.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

4.5.1.2.2 Assumes responsibility

(under the direction of the Chief of Physical Therapy) for program development and refinements within specialty area of subacute-care and long term rehabilitation. This is to include the development of subacute-care and long term-care guidelines and protocols.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

4.5.1.2.3 Interdisciplinary Team

Meetings: The contract Physical Therapist(s) shall participate in continuous interdisciplinary team activities and meetings with committee participation as required by the VA Chief, Physical Therapy, or designee.

100% 100% Periodic Reviews and spot checks

Positive past

Page 4 of 7 Original Date: 09/25/2024

4.5.1.2.4 Staff Meetings: The

contract Physical Therapist(s) shall attend staff meetings as required by the VA Chief, Physical Therapy, or designee.

Physical Medicine & Rehabilitation Service All Staff Conference Call:

Meets every month on the 2nd Tuesday of the month for 30 minutes.

100% 80% Periodic Reviews and spot checks

Positive past performance rating

4.5.1.2.5 QA/QI documentation:

The contract Physical Therapist(s) shall complete the appropriate QM/PI documentation pertaining to all procedures, complications and outcome of examinations. Completion of required clinical and medical record documentation, including the use of computerized patient record system, where applicable.

Document all evaluations and recommendations in electronic patient record;

writing notes and/or orders. Note types may include pre-op notes, progress notes (detailing urgent management), admission history & physical, transfer notes, death notes, restraint notes, and procedure notes.

100% 100% Periodic Reviews and spot checks

Positive past performance rating

4.5.1.2.6 Patient Safety Compliance

and Reporting: Contract Physical Therapist(s) shall follow all established patient safety and infection control standards of care.

Contract Physical Therapist(s) shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication

100% 100% Periodic Reviews and spot checks

Positive past

Page 5 of 7 Original Date: 09/25/2024 errors, and other breaches of patient safety shall be reported immediately using the ePER (Electronic Patient Event Reporting) system as required under VANCHCS Policy 00Q-20.

At the time of submission of the ePER, the contract Physical Therapist(s) shall forward a copy to the VA Chief, Physical Therapy or designee. The contract Physical Therapist shall follow-up with VA as required or requested.

1 See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

5. INCENTIVES/RATING STANDARDS

Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance.

a. DIRECT OBSERVATION

b. PERIODIC INSPECTION

c. USER SURVEY

d. VALIDATED USER/CUSTOMER COMPLAINTS

e. INSPECTION

f. PERIODIC SAMPLING

g. RANDOM SAMPLING

h. PROGRESS OR STATUS MEETINGS

i. ANALYSIS OF CONTRACTOR’S PROGRESS REPORTS

Page 6 of 7 Original Date: 09/25/2024

7. 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:

EXCEPTIONAL: Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified.

VERY GOOD: Performance meets contractual requirements and exceeds some to the Government’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also there should have been NO significant weaknesses identified.

SATISFACTORY: Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.

MARGINAL: Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTORY: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental Deficiency Reports, or letters).

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8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive OR NEGATIVE 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 work with the Contracting Officer (CO) 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. In order to assure that the contractor receives impartial, fair, and equitable treatment under this contract, the COR will work with the contractor to increase performance to an acceptable level.

When the COR and CO determines formal written communication is required, the COR and 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.

9 . FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

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

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature – Contractor

Signature – Contracting Officer Representative

Various methods exist to monitor performance.