QASP_Tracker_VAPIHCS_v2.xlsx

This is a Quality Assurance Surveillance Plan (QASP) Tracking Tool for home oxygen services provided to the VA Pacific Islands Health Care System. The tracker is designed to monitor contractor performance across nine performance categories with specific metrics and acceptable quality levels (AQL), each tracked on a quarterly and/or monthly basis throughout the contract period. The QASP encompasses Order Processing & Timeliness (order confirmation within one hour, same-day or next-day setup, emergency response within 30 minutes to six hours, all requiring 95% compliance); Home Visits & Assessments (90-day visits for oxygen patients, 30-day visits for ventilator patients, visit reports to Contracting Officer's Representative within five business days, all requiring 90-95% compliance); Patient Safety (patient education, emergency preparedness education, backup oxygen supply provision, critical event reporting, patient refusal documentation, high-risk smoker notification, all requiring 90-95% compliance); Equipment & Maintenance (preventive maintenance per manufacturer schedule, equipment labeling with 24-hour contact information, fire safety signage, requiring 95-100% compliance); Staff Qualifications (certified respiratory therapist/registered respiratory therapist licensure with minimum two years experience, staff competency documentation, requiring 95-100% compliance); Reporting (quarterly customer satisfaction, infection control, and performance improvement reports; monthly contract usage and home visit compliance reports); After-Hours Coverage (24/7 emergency capability and unable-to-respond notifications); and Discontinuation procedures (COR notification and equipment removal within specified timeframes, requiring 90% compliance).

The tracker includes detailed worksheets for quarterly performance measures, contractor reports receipt and timeliness, incident and safety event logging, home visit compliance tracking, COR site visits and home inspections, annual compliance measures, and corrective action documentation. All performance indicators are currently in "Pending" status as the template has not yet been populated with actual data. The QASP requires monthly reporting for home visit compliance and contract usage reports (due the 15th of each month), quarterly reports for customer satisfaction, infection control, and performance improvement activities (due the fifth working day after quarter-end), and annual compliance documentation including accreditation maintenance, staff personnel files, patient education materials, emergency management plans, insurance verification, and infection control plans. The contract period spans from October 1, 2026 through September 30, 2031 across five ordering periods, with performance monitoring conducted by the COR (Contracting Officer's Representative) through site visits, incident tracking, and regular review of contractor-submitted documentation.