36C26219R0026-011.docx

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.

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/or revise it on a regular basis at a minimum of annually. The acceptable quality levels will be set at or better than the national VHA average. However, the Government shall coordinate changes with the contractor through contract modification. 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: Chelsea Black Organization or Agency: Department of Veterans Affairs, Loma Linda VA Medical Center

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and shall ensure 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: Dave R Greer Sr

c. CBOC Coordinator – The Coordinator has the program oversight of the CBOCs, to ensure compliance with all VHA policies and directives and external regulatory standards.

Assigned CBOC Coordinator: Erin Pope, MSN, RN, AGCNS-BC

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 Contractor is responsible for ongoing monitoring and surveillance of these performance standards. If the acceptable quality level is not met, the Contractor shall submit a corrective action plan by a defined date established by the COR/CO.

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 can use the following surveillance methods in the administration of this QASP: Direct observation, periodic inspection, validated user/customer complaints, random sampling, contractor provided information and VA automated electronic data. Specific surveillance methods are defined in the PWS table below.

6. MEASURES

PACT CBOC QASP

Task

Method of Surveillance

PERCENT OF TEAMS WITH CORE TEAMLET STAFFING RATIO >=3

100 % of Contractor’s primary care teams shall a core teamlet staffing ratio of >=3.

Periodic Sampling COR will monitor monthly using Electronic report data from the Performance Measure Report, PACT Compass.

COR will monitor and report progress monthly

PROGRESS NOTES AND PATIENT CARE ENCOUNTER (PCE) MODULE DOCUMENTATION

[Local Reports]

of the time.

Contractor shall properly complete documentation for each patient encounter 95% of the time.

COR will monitor using monthly Electronic report using data from VA EHR system and other local customized reports.

COR will send these monthly reports to the contractor to notify them to their current performance.

NON-FORMULARY AND RESTRICTED DRUG REQUESTS

VA will monitor progress quarterly thru automated reports. VA will send status reports to the contractor to notify them to their current performance.

VA will monitor progress quarterly thru automated reports. COR will send status reports to the contractor to notify them to their current performance.

Contractor shall meet or exceed 8% of enrolled patients in PCMHI.

Task

Method of Surveillance

Contractor shall meet or exceed at least 25% in the appropriate ratio of non-traditional encounters.

Contractor shall maintain at least 20% in the appropriate ratio of non-traditional encounters.

COR will monitor using Electronic report using data from Performance Measure Report: T21, Quality and PACT Compass. COR will monitor progress monthly (non-cumulative) thru automated reports

Contractor assigned PACT Team member shall contact at least 55% of patients within two business days of discharge.

COR will monitor using Electronic report using data from Performance Measure Report: T21, Quality and PACT Compass. COR will monitor progress monthly (non-cumulative) thru automated reports.

PCMH SHEP ACCESS COMPOSITE [SHEP Q3]

COR will monitor progress quarterly (non-cumulative) thru automated reports. VA. VHA SAIL and Patient Experience Reports [SHEP] reports.

Contractor shall enroll at least 1.6% of PC assigned patients in Home Telehealth (HT).

PRIMARY CARE PROVIDER CONTINUITY

COR will monitor using Electronic report using data from Performance Measure Report: T21, Quality and PACT Compass. COR will monitor progress monthly (non-cumulative) thru automated reports.

-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).

-mdd40 – Vets screened annually for major depression dx -ptsd51 – PTSD screening using the PC-PTSD tool at required times -sa17 – Vets screened annually for alcohol misuse w/score GE-5 w/timely brief counseling.

-sa7 – Vets screened annually for alcohol misuse -Sre1 – (mdd41 and ptsd52) aggregated scores for timely suicide evaluations.

-ihd53_ec -statn 1_ec -Statin Therapy for patients with cardiovascular disease (eMeasure)

-dmg31h DM: Retinal exam timely by disease (OP) -p61h Colorectal Cancer Screening Ages 50-75 -p42 Cervical Cancer screening women age 30-64 -Pvc11h Pneumococcal Immunizations (OP) EPRP Sample -p32 Breast Cancer Screening including tomography for women 50-74 (OP) HEDIS

-smg8 Pts using tobacco provided w/counsel (OP) -smg9 Pts using tobacco offered referral (OP) -smg10 Pts using tobacco offered meds (OP) -p43h Cervical Cancer screening women age 30-64 -pvc11h Pneumococcal Immunization (OP) EPRP Sample -p32 Breast Cancer screening including tomography for women 50-74 (OP) HEDIS.

7. Ratings:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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.

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.

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.

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