36C26319R0092-004.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

The contractor will 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 revise it on a regular basis. 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: Charles Hurry

Organization or Agency: VHA Network Contracting Office 23

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: Nancy Schellinger Organization or Agency: St. Cloud VA Medical Center

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. 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. Random Surveillance of tour arrival/start times, and hand hygiene for infection control and patient safety, will be observed per quarter.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. For example, five (5) randomly selected patient files per quarter 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. Patient complaint data and information will be collected through the Public Affairs department and reported through the COS Office. The AO to COS (the COR) will followup on all customer complaints in conjunction with the Quality Improvement department.

d. RANDOM SAMPLING. Five (5) 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. The contractor will provide verification of licensure, credentialing, certification, and training (i.e. BLS) completed upon request.

6. SAMPLE QASP PERFORMANCE REPORT

Measures PWS

Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT

MEET AQL-

CPAR

RATING/ADD

COMMENTS

1 -Provider Quality Performance

4.6.4.1. Contract Providers provide

quality care for all services in accordance with standards outlined in PWS.

FPPE (upon hire, or with trigger); then OPPE documentation for all (100%) staff providing services under the contract Bi-Annually. All staff (100%) meet Standards.

Level: 90% meet Standards

OPPE data pertinent to care performed for each provider working under this contract.

OPPE data will review the elements in Attachment A.

2 - Qualifications of Key Personnel

2.7;

4.6.4.2.

Contractor’s Physician(s) shall have current board certified in accordance with PWS requirements.

All (100%) Contractor’s physician

(s) are board certified.

100% Contractor’s physician (s) are board certified.

Random Inspection of qualification documents

3 - Scope of Practice/ Privileging

4.6.4.3. Contractor’s Provider(s)

perform within their individual scopes of practice/privileging

All (100%) Contractor’s Provider(s) perform within their scope of practice/privileges 100% of the time.

100% Contractor’s Provider(s) perform within their scope of practice/privileges 100% of the time..

Random Inspection of records.

4- Patient Access 3.1; Contractor’s Provider(s) All (100%) Contractor’s 100% Contractor’s Periodic Sampling of Time 3.2; shall be available and in Provider(s) are on time and Provider(s) are on and Attendance Sheets 4.4.6.2: location as needed to available to perform services. time and available to

4.6.4.4. properly perform tasks as perform services.

specified.

5 - Patient Safety 4.4.7.4; Patient safety incidents shall All (100%) of patient safety Contractor’s Direct Observation to be reported using Patient incidents are reported using Provider reports

4.6.4.5. Safety Report. All incidents Patient Safety Report within 24 incidents within 24 reported immediately (within hours of incident. hours 100% of the

24 hours.) time.

6 - Maintains licensing, 2.2.1; Updated Licensing, All (100%) licensing, 100% of Periodic Sampling and registration, and 4.6.4.7. registration and certification registration(s) and certification(s) Contractor’s Random Sampling certification shall be provided as they are for Contractor’s Provider(s) shall Provider shall renewed. Licensing and be provided as they are maintain current registration information kept renewed. Licensing and Licensing, current. registration information kept Certification and current. Registration information.

7 - Mandatory Training

6.3;

4.6.4.8.

Contractor shall complete all required training per VAMC policy

All (100%) of required training is complete on time by Contractor’s Provider(s).

100% licensing, registration(s) and certification(s) for Contractor’s

Periodic Sampling

Provider(s) shall be

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT

MEET AQL-

CPAR

RATING/ADD

COMMENTS

provided as they are renewed. Licensing and registration information kept current. No acceptable deviation.

8 - Privacy, 4.4.2; Contractor is aware of all All (100%) Contractor’s Provider(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA

100% Provider(s) will comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

Contractor shall provide Confidentiality and 4.6.4.9. laws, regulations, policies evidence of annual HIPAA and procedures relating to training required by

Privacy, Confidentiality and VAMC, reports violations HIPAA and complies with all per VA Directive 6500.6.

standards Zero breaches of privacy or confidentiality

7. CPAR RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/pdfs/CPARS-Guidance.pdf p. A2-1):

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).

UNSATISFACTO

RY: 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).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

8. DOCUMENTING PERFORMANCE

a. The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using 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 Report (CR), 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 CR in writing. The CR will specify if the contractor is required to prepare an action plan to document how the contractor shall correct the identified issue and avoid a recurrence. The CR will also state how long after receipt the contractor has to present this action plan to the CO. The Government shall review the contractor's action plan. 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 action plan.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CR on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS ISSUE

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. Issue Identified: (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT

RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

Attachment A

Date: August 14, 2018 From: Service Chief, Mental Health Service Line Subj: Quality Assurance Surveillance Program for Mental Health Services To: Network Contracting Office (NCO)

Thru: Medical Center Chief of Staff

Medical Center Director VISN Network Director

1. This QASP adheres to the same quality standards and bench marks as set forth for St. Cloud VA Health Care System staff.

2. Contracted staff will be held to these same performance standards.

Quality Assurance Surveillance Program: Ongoing Peer Performance Evaluation Mental Health (MH) Practitioner Profile Triggers Fiscal Year 2019

Provider-Specific Measure Benchmark Threshold Comments

Activity Data Qtr 1 Qtr 2 Qtr 3 Qtr 4

Number of Inpatient Discharges

N/A N/A

Total Number of Encounters N/A N/A

Panel Size – Target Approximately 500

N/A N/A

Provider Data Qtr 1 Qtr 2 Qtr 3 Qtr 4

Med Rec: % Progress Notes completed 7 day

95% N/A

Encounter Closure:% of Encounters Closed w/in 7 days

99% Less than 99% in two consecutive quarters

Health Maintenance Qtr 1 Qtr 2 Qtr 3 Qtr 4

Depression Screen 90% Less than 81% in

Eval (+) Depression Screen 77% Less than 68% in

Eval (+) PTSD Screen 77% Less than 68% in

Discus Exam 90% Less than 81% in

OEF/OIF Screen 95% Less than 86% in

Audit C- Problem Drinking 62% Less than 51% in

PTSD Screen 95% Less than 86% in

TBI Screen 95% Less than 86% in

Tobacco – offered referral to cessation

58% Less than 51% in

Tobacco use screen 83% Less than 74% in

Tobacco cessation Provider Meds

63% Less than 57% in

Medication Usage Evaluation Data Qtr 1 Qtr 2 Qtr 3 Qtr 4

Lithium Monitor 80% Less than 75% in

Depakote Monitor 80% Less than 75% in

DISCUS Monitor & Metabolic Monitor – Atypical Antipsychotic

80% Less than 75% in

Buprenorphine 80% Less than 75% in

Clinical Pertinence Review (Outpatient) Qtr 1 Qtr 2 Qtr 3 Qtr 4

Evidence of chief complaint or reason for evaluation

90%

Evidence of examination appropriate to complaint

90%

Impression/diagnosis is accurate

90%

Plan is appropriate 90%

Evidence that evaluation addressed reason for visit and was appropriate

90%

Evidence of medication reconciliation documented

90%

Documentation that indicates results of test(s) done day of

90% visit were communicated to the patient

A statement of informed consent is included in the documentation

90%

Clinical Pertinence Review (MH Acute Unit and RRTP) Qtr 1 Qtr 2 Qtr 3 Qtr 4

Reason for admission, treatment and services

90%

Significant findings 90%

Procedures performed and treatment rendered

90%

Patient’s condition at discharge 90%

Discharge instructions/information provided to the patient and family

90%

Provisions for follow-up care 90%

Medical/Clinical Knowledge Qtr 1 Qtr 2 Qtr 3 Qtr 4

% records meeting Clinical Pertinence

100% Less than 80% in

Appropriate level of Seclusion 100% Less than 95% in

Appropriate level of Restraint 100% Less than 95% in

Meet criteria for continued stay (inpatient)

45% Less than 45% in

Interpersonal and Communication Skills Qtr 1 Qtr 2 Qtr 3 Qtr 4

Accepts criticism N/A

Patient Complaints ≤3 complaints in a quarter

Colleague or other staff

≤3 in a quarter

Patient Compliments N/A

Colleague or other staff compliments

N/A

Professionalism Qtr 1 Qtr 2 Qtr 3 Qtr 4

Validated disruptive or unprofessional behavior with patients

0 Discretion of the MH Service Line Director

Validated disruptive or unprofessional behavior with staff

0 Discretion of the MH Service Line Director

Practice-based learning and improvement Qtr 1 Qtr 2 Qtr 3 Qtr 4

Meets CME requirements, reported at the time of re-privileging application (yes/no)

25 hrs. N/A

Mandatory training N/A N/A

Privacy/Security N/A

Med Staff Attendance (for MD/DOs only)

50%

Assigned Committee Attendance

50%

Clinical Pertinence Review Qtr 1 Qtr 2 Qtr 3 Qtr 4

Assigned (Four Per Quarter) 4 N/A

Completed (Four Per Quarter) 4 N/A

Timely completion of credentialing/privileging

Within 14 days

Greater than 14 days

System-Based Practice Qtr 1 Qtr 2 Qtr 3 Qtr 4

ACA principles number of visits/unique (VISNaug)

N/A

Greater than three visits per quarter per unique for two consecutive