ATT D28 Past Performance Questionnaire.docx

Attachment D28 - Past Performance Reference Check Questionnaire 36C25624R0002 Kosciusko CBOC

REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past performance. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (15.506) prohibits the release of the names of individuals providing reference information about Offeror’s past performance. Survey should be completed by evaluator and returned to Melanie.Hawley@va.gov .

Please evaluate the past performance using only the following ratings without variation. If the rating is either Exceptional or Unacceptable, please provide additional information in the appropriate block or in the remarks section of this form.

“E” = Exceptional = Performance exceeded the contract requirements

“S” = Satisfactory = Performance meets the contract requirements

“U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Name of Contractor being evaluated: ______________________________________________ Contract number:____________________ Brief description of services:_____________________ Contractor performed as ___Prime contractor ____ Sub-contractor Dates of performance______________ Total value of contract______________ Name of Government or Commercial organization:_______________ Point of Contact and email: ________________________________________ Date:_________________

Q1. Please provide an estimated number of patients (unique social security numbers) seen annually by the Contractor under your contract?

Q2. Did you or the Contractor collect quality data related to primary care such as:

· Influenza vaccination rates

· Cancer screening rates

· Proportion of diabetics under good control (HgbA1C<8.0%)

· Completion of Clinical Reminders

· Completion of notes, orders, and encounters

· Panel size management

· Patient Aligned Care Team (PACT) measures

· Customer Satisfaction and/or Complaints

· Other Quality Measures (Please Specify)________________________

Yes __ No __

Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __

Q3. Quality control: Rate the overall quality on the contractor’s work.

__Exceptional __Satisfactory __Unsatisfactory

Q4. Were any contract discrepancy reports (CDRs), cure notices, show cause letters, suspension of payments, or terminations sent to the Contractor (if so, please speak briefly to the problem areas below) and, if so, how responsive was the Contractor to correcting the discrepancies? _____________________

Q5. Did the Contractor implement any Patient Aligned Care Team (PACT) principles and processes, and, if so, in your opinion how cooperative and successful were they in this implementation? _____________________________

Q6. Did the Contractor provide any Telehealth Services, and, if so, in your opinion how cooperative and successful were they with providing these services? __________________________________________________________

Q7. Rate and describe the Contractors management of staff, turnover, and how any turnover may have affected the Contractor’s performance: ____________ _______________________________________________________________ __Exceptional

__Satisfactory

__Unsatisfactory

Q8. To what extent was contractor able to meet the performance schedule: ______________________________________________________________ __Exceptional

__Satisfactory

__Unsatisfactory

Q9. What extent was contractor flexible in responding to changing needs?

O S U

Q10. To what extent was the contractor reliable? _______________________ __Exceptional

Q11. To what extent was the contractor responsive to technical directions?

__Exceptional

__Satisfactory

__Unsatisfactory

Q12. If patient studies were conducted, did patients express satisfaction with the Contractor? If no patient satisfaction studies conducted, please indicate so in the space provided. _____________________________________________

Q13. Would you recommend another contract be awarded to the Contractor being evaluated? If no, please explain: ________________________________

Q14. How would you rate the Contractor on customer satisfaction?

__Exceptional

Q15. To what extent did contractor notify you of problems or potential problems? ______________________________________________________________

__Exceptional

Q16. Business Relations:

· Was management effective?

· Did the Contractor exhibit reasonable/cooperative behavior?

· Was Contractor flexible?

· Did Contractor exhibit business-like concern for the interests of the contracting agency?

· How would you rate the Contractor in the area of business relations?

__E __S __U __E __S __U __E __S __U __E __S __U

__E __S __U

Additional Remarks: ______________________________________________