Attachment 1 - QASP ED Physician Services.pdf

Quality Assurance Surveillance Plan (QASP)

Revision 04/28/2021 Page 28 of 34

6. SAMPLE QASP PERFORMANCE REPORT DATE: 05/21/2021

LOCUM TENENS PROFESSIONAL SERVICES – EMERGENCY MEDICINE SERVICE (621-002)

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT

MEET AQL-

CPAR RATING/ADD

COMMENTS

Provider Quality Performance

4.6.4.1 All contractor’s

physician(s) shall perform in accordance with clinical standards

100% of care provided within clinical standards of care

100% OPPE

Will review clinical standards of:

1. Patient Care Performance

2. Medical/Clinical knowledge

3. Practiced Based Learning Improvement

4. Interpersonal and Communication skills

5. Professionalism

6. System Based Practice

Met- Favorable contactor performance evaluation.

Did not meet - Unfavorable contractor performance evaluation. Removal from contract until such time the contract physician (s) meet qualification standard.

Qualifications of Key Personnel

4.6.4.2 All contractor’s

physician(s) shall have current board certification or eligibility in accordance with

PWS

requirements.

All (100%) contractor’s physician(s) are board certified/board eligible.

100% Random sampling of qualification documents

Met- Favorable contactor performance evaluation.

Did not meet- Unfavorable contractor performance evaluation. Removal from contract until such time the contract physician (s) meet

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Scope of Practice/Privileging 4.6.4.3 Contractor’s physician(s) perform within their individual scopes of practice/privileging

All (100%) contractor’s physician(s) perform within their scope of practice/privilege s 100% of the time.

100% Random sampling of records.

Met- Favorable contactor performance evaluation.

Did not meet- Unfavorable contractor performance evaluation. Removal from contract until such time the contract physician (s) meet qualification standard.

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Patient Access 4.6.4.4 Contractor’s physician(s) shall be available and in location as needed to properly perform tasks as specified.

All (100%) contractor’s physician(s) are on time and available to perform services.

90% Periodic Inspection of Time and Attendance Sheets

Met- Favorable contactor performance evaluation.

Did not meet- Unfavorable contractor performance evaluation.

Patient Safety 4.6.4.5 Patient safety incidents shall to be reported using VA Patient Safety Reporting System.

All incidents reported immediately (within 24 hours.)

All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

100% Periodic Inspection or Random Sampling

Met- Favorable contactor performance evaluation.

Did not meet- Unfavorable contractor performance evaluation.

Maintains licensing, registration, and certification

4.6.4.6 Updated

Licensing, registration and certification shall be provided as they are renewed.

Licensing and registration information kept current.

All (100%) licensing, registration(s) and certification(s) for contractor’s physician(s) shall be provided as they are renewed.

Licensing and registration information kept current.

100% Periodic Inspection or Random Sampling

Met- Favorable contactor performance evaluation.

Did not meet- Unfavorable contractor performance evaluation. Removal contract until such time the contract physician (s) meet qualification standard

Mandatory Training 4.6.4.7 Contractor shall complete all required training per VAMC policy

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

85% Periodic Inspection or Random Sampling

Met- Favorable contactor performance evaluation.

Did not Meet-Suspension or termination of all physical and/or electronic access privileges and removal from contract until such time as the training is complete

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Privacy, Confidentiality and

HIPAA

4.6.4.8 Contractor is

aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality

All (100%) contractor’s physician(s) (s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA

90% Contractor shall provide evidence of annual training required by

VAMC,

reports violations per VA Directive 6500.6.

Met- Favorable contactor performance evaluation.

Did not Meet- Immediate removal from contract

EDIS Utilization 4.6.4.9 Contractor must complete training for the proper utilization of EDIS and utilize the software as it was designed to be used.

All (100%) contractor’s physician(s) (s) must complete training for the proper utilization of EDIS and utilize the software as it was designed to be used.

EDIS Adoption Metrics as captured on EMMT must meet 75% threshold for all contractor’s physicians.

Periodic sampling of EDIS adoption metric compliance through review of data on the Emergency Medicine Management Tool, (EMMT)

Met- Favorable contactor performance evaluation.

Did not Meet-Unfavorable contractor performance evaluation. Deduction after failure to meet this requirement for 2 quarters.

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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/documents/CPARS-Guidance.pdf:

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. 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 a corrective action plan to document how the contractor shall correct the unacceptable performance and avoid a recurrence.

The CR will also state how long after receipt the contractor has to 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 CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

See Sample CR on the following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Pamela S. Many/COR/AO Primary Care Service

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

118127 Many 118127

-08'00'

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CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

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.

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13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER