Attachment 1 - Quality Assurance Surveillance Plan.docx

ATTACHMENT 1

Quality Assurance Surveillance Plan (QASP) Outpatient Site of Care Service: __________________ Contract number:

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.

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: Carol Franklin Organization or Agency: Department of Veterans Affairs (NCO 9)

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: Kenton Smith

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 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. TVHS reserves the right to conduct on-site inspection of outpatient care facility at any time, and without notification. Such inspections shall be conducted in accordance with VA policies and procedures. Inspection findings shall be prepared and a copy of the report provided to the Contractor.

b. PERIODIC INSPECTION. Inspections scheduled monthly and reported monthly or quarterly per COR delegation or as needed. A minimum of ten (10) randomly selected patient files 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 complaints will be forwarded to the COR within 24 hours of receipt. The Contractor shall have 10-days to investigate any patient complaint and provide a report to TVHS COR on the results of their investigation. The VA shall similarly conduct an investigation of any patient complaints and shall take appropriate action, including involvement of the CO, when any complaint has been verified/validated.

d. RANDOM SAMPLING. A minimum of ten (10) 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.

6. Measures:

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template As of: April 2020

(tailor to meet your requirements) Method of Surveillance and frequency Met AQL/Did Not Meet AQL (Add comment)

DOMAIN: ACCESS

New PC Appointments Completed within 30 Days of Create Date

PWS para.

4.12.1

VA will monitor progress monthly by using data from PMR verified by the GPM office. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.2

Contractor shall provide completed appointments for established PC patients <=30 days from the patient indicated date no less than 94% of the time

VA will monitor progress monthly by using data from the PMR verified by the GPM office. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Penetration (PACT21)

PWS para.

4.12.3

VA will monitor progress monthly by PACT Compass report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.4

VA will monitor progress monthly by using data from the SHEP/PCMH report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.5.

VA will monitor progress monthly by using data from SHEP/PCMH report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Same-Day Appts w/ PCP

PWS para.

4.12.6.

Contractor shall provide same day appointments with primary care provider

VA will monitor progress monthly by using data from the PACT Compass. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.7.

VA will monitor progress monthly by using data from the Performance Measure Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance

DOMAIN:

QUALITY OF CARE

PWS para.

4.12.8.

Contractor shall maintain a behavioral health composite score of at least 96%, no more than two failures to screen identified on chart review per 1000 patients assigned to clinic.

VA will monitor progress monthly by using data from the CBOC Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Composite – Diabetes

PWS para.

4.12.9.

Contractor shall manage patients with diabetes in accordance with VA standards

VA will monitor progress monthly by using data from the CBOC Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.10.

Contractor shall manage patients with ischemic heart disease in accordance with VA standards

VA will monitor progress monthly by using data from the CBOC Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.11.

Contractor shall provide preventive health care in accordance with VA standards

VA will monitor progress monthly by using data from the CBOC Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.12

VA will monitor progress monthly by using data from the CBOC Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

4.12.13.

Contractor shall complete no less than 100% of all clinical reminders as indicated in the VA HER, within two business days of inception.

VA will monitor progress monthly by using VA EHR reports. COR will send reports weekly to the Contractor and CO to notify them of current performance.

4.12.14 Contractor shall complete workload and encounter documentation as defined in the PWS within 2 business days. Progress notes must be connected to the correct visit/encounter and location and entered into the VA EHR on the same day as the visit/encounter, meet CMS guidelines, and include content as defined in PWS.

VA will monitor progress weekly by using VA EHR reports. COR will send reports weekly to the Contractor and CO to notify them of current performance.

DOMAIN:

PANEL MANAGEMENT

PWS para.

4.12.15.

(WH1)

PWS para.

4.12.16.

Contractor shall ensure that an appropriate number of WH-PACTs or WH-PCPs are available at site of care to ensure that all VHA access goals are met for women Veterans who choose to be seen by a designated women’s health provider.

VA will monitor progress monthly by using data from the PACT Compass. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Percent Primary Care Patients Enrolled in Home Telehealth

PWS para.

4.12.17.

Contractor shall offer and refer patients to home telehealth

Contractor shall exceed 1.3% of PC patients enrolled in Home Telehealth (HT)

Contractor shall exceed 1.3% of patients enrolled in Home Telehealth (HT)

VA will monitor progress monthly by using data from the PACT Compass. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.18.

Contractor shall provide telephone encounters, group encounters, and secure messaging

VA will monitor progress monthly by using data from the PACT Compass. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

DOMAIN:

VETERAN SATISFACTION

PWS para.

4.12.19.

The Contractor’s PCPs shall provide care that Veterans rate as a 9 or 10 on question 32 of the SHEP/PCMH survey

VA will monitor progress monthly by using data from SHEP/PCMH report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

DOMAIN:

COORDINATION OF CARE

PWS para.

4.12.20.

The Contractor’s PACT teamlets shall contact their assigned patients within 2 business days of discharge from any VA facility

VA will monitor progress monthly by using data from the PACT Compass. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

DOMAIN:

ENVIRONMENT OF CARE (EOC)

Percentage of Deficiencies Identified During EOC Rounds that are Closed Timely (e5eoc1)

PWS para 4.12.21.

Contractor shall address deficiencies identified in EOC rounds within 14 business days or have a documented Plan for Action (PFA)

VA will monitor progress monthly by using data from the Performance Measure Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

DOMAIN: PHARMACY

4.12.22.

Any issues discovered shall be resolved by the Contractor and reported to the COR within 15 days of the inspection date.

The Contractor shall ensure that 100% of medication storage areas are inspected monthly and documented on VA Form 10-0053 (or local VA medical center form). Inspection documentation will be sent to the COR within 10 days of the end of each month. Any issues discovered are resolved by the Contractor and reported to the COR within 15 days of the inspection date.

COR will monitor performance via receipt of VA Form 10-0053 (or local medical center form) and documented resolution of any issues discovered during inspections. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PWS para.

4.12.23.

7. Ratings:

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

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.

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).

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).

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 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