Attachment 3 - QASP Performance Report.pdf

Quality Assurance Surveillance Plan (QASP)

QASP PERFORMANCE REPORT DATE: __________________

Measures PWS

Reference

Performance

Requirement

Standard Acceptable Quality Level

(AQL)

Surveillance

Method

Met AQL / DID NOT

MEET AQL

Contractor Performance

Assessment Reporting System (CPARS)

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

__97__% meet Standards

OPPE

Qualifications of Key Personnel

4.6.4.2. All Contractor’s

physician(s) shall be Board Certified in accordance with American Board of Pathology (ABPTH) Standards for General Surgery

All (100%) Contractor’s physician(s) are Board Certified Eligible

_100___% Random Sampling of qualification documents

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

_100__% Contractor’s physician(s) perform within their scope of practice/privileg

Random Sampling of records practice/privileges 100% of the time es 100% of the time

Patient Access 4.6.4.4 The Contractor shall provide Contractor’s physician(s) in accordance with the operating hours and VA clinical schedule outlined in this PWS

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

Contractor’s physician(s) are on-time and available to perform services __95_% of the time

Periodic Inspection of Time and Attendance Sheets

Patient Safety 4.6.4.5. Patient safety incidents shall be reported using Department of Veterans Affairs (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_% of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident

Direct Observation

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

_100__% licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed.

Licensing and

Periodic Inspection or Random Sampling information kept current registration information kept current. No acceptable deviation

Mandatory Training

4.6.4.7. Contractor shall complete

all required training on time per facility policy

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

_100__% completions

Periodic Sampling

Privacy, Confidentiality and Health Insurance Portability and Accountability Act (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) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA

_100__% compliance

Periodic Inspection;

Contractor shall provide evidence of annual training required by the facility, reports violations per

VA

Handbook 6500.6