Attachment 9 - Quality Assurance Surveillance Plan 7-20-2023.pdf

Department of Veteran Affairs

Veteran Family Member Programs Pharmacy Benefits Manager

ATTACHMENT 9, QUALITY ASSURANCE SURVEILLANCE PLAN

Contract No: ___________________

Contract Description: The Veterans Health Administration (VHA) Integrated Veteran Care (IVC) Veteran Family Member Programs (VFMP) processes Pharmacy transactions for a variety of health benefit programs administered by the Department of Veterans Affairs (VA). The programs covered include Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) 38 CFR, Section 17.270 to 17.278 to include the Caregiver Program, Spina Bifida Health Care (SB) and Children of Women Vietnam Veterans Healthcare (CWVV) programs 38 CFR, Section 17.900 to 17.905. VFMP intends to add Camp Lejeune 38 CFR

3.307 to its family member programs in fiscal year (FY) 24. VFMP will adjudicate Pharmacy transactions via Health Insurance Portability and Accountability Act (HIPAA) Compliant Electronic Data Interchange (EDI). VFMP intends to utilize the expertise of a Contracted Pharmacy Benefit Manager (PBM) with an extensive nationwide network of retail pharmacies.

1. PURPOSE: Each Contractor is required to submit this document within 30 calendar days after the contract award date that outlines how the Contractor plans to provide continued uninterrupted quality of service. This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract and explains the following:

a. What shall be monitored?

b. How monitoring shall take place?

c. Who shall conduct the monitoring?

d. How monitoring efforts and results shall be documented?

e. Incentives/disincentives.

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 contra fair, and consistent in evaluating performance.

basis. However, the Government shall coordinate changes with the Contractor. 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 Contracting Officer (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 (U.S) 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

Assigned CO: Sandra McAnany

b. The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the empowered to make any Contractual commitments or to authorize any Contractual changes

Assigned COR: Melissa Friese

c. Other Key Government Personnel: Upon award, Government shall enter name, if applicable and shall include Performance Monitors, Clinical Quality experts, etc. who act on behalf of the COR to monitor performance.

3. CONTRACTOR REPRESENTATIVES: The following employees of the Contractor serve as

a. Project Manager (PM): ___________________

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 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: Can be performed periodically or through 100% surveillance.

b. Periodic Inspection: Evaluates outcomes on a periodic basis. Inspections shall be scheduled daily, weekly, monthly, quarterly, annually, or unscheduled, as required based in part of results of Quality Assurance (QA) surveillance results.

c. User Survey: Combines elements of validated user complaints and random sampling.

Random surveys shall be conducted to solicit user satisfaction, generate inspections, and sampling.

d. Validated User/Customer Complaints: The COR shall identify deficiencies, investigate, and validate complaints.

e. Random Sampling: Designed to evaluate performance by randomly selecting and inspecting a sample of uploads.

f. Progress or Status Meetings: Held with the Contractor to elicit and provide feedback.

g Submitted electronically by the

COR.

6. SAMPLE QASP PERFORMANCE REPORT:

Tailor to specific procurement. Consider the performance measures the VA may have for the service the procurement involves.

MEASURES PWS

Reference (Fill-in)

PERFORMANCE

REQUIREMENTS

STANDARD Acceptable Quality Level

(AQL)

Surveillance Method

MET AQL/

DID NOT

MEET AQL-

CPARS

RATING/

Add comments

General Section 3.H Provide pharmacy ID card timely

98% mailed no later than 7 days after request

98% compliance

Analysis of

Monthly Progress Reports

Pharmacy Network Access & Size

Section

4.2. B.

Pharmacy network access will stay within standards.

Pharmacy network size will not decrease by more than 10 %.

Urban pharmacies within 2 miles of driving distance.

Suburban pharmacies within 5 miles of driving distance.

Rural pharmacies within 15 miles of driving distance 90% of time.

90% compliance

Random Sampling of qualification documents

Electronic Data Interchange

(EDI)

Standards

Section 5.1 Files are received and transmitted timely

99% of transferred files (received and transmitted) are sent within times specified

98% compliance

Random Sampling of files.

Reporting Section 5.2 Reports shall be provided timely

98% of reports are supplied timely

98% compliance

Direct Observation

Beneficiary Help Desk

Section 5.3 Contractor shall not exceed time limits for responding to help desk calls

98% of beneficiary calls are responded to timely

98% compliance

Analysis of

Monthly

Pharmacy Help Desk

Section 5.3 Contractor shall not exceed time limits for responding to help desk calls

98% of pharmacy help desk calls are responded to timely

98% compliance

Analysis of

Monthly

Training Section 8 Contractor shall complete all required training per VMFP guidance

98% of required training is complete on time by agents.

98% completions

Periodic Inspection

7. CONTRACTOR PERFORMANCE ASSESSMENT REPORTING SYSTEM (CPARS)

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 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 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 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

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. Acceptable Performance: The Government shall document positive performance. Any report shall become a part of the supporting documentation for any Contractual action and preparing annual past performance using CONTRACTOR PERFORMANCE ASSESSMENT

REPORTING SYSTEM (CPARS).

b. Unacceptable Performance: When unacceptable performance occurs, a written notice shall be issued to the Contractor, outlining the performance measure(s) that is not met. The Contractor shall provide a written corrective action plan to the COR within 10 business days.

The COR shall document the discussion and place it in the COR file.

The COR shall prepare a Contract Discrepancy Report (CDR), and present it to the Contractor's PM. The Contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall state how long after receipt the Contractor must present this corrective action plan to the COR. The Government shall review the Contractor's corrective action plan to determine acceptability.

deemed necessary by the CO.

8. FREQUENCY OF MEASUREMENT: During contract performance, the COR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Various methods cited in para five shall be utilized.

9. FREQUENCY OF PERFORMANCE ASSESSMENT MEETINGS: The COR shall meet with the Contractor annually to assess performance and shall provide a written assessment.

Feedback shall be provided quarterly.

This document will be signed by the Contractor and COR after the award of contract.

Signature Contractor Program Manager

Signature