ATTACHMENT D.1 -QASP.pdf

ATTACHMENT D.1 – 36C25620Q0622 – Psychiatrist Physician Services

Quality Assurance Surveillance Plan (QASP)

The contractor will 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.

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 contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.

This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor through contract modification. 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 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: Corey Labbe

Organization or Agency: Michael E. DeBakey VA Medical Center (MEDVAMC)

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: Ashish Patel, Health Care Systems Specialist Organization or Agency: The Michael E. DeBakey VA Medical Center (MEDVAMC)

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. 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. 100% surveillance. Direct Observation Surveillance will be accomplished during the day Monday – Friday from 8:00 to 4:30pm. Surveillance will consist of visual observation and medical record reviews to ensure contract Psychiatrists are providing safe and appropriate patient care within the standard of care.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. A minimum of five (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. Customer Satisfaction Surveys and Patient Advocate Reports will be used to evaluate any complaints reported by patients

d. RANDOM SAMPLING. A minimum of five (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.

PERFORMANCE MEASURES

Measures PWS Referen ce

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT

MEET AQL-

CPAR RATING/ADD

COMMENTS

Provider Quality Performance 4.5.4.1. All contract

Psychiatrist(s) shall perform in accordance with clinical standards

100% of care provided within clinical standards of care

100% Focused/On-going Professional Practice Evaluation

(F/OPPE)

Qualifications of Key Personnel 4.5.4.2. All contract

Psychiatrist(s) shall have current board certification or eligibility in accordance with PWS requirements.

All (100%) contract

Psychiatrist(s) are board certified/board eligible.

100% No deviations accepted.

Random Inspection of qualification documents

Scope of Practice/Privileging 4.5.4.3 Contract

Psychiatrist(s) perform within their individual scopes of practice/privileging

All (100%) contract

Psychiatrist(s) perform within their scope of practice/privileges 100% of the time.

All (100%) contract

Psychiatrist(s) perform within their scope of practice/privileges 100% of the time.

No deviations accepted.

Random Inspection of records.

Patient Access 4.5.4.4. Contract

Psychiatrist(s) shall be available and in location as needed to properly perform tasks as specified.

All (100%) contract Psychiatrist(s) are on time and available to perform services.

Contract physician(s) are on-time and available to perform services 100% of the time

Time and Attendance Sheets and Direct Observation

Patient Safety 4.5.4.5. Patient safety incidents shall to be reported using Patient IncidentReport. All incidents reported immediately (within 24 hours.)

All (100%) of patient safety incidents are reported using Patient Incident Report within 24 hours of incident.

All (100%) of patient safety incidents are reported using Patient Incident Report within 24 hours of incident.

No acceptable deviation.

Report Reviews as occurs and Direct Observation

Maintains licensing, registration, and certification

4.5.4.6. 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 contract

Psychiatrist(s) shall be provided as they are renewed. Licensing and registration information kept current.

All (100%) licensing, registration(s) and certification(s) for contract

Psychiatrist(s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation.

Periodic Sampling and Random Sampling

Mandatory Training 4.5.4.7. Contractor shall complete all required training per VAMC policy

All (100%) of required training is complete on time by contract

Psychiatrist(s).

100% completions, no deviations.

Periodic Sampling of TMS records

Privacy, Confidentiality and

HIPAA

4.5.4.8. 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

Psychiatrist(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

100% compliance;

no deviations.

Contractor shall provide evidence of annual training required by VAMC, reports violations per VA Directive 6500.6.

Timely Invoicing 4.5.4.9 Within 30 days of the end of each month services were provided, as described above, the vendor shall provide itemized invoicing

All itemized invoices provided within 30 days of end of each month services delivered

100% Periodic Sampling and Inspection

Customer Service/Patient Experience

4.5.4.10 Contractor shall ensure

contract physicians provides excellent customer service to patients and VA employees

All (100%) contract physicians provide positive customer service to patients and employees

Valid complaints monitored through OPPE/FPPE and various customer service tools

Review of PATS, Speak to the Director, Patient Advocacy Rpts, Fact Findings, Congressional Correspondences

The table below is a sample that can be tailored – note that the table must identify where in the PWS the standards are found for monitoring performance. Check the MSO Customer Resource Center for approved mandatory QASPs.

7. RATINGS

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

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).

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 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

See Sample CDR below.

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CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (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, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

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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:

Ashish Patel, AO/COR DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE