Attachment D.1 - Quality Assurance Surveillance Plan.docx
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- Solicitation number
- 36C24923R0047
About this file
This document includes a Quality Assurance Surveillance Plan (QASP) for solicitation number 36C24923R0047 to provide Community Based Outpatient Clinic services in Helena, Arkansas. The QASP outlines metrics and acceptance criteria for key performance requirements in domains such as access, care coordination, and customer service. Metrics include new patient appointment completion rates within 20 days of scheduling and performance of required care coordination activities. The QASP defines methods for monitoring contractor performance against metrics including utilization of appointment data from the facility's Pyramid Analytics tool and review of care coordination documentation. It establishes classifications for acceptably meeting or not meeting quality assurance levels to support invoice reviews and determination of award fee payments.
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36C24923R0047 – Helena CBOC Attachment D.1 – Quality Assurance Surveillance Plan
Quality Assurance Surveillance Plan (QASP)
| METRIC |
| PWS Para |
| Performance Requirement |
| Standard |
| Acceptable Quality Level |
(tailor to meet your requirements) Method of Surveillance and frequency Met AQL/Did Not Meet AQL (Add comment)
DOMAIN: ACCESS
New Patient Appointments Completed within 20 Calendar Days of Create Date
Appointments for new patients completed in less than or equal to 20 calendar days from create date
(See the Appointments Cube in Pyramid Analytics for more information) PWS para.
4.13.1
| Contractor shall provide completed appointments for new patients <=20 calendar days from the create date |
| Contractor shall provide completed appointments for new patients <=20 calendar days from the create date no less than 100% of the time |
| Contractor shall provide completed appointments for new patients <=20 calendar days from the create date no less than 80% of the time |
VA will monitor progress monthly by using the Appointments Cube.
Established PC Patient Average Wait Time in Days
Appointments for established patients completed in less than or equal to 20 calendar days from Patient Indicated Date
(See the Appointments Cube in Pyramid Analytics for more information) PWS para.
4.13.2
| Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date |
| Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date no less than 92% of the time |
| Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date no less than 80% of the time |
VA will monitor progress monthly by using the Appointments Cube.
PCMHI
Penetration (PACT21)
Percent of All Primary Care Patients engaged in Primary Care-Mental Health Integration (PC-MHI)
(See PACT Compass for more information) PWS para.
4.13.3 Contractor shall involve PCMHI staff in the care of patients with mental health needs
| Contractor’s PCMHI penetration rate shall meet or exceed 8% |
| Contractor’s PCMHI penetration rate meets or exceeds 8% |
VA will monitor progress quarterly, non-cumulative by reviewing data from the PACT Compass Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.
PCMH SHEP Access Composite
Composite % based on 3 questions from the SHEP/PCMH report: 1) Get an urgent care appointment as soon as needed, 2) Get a routine care appointment as soon as needed, and 3) Get same day answer to your medical question.
(See SHEP/PCMH Report for more information)
PWS para.
4.13.4
| Contractor shall provide: 1) urgent care appointments as soon as needed, 2) routine care appointments as soon as needed, and 3) same day answers to patients’ medical questions |
| Contractor’s SHEP access composite score shall meet or exceed 51% |
| Contractor’s SHEP access composite score shall meet or exceed 50% |
VA will monitor progress monthly by reviewing the VHA SAIL Report or Patient Experience Report.
SHEP Question 7
In the last 6 months, how many days did you usually have to wait for an appointment when you needed care right away? (Less is better)
(See SHEP/PCMH Report for more information)
PWS para.
4.13.5
| Contractor shall provide timely appointments when patients need care right away |
| Contractor’s SHEP question 7 score shall meet or exceed 34% |
| Contractor’s SHEP question 7 score shall meet or exceed 39%. |
VA will monitor progress monthly by reviewing the VHA SAIL Report.
Same-Day Appts w/ PCP
Measures the percent of requested same day appointments with PCP
(See PACT Compass for more information)
PWS para.
4.13.6
| Contractor shall provide same day appointments with primary care provider |
| Contractor’s same day appointments with PCP rate shall meet or exceed 54% |
| Contractor’s same day appointments with PCP rate shall meet or exceed 62% |
VA will monitor progress monthly by reviewing the PACT Compass Report.
Appointment Cancellations
Cancelled by clinic rate for all active clinic stop codes (mop13) (Lower is better)
(See Performance Measure Report for more information)
PWS para.
4.13.7
| Contractor shall not unnecessarily cancel patient appointments |
| Contractor’s rate of appointments cancelled by clinic shall not exceed 8% |
| Contractor’s rate of appointments cancelled by clinic shall not exceed 8% |
VA will monitor progress monthly by reviewing the Performance Measures Report on VSSC.
DOMAIN:
QUALITY OF CARE
Composite - Behavioral Health Screening
Composite of mdd40 -- Vets screened annually for major depression dx.
ptsd51 -- PTSD screening using the PC-PTSD at required times sa17 -- Vets screened for alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened annually for alcohol misuse
(See the CBOC Report for more information) PWS para.
4.13.8
| Contractor shall complete all behavioral health screenings and follow-up evaluations |
| Contractor shall maintain a behavioral health composite score of at least 94% |
| Contractor shall maintain a behavioral health composite score of at least 94% |
VA will monitor progress monthly by reviewing the CBOC Report.
Composite- Cardiovascular Risk Management (eQM)
Composite measure monitors cardiovascular and diabetes patients for blood pressure management and statin prescribing. The eQM performance measures ihd53h, dmg27h_ec, statn1_ec, and statn7_ec are included in the composite with data collected and scored using electronic extraction from the CDW.
(See the CBOC Report for more information)
PWS para.
4.13.9
| Contractor shall manage patients with diabetes and cardiovascular disease in accordance with VA standards. |
| Contractor shall maintain a cardiovascular risk management composite score of at least 59% |
| Contractor shall maintain a cardiovascular risk management composite score of at least 77% |
VA will monitor progress monthly by reviewing the CBOC Report.
Composite – Prevention
Composite of dmg31h DM: Retinal exam, timely by disease (OP) p61h Colorectal Cancer Screening Ages 50-75 p42 Cervical Cancer Screening Women age 21-29y p43h Cervical Cancer Screening Women age 30-64 pvc11h Pneumococcal Immunizations (OP) EPRP sample p32h Breast Cancer Screening including tomography for Women 50-74y (OP) HEDIS
(See the CBOC Report for more information)
PWS para.
4.13.10
| Contractor shall provide preventive health care in accordance with VA standards |
| Contractor shall maintain a prevention composite score of at least 80% |
| Contractor shall maintain a prevention composite score of at least 83% |
VA will monitor progress monthly by reviewing the CBOC Report.
Composite – Tobacco
Composite of smg8 Pts using tobacco provided w/counsel (OP) smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds (OP)
(See the CBOC Report for more information) PWS para.
4.13.11
| Contractor shall provide tobacco counseling and care in accordance with VA standards |
| Contractor shall maintain a tobacco composite score of at least 94% |
| Contractor shall maintain a tobacco composite score of at least 99% |
VA will monitor progress monthly by reviewing the CBOC Report.
| Clinical Reminders |
| PWS para. |
4.13.12
| Contractor shall complete all clinical reminders as indicated in the VA EHR. |
| Contractor shall complete no less than 90% of all clinical reminders as indicated in the VA EHR. |
| Contractor shall complete no less than 95% of all clinical reminders as indicated in the VA EHR. |
| VA will monitor progress monthly by utilizing local reports. |
| Progress Notes and Patient Care Encounter (PCE) Module Documentation |
| PWS para. |
4.13.13
| 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, entered into the VA EHR on the same day as the visit/encounter, meet CMS guidelines, and include content as defined in PWS. |
| Contractor shall properly complete documentation for each patient encounter 100% of the time |
| Contractor shall properly complete documentation for each patient encounter 100% of the time |
VA will monitor progress monthly by utilizing local encounter reports.
PANEL MANAGEMENT
Percent of Teams with Core Teamlet Staffing Ratio >=3
The total Core Primary Care Support Staff (clerical/administrative associate, RN care manager, and clinical associate) FTE divided by the total Primary Care Provider FTE entered in the PCMM Web Application.
(See the PACT Compass Cube for more information)
PWS para.
4.13.14
| Contractor shall provide core teamlet staffing at a ratio of >=3 FTE core teamlet members (RN care manager, clinical associate, administrative associate) for each PCP FTE |
| 100% of Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3 |
| 100% of Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3 |
| VA will monitor progress quarterly by reviewing the PACT Compass Report. |
Percent of Women Assigned to Women’s Health PACT or Designated Women’s Health Provider
(WH1)
The total number of female patients assigned to a Women’s Health PACT (identified by having *WH* in the team name or a primary or secondary team focus of Women’s Health) OR to a provider with a team role of DESIGNATED WH PROVIDER (WH-PCP) divided by the total number of unique female patients assigned to Primary Care Teams
(See PACT Compass for more information)
PWS para.
4.13.15 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.
Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 83%
Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 92%
VA will monitor progress quarterly by reviewing the PACT Compass Report.
Percent Primary Care Patients Enrolled in Home Telehealth
Reflects the total number of unique PC patients enrolled in home telehealth (numerator) divided by the total number of unique patients assigned to primary care teams (denominator)
(See PACT Compass for more information)
PWS para.
4.13.16 Contractor shall offer and refer patients to home telehealth Contractor shall exceed 2.0% of PC patients enrolled in Home Telehealth (HT)
Contractor shall exceed 1.85% of patients enrolled in Home Telehealth (HT)
VA will monitor progress quarterly by reviewing the PACT Compass Report.
Ratio of Non-Traditional Encounters
This is the sum of all PC telephone encounters added to the sum of all PC group encounters added to the sum of all incoming and outgoing secure messages as the numerator. The denominator is the total team assignments for the reporting period.
(See PACT Compass for more information) PWS para.
4.13.17
| Contractor shall provide telephone encounters, group encounters, and secure messaging |
| Contractor shall exceed 46% ratio of non-traditional encounters |
| Contractor shall exceed 35% ratio of non-traditional encounters |
VA will monitor progress quarterly by reviewing the PACT Compass Report.
VETERAN SATISFACTION
Veteran Satisfaction
Overall rating of Primary Care Provider on question 32 of the SHEP/PCMH survey
(See SHEP/PCMH Report for more information)
PWS para.
4.13.18
| The Contractor’s PCPs shall provide care that Veterans rate as a 9 or 10 on question 32 of the SHEP/PCMH survey |
| Contractor’s SHEP question 32 score shall meet or exceed 73% |
| Contractor’s SHEP question 32 score shall meet or exceed 75% |
VA will monitor progress quarterly by utilizing the SHEP/PCMH Report.
DOMAIN:
COORDINATION OF CARE
Post Discharge Contact by PACT Teamlet
The percent of assigned primary care patients discharged from any VA facility who have been contacted by PACT teamlet within two business days
(See PACT Compass for more information)
PWS para.
4.13.19
| The Contractor’s PACT teamlets shall contact their assigned patients within 2 business days of discharge from any VA facility |
| Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 62% |
| Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 60% |
VA will monitor progress monthly by reviewing the PACT Compass Report.
DOMAIN:
ENVIRONMENT OF CARE (EOC)
Percentage of Deficiencies Identified During EOC Rounds that are Closed Timely (e5eoc1)
Percentage of deficiencies identified during EOC rounds that are closed within 14-business days or have a documented Plan for Action (PFA)
(See Performance Measure Report for more information) PWS para.
4.13.20
| Contractor shall address deficiencies identified in EOC rounds within 14 business days or have a documented Plan for Action |
| Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 91% |
| Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA shall meet or exceed 91% |
| VA will monitor progress as EOC deficiencies are identified. |
DOMAIN: PHARMACY
| Medication Storage Area Inspections |
| PWS para. |
4.13.21
| Contractor shall inspect medication storage areas monthly |
| 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 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. |
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