Attachment D.1 Quality Assurance Surveillance Plan - QASP.pdf

D.1 QASP - RFP 36C24925R0056

Attachment D.1 – Quality Assurance Surveillance Plan (QASP)

Outpatient Site of Care Service

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 will monitoring take place?

• Who will conduct the monitoring?

• How will monitoring efforts and results 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.

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

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: Christy Wright

3. CONTRACTOR REPRESENTATIVES

The following staff 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.

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.

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.

DASHBOARDS.

DIRECT OBSERVATION. 100% surveillance.

PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

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

Cube in Pyramid Analytics for more information)

PWS

para.

15.1.1

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

Cube.

Established PC Patient Average Wait Time in Days

Appointments for established patients

PWS

para.

15.1.2

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

Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date no

VA will monitor progress monthly by using the

Cube.

https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258 completed in less than or equal to 20 calendar days from Patient Indicated Date

(See the Appointments Cube in Pyramid Analytics for more information) less than 92% of the time less than 80% of the time

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.

15.1.3

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% 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

PWS

para.

15.1.4

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% by reviewing the VHA SAIL Report or Patient Experience Report.

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render 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) 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.

15.1.5

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%.

by reviewing the VHA SAIL Report.

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP

PWS

15.1.6 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% by reviewing the PACT Compass https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx information) 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.

15.1.7

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% by reviewing the Performance Measures Report on VSSC.

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

PWS

para.

15.2.1

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%

CBOC Report.

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened annually for alcohol misuse

(See the CBOC Report for more information)

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

PWS

15.2.2 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 of at least 77% http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx extraction from the

CDW.

(See the CBOC Report for more information)

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

15.2.3

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 of at least 83%

(See the CBOC

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

15.2.4

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 of at least 99%

Clinical Reminders

PWS

para.

15.2.5

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.

complete no less than 95% of all clinical reminders as indicated in the VA EHR.

by utilizing local reports.

Progress Notes and Patient Care Encounter (PCE) Module Documentation

PWS

para.

15.2.6

Contractor shall complete workload and encounter documentation as defined in the PWS

Contractor shall properly complete documentation for each patient

Contractor shall properly complete documentation for each patient

VA will monitor progress monthly by utilizing local encounter reports.

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.

encounter 100% of the time encounter 100% of the time

PANEL

MANAGEMENT

Percent of Teams with Core Teamlet Staffing Ratio >=3

The total Core Primary Care Support Staff (clerical/administra tive associate, RN care manager, and clinical associate) FTE divided by the total Primary Care Provider FTE entered in the PCMM Web Application.

PWS

para.

15.3.1

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

(See the PACT Compass Cube for more information) 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

15.3.2

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.

percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 83% percent of women assigned to Women’s

Health PACT or Designated

Women’s Health Provider shall

92% progress quarterly by reviewing the https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96 https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96

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)

15.3.3 offer and refer patients to home telehealth exceed 2.0% of PC patients enrolled in Home Telehealth (HT) exceed 1.85% of patients enrolled in Home Telehealth (HT) by reviewing the

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

PWS

para.

15.3.4

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 by reviewing the https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render incoming and outgoing secure messages as the numerator. The denominator is the total team assignments for the reporting period.

VETERAN

SATISFACTION

Veteran Satisfaction

Overall rating of Primary Care Provider on question 32 of the

SHEP/PCMH

survey

(See SHEP/PCMH information)

PWS

para.

15.4.1

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

75% by utilizing the

SHEP/PCMH

COORDINATION

OF CARE

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render

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 information)

PWS

para.

PWS

para.

15.5.1

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

60% by reviewing the

ENVIRONMENT

OF CARE (EOC)

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render

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 para

PWS

para.

15.6.1

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% progress as EOC deficiencies are identified.

PHARMACY

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

7. CPARS RATINGS ASSIGNED TO QASP ITEMS:

Measures and methods are designed to determine rating for a given standard and AQL.

The following ratings shall be used (Reference: CPARS User Manual: https://www.cpars.gov/documents/CPARS-Guidance.pdf.

Medication Storage Area Inspections

PWS

para.

15.7.1

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.

https://www.cpars.gov/documents/CPARS-Guidance.pdf.

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

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 Reporting System (CPARS).

If contractor performance does not meet the AQL, 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 Report (CR), 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 CR in writing. The CR 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 CR 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 CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See sample on following page.

9. FREQUENCY OF MEASUREMENT

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.

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

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER

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

5. DATES

a. CR PREPARED

b. RETURNED BY CONTRACTOR: c. ACTION COMPLETE

6. Issue Identified (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 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.

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