ATTACHMENT D.5 - PAST PERFORMANCE QUESTIONNAIRE.pdf

ATTACHMENT D.6 – 36C25620Q0622 – Psychiatrist Physician Services

PAST PERFORMANCE QUESTIONNAIRE

1. The Contractor identified below has requested that you complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Specialist, Steven A. Berkeley, to assess the likelihood that the Contractor will perform successfully on an impending requirement for Onsite Psychiatry Care Physician Services for the Michael E. DeBakey VA Healthcare System, nine (9) CBOCs and/or its two (2) future outpatient clinics. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. The Michael E. DeBakey VA Healthcare System, nine (9) CBOCs and/or its two (2) future outpatient clinics has a requirement for Board-Certified or Board-Eligible Psychiatrist(s) to provide no more than 10 hours per day 6 days a week services to eligible beneficiaries of the Michael E.

DeBakey VA Healthcare System, nine (9) CBOCs and/or its two (2) future outpatient clinics. The contractor shall provide a pool of Full-time Equivalent (FTE) to sufficiently provide the Psychiatry coverage required that have been credentialed and privileged along with current background and training at a minimum. The number of Board-Certified or Board-Eligible Psychiatrist(s) required to be on site on a daily basis is 2.85 as defined in the PWS.

3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated)

Name of Government or Commercial Organization:______________________________

Address:_________________________________

Contract Number:______________________________

Brief Description:_________________________________________________________

Contractor Performed as: Prime Contractor Sub-Contractor

Dates of Performance (if current include expiration):____________________

Total Cost of Contract:__________________Award/Incentive/Deduction_____________

Any terminations for cause or default? Circle YES or NO

If yes, brief explanation:___________________________

Point Of Contact/COR:____________________________

Title:___________________________________

Telephone Number:____________________________

Point of Contact’s email address:______________________

ATTACHMENT D.6 – 36C25620Q0622– Psychiatrist Physician Services

4. Please answer the following questions pertaining to the relevancy of the services provided to you as compared to the description in paragraph 2.

Q1. Did the contractor provide Psychiatrists board eligible or board-certified physicians for your

Psychiatry Care (Y/N)? ___________ If yes, how many FTE board certified psychiatrists did they provide? ___________.

Q2. If no, please provide a short description of the type of psychiatrists provided (e.g. non-board eligible or psychiatrists), the number of FTE, and to what department they were assigned.

Q3. Did the contractor provide a psychiatry physician/liaison who provided contract administrative support and daily oversight of contractor providers including management of the shift schedules.

(Y/N)? ______________. (please provide details if appropriate)

Q4. Did the contractor provide any additional psychiatry coverage for your Psychiatry Care

(Y/N)?_________ If so, how many FTE? __________

5. Please use the below matrix to answer questions relating to performance using the following template.

Please evaluate the past performance using only the following ratings without variation. If the rating is

Outstanding, Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“O” = Outstanding = Performance greatly exceeded the minimum performance or capability requirements in a way beneficial to the Government.

“E” = Excellent = Performance exceeded the minimum performance or capability requirements in a way beneficial to the Government.

“A” = Acceptable = Performance met the minimum performance or capability requirements.

“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory

“U” = Unacceptable = Performance fails to meet the performance or capability requirements.

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or

U rating please provide a short summary explanation of rating.

Please rate and provide information/comments for the following: Circle one

Q1. To what extent did the contractor comply with overall contract requirements? O E A M U

Q2. How successful was the Contractor in filling all required physicians to include the additional shifts if applicable?

O E A M U

Q3. How would you rate the quality of the Physicians provided by this Contractor in terms of technical competence, reliability, and demeanor with patients and staff.

O E A M U

Q4. To what extent was the Contractor able to meet unexpected and short notice changes and/or requirements (e.g. unexpected shift vacancies, training requirements).

O E A M U

Q5. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to complete credentialing and privileging, billing and invoicing processes, and overall contract management?

O E A M U

Q6. Did you issue any cure notices, show cause letters, or suspension of payment? If yes, please explain.

Yes No

Q7. Would you award another contract to the Contractor being evaluated? If no, please explain:

Yes No

Q8. Additional Comments pertaining to contractor performance:

Printed Name & Signature of Evaluator Date

6. Thank you for your time! Please return completed questionnaire to Steven A. Berkeley, Contracting Specialist for this acquisition, at steven.berkeley@va.gov not later than 4:00 PM CT on Tuesday, June 30, 2020. For any questions, please call me at 713-770-2823.

mailto:steven.berkeley@va.gov