Attachment D1- Quality Assurance Surveillance Plan.pdf

Attachment 1: Quality Assurance Surveillance Plan

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 monitoring will take place.

• Who will conduct the monitoring.

• How monitoring efforts and results will be documented.

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: Alice McGruder

Organization or Agency: Department of Veterans Affairs (SAO West, Network Contracting Office 22)

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: Marvin Bailey

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.

* To be paid the full capitated rate on the schedule, the contractor must provide services as required in the entire contract and to meet or exceed the acceptable quality level outlined in this section/sub-sections. 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

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: The COR and Primary Care Service Chief will visit the CBOC at least quarterly.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. The CBOC will receive environment of care inspections and other random inspections from various services from the VASDHS.

c. VALIDATED USER/CUSTOMER COMPLAINTS. All customer complaints received by the COR will be sent to the CBOC manager for review, response, and service recovery. The COR will track customer complaints and report valid complaints to the Contract Officer.

d. RANDOM SAMPLING. The VASDHS Primary Care Service and COR will meet bi-monthly with

CBOC management regarding: Clinical Reminders, PACT Compass Measure, SAIL, and access measures.

e. Verification and/or documentation provided by Contractor. The COR will monitor unsigned/un-cosigned notes and open encounters weekly and provide this information to the CBOC management for action.

6. MEASURES

PACT CBOC QASP

METRIC PWS

Para

Performanc e

Requiremen t

Standar d

Acceptable

Quality

Level

(tailor to meet your requiremen ts)

Method of

Surveillanc e and frequency

Met

AQL/Di d Not

Meet

AQL

(Add commen t)

DOMAIN:

ACCESS

New PC

Appointments

Completed within

30 Days of Create

Date (pc18)

New Primary Care

Completed

Appointments less than or equal to 30 days from create date

(See Performance

Measure Report for more information)

PWS

para.

4.16.1.

Contractor shall provide completed appointment s for new PC patients

<=30 days from the create date

Contractor shall provide completed appointment s for new

PC patients

<=30 days from the create date no less than

76% of the time

Contractor shall provide completed appointment s for new PC patients

<=30 days from the create date no less than

97% of the time

VA will monitor progress by

Quarterly reports found on

Performance

Measure

Report

Contractor can check status of their performance by running reports in the above link to the

Performance

Measure

Report.

Established PC

Patient Average

Wait Time in

Days (pc17)

Established

Primary Care

Completed

Appointments less than or equal to 30 days from Patient

Indicated Date

(patient desired

PWS

para.

4.16.1.

Contractor shall provide completed appointment s for established

PC patients

<=30 days from the patient indicated date

Contractor shall provide completed appointment s for established

PC patients

<=30 days from the patient indicated date no less

Contractor shall provide completed appointment s for established

PC patients

<=30 days from the patient indicated date no less than 94% of the time

VA will monitor progress by

Quarterly reports found on

Performance

Measure

Report

Contractor can check status of their performance http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render date) or the clinically indicated date more information) than 97% of the time by running reports in the above link to the

Performance

Measure

Report.

PCMHI

Penetration

(PACT21)

The percent of assigned Primary

Care patients seen in Primary Care-

Mental Health

Integration

(PCMHI)

(Only required divisions – those with 5,000 or more unique patients – are included in this measure).

(See PACT

Compass for more information)

PWS

para.

4.6.1.3

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 4% progress by

COR will monitor using

Electronic report using data from the PACT

Compass.

VA will monitor progress quarterly

(non-cumulative) thru automated reports.

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

4.16.1.

shall provide: 1) urgent care appointment s as soon as needed, 2) routine care appointment s as soon as needed, and

3) same day answers to patients’ medical questions

Contractor’s

SHEP

access composite score shall meet or exceed 52%

Contractor’s

SHEP

access composite score shall meet or exceed 52% progress by

COR will review and provide reports to the contractor from the

VHA SAIL

Report or

Patient

Experience

Report quarterly.

http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue

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) information)

PWS

para.

4.16.1.

Contractor shall provide timely appointment s when patients need care right away

Contractor’s

SHEP

question 7 score shall meet or exceed 40%

Contractor’s

SHEP

question 7 score shall exceed 40%.

progress by

COR will monitor progress quarterly using data from

SHEP/PCM

H Report .

COR will send reports to the

Contractor during the bi-monthly meeting.

Same-Day

Appts w/ PCP

Measures the percent of requested same day appointments with

PCP

information)

PWS

para

4.16.1.

shall provide same day appointment s with primary care provider

Contractor’s same day appointment s with PCP rate shall meet or exceed 62%

Contractor’s same day appointment s with PCP rate shall exceed 62% progress by

The COR will monitor progress quarterly using data from the

PACT

Compass .

The COR will send reports to the

Contractor and CO quarterly.

Appointment

Cancellations

Cancelled by clinic rate for all active clinic stop codes

(mop13)

(Lower is better) more information)

PWS

para.

4.16.1.

Contractor shall not unnecessaril y cancel patient appointment s

Contractor’s rate of appointment s cancelled by clinic shall not exceed 7.4%

Contractor’s rate of appointment s cancelled by clinic shall not exceed 7.4% progress by

The COR will monitor progress quarterly using data from the

Performance

Measure

Report .

COR will send reports https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render to the quarterly to notify them of current

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 sre1 -- (mdd41 and ptsd52) aggregated scores for timely suicide evaluations

(See the CBOC information)

PWS

para

4.16.2.

1.

complete all behavioral health screenings and follow-up evaluations

Contractor shall maintain a behavioral health composite score of at least 96%

Contractor shall maintain a behavioral health composite score of at least 95% progress by:

progress quarterly using data from the

CBOC

Report.

COR will send reports to the

Contractor quarterly to notify them of current

Composite –

Diabetes dmg27h_ec DM:

BP LT 140/90

(eMeasure)

PWS

4.9.1.

shall manage patients with diabetes in accordance with VA standards

Contractor shall maintain a diabetes composite score of at least 79%

Contractor shall maintain a diabetes composite least 78% progress quarterly using data http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx dmg34h_ec DM:

Medical attention for nephropathy -

Renal Testing

(OP)(eMeasure) statn7_ec Statin therapy for patients with diabetes

(eMeasure) from the

CBOC

Report.

COR will send reports to the

Contractor quarterly to notify them of current

Composite -

Ischemic Heart ihd53_ec and statn1_ec Statin

Therapy for patients with cardiovascular disease (eMeasure)

4.16.2.

shall manage patients with ischemic heart disease in accordance with VA standards

Contractor shall maintain an ischemic heart composite score of at least 78%

Contractor shall maintain an ischemic heart composite least 77% progress quarterly using data from the

CBOC

Report.

COR will send reports to the

Contractor quarterly to notify them of current

Prevention dmg31h DM:

Retinal exam, timely by disease

(OP)

p61h Colorectal

Cancer Screening

Ages 50-75 p42 Cervical

Cancer Screening

Women age 21-29y

PWS

para.

4.16.2.

Contractor shall provide preventive health care in accordance with VA standards

Contractor shall maintain a prevention composite score of at least 78%

Contractor shall maintain a prevention composite least 78% progress quarterly using data from the

CBOC

Report.

COR will send reports 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

and CO quarterly to notify them of current performance

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)

4.16.2.

Contractor shall provide tobacco counseling and care in accordance with VA standards

Contractor shall maintain a tobacco composite score of at least 95%

Contractor shall maintain a tobacco composite least 95% progress quarterly by:

The COR will monitor progress quarterly using data from the

CBOC

Report.

COR will send reports to the

Contractor and CO quarterly to notify them of current

Clinical

Reminders

PWS

para.

4.16.2.

Contractor shall complete all clinical reminders as indicated in

VISTA/CPR

S.

Contractor shall complete no less than

90% of all clinical reminders as indicated in

Contractor shall complete no less than

90% of all clinical reminders as indicated in

VA will monitor progress weekly thru automated reports

Random

Sampliner

VISTA/CPR

S

VISTA/CPR

S

Reviews, Clinical

Reminder

Reports).

Periodic

Sampling

VA will monitor using

Electronic report using data from

VA

VISTA/CPR

S system.

VA will send these monthly reports to the contractor to notify them of their current

Progress Notes and Patient Care

Encounter (PCE)

Module

Documentation

PWS

para.

4.16.2.

Contractor shall complete workload and encounter documentati on as defined in the PWS within 2 business days.

Progress notes must be connected to the correct visit/encount er and location, entered into

CPRS/VIST

A on the same day as the

Contractor shall properly complete documentati on for each patient encounter

100% of the time

Contractor shall properly complete documentati on for each patient encounter

100% of the time progress weekly by using

Electronic report using data from

VA

VISTA/CPR

S system.

VA will monitor progress weekly thru automated reports. VA will send these visit/encount er, meet

CMS

guidelines, and include content as defined in

PWS.

PANEL

MANAGEMENT

Percent of Teams with Core Teamlet

Staffing Ratio >=3

The total Core

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.

Dashboard for more information)

PWS

para.

4.16.3.

Contractor shall provide core teamlet staffing at a ratio of >=3

FTE core teamlet members

(RN care manager, clinical associate, administrativ e 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 by

VA will monitor progress by

COR will monitor using

Electronic report using data from the PACT

Compass.

VA will monitor progress quarterly

(non-cumulative) thru reports.

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

PWS

para.

4.16.3.

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

Contractor’s percent of women assigned to

Women’s

Health

PACT or

Designated

Women’s

Health

Provider shall meet or exceed

100%

Contractor’s percent of women assigned to

Women’s

Health

PACT or

Designated

Women’s

Health

Provider shall meet or exceed

100%

VA will progress by

VA will monitor progress by

COR will monitor using

Electronic https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e97f10a0-94e2-4186-b157-3e30a33fb349|ispasFalse|reporta945bca6-c8d6-4239-9190-f20255341eb2|ws4|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e97f10a0-94e2-4186-b157-3e30a33fb349|ispasFalse|reporta945bca6-c8d6-4239-9190-f20255341eb2|ws4|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue 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

Teams

Veterans who choose to be seen by a designated women’s health provider.

report using data from the PACT

Compass.

VA will monitor progress quarterly

(non-cumulative) thru reports

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)

4.16.3.

offer and refer patients to home telehealth shall exceed

1.3% of PC patients enrolled in Home

(HT)

shall exceed

1.3% of patients enrolled in Home

(HT)

progress by

COR will monitor using

Electronic report using data from the PACT

Compass.

VA will monitor progress quarterly

Ratio of Non-

Traditional

Encounters

This is the sum of all PC telephone encounters added to

PWS

para.

4.16.3.

Contractor shall provide telephone encounters, group encounters, Contractor shall exceed

26% ratio of non-traditional encounters

Contractor shall exceed

12% ratio of non-traditional encounters progress by

COR will monitor using

Electronic https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=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://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render the sum of all PC group encounters added to the sum of all incoming and outgoing secure messages, and video as the numerator. The denominator is the total team assignments for the reporting period.

and secure messaging report using data from the PACT

Compass.

VA will monitor progress quarterly

(non-cumulative) thru automated reports

DOMAIN:

VETERAN

SATISFACTION

Veteran

Satisfaction

Overall rating of

Primary Care

Provider on question 32 of the

SHEP/PCMH

survey information)

PWS

para.

4.16.4.

The

Contractor’s

PCPs shall provide care that Veterans rate as a 9 or

10 on question 32 of the

SHEP/PCM

H survey

Contractor’s

SHEP

question 32 score shall meet or exceed

70.5%

Contractor’s

SHEP

question 32 score shall meet or exceed

70.5% progress by

COR will monitor progress quarterly using data from

SHEP/PCM

H report.

COR will send reports to the

Contractor during the bi-monthly meeting.

COORDINATIO

N OF CARE

https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue

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.

4.16.5.

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 60%

Contractor’s rate of post discharge contact by

PACT

teamlet shall exceed 60% progress by

COR will monitor progress quarterly using data from the

PACT

Compass.

COR will send reports

Contractor.

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)

more information)

4.16.6.

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 90%

Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA shall exceed 90% progress quarterly using data from the

Performance

Measure

Report.

COR will send reports

Contractor.

PHARMACY

https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

Non-Formulary and Restricted

Drug Requests

PWS

para.

4.16.6.

Contractor shall submit non-formulary and restricted drug requests in

CPRS/VIST

A using the

PBM consult option shall submit non-formulary and restricted drug requests in

CPRS/VIST

A using the

PBM

consult option 100% of the time.

(Zero disapproval ratings for non-formulary and restricted drug requests quarterly).

Contractor shall submit non-formulary and restricted drug requests in

CPRS/VIST

A using the

PBM

consult option 90% of the time.

(No more than 10% disapproval ratings for non-formulary and restricted drug requests quarterly).

performance monthly via electronic reports pulled from

CPRS/VIST

A.

COR will send monthly status reports to the

Contractor to notify them of current

Pharmacy New

Drug Order

Requests

4.16.6.

Contractor shall submit new drug orders through

CPRS/VIST

A

The contractor shall ensure that 100% all new drug order requests follow all prescribing guidelines.

This is including but not limited to ensuring all appropriate labs have been previously ordered and that the order is not a non-

The contractor shall ensure that 100% all new drug order requests follow all prescribing guidelines.

This is including but not limited to ensuring all appropriate labs have been previously ordered and that the order is not a non-

COR will monitor performance quarterly via electronic reports pulled from

CPRS/VIST

A. COR

will send quarterly status reports to the

Contractor to notify them of current

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).

formulary drug.

formulary drug.

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.

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:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE