D.1 10.28.22_ QASP Molokai CBOC-COR SIGNED.pdf

1. 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.

2. 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. PERIODIC INSPECTION. Ten (10) randomly selected patients per month will be surveyed by the

VAPIHCS PCP.

b. VALIDATED USER/CUSTOMER COMPLAINTS. Relies on the patient to identify deficiencies.

Complaints are then invested by the VAPIHCS and Contractor and validated.

c. Analysis of contractor's progress reports, peer review, and contractor documentation. (Evaluate cost, schedule, etc.)

3. Measures

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template As of: October 2022

METRIC PWS

Para

Performance

Requirement

Standard Acceptable

Quality

Level

(tailor to meet your requirement s)

Method of

Surveillance and frequency

Met

AQL/Did Not

Meet AQL

(Add comment)

DOMAIN:

QUALITY OF CARE

Clinical

Reminders

PWS

para.

4.7.5

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

Contractor shall complete no less than 81% of all clinical reminders as indicated in the VA EHR

VA will monitor progress by periodic inspection by the VAPIHCS

PACT

members.

Progress Notes and

Patient Care

Encounter

(PCE)

Module

Documentatio n

PWS

para.

4.7.6.

4.7

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 documentatio n for each patient encounter 100% of the time

Contractor shall properly complete documentatio n for each patient encounter 95% of the time

VA will monitor progress monthly by reviewing the

VA EHR

reports.

DOMAIN:

VETERAN SATISFACTION

Veteran

Satisfaction

PWS

para.

2.3.4

The Contractor’s administrative assistant shall provide quality customer service to the veteran-patients.

Contractor shall provide customer service to veterans.

Contractor shall not have more than two documented customer complaints per month related to administrativ e assistant functions.

VA will monitor progress monthly by reviewing validated/user complaints.

4. 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).

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

6. 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.

7. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

ATTACHMENTS-FOR SECTION D

YOU CANNOT EMBED THESE- they must be included at attachments in Section D

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