D.1 36C26126R0014 QASP.docx

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: TBD ???

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: Aaron Wolfe - Aaron.Wolff2@va.gov

3. CONTRACTOR REPRESENTATIVES

The following staff of the contractor serve as the contractor’s program manager(s) for this contract.

Primary: Aaron Wolfe - Aaron.Wolff2@va.gov Alternate: TBD

4. PERFORMANCE STANDARDS

The contractor is responsible for the 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 employ the following surveillance methods to monitor and evaluate contractor performance. All reviews, observations, and data collection will be conducted in compliance with VA privacy, information security, and HIPAA standards.

REPORTS: VA Scheduling Reports – Monitor appointment availability, wait times, and scheduling accuracy; SAIL (Strategic Analytics for Improvement and Learning) Reports – Track clinical quality, efficiency, and patient safety metrics; Performance Measurement Reports – Evaluate contractor performance against key operational and clinical benchmarks; SHEP (Survey of Healthcare Experiences of Patients) Reports – Assess patient satisfaction and experience with care; VA EHR (Electronic Health Record) Reviews – Evaluate documentation completeness, accuracy, timeliness, and compliance with VA standards, including proper use of templates, coding, and clinical reminders; Clinical Performance Scoreboard / Report Viewer – Provide real-time access to key performance indicators for patient care, operational throughput, and compliance with quality measures; EARR (External Peer Review Program / Audit and Review Reports) – Summarize findings from internal or external audits, peer reviews, and compliance checks to identify performance gaps and ensure corrective action; PCMM (Primary Care Management Module) Panel Reports – Track provider panel sizes, patient assignments, and workload distribution to ensure compliance with PACT (Patient Aligned Care Team) model standards; VAEHR Workload Reports – Provide quantitative data on patient encounters, visit volumes, workload credit, and provider productivity for trend analysis and performance monitoring; EOC (Environment of Care) Deficiency Reports – Document facility and safety inspections, identifying deficiencies in environmental, safety, or infection control standards that require remediation.

DASHBOARDS: PACT dashboard: COR will send reports to the contractor and CO quarterly to notify them of current performance. The COR will use VA-approved performance dashboards to obtain real-time and aggregated data on clinic operations. Dashboards will provide visual tracking of key indicators such as appointment timeliness, clinical outcomes, and workload distribution. The COR will review dashboards at least monthly to detect performance deviations early and coordinate remediation.

DIRECT OBSERVATION: The COR or designated representative will conduct 100% surveillance for selected clinical or administrative processes. This includes on-site visits, virtual observations, or shadowing of staff to ensure adherence to protocols, professional standards, and VA policies. Findings will be documented and discussed with the contractor to confirm compliance or initiate corrective measures.

PERIODIC INSPECTION: The COR will perform scheduled inspections (e.g., quarterly or semi-annually) of facility spaces, equipment, and processes to verify compliance with contract requirements. This may include inspection of physical security, cleanliness, equipment maintenance, signage, and adherence to infection control practices. Ten (10) randomly selected patient files will be reviewed per inspection period. Inspection results will be recorded, and deficiencies will be addressed through a documented corrective action process. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards. Audit of contractor personnel, Hazardous Materials storage VA Form 10-0053

VALIDATED USER/CUSTOMER COMPLAINTS: The COR will monitor and address validated patient or stakeholder complaints, primarily through the PATS (Patient Advocate Tracking System) or other official VA reporting channels. Complaints will be verified for accuracy, categorized by type (e.g., timeliness, quality, professionalism), and analyzed for trends. Substantiated complaints will result in follow-up actions with the contractor and may trigger focused surveillance in problem areas.

RANDOM SAMPLING: The COR will review a random sample of 10 patient files per quarter to assess compliance with documentation, clinical, and administrative standards. Sampling will be conducted using an approved VA randomization method to ensure unbiased selection. Review findings will be used to identify trends, validate performance, and confirm adherence to contract requirements. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

Revision 04/04/2025

6. MEASURES

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template As of: August 14, 2025

surveillance and frequency Met AQL/Did Not Meet AQL (Add comment)

DOMAIN: ACCESS

New PC Appointments Completed within 20 Calendar Days of Reference Date (RD)

New primary care appointments completed within 20 calendar days of the RD.

(See the Appointments Cube in Pyramid Analytics for more information. Note: Pyramid Analytics information, access, and training can be found here.)

PWS page

VA will monitor progress quarterly by SAIL Report.

Established PC Patient Appointments Completed within 20 calendar days of Patient Indicated Date (PID)

Established primary care appointments completed within 20 calendar days of PID (patient desired date) or the clinically indicated date.

(See the Appointments Cube in Pyramid Analytics for more information. Note: Pyramid Analytics information, access, and training can be found here.)

PWS page

VA will monitor progress periodically by VA scheduling Report.

PCMHI

Penetration (PACT21)

The percent of assigned Primary Care patients seen in Primary Care- Mental Health Integration (PCMHI)

(See PACT Compass for more information) PWS page

Contractor shall involve PCMHI staff in the care of patients with mental health needs.

VA will monitor progress quarterly by using data from the Performance Measure Report.

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 page

VA will monitor progress quarterly by SHEP report review.

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 page

VA will monitor progress quarterly by SHEP report review.

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP.

(See PACT Compass for more information) PWS page

Contractor shall provide same day appointments with primary care provider.

VA will monitor progress periodically by review of Performance Measure report and PACT dashboard.

Appointment Cancellations (MOP 13)

Cancelled by clinic rate for all active clinic stop codes (mop13) (Lower is better)

(See Performance Measure Report for more information) PWS page

VA will monitor progress periodically by VA EHR

DOMAIN: QUALITY OF CARE

Composite – BH90 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 CSSRS1--Annual Suicide Risk Screen

(See the Outpatient Sites of Care Report for more information) PWS page

VA will monitor progress periodically by PACT dashboard.

Composite – CVRM90_EC Cardiovascular/Diabetes Risk Management (EQM)

Composite of dmg27h_ec (DM: BP LT 140/90 (eMeasure)) ihd53h_ec (Controlling High Blood Pressure (eMeasure)) statn1_ec (Statin Therapy for patients with cardiovascular disease (eMeasure)) statn7_ec (Statin therapy for patients with diabetes (eMeasure))

(See the Outpatient Sites of Care Report for more information) PWS page

Composite – PRV90_EC Prevention

Composite of bcs01_ec (Breast Cancer Screening for Women 50-74y (Electronic)) ccs01_ec (Cervical Cancer Screening (eMeasure)) col01_ec (Colorectal Cancer Screening Ages 45-75 (eMeasure)) psa1_ec (Non-Recommended PSA-Based Screening (eMeasure))

(See the Outpatient Sites of Care Report for more information) PWS page

VA will monitor progress periodically by PACT dashboard.

Composite – SMG90_1 Tobacco Use and Cessation

Composite of p7 (Tobacco Use - Screened for Use - NEXUS (Outpt)) smg10 (Tobacco Use Cessation - Discussed Cessation Medications (Outpt)) smg8 (Tobacco Use Cessation - Advised to Quit (Outpt)) smg9 (Tobacco Use Cessation - Discussed Cessation Strategies (Outpt))

(See the Outpatient Sites of Care Report for more information) PWS page

VA will monitor progress periodically by PACT dashboard.

Composite - FLU90_EC Outpatient Influenza Immunization

Composite of p28h_ec (Influenza Immunizations 66 years of age and older (eMeasure)) p29h_ec (Influenza Immunization 19-65 years of age (eMeasure))

(See the Outpatient Sites of Care Report for more information)

PWS page

VA will monitor progress monthly using the Clinical Performance Scorecard report viewer.

Composite – AIS90_EC Adult Immunization Status

Composite of ais01_ec Pneumococcal Immunization (eMeasure) ais10td_ec Tdap Immunization (eMeasure) ais20zos_ec Zoster Immunization (eMeasure)

(See the Outpatient Sites of Care Report for more information)

PWS page

VA will monitor progress monthly using the Clinical Performance Scorecard report viewer.

Composite – DMG91_EC Diabetes

Composite of dmg23h_ec (DM: HbA1c poor control (eMeasure)) dmg31h_ec (Diabetes Mellitus - Outpatient - Retinal exam, timely by disease (eMeasure)) ked01_ec (Kidney Health Evaluation for Patients With Diabetes (eMeasure))

(See the Outpatient Sites of Care Report for more information) PWS page

VA will monitor progress periodically by PACT dashboard.

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

VA will monitor progress periodically by PACT dashboard.

Contractor shall complete workload and encounter documentation as defined in the PWS within 2 business days. Progress notes shall 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.

VA will monitor monthly by review of EARR Report

DOMAIN: PANEL MANAGEMENT

Percent of Teams with Core Teamlet Staffing Ratio 3 or More (PACT 22)

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

(See PACT Compass for more information) PWS page

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 page 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 patients who choose to be seen by a designated WH provider.

Ratio of Non-Traditional Encounters

This is the sum of all PC Telephone encounters added to the sum of all PC Group Encounters (including Shared Medical Appointments for Primary Care and Shared Medical Appointments for Primary Care-Mental Health Integration) added to the sum of all Virtual Video Connect encounters added to the sum of all incoming and outgoing secure messages as the numerator.

The denominator is the total number of team assignments for the reporting period.

(See PACT Compass for more information) PWS page

VA will monitor progress monthly via Workload reports.

DOMAIN: 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 page

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 page

Surveillance Frequency and Method: VA will monitor progress periodic review by VA EHR.

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 page

VA will monitor progress quarterly via EOC deficiency reports.

DOMAIN: PHARMACY

Any issues discovered shall be resolved by the contractor and reported to the COR within 15 calendar days of the inspection date.

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/cparsweb/assets/documents/CPARS_User_Manual.pdf

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.

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.

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.

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).

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 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. 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:

Aaron Wolfe/ RNMichelle Gradnigo/ Site Manager, COR DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT DISCREPANCY REPORT

5. DATES

a. CDR PREPARED

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

10. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

12. GOVERNMENT EVALUATION. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

a. CONTRACTOR NOTIFIED

b. COR

c. CONTRACTING OFFICER