D.1 QASP.pdf

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 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: Mario L. Santiago

Organization or Agency: Department of Veterans Affairs, Network Contracting Office 6

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: Jennifer Divers

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. PERIODIC INSPECTION. Salem VA Medical Center Environment of Care (EOC) Team will visit the CBOC twice annually to perform EOC rounds. Deficiencies will be reported and require submission of corrective action plans. The COR and Primary Care Leadership will visit the

CBOC quarterly for engagement rounds. Salem VA Medical Center Leadership also performs periodic leadership rounds.

b. VALIDATED USER/CUSTOMER COMPLAINTS. Patient complaints are received at Salem

VAMC via Patient Advocacy, direct calls to the facility leadership, Congressional complaints and

White House Hot Line inquiries. These are sent to designated CBOC leadership and PACT teams for follow up information. Data is kept about number of complaints and time to resolution.

c. CLINICAL PERFORMANCE METRICS. Clinical performance metrics are tracked and reported monthly directly to PACT teams. Reports are shared with the contract leadership as well.

6. Measures

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template

As of: July 2020

METRIC PWS

PARA

PERFORMANCE

REQUIREMENT

STANDARD ACCEPTABLE

QUALITY

LEVEL (AQL)

METHOD OF

SURVEILLANCE

AND FREQUENCY

New Patient

Appointments

Completed within 20 Days of

Create Date

Appointments for new patients completed in less than or equal to

20 days from create date

4.13.1 Contractor shall

provide completed appointments for new patients

<=20 days from the create date

Contractor shall provide completed appointments for new patients <=20 days from the create date no less than 72% of the time

Contractor shall provide completed appointments for new patients

<=20 days from the create date no less than 72

% of the time

COR will monitor progress quarterly using data from the

Appointments Cube.

COR will send reports to the Contractor and

CO quarterly to notify them of current performance.

Established

Patient

Appointments

Completed within 20 days of

Patient Indicated

Date (PID)

Appointments for established patients completed in less than or equal to

20 days from

Patient Indicated

Date

4.13.2 Contractor shall

provide completed appointments for established patients <=20 days from the patient indicated date

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

94% of the time

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

94% of the time

COR will monitor progress quarterly using data from the

Appointments Cube.

COR will send reports to the Contractor and

CO quarterly to notify them of current performance

PCMHI

Penetration

(PACT21)

Percent of All

Primary Care

Patients engaged in Primary Care-

Mental Health

Integration (PC-

MHI)

4.13.3 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%

COR will monitor progress quarterly using data from the

PACT Compass. COR will send reports to the

Contractor and CO quarterly to notify them of current performance.

PCMH SHEP

Access

CompositeComp osite % 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.

4.13.4 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 52%

Contractor’s

SHEP access composite score shall meet or exceed 52%

COR will monitor progress quarterly using data from

SHEP/PCMH report.

COR will send reports to the Contractor and

CO quarterly to notify them of current performance.

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)

4.13.5 Contractor shall

provide timely appointments when patients need care right away

Contractor’s

SHEP

question 7 score shall meet or exceed 40%

Contractor’s

SHEP question

7 score shall meet or exceed

40%

Salem VA will use the measure reported in

SHEP located via

VSSC or as supplied by

Customer Service

Manager. COR will monitor progress quarterly using data from SHEP/PCMH report. COR will send reports to the

Contractor and CO quarterly to notify them of current performance

Same-Day

Appts w/ PCP

Measures the percent of requested same day appointments with PCP

4.13.6 Contractor shall

provide same day appointments with primary care provider

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

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

COR will monitor progress quarterly using data from the

PACT Compass. COR will send reports to the

Contractor and CO quarterly to notify them of current performance.

Appointment

Cancellations

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

(Lower is better)

4.13.7 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 7.5%

COR will monitor progress quarterly using data from the

Performance Measure

Report. COR will send reports to the

Contractor and CO quarterly to notify

Composite -

Behavioral

Health Screening

Composite ofmdd40 -- Vets screened annually for major depression dx.ptsd51 --

PTSD screening using the PC-

PTSD at required timessa17 -- 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

4.13.8 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%

VA will monitor progress utilizing the

CBOC Report. The

COR will monitor progress quarterly and will send reports to the

Contractor and CO quarterly to notify them of current performance

Composite –

Diabetes

Composite of dmg27h_ec DM:

BP LT 140/90

(eMeasure ) dmg34h_ec DM:

Medical attention for nephropathy -

Renal Testing

(OP)

(eMeasure) statn7_ec Statin therapy for patients with diabetes

(eMeasure )

4.13.9 Contractor 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 score of at least 80%

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 performance.

Composite -

Ischemic Heart

Composite of ihd53_ec and statn1_ec Statin

Therapy for patients with cardiovascular disease

(eMeasure )

4.13.10 Contractor shall

manage patients with ischemic heart disease in accordance with

VA standards

Contractor shall maintain an ischemic heart composite score of at least 75%

Contractor shall maintain an ischemic heart composite score of at least

80%

COR will monitor progress quarterly using data from the

CBOC Report. COR will send reports to the

Contractor and CO quarterly to notify

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-pvc11h

Pneumococcal

Immunizations

(OP) EPRP

sample p32h Breast

Cancer

Screening including tomography for

Women 50-74y

(OP) HEDIS

4.13.11 Contractor shall

provide preventive health care in accordance with

VA standards

Contractor shall maintain a prevention composite score of at least 82%

Contractor shall maintain a prevention composite score of at least 82%

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 performance

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)

4.13.12 Contractor shall

provide tobacco counseling and care in accordance with

VA standards

Contractor shall maintain a tobacco composite score of at least 99%

Contractor shall maintain a tobacco composite score of at least 99%

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 performance.

Progress Notes and Patient Care

Encounter (PCE)

Module

Documentation

4.13.13 Contractor shall

complete workload and encounter documentation as defined in the

PWS within 2 business days.

Progress notes must be connected to the correct

Contractor shall properly complete documentatio n for each patient encounter

100% of the time

Contractor shall properly complete documentation for each patient encounter

100% of the time

VA will monitor progress through daily reporting on morning report as well as by monitoring of unsigned note, uncosigned notes, encounters without notes and coding queries. Requests for resolution will be sent to the CBOC as discovered with 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.

expected resolution within 3 days of the encounter. If notes are not resolved, issue will be escalated to CBOC management

Percent of Teams with Core

Teamlet Staffing

Ratio >=3The total Core

Primary Care

Support Staff

(clerical/administ rative associate, RN care manager, and clinical associate)

FTE divided by the total Primary

Care Provider

FTE entered in the PCMM Web

Application.

4.13.14 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

COR will monitor progress monthly using data from the mPACT

Dashboard. COR will send reports monthly to the Contractor and

CO to notify them of current performance.

Biweekly meetings are held with CBOC management and PCSL leadership where staffing is standing agenda item MAY NOT

APPLY DUE TO THE

SIZE OF THE CLINIC

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

4.13.15 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.

Contractor’s percent of women assigned to

Women’s

Health PACT or Designated

Women’s

Health

Provider shall meet or exceed 82%

Contractor’s percent of women assigned to Women’s

Health PACT or Designated

Women’s

Health Provider shall meet or exceed 82%

COR will monitor progress quarterly using data from the

PACT Compass. COR will send reports to the

Contractor and CO quarterly to notify performance to Primary Care

Teams

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)

4.13.16 Contractor shall

offer and refer patients to home telehealth

Contractor shall exceed

1.2% of PC patients enrolled in Home

Telehealth

(HT)

Contractor shall exceed

1.2% of patients enrolled in

Home

Telehealth (HT)

COR will monitor progress quarterly using data from the

PACT Compass. COR will send reports to the

Contractor and CO quarterly to notify them of current performance

Ratio of Non-

Traditional

EncountersThis is the sum of all

PC telephone encounters added to 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.

4.13.17 Contractor shall

provide telephone encounters, group encounters, and secure messaging

Contractor shall exceed

40% ratio of non-traditional encounters

Contractor shall exceed

40% ratio of non-traditional encounters

COR will monitor progress quarterly using data from the

PACT Compass. COR will send reports to the

Contractor and CO quarterly to notify them of current performance

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)

4.13.18 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 73.5%

Contractor’s

SHEP question

32 score shall meet or exceed

73.5%

COR will monitor progress quarterly using data from

SHEP/PCMH report.

COR will send reports to the Contractor and

CO quarterly to notify performance

Post Discharge

Contact by

PACT

TeamletThe percent of assigned primary care patients discharged from any VA facility who have been contacted by

PACT teamlet within two business days

4.13.19 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 61%

Contractor’s rate of post discharge contact by

PACT teamlet shall meet or exceed 61%

COR will monitor progress quarterly using data from the

PACT Compass. COR will send reports to the

Contractor and CO quarterly to notify them of current performance

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)

4.13.20 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%

The Salem VAMC

EOC team performs

EOC rounds at the

CBOCs twice annually.

Upon the completion of

EOC rounds, any deficiencies will be reported to the CBOC

Manager and the COR.

Resolution of the deficiency or action plan should be submitted to the COR within 14 days of notification.

Medication

Storage Area

Inspections

4.13.21 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 documentatio n 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.

Clinical

Pharmacy

Specialist (CPS)

Use of Pharm D tool

4.13.22 The Contractor

shall ensure

CPSs utilize the

Pharm D tool to document workload.

The

Contractor shall ensure that CPS documents workload via the PharmD tool 100% of the time.

The Contractor shall ensure that CPS documents workload via the PharmD tool 90% of the time.

COR will monitor performance quarterly via PBM Pharm D report found at https://spsites.cdw.va.g ov/sites/PBM_CPPO/P harmD/default.aspx.

COR will send reports to the Contractor and

CO quarterly to notify https://spsites.cdw.va.gov/sites/PBM_CPPO/PharmD/default.aspx

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).

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 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.

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