D.1 QASP.pdf

Attachment D1 RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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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: Alexander Daniel Organization or Agency: Department of Veterans Affairs, Network Contracting Office 10

Assigned CS: Karen Williams Organization or Agency: Department of Veterans Affairs, Network Contracting Office 10

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: Terry Anderson

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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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/CS 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 by COR during visits to CBOC.

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b. PERIODIC INSPECTION. Ten (10) randomly selected patient files will be reviewed per quarter. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints made to Patient Advocate office at the Detroit VAMC will be reviewed.

d. RANDOM SAMPLING. Ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. Verification and/or documentation provided by Contractor. Cor will audit and review invoices monthly for accuracy of documentation relating to patient visits.

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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6. Measures

METRIC PWS

Para

Performance Requirement

Standard Acceptable Quality Level

Method of Surveillance and frequency

Met AQL/Did Not Meet AQL (Add comment)

DOMAIN: ACCESS

New PC Appointments Completed within 20 Calendar Days of Create Date

New Primary Care Completed Appointments less than or equal to 20 calendar days from create date

(See the Appointments Cube in Pyramid Analytics for more information)

PWS

para.

4.13.1

Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date

Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date no less than 71% of the time

Contractor shall provide completed appointments for new PC patients <=20 calendar days from the create date no less than 71% 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.

Periodic Inspection

Established PC Patient Average Wait Time in Days

PWS

para.

4.13.2

Contractor shall provide completed appointments for established PC patients <=20 calendar days from the patient indicated date

Contractor shall provide completed appointments for established PC patients <=20 calendar days from the patient

Contractor shall provide completed appointments for established PC patients <=20 calendar days

COR will monitor progress quarterly using data from the Appointments Cube. COR will send reports to the Contractor and CO https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258

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Established Primary Care Completed Appointments less than or equal to 20 calendar days from Patient Indicated Date (patient desired date) or the clinically indicated date

(See the Appointments Cube in Pyramid Analytics for more information) indicated date no less than 92% of the time from the patient indicated date no less than 92% of the time quarterly to notify them of current performance.

Periodic Inspection

PCMHI

Penetration

(PACT21)

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

(PCMHI)

( (AS OF

OCTOBER 1, 2019

THIS MEASURE

WILL APPLY TO

ALL SITES

REGARDLESS OF

THE NUMBER OF

PWS

para.

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% using data from the PACT Compass.

COR will send reports to the Contractor and CO quarterly to notify them of current

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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UNIQUE

PATIENTS

ASSIGNED).

(See PACT Compass for more information)

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.

4.13.4

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 51%

Contractor’s SHEP access composite score shall meet or exceed 51% using data from the SHEP report.

COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Validated User/Customer Complaints

SHEP Question 7

In the last 6 months, how many days did you usually have to wait for an appointment when you needed care

PWS

para.

4.13.5

Contractor shall provide timely appointments when patients need care right away

Contractor’s SHEP question 7 score shall meet or exceed 34%

Contractor’s SHEP question 7 score shall meet or exceed 34% using data from the SHEP report.

COR will send reports to the https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx

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(See SHEP/PCMH Report for more information) them of current performance.

Validated User/Customer Complaints

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with

PCP

(See PACT Compass for more information)

PWS

para.

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 54%

Contractor’s same day appointments with PCP rate shall meet or exceed 54% using data from the PACT Compass.

COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Periodic Inspection and Random Sampling

Appointment Cancellations

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

(See Performance Measure Report for more information)

PWS

para.

4.13.7

Contractor shall not unnecessarily cancel patient appointments

Contractor’s rate of appointments cancelled by clinic shall not exceed 9%

Contractor’s rate of appointments cancelled by clinic shall not exceed 9% using data from the Performance Measure Report.

COR will send reports to the Contractor and CO quarterly to notify them of current

DOMAIN:

QUALITY OF CARE

https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

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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 Report for more information)

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 92%

Contractor shall maintain a behavioral health composite score of at least 92% using data from the CBOC Report.

COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Period Inspection

Composite – Diabetes

Composite of

PWS

4.13.9

Contractor shall manage patients with diabetes in

Contractor shall maintain a diabetes composite score of at least 74%

Contractor shall maintain a diabetes

COR will monitor progress quarterly using data from the CBOC Report.

http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

Page | 9 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 )

(See the CBOC accordance with VA standards of at least 74%

COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Period Inspection and Random Sampling

Composite - Ischemic Heart

Composite of ihd53_ec and statn1_ec Statin Therapy for patients with cardiovascular disease ( eMeasure

(See the CBOC

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 59%

Contractor shall maintain an ischemic heart of at least 59% using data from the CBOC Report.

COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Period Inspection

Composite – Prevention

4.13.11

Contractor shall provide preventive health care in

Contractor shall maintain a prevention

Contractor shall maintain a prevention

COR will monitor using data from the

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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 30-64 pvc11h Pneumococcal Immunizations (OP) EPRP sample p32h Breast Cancer Screening including tomography for Women 50-74y

(OP) HEDIS

(See the CBOC accordance with VA standards composite score of at least 80% of at least 80% reports to the Contractor and CO quarterly to notify them of current performance.

Period Inspection and Random Sampling

Composite – Tobacco

Composite of smg8 Pts using tobacco

PWS

para.

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 94%

Contractor shall maintain a tobacco composite score of at least 94%

COR will monitor progress quarterly using data from the

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(OP)

smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds (OP)

(See the CBOC quarterly to notify them of current performance.

Period Inspection and Random Sampling

Clinical Reminders

PWS

para.

4.13.13

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 90% of all clinical reminders as indicated in the

VA EHR

The COR will monitor progress weekly using VA EHR reports. COR will send reports to the Contractor and CO quarterly to notify them of current

Progress Notes and Patient Care Encounter (PCE) Module Documentation

PWS

para.

4.13.14

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

Contractor shall properly complete documentation for each patient encounter 100% of the time

Contractor shall properly complete documentation for each patient encounter 100% of the time

The COR will monitor progress weekly using VA EHR reports. COR will send reports to the Contractor and CO quarterly to notify them of current

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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PANEL MANAGEMENT

Percent of Teams with Core Teamlet Staffing Ratio >=3

The total Core Primary Care 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.

(See PACT Compass Cube for more information)

PWS

para.

4.13.15

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 PACT Compass Cube. COR will send reports to the Contractor and CO quarterly to notify them of current

Percent of Women Assigned to Women’s Health PACT or Designated

PWS

para.

4.13.16

Contractor shall ensure that an appropriate number of WH-PACTs or WH-PCPs are available at site of care to ensure that all VHA

Contractor’s percent of women assigned to Women’s Health PACT or Designated

Contractor’s percent of women assigned to Women’s Health PACT or Designated

COR will monitor progress quarterly using data from the PACT Compass.

https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96 https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96

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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 access goals are met for women Veterans who choose to be seen by a designated women’s health provider.

Provider shall meet or exceed 83%

Provider shall meet or exceed 83% them of current

Percent Primary Care Patients Enrolled in Home Telehealth

4.13.17 offer and refer patients to home telehealth exceed 1.1% of PC patients enrolled in Home Telehealth (HT) exceed 1.1% of patients enrolled in Home Telehealth (HT)

COR will monitor progress quarterly using data from the PACT Compass.

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=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

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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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)

(See PACT them of current performance.

Periodic Inspection

Ratio of Non- Traditional Encounters

This 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.

4.13.18

Contractor shall provide telephone encounters, group encounters, and secure messaging

Contractor shall exceed 46% ratio of non-traditional encounters

Contractor shall exceed 46% ratio of non-traditional encounters using data from the PACT Compass.

COR will send reports to the Contractor and CO quarterly to notify them of current https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render

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(See PACT

VETERAN SATISFACTION

Veteran Satisfaction

Overall rating of Primary Care Provider on question 32 of the

SHEP/PCMH

survey

(See SHEP/PCMH information)

PWS

para.

4.13.19

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%

Contractor’s SHEP question 32 score shall meet or exceed 73% using data from the

SHEP/PCMH

Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Validated User/Customer Complaints

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

PWS

para.

4.13.20

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 62%

Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 62% using data from the PACT Compass.

COR will send reports to the Contractor and CO quarterly to notify them of current https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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(See PACT information)

Periodic Inspection and Random Sampling

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) para 4.13.21

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 92%

Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA shall meet or exceed 92% using data from the Performance Measure Report.

COR will send reports to the Contractor and CO quarterly to notify them of current

Random Sampling

DOMAIN: PHARMACY

https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

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Medication Storage Area Inspections

PWS

4.13.22

Contractor shall inspect medication storage areas monthly

All vaccines and medications must be stored in pharmaceutical grade purpose-built refrigerators and freezers

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 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.

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

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Clinical Pharmacy Specialist (CPS) Use of Pharm D tool

Clinical Pharmacy Specialist (CS) Clinic Utilization rate.

4.13.23

The Contractor shall ensure CPSs utilize the Pharm D tool to document workload.

The contractor shall ensure proper clinic utilization rate.

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.

performance quarterly via PBM Pharm D report found at https://spsites.cdw.

va.gov/sites/PBM_ CPPO/PharmD/def ault.aspx. COR will send reports to the Contractor and CO quarterly to notify them of current https://spsites.cdw.va.gov/sites/PBM_CPPO/PharmD/default.aspx

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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

RFP 36C25021R0088 VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

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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.

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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