D.1 QASP - GRANBURY CBOC - 10 OCT 2024.pdf

Quality Assurance Surveillance Plan (QASP) Outpatient Site of Care Service

Granbury CBOC

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: Noel E. Ramirez

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: Teri Stewart

3. CONTRACTOR REPRESENTATIVES

The following staff 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. 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 use the surveillance methods listed below in the administration of this QASP.

DASHBOARDS. Reports as specified in the table below from VSSC, Power Analytics and other sources will be used to monitor performance on a quarterly basis.

PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Environment of Care (EOC) rounds will be performed by the VA EOC rounding team at least two times per year. Results are included in the quarterly QASP measures report prepared by the COR.

VALIDATED USER/CUSTOMER COMPLAINTS. V-Signals and PATS-R will be used to monitor and validate customer complaints. PATS-R cases are reviewed daily by the service level advocate. The SHEP and Press Ganey patient experience results will be reviewed monthly with a quarterly report prepared by the COR.

6. MEASURES

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) – Granbury CBOC

As of: June 3, 2024

Measure PWS Refere nce

Performance Requirement

Standard Acceptable Quality Level

(AQL)

Method of 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.)

15.5.1 Contractor shall

provide completed appointments for new PC patients within 20 calendar days of the RD.

Contractor shall provide completed appointments for new PC patients within 20 calendar days of the RD no less than 53% of the time.

Contractor shall provide completed appointments for new PC patients within 20 calendar days of the RD no less than 75% 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 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

15.5.2 Contractor shall

provide completed appointments for established PC patients within 20 calendar days of the PID.

Contractor shall provide completed appointments for established

PC patients within 20 calendar days of the PID no less than 93% of the time.

Contractor shall provide completed appointments for established PC patients within 20 calendar days of the PID no less than 93% of the time.

progress quarterly using data from the Appointments

Cube. COR will send reports to the contractor and CO quarterly to notify them of in Pyramid Analytics for more information. Note:

Pyramid Analytics information, access, and training can be found here.)

PCMHI

Penetration

(PACT21)

The percent of assigned Primary Care patients seen in

Primary Care- Mental Health

Integration

(PCMHI)

(See PACT

Compass for more information)

15.5.3 Contractor shall

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

Contractor’s

PCMHI

penetration rate shall meet or exceed 9%.

Contractor’s

PCMHI

penetration rate meets or exceeds

9%.

progress quarterly using data from the

PACT

Compass. COR will send reports to the contractor and

CO quarterly to notify them of

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)

15.5.4 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 49%.

Contractor’s SHEP access composite score shall meet or exceed 49%.

progress quarterly using data from

SHEP/PCMH

report. COR will send reports to the contractor and

CO quarterly to notify them of

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)

15.5.5 Contractor shall

provide timely appointments when patients need care right away.

Contractor’s SHEP question

7 score shall meet or exceed

33%.

Contractor’s SHEP question 7 score shall meet or exceed 50%.

progress quarterly using data from

SHEP/PCMH

report. COR will send reports to the contractor and

CO quarterly to information) notify them of current performance.

Same-Day

Appts w/ PCP

Measures the percent of requested same day appointments with

PCP.

information)

15.5.6 Contractor shall

provide same day appointments with primary care provider.

Contractor’s same day appointments with PCP rate shall meet or exceed 43%.

Contractor’s same day appointments with PCP rate exceed 43%.

progress quarterly using data from the

PACT

Compass. COR will send reports to the contractor and

CO quarterly to notify them of

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)

15.5.7 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%.

progress quarterly using data from the

PACT

Compass. COR will send reports to the contractor and

CO quarterly to notify them of

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.

15.5.8 Contractor shall

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 96%.

progress quarterly using data from the

Outpatient Sites of Care Report.

COR will send reports to the contractor and

CO quarterly to notify them of sa7 -- Vets screened annually for alcohol misuse.

CSSRS1--Annual

Suicide Risk Screen

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

CVRM90_EC

Cardiovascular/Di abetes Risk Management

(EQM)

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)) for more information)

15.5.9 Contractor shall

manage patients with diabetes and cardiovascular disease in accordance with VA standards.

Contractor shall maintain a cardiovascular risk management composite score of at least 73%.

Contractor shall maintain a cardiovascular risk management composite score of at least 73%.

COR will monitor progress quarterly using data from the

Outpatient Sites of Care Report.

COR will send reports to the contractor and

CO quarterly to notify them of

Composite –

PRV90_EC

Prevention bcs01_ec (Breast Cancer Screening for Women 50-74y (Electronic)) ccs01_ec (Cervical Cancer Screening

(eMeasure)) col01_ec

(Colorectal Cancer Screening Ages 45-

15.5.10 Contractor shall

provide preventive health care in accordance with VA standards.

Contractor shall maintain a prevention composite score of at least 63%.

Contractor shall maintain a prevention at least 63%.

progress quarterly using data from the

Outpatient Sites of Care Report.

COR will send reports to the contractor and

CO quarterly to notify them of

75 (eMeasure)) psa1_ec (Non- Recommended

PSA-Based Screening for more information) 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)) for more information)

15.5.11 Contractor shall

provide tobacco counseling and care in accordance with VA standards.

Contractor shall maintain a tobacco composite score of at least 96%.

Contractor shall maintain a tobacco at least 96%.

progress quarterly using data from the

Outpatient Sites of Care Report.

COR will send reports to the contractor and

CO quarterly to notify them of

Composite -

FLU90_EC

Outpatient Influenza

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

15.5.12 Contractor shall

provide flu immunizations in accordance with VA standards.

Contractor shall maintain an influenza immunization composite score of at least 40%.

Contractor shall maintain an influenza immunization at least 40%.

progress quarterly using data from the

Outpatient Sites of Care Report.

COR will send reports to the contractor and

CO quarterly to notify them of for more information)

AIS90_EC Adult

Status ais01_ec

Pneumococcal Immunization

(eMeasure) ais10td_ec Tdap Immunization

(eMeasure) ais20zos_ec Zoster

(eMeasure) for more information)

15.5.13 Contractor shall

provide adult immunizations in accordance with VA standards.

Contractor shall maintain an adult immunization status composite score of at least 58%.

Contractor shall maintain an adult immunization status composite score of at least

58%.

progress quarterly using data from the

Outpatient Sites of Care Report.

COR will send reports to the contractor and

CO quarterly to notify them of

DMG91_EC

Diabetes 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 for more information)

15.5.14 Contractor shall

provide diabetes care in accordance with VA standards.

Contractor shall maintain a diabetes composite score of at least 70%.

Contractor shall maintain a diabetes composite score of at least

70%.

progress quarterly using data from the

Outpatient Sites of Care Report.

COR will send reports to the contractor and

CO quarterly to notify them of

Clinical Reminders 15.5.15 Contractor shall complete all clinical reminders

Contractor shall complete no less than 90% of all clinical

Contractor shall complete no less than 90% of all clinical reminders

COR will monitor performance quarterly by as indicated in the

VA EHR.

reminders as indicated in the as indicated in the reviewing data from the

External Peer Review and monitor ad hoc through note reviews.

Progress Notes and

Patient Care Encounter (PCE)

Module Documentation

15.5.16 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.

Contractor shall properly complete documentation for each patient encounter within 2 business days 100% of the time.

Contractor shall properly complete documentation for each patient encounter within 2 business days

100% of the time.

progress quarterly using the VSSC Encounter Workload report. COR will send quarterly reports to the contractor and the CO to notify them of current

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.

information)

15.5.17 Contractor shall

provide core teamlet staffing at a ratio of 3 or more. 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 or more.

99% of contractor’s primary care teams shall have a core teamlet staffing ratio of 3 or more.

COR will monitor progress quarterly using data from the

PACT

Compass. COR will send reports quarterly to the contractor and CO to notify them of current

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 information)

15.5.18 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.

Contractor’s percent of women assigned to

WH-PACT or designated WH provider shall meet or exceed 88%.

Contractor’s percent of women assigned to WH-

PACT or designated WH provider shall meet or exceed 88%.

progress quarterly using data from the

PACT

Compass. COR will send reports to the contractor and

CO quarterly to notify them of

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

15.5.19 Contractor shall

provide telephone encounters, group encounters, and secure messaging.

Contractor shall exceed 53% ratio of non-traditional encounters.

Contractor shall exceed 53% ratio of non-traditional encounters.

progress quarterly using data from the

PACT

Compass. COR will send reports to the contractor and

CO quarterly to notify them of 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.

information)

DOMAIN: VETERAN SATISFACTION

Veteran Satisfaction

Overall rating of

Primary Care Provider on question 32 of the

SHEP/PCMH

survey information)

15.5.20 The contractor’s

PCPs shall provide care that patients 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%.

progress quarterly using data from

SHEP/PCMH

report. COR will send reports to the contractor and

CO quarterly to notify them of

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.

information)

15.5.21 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%.

progress quarterly using data from the

PACT

Compass. COR will send reports to the contractor and

CO quarterly to notify them of

DOMAIN: ENVIRONMENT OF CARE

7. CPARS RATINGS ASSIGNED TO QASP ITEMS:

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)

15.5.22 Contractor shall

address deficiencies identified in EOC rounds within 14 business days or have a documented PFA.

Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 93%.

Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA exceed 93%.

progress quarterly using data from the Performance

Measure Report. COR will send reports to the contractor and

CO quarterly to notify them of

DOMAIN: PHARMACY

Medication Storage Area Inspections

15.5.24 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 VA parent facility form).

Inspection documentation will be sent to the COR within 10 calendar days of the end of each month.

Any issues discovered shall be resolved by the contractor and reported to the COR within

15 calendar days of the inspection date.

The contractor shall ensure that

99% of medication storage areas are inspected monthly and documented on VA Form 10-

0053 (or VA parent facility form). Inspection documentation will be sent to the COR within 10 calendar days of the end of each month. Any issues discovered are resolved by the contractor and reported to the COR within 15 calendar days of the inspection date.

COR will monitor performance via receipt of VA Form 10-0053 (or VA parent facility form) and documented resolution of any issues discovered during inspections.

COR will send reports to the contractor and

CO quarterly to notify them of

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/documents/CPARS- Guidance.pdf.

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

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 Report (CR), 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 CR in writing. The CR 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 CR 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 CRs 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

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.

10. 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.

11. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Teri Stewart, Chief of Outpatient Services and COR

COR NAME/TITLE

SIGNED:

CONTRACTOR NAME/TITLE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

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

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

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

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER