D.1 QUALITY ASSURANCE SURVEILLANCE PLAN.docx

D.1 ATTACHMENT 36C25622R0004 QUALITY ASSURANCE SURVEILLANCE PLAN

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: Christopher Vu, Assigned CS Frank Mendoza Organization or Agency: Department of Veterans Affairs NCO 16 Division III 2002 Holcombe Boulevard (90C) Houston Texas 77030.

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: Michelle Taylor Department of Veterans Affairs G.V (Sonny) Montgomery Veterans Affairs Medical Center 1500 E. Woodrow Wilson Avenue Jackson Mississippi 39216.

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. DIRECT OBSERVATION. 100% surveillance: (if this method is used, define how surveillance will be accomplished.)

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. (Define what and how often it will be inspected. For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)

c. VALIDATED USER/CUSTOMER COMPLAINTS. If this method is used, explain how data will be collected and reported.

d. RANDOM SAMPLING. If this method is used, define what and how often it will be sampled. (For example, 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. Review PWS and if this method of surveillance is selected, define how documentation will be verified and how assessment will be conducted.

The following table is a sample that can be tailored after discussion with PCS. Note that the table must identify where in the PWS the standards are found for monitoring performance.

6. Measures VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template As of: February 1, 2021

(tailor to meet your requirements) Method of Surveillance and frequency Met AQL/Did Not Meet AQL (Add comment)

DOMAIN: ACCESS

New PC Appointments Completed within 20 Days of Create Date

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

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

4.14.1.1

VA will monitor progress by by periodic sampling using report using data from EHR system monthly.

Contractor can check status of their performance by running reports in EHR as frequently as needed.

Established PC Patient Average Wait Time in Days

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

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

4.14.1.2

VA will monitor progress by by periodic sampling using report using data from EHR system monthly.

Contractor can check status of their performance by running reports in EHR as frequently as needed.

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 UNIQUE PATIENTS ASSIGNED).

(See PACT Compass for more information) PWS para.

4.14.1.3

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

VA will monitor progress by quarterly or less using Electronic report using data from the PACT Compass quarterly (non-cumulative) thru automated reports.

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.

4.14.1.4

VA will monitor progress by quarterly or less using Electronic report using data from the PACT Compass quarterly (non-cumulative) thru automated reports.

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 para.

4.14.1.5

VA will monitor progress by VHA SAIL Report or Patient Experience Report quarterly or less (non-cumulative)

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP

(See PACT Compass for more information) PWS para.

4.14.1.6

Contractor shall provide same day appointments with primary care provider

VA will monitor progress by Periodic Inspection audit of PACT Compass, monitor and report progress quarterly or less (non-cumulative).

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.

4.14.1.7

VA will monitor progress by quarterly audits using automated reports. Contractor can check the status of their performance by running reports in VA EHR system.

DOMAIN:

QUALITY OF CARE

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)

PWS para.

4.14.2.1

VA will monitor progress by VHA SAIL Report or Patient Experience Report and quarterly (non-cumulative) thru automated reports.

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 )

(See the CBOC Report for more information)

PWS para.

4.14.2.2

Contractor shall manage patients with diabetes in accordance with VA standards

VA will monitor progress by VHA SAIL Report or Patient Experience Report and quarterly (non-cumulative) thru automated reports.

Composite - Ischemic Heart

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

(See the CBOC Report for more information)

PWS para.

4.14.2.3

VA will monitor progress by VHA SAIL Report or Patient Experience Report and quarterly (non-cumulative) thru automated reports.

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

(See the CBOC Report for more information)

PWS para.

4.14.2.4

VA will monitor progress by VHA SAIL Report or Patient Experience Report and quarterly (non-cumulative) thru automated reports.

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)

(See the CBOC Report for more information)

PWS para.

4.14.2.5

VA will monitor progress by VHA SAIL Report or Patient Experience Report and quarterly (non-cumulative) thru automated reports.

4.14.2.6

Contractor shall complete no less than 89% of all clinical reminders as indicated in the VA EHR

VA will monitor progress by VA will monitor progress by random sampling using VA EHR records weekly.

4.14.2.7 Contractor shall complete workload and encounter documentation as defined in the PWS within 2 business days. Progress notes must be connected to the correct visit/encounter and location, entered into the VA EHR on the same day as the visit/encounter, meet CMS guidelines, and include content as defined in PWS.

VA will monitor progress by VA will monitor progress by random sampling using VA EHR records weekly.

DOMAIN:

PANEL MANAGEMENT

Percent of Teams with Core Teamlet Staffing Ratio >=3

The total Core Primary Care Support Staff (clerical/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 Operations Dashboard for more information) PWS para.

4.14.3.1

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 para.

4.14.3.2 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.

VA will monitor progress by Periodic Inspection audit of PACT Compass or SAIL reports, monitor and report progress Quarterly (non- cumulative).

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)

PWS para.

4.14.3.3

Contractor shall offer and refer patients to home telehealth

Contractor shall exceed 1.1% of PC patients enrolled in Home Telehealth (HT)

Contractor shall exceed 1.1% of patients enrolled in Home Telehealth (HT)

VA will monitor progress by Periodic Inspection audit of PACT Compass or SAIL reports, monitor and report progress Quarterly (non- cumulative).

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.

PWS para.

4.14.3.4

VA will monitor progress by Periodic Inspection audit of PACT Compass or SAIL reports, monitor and report progress Quarterly (non- cumulative).

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)

VA will monitor progress by Periodic Inspection audit of PACT Compass or SAIL reports, monitor and report progress Quarterly (non- cumulative).

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

PWS para.

4.14.5.1

VA will monitor progress by Periodic Inspection audit of PACT Compass or SAIL reports, monitor and report progress Quarterly (non- cumulative).

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 para 4.14.6.1

VA will monitor progress by Periodic Inspection audit of PACT Compass or SAIL reports, monitor and report progress Quarterly (non- cumulative).

DOMAIN: PHARMACY

4.14.7.1

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.

7. Ratings:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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.

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.

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