D.1 Quality Assurance Surveillance Plan (QASP).docx

RFP 36C24421R0034

Attachment # 1 – Quality Assurance Surveillance Plan (QASP) CBOC Service The contractor will 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.

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.

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:

Organization or Agency: Department of Veterans Affairs, VA Butler Healthcare

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: Bradley Meredith

3. CONTRACTOR REPRESENTATIVES

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

Primary:

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.

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. INCENTIVES/DISINCENTIVES (DEDUCTS)

The Government shall use past performance as incentives/disincentives. Incentives/disincentives shall be based on exceeding, meeting, or not meeting performance standards. Contractor will not be disincentivized during the initial six (6) months of this contract.

6. 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. Inspections scheduled and reported quarterly per COR delegation or as needed. VA Butler Healthcare Environment of Care (EOC) inspections will be conducted at least semi-annually. Other inspections (e.g., VISN Quality and Patient Safety, etc.) will be conducted periodically, as announced. Performance measure specific inspections and reviews will be conducted per the following QASP. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

b. VALIDATED USER/CUSTOMER COMPLAINTS. Veteran complaints will be handled on a case-by-case basis or when performance reports are made available to the Contractor. Complaints may be communicated via the VA Butler Healthcare Patient Advocate (as occurring and quarterly), the Veterans Service Satisfaction Council (quarterly), or other sources (as occurring). Contractor shall be given an opportunity to investigate complaints, perform service recovery, and respond to the COR with a report on any extenuating circumstances and actions taken.

c. RANDOM SAMPLING. Sampling of twenty (20) randomly selected patient files will be reviewed quarterly to evaluate proper Encounter documentation and five (5) randomly selected patient files per provider quarterly to evaluate proper notification of test results, per the QASP below. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

Surveillance and frequency Met AQL/Did Not Meet AQL

DOMAIN: ACCESS

New Patient Appointments Completed within 20 Calendar Days of Create Date

Appointments for new patients completed in 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

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs.

Established PC Patient Average Wait Time in Days

Appointments for established patients completed in less than or equal to 20 calendar days from Patient Indicated Date

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

4.13.2

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

PCMHI

Penetration (PACT21)

Percent of All Primary Care Patients engaged in Primary Care-Mental Health Integration (PC-MHI)

(See PACT Compass for more information) PWS para.

4.13.3

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

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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.

4.13.5

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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

(See the CBOC Report for more information)

PWS para.

4.13.8

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

Composite- Cardiovascular Risk Management (eQM)

Composite measure monitors cardiovascular and diabetes patients for blood pressure management and statin prescribing. The eQM performance measures ihd53h, dmg27h_ec, statn1_ec, and statn7_ec are included in the composite with data collected and scored using electronic extraction from the CDW.

(See the CBOC Report for more information)

PWS para.

4.13.9

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

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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.

4.13.10

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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.

4.13.11

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

4.13.12

Contractor shall complete no less than 90% of all clinical reminders as indicated in the VA EHR.

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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 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 notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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 the PACT Compass Cube for more information)

PWS para.

4.13.14

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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

PWS para.

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 83%

Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 82%

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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.

4.13.16

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 1.6% of patients enrolled in Home Telehealth (HT)

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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 as the numerator. The denominator is the total team assignments for the reporting period.

PWS para.

4.13.17

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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 notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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.

4.13.19

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

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 4.13.20

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

DOMAIN: PHARMACY

4.13.21

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.

VA will notify Contractor using a Contract Discrepancy Report (CDR) when this AQL is not met.

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

Clinical Pharmacy Specialist (CPS) Use of Pharm D tool

PWS para.

4.13.22

Failure to meet VA performance measures shall result in the following:

Marginal or unsatisfactory past performance when evaluating Contractor for option years, future contracts, and when providing references to other VAMCs

7. Ratings:

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. 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 shall 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 shall 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 shall have been NO significant weaknesses identified.

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g., Management, Quality, Safety or Environmental Deficiency Report or letter).

Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental Deficiency Reports, or letters).

8. DOCUMENTING PERFORMANCE

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 determine formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the 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 negotiated 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:

Bradley S. Meredith, Butler VA Healthcare CBOC Manager DATE

SIGNED:

Contractor Signature DATE