D.1- QUALITY ASSURANCE SURVEILLANCE PLAN - QASP.pdf

ATTACHMENT D.1- Solicitation 36C24224R0049

D.1 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 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 Contracting Officer (CO):

Jadwiga Kustra Department of Veterans Affairs VHA RPO-East/Network Contracting Office (NCO) 2 Ph: 646-285-2761 Email: Jadwiga.Kustra@va.gov

Assigned Administrative Contracting Officer (ACO):

Danelle Wassink Department of Veterans Affairs VHA RPO-East/NCO 2 Ph: 607-664-6337 Email: Danelle.Wassink@va.gov mailto:Jadwiga.Kustra@va.gov mailto:Danelle.Wassink@va.gov

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:

Diane Mejias Department of Veterans Affairs Syracuse VA Medical Center 800 Irving Avenue Syracuse, NY 13210 Ph: 315-425-4400 Ext. 52737 Email: Diane.Mejias@va.gov

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Name Title:

Alternate:

Name Title:

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.

mailto:Diane.Mejias@va.gov

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. The following reports are to be used to measure performance. Surveillance of the dashboard reports will be completed by both VA and the contractor continuously. The reports are accessible to the contractor. The contractor shall be responsible for monitoring the reports and reporting back to VA details of proactive measures taken to improve deficiencies that do not meet acceptable quality levels. The COR shall review the dashboard reports and metrics periodically, quarterly at minimum.

• Performance Measure Report data to be reviewed quarterly (at minimum).

• PACT Compass Report data to be reviewed quarterly (at minimum).

• SHEP/PCMM Report data to be reviewed quarterly (at minimum).

• CBOC Report data to be reviewed quarterly (at minimum).

• VA EHR Report data to be reviewed weekly (at minimum).

• mPACT Dashboard Report data to be reviewed monthly (at minimum)

DIRECT OBSERVATION. 100% surveillance: VA will continuously monitor performance in the CBOC and address any reports with the contractor received after direct observation by onsite VA providers/associates.

PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. VA staff will verify staff training charts, staff scheduling reports, and all Dashboard reports referenced herein periodically to ensure that the quality standards meet or exceed acceptable quality levels. On a quarterly basis (at minimum), the COR will facilitate an oversight conference call to review reports with the contractor, VA Primary Care team and CO and address deficiencies. All inspections and reports will be conducted in compliance with VA Privacy and Information Security standards.

VALIDATED USER/CUSTOMER COMPLAINTS. 100% surveillance of complaints, as received from the VAMC patient advocate and reported to the COR in real time.

RANDOM SAMPLING. In addition to periodic sampling, VA may randomly spot-check the contractor’s work and environment of care. VA may audit patient records in EHR for completion, view patient grids, check physical security requirements, or review any requirement of the contract to address with the contractor.

VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. The contractor must report to VA action plans and details of the proactive measures taken to improve deficiencies that do not meet acceptable quality levels. VA will verify documentation provided by the contractor related to performance improvement, insurance requirements, subcontracting plan requirements. VA will verify licensure, certification and other training paperwork provided by the contractor on an ongoing basis and when needed.

6. MEASURES (Section 16 of PWS)

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) As of: October 1, 2025

Measure PWS Page

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.)

PWS

page

Contractor shall provide completed appointments for new PC patients within 20 calendar days of the

RD.

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

On average, Contractor shall complete appointments for new patients <=20 calendar days from the RD. (The average of all new patient appointments shall be measured.)

The Contractor shall meet this measure if averages for the reporting period are <= 20 calendar days.

Periodic Inspection-

VA will monitor progress quarterly through automated reports via the Access Care Report which is accessible to the Contractor.

Frequency:

Quarterly

Established PC Patient Appointments Completed within 20 calendar days of Patient

PWS

page

Contractor shall provide completed appointments for established PC patients within 20

Contractor shall provide completed appointment s for established PC patients

On average, Contractor shall complete appointments for established patients <=20

Periodic Inspection-

VA will monitor progress quarterly through automated https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fpyramid.cdw.va.gov%2Fdirect%2F%3Fid%3De4d83f25-d59f-4b05-9227-b1455f52c258&data=05%7C02%7C%7C5a74c31e2d6d434a7de108dc534cd811%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638476836701605421%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=YncSjQ2ey1%2FLLObbsQ8mo8hcJMYzNVFk4B2w1icYHTQ%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fpyramid.cdw.va.gov%2Fdirect%2F%3Fid%3De4d83f25-d59f-4b05-9227-b1455f52c258&data=05%7C02%7C%7C5a74c31e2d6d434a7de108dc534cd811%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638476836701605421%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=YncSjQ2ey1%2FLLObbsQ8mo8hcJMYzNVFk4B2w1icYHTQ%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdvagov.sharepoint.com%2Fsites%2Fvhapyramid%2FSitePages%2FPyramid-Analytics-Support-Site.aspx&data=05%7C02%7C%7C5a74c31e2d6d434a7de108dc534cd811%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638476836701612062%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=xYIR%2FSqPJr4zahWEaP7xESWUvbO9j1%2FBpAMmR0N738o%3D&reserved=0

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 in Pyramid Analytics for more information.

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

calendar days of the PID.

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

calendar days from the RD.

(The average of all established patient appointments shall be measured.)

The Contractor shall meet this measure if averages for the reporting period are <= 20 calendar days.

reports via the Access Care Report which is accessible to the Contractor.

Frequency:

Quarterly

PCMHI

Penetration

(PACT21)

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

(PCMHI)

(See PACT Compass for more information)

PWS

page

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 5%.

Periodic Inspection-

VA will monitor progress quarterly using data from the

PACT

Compass Report which is accessible to the Contractor.

Frequency:

Quarterly

PCMH SHEP

Access Composite

Composite % based on 3

PWS

page

Contractor shall provide:

1) urgent care appointments as soon as needed, 2)

Contractor’s

SHEP

access composite score shall meet or

Contractor’s SHEP access composite score shall meet or exceed 49%, Periodic Inspection-

VA will monitor progress quarterly using https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fpyramid.cdw.va.gov%2Fdirect%2F%3Fid%3De4d83f25-d59f-4b05-9227-b1455f52c258&data=05%7C02%7C%7C5a74c31e2d6d434a7de108dc534cd811%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638476836701605421%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=YncSjQ2ey1%2FLLObbsQ8mo8hcJMYzNVFk4B2w1icYHTQ%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fpyramid.cdw.va.gov%2Fdirect%2F%3Fid%3De4d83f25-d59f-4b05-9227-b1455f52c258&data=05%7C02%7C%7C5a74c31e2d6d434a7de108dc534cd811%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638476836701605421%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=YncSjQ2ey1%2FLLObbsQ8mo8hcJMYzNVFk4B2w1icYHTQ%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdvagov.sharepoint.com%2Fsites%2Fvhapyramid%2FSitePages%2FPyramid-Analytics-Support-Site.aspx&data=05%7C02%7C%7C5a74c31e2d6d434a7de108dc534cd811%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638476836701612062%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&sdata=xYIR%2FSqPJr4zahWEaP7xESWUvbO9j1%2FBpAMmR0N738o%3D&reserved=0 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 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) routine care appointments as soon as needed, and

3) same day answers to patients’ medical questions.

exceed 49%.

data from the

SHEP/PCMH

Report which is accessible to the Contractor.

Frequency:

Quarterly

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

page

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 33%.

Periodic Inspection-

VA will monitor progress quarterly using data from the

SHEP/PCMH

Report which is accessible to the Contractor.

Frequency:

Quarterly

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP.

PWS

page

Contractor shall provide same day appointments with primary care provider.

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

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

Periodic Inspection-

VA will monitor progress quarterly using data from the

PACT

Compass Report which is accessible to the Contractor.

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://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx

(See PACT Compass for more information)

Frequency:

Quarterly

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)

PWS

page

Contractor shall not unnecessarily cancel patient appointments.

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

Contractor’s rate of appointments cancelled by clinic (% of closures < 45 days) shall not exceed the most recent

VISN 2

average.

Cancel by clinic pre-appointment and cancel by patient information shall not be included in this measure.

(To be monitored:

Cancel by clinic post-appointment/ missed opportunity)

Periodic Inspection-

VA will monitor progress quarterly using data from automated reports (i.e.

Access to Care Dashboard), Report which are accessible to the Contractor.

Frequency:

Quarterly

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

PWS

page

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%.

Periodic Inspection-

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report, which is accessible to the Contractor.

Frequency:

Quarterly 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 https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render sa17 -- Vets screened for alcohol misuse w/ score GE 5 w/ timely brief counselling 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

Cardiovascula r/Diabetes Risk Management

(EQM)

Composite of 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))

PWS

page

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

Contractor shall maintain a cardiovascul ar risk managemen t composite score of at least 73%.

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

Periodic Inspection-

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report, which is accessible to the Contractor.

Frequency:

Quarterly https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true

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

PRV90_EC

Prevention

Composite of bcs01_ec (Breast Cancer Screening for Women 50-74y (Electronic)) ccs01_ec (Cervical Cancer Screening (eMeasure)) col01_ec (Colorectal Cancer Screening Ages 45-75 (eMeasure)) psa1_ec (Non- Recommended PSA-Based Screening (eMeasure))

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

PWS

page

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 composite score of at least 63%.

Periodic Inspection-

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report, which is accessible to the Contractor.

Frequency:

Quarterly

Composite –

SMG90_1

Tobacco Use and Cessation

Composite of p7 (Tobacco Use - Screened for Use -

NEXUS

(Outpt)) smg10 (Tobacco Use Cessation -

PWS

page

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 composite score of at least 96%.

Periodic Inspection-

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report, which is accessible to the Contractor.

https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true

Discussed Cessation Medications (Outpt)) smg8 (Tobacco Use Cessation - Advised to Quit (Outpt)) smg9 (Tobacco Use Cessation - Discussed Cessation Strategies (Outpt))

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

Frequency:

Quarterly

Composite -

FLU90_EC

Outpatient Influenza Immunization

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

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

PWS

page

Contractor shall provide flu immunization s in accordance with VA standards.

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

Contractor shall maintain an influenza immunization composite score of at least 38% by the beginning of the third quarter of each fiscal year.

Periodic Inspection-

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report, which is accessible to the Contractor.

Frequency:

Quarterly

Composite –

AIS90_EC

Adult Immunization Status

PWS

page

Contractor shall provide adult immunization s in

Contractor shall maintain an adult immunizatio

Contractor shall maintain an adult immunization status

Periodic Inspection-

VA will monitor progress https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true

Composite of ais01_ec Pneumococcal Immunization (eMeasure) ais10td_ec Tdap Immunization (eMeasure) ais20zos_ec Zoster Immunization (eMeasure)

(See the Outpatient Sites of Care Report for more information) accordance with VA standards.

n status composite score of at least 58%.

composite score of at least 58%.

quarterly using data from the Outpatient Sites of Care Report, which is accessible to the Contractor.

Frequency:

Quarterly

Composite –

DMG91_EC

Diabetes

Composite of 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 (eMeasure))

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

PWS

page

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%.

Periodic Inspection-

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report and via the CBOC Dashboard eQM tab, link to the “Performance Measurement

CBOC

Reports” which are accessible to the Contractor.

Frequency:

Quarterly https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true

Clinical Reminders/ Alerts

PWS

page

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 all (100%) of clinical reminders as indicated in the VA EHR.

Contractor shall ensure employees maintain less than or equal to 250 unresolved alerts at any given time.

Periodic Inspection – VA will monitor progress using the Unresolved View Alerts- National- Power BI application, which is accessible to the Contractor.

Power BI (powerbigov.us ) Specific metrics from the eQM Annual Progress Report will be selected annually and communicated to the Contractor at the start of each annual period.

Frequency:

Weekly

Progress Notes and Patient Care Encounter (PCE) Module Documentatio n

PWS

page

Contractor shall complete workload and encounter documentatio n as defined in the PWS within 2 business days.

Progress notes shall be connected to the correct visit/encounte r and location, entered into the VA EHR on the same

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

Contractor shall properly complete documentatio n for each patient encounter within 5 business days 100 % of the time.

Periodic Inspection–

VA will monitor progress quarterly using VA Data Warehouse Report which is accessible to the Contractor.

Frequency:

quarterly day as the visit/ encounter, meet CMS guidelines, and include content as defined in

PWS.

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.

(See PACT Compass for more information)

PWS

page

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.

100% of contractor’s primary care teams shall have a core teamlet staffing ratio of 3 or more.

Periodic Inspection –

VA will monitor progress using data from the

PACT

Compass Cube, which is accessible to the Contractor.

Frequency:

Monthly

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

(WH1)

PWS

page

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

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 80%.

Periodic Inspection –

VA will monitor the progress using data from the PACT Compass, which is accessible to the Contractor.

https://reports.vssc.med.va.gov/reportserver/pages/reportviewer.aspx?/PC/PACTCompassCubeSSRS/MainMenu&rs:Command=Render https://reports.vssc.med.va.gov/reportserver/pages/reportviewer.aspx?/PC/PACTCompassCubeSSRS/MainMenu&rs:Command=Render

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) goals are met for women patients who choose to be seen by a designated WH provider.

Frequency:

Quarterly

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

PWS

page

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

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

Contractor shall exceed 25% ratio of non-traditional encounters.

Periodic Inspection –

VA will monitor the progress using data from the PACT Compass, which is accessible to the Contractor.

Frequency:

Quarterly 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

Care-Mental Health Integration) added to the sum of all Virtual Video Connect encounters 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.

(See PACT Compass for more information)

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)

PWS

page

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 70.5%

Periodic Inspection –

VA will monitor the progress using data from the

SHEP/PCMH

Report, which is accessible to the Contractor.

Frequency:

Quarterly

DOMAIN: COORDINATION OF CARE

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

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.

(See PACT Compass for more information)

PWS

page

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 75%.

Periodic Inspection –

VA will monitor the progress using data from PACT Compass, which is accessible to the Contractor.

Frequency:

Quarterly

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

PWS

page

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 shall meet or exceed 90%.

Periodic Inspection –

VA will monitor the progress using data from the Performance Measure Report and Performance Logic tracking system for

EOC

deficiencies, which is accessible to the Contractor.

Frequency:

Quarterly 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

7. CPARS RATINGS ASSIGNED TO QASP ITEMS:

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.

Report for more information)

DOMAIN: PHARMACY

Medication Storage Area Inspections

PWS

page

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 documentati on 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 100% of medication storage areas are inspected monthly and documented on VA Form 10-0053 (or VA parent facility form).

Inspection documentatio n 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.

Periodic Inspection –

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.

Frequency:

Monthly https://www.cpars.gov/documents/CPARS-Guidance.pdf.

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

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

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.

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

D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)