D.2 QUALITY ASSURANCE SURVEILLANCE PLAN QASP - ATTACHED.docx

D.2 – QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) - 36C26225R0004

D.2 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

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 CO: Alice McGruder

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: Marvin Bailey

3. CONTRACTOR REPRESENTATIVES

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

Primary: Marvin Bailey Alternate: N/A

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. COR will monitor progress quarterly using data from the PACT Compass, Outpatient Sites of Care, SHEP and appointment dashboards. COR will meet with the Clinic manager monthly to discuss.

DIRECT OBSERVATION. 100% surveillance: The COR will visit the CBOC quarterly to observe CBOC operations. Environment of care rounds will be conducted at this contract facility every six-months. Laboratory inspections will also be conducted every 3-4 months and as needed.

PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

VALIDATED USER/CUSTOMER COMPLAINTS. The COR will monitor PATS-R complaints. The Escondido Contract will have a team assigned to the PATS-R program to receive and respond to patient complaints daily. Complaints will be discussed with the contractor for their knowledge and corrective action.

RANDOM SAMPLING. Ongoing Provider Practice and Focused Provider Evaluations will be conducted per Chief of Staff/Medical Director protocol. Peer reviews will be conducted. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

D. 2 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) - 36C26225R0004

6. MEASURES

Quality Assurance Surveillance Plan (QASP)

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

VA will monitor progress quarterly by using data from the Appointments Cube.

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

PWS page

VA will monitor progress quarterly by using data from the Appointments Cube.

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.

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

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 page

VA will monitor progress quarterly using data from the SHEP/PCMH report.

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

VA will monitor progress quarterly using data from the SHEP/PCMH report.

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP.

(See PACT Compass for more information) PWS page

Contractor shall provide same day appointments with primary care provider.

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

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 88

VA will monitor progress quarterly using data from the Performance Measures Report.

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 sa7 -- Vets screened annually for alcohol misuse CSSRS1--Annual Suicide Risk Screen

(See the Outpatient Sites of Care Report for more information) PWS page 88

VA will monitor progress quarterly using data from the Outpatient Sites of Care Report.

Composite – CVRM90_EC Cardiovascular/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))

(See the Outpatient Sites of Care Report for more information) PWS page 88

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)

VA will monitor progress quarterly using data from the Outpatient Sites of Care report.

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))

(See the Outpatient Sites of Care Report for more information) PWS page 89

VA will monitor progress quarterly using the Outpatient Sites of Care report.

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 89

VA will monitor progress quarterly using data from the Outpatient Sites of Care report.

Composite – AIS90_EC Adult Immunization Status

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)

PWS page 89

VA will monitor progress quarterly using the Outpatient Sites of Care report.

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 90

VA will monitor progress quarterly using the Outpatient Sites of Care report.

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

VA will monitor progress monthly using the EHR reports.

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.

VA will monitor progress quarterly using the VA EHR reports.

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 91

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 page 91

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 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)

VA will monitor progress quarterly using date from the PACT Compass report.

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 quarterly using the SHEP report.

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.

(See PACT Compass for more information)

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

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)

VA will monitor progress quarterly using reports from the EOC rounds.

DOMAIN: PHARMACY

Any issues discovered shall be resolved by the contractor and reported to the COR within 15 calendar days of the inspection date.

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.

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.

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

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

CONTRACT REPORT

5. DATES

a. CR PREPARED

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

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.)

12. GOVERNMENT EVALUATION.

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

14. CLOSE OUT

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER