D.22 Past Performance Questionnaire Worksheet - RFP 36C25726R0018 - Sherman CBOC.docx
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- Attached to
- The VA North Texas Health Care system requires community based Outpatient clinic (CBOC))
- Solicitation number
- 36C25726R0018
About this file
This is a Past Performance Questionnaire Worksheet designed for contractors responding to RFP 36C25726R0018 for Community Based Outpatient Clinic (CBOC) services in Sherman, Texas, under the VA North Texas Health Care System. The worksheet is a template requiring offerors to document their relevant contract experience and performance history to demonstrate qualification for managing CBOC operations.
The questionnaire requests twelve key information items from prospective contractors, including the legal entity name, contract numbers, and dates of performance for previous similar work. Contractors must provide detailed narratives addressing their historical performance in meeting CBOC PWS requirements and achieving quality, management, staffing, transition, and startup objectives. Specific metrics required include annual per member per month (PMPM) costs for CBOC services, clinical quality performance measures with quality improvement initiative examples, Survey of Healthcare Experience of Patients (SHEP) domain outcomes, and vacancy rates. The worksheet also requires documentation of provider coverage plans for leave and unscheduled access, floor plans demonstrating knowledge of PACT space design and expansion allowances, and evidence of on-time clinic opening or mitigation efforts. Finally, offerors must provide contact information for a reference person at the entity with whom they held the previous contract to verify the information provided. This template is intended to evaluate offerors' past performance in operating similar VA outpatient clinic facilities serving rural veteran populations in Texas.
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D.21 Past Performance Questionnaire Worksheet – RFP 36C25726R0018 – Sherman CBOC
1. The legal name of entity with whom the Contractor held the contract.
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2. Contract Number(s)
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3. Overall, how has the contractor performed services required for the Community Based Outpatient Clinic, met the requirements of the Performance Work Statement (PWS) and detail how did they effectively achieve the performance objectives of the referenced Quality, management, experience and staffing, transition plan, start-up plan, and geographic location requirements.
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4. In what geographic location the contractor performed these services.
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5. What are the dates during which the contractor performed the contract.
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6. What is the annual size of the per member per month (PMPM) for the CBOC services.
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7. What is the clinical quality performance measure outcomes, combined and by individual CBOC. Provide two examples of related quality improvement initiatives.
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8. What is the Survey of Healthcare Experience of Patients (SHEP) domain outcomes, combined and by individual CBOC. Provide examples of related quality improvement initiatives.
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9. What were the vacancy rates, combined and by individual CBOC.
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10. What was the plan for provider coverage for leave, unscheduled access, and vacancies with list of currently VA credentialed providers available for coverage.
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11. Provide your floor plan that demonstrates knowledge of current PACT space design and explain how allowance for expansion over the life of the contract were included. Did the clinic open within the timeframe specified in the contract and if not, what attempts were made to mitigate obstacles to an on time opening?
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12. The name, phone number, and email address of a person at the entity with whom the Offeror held this contract who can verify the information the Offeror provides in the narrative description for this contract.
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