D.22 Quality Assurance Surveillance Plan - McCurtain.pdf

D.22 QUALITY ASSURANCE SURVEILLANCE PLAN

36C25923R0040

QUALITY ASSURANCE SURVEILLANCE PLAN

Outpatient Site of Care Service 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: Yomika Brock Organization or Agency: Department of Veterans Affairs

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: Leon Langguth

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, 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.

6. Measures VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP)

METRIC PWS

Para

Performance Requirement

Standard Acceptable Quality Level

Method of Surveillance and frequency

Met AQL/Did Not Meet AQL (Add comment)

DOMAIN:

ACCESS

New Patient Appointments Completed within 20

PWS

para.

4.13.

Contractor shall provide completed appointments for new patients <=20

Contractor shall provide completed appointments for new

Contractor shall provide completed appointments for new

VA will monitor performance quarterly using data from the

Calendar Days of Reference Date (RD) for new patients completed in less than or equal to 20 calendar days from reference date

(See the

Cube in Pyramid Analytics for more information) calendar days from the reference date patients <=20 calendar days from the reference date no less than 56% of the time patients <=20 calendar days from the reference date no less than 56% of the time

Cube in Pyramid Analytics.

COR will send reports to the Contractor and CO quarterly to notify them of current performance.

Established PC Patient Appointments Completed within 20 calendar days of Patient Indicated Date

(PID)

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

(See the Appointments

PWS

para.

4.13.

2.

Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date

Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date no less than 92% of the time

Contractor shall provide completed appointments for established patients <=20 calendar days from the patient indicated date no less than 92% of the time

VA will monitor performance quarterly by using data from Appointments Cube in Pyramid Analytics. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

https://pyramid.cdw.va.gov/direct/?id=e4d83f25-d59f-4b05-9227-b1455f52c258

Cube in Pyramid Analytics for more information)

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

Contractor’s

PCMHI

penetration rate shall meet or exceed 8%

Contractor’s

PCMHI

penetration rate meets or exceeds 8%

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

COR will send reports to the Contractor and CO quarterly to notify them of

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

PWS

para.

4.13.

4.

Contractor shall provide: 1) urgent care appointments as soon as needed,

2) routine care appointments as soon as needed, and 3) same day answers to patients’ medical questions

Contractor’s SHEP access composite score shall meet or exceed 50%

Contractor’s SHEP access composite score shall meet or exceed 50%

VA will monitor performance quarterly using data from

SHEP/PCMH

report. COR will send reports to the Contractor and CO quarterly to notify them of 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 medical question.

(See

SHEP/PCMH

Report for more information) SHEP Question

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.

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%.

performance quarterly using data from

SHEP/PCMH

report. COR will send reports to the Contractor and CO quarterly to notify them of

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP

(See PACT Compass for more information)

PWS

para.

6.

provide same day appointments with primary care provider

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

Contractor’s same day appointments with PCP rate shall meet or exceed 43% performance quarterly using data from the PACT Compass.

COR will send reports to the Contractor and CO quarterly to notify them of

Appointment Cancellations

PWS

para.

Contractor shall not unnecessarily

Contractor’s rate of

Contractor’s rate of 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 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

Cancelled by clinic rate for all active clinic stop codes (mop13) (Lower is better)

(See Performance Measure Report for more information)

4.13.

7.

cancel patient appointments appointments cancelled by clinic shall not exceed 9% appointments cancelled by clinic shall not exceed 9% performance data from the Performance Measure Report. COR will send reports to the Contractor and CO quarterly to notify them of

QUALITY OF

CARE

Composite – BH90 Behavioral Health Screening

Composite of mdd40 -- Vets screened annually for major depression dx.

ptsd51 -- PTSD screening sa17 -- Vets screened for alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened

PWS

para.

4.13.

8.

Contractor shall complete all behavioral health screenings and follow-up evaluations

Contractor shall maintain a behavioral health composite score of at least 95%

Contractor shall maintain a behavioral health composite score of at least 95% progress quarterly using data from the Outpatient Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of 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 annually for alcohol misuse CSSRS1--Annual Suicide Risk Screen

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

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 ))

Outpatient Sites of Care Report

PWS

para.

9.

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

Contractor shall maintain a cardiovascular /diabetes risk management composite score of at least 72%

Contractor shall maintain a cardiovascular risk management composite least 72% progress quarterly using data from the Outpatient Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of

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 )) of Care Report

4.13.

10.

Contractor shall provide preventive health care in accordance with VA standards

Contractor shall maintain a prevention composite score of at least 62%

Contractor shall maintain a prevention composite least 62% progress quarterly using data from the Outpatient Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of

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

PWS

para.

4.13.

11.

Contractor shall provide tobacco counseling and care in accordance with VA standards

Contractor shall maintain a tobacco use and cessation composite score of at least 95%

Contractor shall maintain a tobacco use and cessation composite least 95% progress quarterly using data from the Outpatient Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of

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

Outpatient Sites of Care Report for more

4.13.

Contractor shall provide flu immunizations in accordance with VA standards

Contractor shall maintain an influenza immunization composite score of at least 29%

Contractor shall maintain an influenza immunization composite least 2% progress quarterly using data from the Outpatient Sites of Care Report.

COR will send reports to the Contractor and CO quarterly to notify them of

Adult Immunization Status

PWS

para.

4.13.

Contractor shall provide adult immunizations in

Contractor shall maintain an adult

Contractor shall maintain an adult immunization

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

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

Sites of Care Report for accordance with VA standards immunization status composite score of at least 56% status composite least 56% data from the

Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of

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))

4.13.

Contractor shall provide diabetes care in accordance with VA standards

Contractor shall maintain a diabetes composite score of at least 68%

Contractor shall maintain a diabetes composite least 68% progress quarterly using data from the Outpatient Sites of Care Report. COR will send reports to the Contractor and CO quarterly to notify them of 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)

Clinical Reminders

PWS

para.

4.13.

15.

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 no less than 95% of all clinical reminders as indicated in the VA EHR.

progress quarterly by using data from the External Peer Review and monitor ad hoc through note reviews. COR will send reports to the Contractor and CO quarterly to notify them of

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

PWS

para.

4.13.

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

Contractor shall properly complete documentatio n for each patient encounter 100% of the time

Contractor shall properly complete documentatio n for each patient encounter 100% of the time performance weekly by using VSSC Encounter reports. COR will send reports to the Contractor and CO quarterly to notify them of 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 include content as defined in PWS.

PANEL

MANAGEMEN

T

Percent of Teams with Core Teamlet Staffing Ratio

>=3 (PACT 22)

The total Core Primary Care Support Staff (clerical/admini strative 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.

17.

Contractor shall provide core teamlet staffing at a ratio of >=3 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

99% of Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

VA will monitor progress quarterly using data from the PACT Compass Cube. COR will send reports to the Contractor and CO quarterly to notify them of

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

PWS

para.

4.13.

18.

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

Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health

Contractor’s percent of women assigned to Women’s

Health PACT or Designated

Women’s Health

VA will monitor performance quarterly using data from the PACT COR will send reports to the Contractor and CO https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96 https://pyramid.cdw.va.gov/direct/?id=92c5f3b6-c855-49ed-9d7e-24583efa6f96

(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

Teams women Veterans who choose to be seen by a designated women’s health provider.

Provider shall exceed 88%

Provider shall exceed 88% quarterly to current

Compass.

Percent

Patients Enrolled in Home Telehealth

Reflects the

19.

offer and refer patients to home telehealth shall exceed 2% of PC patients enrolled in Home

(HT)

shall exceed 2% of patients enrolled in Home

(HT)

performance quarterly using data from the PACT Compass.

COR will send reports to the 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 http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed 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)

Contractor and notify them of current performance.

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

PWS

para.

4.13.

20.

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

Contractor shall exceed 44% ratio of non-traditional encounters

Contractor shall exceed 44% ratio of non-traditional encounters performance quarterly using data from the PACT Compass.

COR will send reports to the Contractor and CO quarterly to notify them of 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 reporting period.

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

para.

4.13.

21.

The Contractor’s PCPs shall provide care that Veterans 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 exceed 73% performance quarterly using data from

SHEP/PCMH

report. COR will send reports to the Contractor and CO quarterly to notify them of

COORDINATIO

N OF CARE

Post Discharge Contact by PACT Teamlet

The percent of assigned primary care patients discharged from any VA facility who

PWS

para.

4.13.

22.

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 60%

Contractor’s rate of post discharge contact by PACT teamlet exceed 60% performance quarterly using data from the PACT Compass.

COR will send reports to the Contractor and 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 have been contacted by PACT teamlet within two business days more information) current performance.

DOMAIN:

ENVIRONMEN

T 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 para 4.13.

23.

Contractor shall address deficiencies identified in EOC rounds within 14 business days or have a documented Plan for Action

Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 91%

Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA exceed 91% performance quarterly using data from the Performance Measure Report.

COR will send reports to the Contractor and CO quarterly to notify them of 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

PHARMACY

Medication Storage Area Inspections

PWS

para.

4.13.

24.

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 local VA medical center form).

Inspection documentatio n will be sent to the COR within 10 days of the end of each month.

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 documentatio n 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 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

7. Ratings:

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

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

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 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