D.27 - Quality Assurance Surveillance Plan (QASP).pdf

VHA Contracted Outpatient Sites of Care Quality Assurance

Surveillance Plan (QASP) for Alamogordo, NM CBOC

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.

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.

This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and government officials implementing surveillance activities.

2) GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s

• Assigned CO: James Moran, James.Moran3@va.gov

• Organization or Agency: Department of Veterans Affairs – Network Contracting Office

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(s):

o Gary Hotovec, Gary.Hotovec@va.gov o Janet Louks, Janet.Louks@va.gov mailto:James.Moran3@va.gov mailto:Gary.Hotovec@va.gov mailto:Janet.Louks@va.gov

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. 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.

a. PERIODIC INSPECTION. Inspections (announced or unannounced) scheduled and reported quarterly per COR delegation or as needed.

b. VALIDATED USER/CUSTOMER COMPLAINTS. Validated user/customer complaints and compliments will be considered in the Veteran Satisfaction measure at the COR’s discretion.

c. RANDOM SAMPLING. If this method is used, define 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).

6) MEASURES

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) dated: _________________

Measure

PWS

Section

Performance

Requirement Standard

Acceptable

Quality Level

Method of

Surveillance and frequency

Met

AQL/Did

Not Meet

AQL

DOMAIN: ACCESS

New PC Appointments Completed within 20 Calendar Days of

Reference Date (RD)

Section 15, Para 2

Contractor shall provide completed

Contractor shall provide completed

Contractor shall provide completed

VA will monitor performance

Quarterly by

New primary care appointments completed within 20 calendar days of

RD.

(See the Appointments Cube in

Pyramid Analytics for more information. Note: Pyramid

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

appointments for new PC patients within 20 calendar days of the RD.

appointments for new PC patients within

20 calendar days of the RD no less than

53% of the time.

appointments for new PC patients within

20 calendar days of the RD no less than 60% of the time.

using data from the Appointments

Cube. COR will send report 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)

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.)

Section 15, Para 3

Contractor shall provide completed appointments for established PC patients within 20 calendar days of the PID.

Contractor shall provide completed appointments for established PC patients within

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

Contractor shall provide completed appointments for established PC patients within 20 calendar days of the PID no less than 94% of the time.

VA will monitor performance

Quarterly by using data from the

Appointments

Cube. COR will send report to the

Contractor and CO quarterly to notify them of current

PCMHI Penetration (PACT21)

Percent of All Primary Care Patients engaged in Primary Care- Mental

Health Integration (PC MHI).

(See PACT Compass for more information)

Section 15, Para 4

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

9%.

VA will monitor performance

Quarterly by using data from the VSSC. COR will send report to the Contractor and Quarterly to notify them of current

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

Section 15, Para 5

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 49%.

Contractor’s

SHEP access composite score shall meet or exceed 50%.

VA will monitor performance biyearly by using data from the

SHEP/PCMH

Report. COR will send report to the

Contractor and CO to notify them of

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

Section 15, Para 6

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 34%.

VA will monitor performance biyearly by using data from the

SHEP/PCMH

Report. COR will send report to the

Contractor and CO to notify them of

Same-Day Appts w/ PCP

Section 15, Para 7

Contractor shall provide same day

Contractor’s same day appointments

Contractor’s same day appointments with PCP rate

VA will monitor performance quarterly by 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://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 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

Measures the percent of requested same day appointments with PCP.

appointments with primary care provider with PCP rate shall meet or exceed 43% shall meet or exceed 44% using data from the VSSC. COR will send report to the Contractor and

CO quarterly to notify them of current performance.

Appointment Cancellations

(MOP13)

Cancelled by clinic rate for all active clinics stop codes (mop13), (lower is better).

(See Performance Measure Report for more information)

Section 15, Para 8

Contractor shall not unnecessarily cancel patient appointments.

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

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

VA will monitor performance quarterly by using data from the

Performance

Measure Report.

COR will send report to the

Contractor and CO quarterly to notify

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

Section 15, Para 9

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

Contractor shall maintain a behavioral health composite score of at least

96%.

maintain a behavioral health composite score of at least 96%.

VA will monitor performance quarterly by using VA performance data sources (VSSC).

COR

will send report to the Contractor and

CO quarterly to notify them of

Composite – CVRM90_EC

Cardiovascular/Diabetes Risk

Management (EQM)

- 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))

Para 10 manage patients with diabetes and cardiovascular disease in accordance with

VA standards.

Contractor shall maintain a cardiovascular/di abetes risk management composite score of at least 73%.

cardiovascular/di abetes risk management composite score of at least 73%.

VA will monitor performance quarterly by using VA performance data sources (VSSC).

COR will send report 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%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render 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

Report for more information)

Composite – PRV90 _EC

Prevention

- bcs01_ec (Breast Cancer

Screening for Women 50-74y

(Electronic))

- ccs01_ec (Cervical Cancer

Screening (eMeasure))

- col01_ec (Colorectal Cancer

Screening Ages 45-75

- psa1_ec (Non-Recommended

PSA-Based Screening

Section 15, Para 11

Contractor shall provide preventive health care in accordance with

VA standards.

Contractor shall maintain a prevention composite score of at least 63%.

cardiovascular/di abetes risk management composite score of at least 70%.

VA will monitor performance quarterly by using VA performance data sources (VSSC).

COR will send report to the

Contractor and

CO quarterly to notify them of

Composite – SMG90_1Tobacco Use and Cessation 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))

Section 15, Para 12

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 use and cessation composite score of at least 96%.

VA will monitor performance quarterly by using data from the VA

HER reports. COR will send report to the Contractor and

CO quarterly to notify them of

Composite - FLU90_EC Outpatient

Influenza Immunization

- p28h_ec (Influenza Immunizations

66 years of age and older

- p29h_ec (Influenza Immunization

19-65 years of age (eMeasure))

Section 15, Para 13

Contractor shall provide flu immunizations in accordance with

VA standards

Contractor shall maintain an influenza immunization composite score of at least 40%

Contractor shall maintain an influenza immunization composite score of at least 40%

VA will monitor progress quarterly by using VA performance data sources (VSSC).

COR will monitor 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 – AIS90_EC Adult

Immunization Status

Section 15, Para 14

Contractor shall provide adult

Contractor shall maintain an adult

Contractor shall maintain an adult

VA will monitor progress 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 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

- ais01_ec Pneumococcal

Immunization (eMeasure)

- ais10td_ec Tdap Immunization

(eMeasure)

- ais20zos_ec Zoster Immunization

(eMeasure) immunizations in accordance with

VA standards immunization status composite score of at least

58% immunization status composite score of at least

58% by using VA performance data sources (VSSC).

COR will monitor 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 current

Composite – DMG91_EC Diabetes

- 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))

Section 15, Para 15

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%

VA will monitor progress quarterly by using VA performance data sources (VSSC).

COR will monitor 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

Clinical Reminders

Para 16

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 90% of all clinical reminders as indicated in the

VA EHR.

VA will monitor performance quarterly by using data from the VA HER reports. COR will send report to the

Contractor and

CO quarterly to notify them of

Progress Notes and Patient Care

Encounter (PCE) Module

Documentation

Section 15, Para 17

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.

Contractor shall properly complete documentation for each patient encounter within

2 business days

100% of the time.

Contractor shall properly complete documentation for each patient encounter within 2 business days

100% of the time.

VA will monitor performance weekly by using the Encounter

Action Required

Reports provided by HAS using VA

HER reports. COR will notify

Contractor and CO of any outliers.

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

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)

Section 15, Para 18

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.

99% of contractor’s primary care teams shall have a core teamlet staffing ratio of 3 or more.

VA will monitor performance quarterly by using data from

VSSC.

COR will notify

Contractor and CO quarterly to notify

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)

Section 15, Para 19

Contractor shall ensure that an appropriate number of WH-

PACTs or WH-

PCPs are available at site of care to ensure that all

VHA access goals are met for women patients who choose to be seen by a designated

WH provider.

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

88%

VA will monitor performance quarterly by using data from the VSSC. COR will send reports to the Contractor and

CO quarterly to notify them of

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.

Section 15, Para 20

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

Contractor shall exceed 53% ratio of non-traditional encounters

Contractor shall exceed 53% ratio of non-traditional encounters

VA will monitor performance quarterly by using data from the VSSC. COR will send reports to the Contractor and

CO quarterly to notify them of

DOMAIN: VETERAN SATISFACTION

Veteran Satisfaction

Overall rating of Primary Care

Provider on question 32 of the

SHEP/PCMH survey.

(See SHEP/PCMH

Section 15, Para 21

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 73%

VA will provide

SHEP results and

VSignals data when they are available with

Contractor and

CO. Any complaints or compliments 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 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 voluntarily initiated by users and patients will be shared with the Contractor and CO shortly after VA receives them and can be considered when evaluating

Veteran’ satisfaction.

DOMAIN: COORDINATI ON 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.

Section 15, Para 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 within 2 business days shall meet or exceed 61%.

Contractor’s rate of post discharge contact by PACT teamlet within 2 business days shall meet or exceed 62%.

VA will monitor performance quarterly by using data from the VSSC. COR will send reports to the Contractor and

CO quarterly to notify them of

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)

Section 15, Para 23

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 93%

VA will provide

EOC reports to the contractor CO when they are made available by the EOC team

DOMAIN: PHARMACY

Medication Storage Area

Inspections

Section 15, Para 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

The Contractor shall ensure that 99% of medication storage areas are inspected monthly and documented on

VA Form 10-

0053 (or local VA medical center form).

Inspection documentation will be sent to the COR within 10 days of the end of each month. Any issues discovered are resolved by the Contractor and reported to the COR within

15 days of the inspection date.

VA will 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 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%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs%3ACommand=Render within 15 days of the inspection date.

The table below identifies where in the PWS the standards are found for monitoring performance.

7) RATINGS

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.

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).

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

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

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 Reporting System (CPARS).

b. 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.

c. 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.

d. 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

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:

Gary Hotovec/COR DATE

Signed:

CONTRACTOR NAME/TITLE DATE

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER

2. REPORRT NUMBER

3. TO: (Contracting Officer)

4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO

PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

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

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER