D.28 Past Performance Questionnaire.pdf

Past Performance Reference Check Questionnaire

REFERENCE INSTRUCTIONS: The Department of Veterans Affairs is considering the Offeror listed above for award of a VA contract. Your comments would be appreciated regarding this firm’s past perfor-mance. Your comments are considered Source Selection Sensitive; therefore, you are advised that the Federal Acquisition Regulation (15.506) prohibits the release of the names of individuals providing refer-ence information about Offeror’s past performance. Survey should be completed by evaluator and re-turned to Bethany.Diaz@va.gov

Please evaluate the past performance using only the following ratings without variation. If the rating is Unacceptable, please provide additional information in the appropriate block or in the remarks section of this form.

“O” = Outstanding = Performance exceeded the contract requirements “S” = Satisfactory = Performance meets the contract requirements “U” = Unacceptable = Performance was poor and/or did not satisfy contract requirements

Name of Contractor being evaluated: ______________________________________________

Respondent: ________________________________________ Date:_________________

Please rate and provide information/comments for the following: Circle one Q1. Please provide an estimated number of patients (unique social security numbers) seen annually by the Contractor under your contract? _____________ Q2. Did you or the Contractor collect quality data related to primary care such as:

Influenza vaccination rates Cancer screening rates Proportion of diabetics under good control (HgbA1C<8.0%) Completion of Clinical Reminders Completion of notes, orders, and encounters Panel size management Patient Aligned Care Team (PACT) measures Customer Satisfaction and/or Complaints Other Quality Measures (Please Specify)________________________

Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __ Yes __ No __

Q3. Quality control: Rate the overall quality on the contractor’s work.

O S U

Q4. Were any contract discrepancy reports (CDRs), cure notices, show cause letters, suspension of payments, or terminations sent to the Contractor (if so, please speak briefly to the problem areas below) and, if so, how responsive was the Contractor to correcting the discrepancies? _____________________

Yes __ No __

Q5. Did the Contractor implement any Patient Aligned Care Team (PACT) principles and processes, and, if so, in your opinion how cooperative and successful were they in this implementation? _____________________________

Q6. Did the Contractor provide any Telehealth Services, and, if so, in your opinion how cooperative and successful were they with providing these services?

Q7. Rate and describe the Contractors management of staff, turnover, and how any turnover may have affected the Contractor’s performance: ____________

O S U

Q8. To what extent was contractor able to meet the performance schedule:

O S U

Q9. What extent was contractor flexible in responding to changing needs?

O S U

Q10. To what extent was the contractor reliable? _______________________

O S U

Q11. To what extent was the contractor responsive to technical directions?

O S U

Q12. If patient studies were conducted, did patients express satisfaction with the Con-tractor? If no patient satisfaction studies conducted, please indicate so in the space pro-vided. _____________________________________________

Q13. Would you recommend another contract be awarded to the Contractor being eval-uated? If no, please explain: ________________________________

Q14. How would you rate the Contractor on customer satisfaction?

O S U

Q15. To what extent did contractor notify you of problems or potential problems?

Q16. Business Relations:

Was management effective?

Did the Contractor exhibit reasonable/cooperative behavior?

Was Contractor flexible?

Did Contractor exhibit business-like concern for the interests of the contracting agency?

How would you rate the Contractor in the area of business relations?

O S U O S U

O S U

Additional Remarks: ______________________________________________