Quality Assurance Surveillance Plan (QASP)

6. QASP PERFORMANCE REPORT

Measures PWS

Reference

Performance

Requirement

Standard Acceptable Quality Level

Surveillance

Method

Met AQL/DID NOT MEET AQL-

CPARS RATING/ADD COMMENTS

Provider Quality Performance 4.5.4.1 All Contractor’s physician(s) shall perform in accordance with clinical standards

100% of care provided within clinical standards of care

95% Periodic Inspection via

F/OPPE

Qualifications of Key Personnel 4.5.4.2 All Contractor’s physician(s) shall be board certified/board eligible in accordance with ACC Standards for Dermatology.

All (100%) Contractor’s physician(s) are board certified.

100% Random sampling of qualification documents

Scope of Practice/Privileging 4.5.4.3 Contractor’s physician(s) perform within their individual scopes of practice/privileging

All (100%) Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time.

100% Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time.

Random sampling of records.

Patient Access 4.5.4.4 The Contractor shall provide contractor’s physician(s) in accordance with the operating hours and VA Clinical schedule as outlined in this

PWS.

All (100%) Contractor’s physician(s) are on time and available to perform services.

Contractor’s physician(s) are on-time and available to perform services 90% of the time

Periodic Inspection of Time and Attendance Sheets

Patient Safety 4.5.4.5 Patient safety incidents shall be reported using VA Patient Safety Reporting System. All incidents reported

All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System

100% of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

Random Sampling using VA Patient Safety Reporting System

D.3 RFQ 36C25626Q1162_1 QASP

VHAHOUKellyAJ Cross-Out

VHAHOUKellyAJ Cross-Out immediately (within 24 hours.)

within 24 hours of incident.

Maintains licensing, registration, and certification

4.5.4.6. Updated Licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current.

All (100%) licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed.

Licensing and registration information kept current.

100% licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation.

Mandatory Training 4.5.4.7. Contractor shall complete all required training on time per facility policy

All (100%) of required training is complete on time by Contractor’s physician(s).

90% completions Random Sampling

Privacy, Confidentiality and

HIPAA

4.5.4.8. Contractor is aware of

all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality

All (100%) Contractor’s physician(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

100% compliance Periodic Inspection- Contractor shall provide evidence of annual training required by facility, reports violations per VA Directive 6500.6.

D.3 RFQ 36C25626Q1162_1 QASP

Periodic Inspection contractors must submit current, valid, and accurate licensing, registration, and certification documents for their physicians

7. CPARS RATINGS ASSIGNED TO QASP ITEMS:

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

https://www.cpars.gov/cparsweb/assets/documents/CPARS_User_Manual.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).

D.3 RFQ 36C25626Q1162_1 QASP

8. DOCUMENTING PERFORMANCE

a. The VA 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 Acceptable Quality level, the CO shall inform the contractor. This shall 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 shall in turn review and shall present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall also state how long after receipt the contractor has to present this corrective action plan to the CO. The VA 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.

See Sample on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Jana Atkinson, Medicine Service Business Manager DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

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

a. CONTRACTOR

NOTIFIED

b. COR c.

CONTRACTING

OFFICER