D.3 - Quality Assurance Surveillance Plan (QASP).xls
XLS spreadsheet 54 KB Posted
- Solicitation number
- 36C26323R0032
About this file
This document contains a Quality Assurance Surveillance Plan (QASP) template and details for a Medical Officer of the Day solicitation. The QASP template outlines ongoing professional practice evaluation metrics for providers across areas such as patient care skills, medical knowledge, interpersonal communication, and systems-based practice. Metrics include the percentage of progress notes signed within seven days, use of evidence-based treatment plans, compliance with continuing education requirements, and other quality of care indicators. The Medical Officer of the Day solicitation is seeking questions and answers from the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 23. No further information is provided on products or services required by the solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C26323R0032_3.docx | DOCX document | |
| D.2 - Background Investigation Procedure and Documents-Updated.pdf | ||
| 36C26323R0032_2.docx | DOCX document | |
| D.1 - VA Rules of Behavior.pdf | ||
| 36C26323R0032_1.docx | DOCX document | |
| D.2 - Background Investigation Procedure and Documents.pdf | ||
| D.4 - Immigration and Nationality Act Requirement.pdf | ||
| S02 - 36C26323R0032.pdf | ||
| D.6 - Organizational Conflict of Interest.pdf | ||
| D.5 - VA Handbook 6500.6.pdf |
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Text version
Sheet1
| Ongoing Professional Practice Evaluation (OPPE) | Sample/Data Source | |||||||
| PROVIDER: | Service: CD | |||||||
| MEASURE | Sample/Data Source | Target | Qtr 1 | Qtr 2 | Qtr 3 | Qtr 4 | ||
| PATIENT CARE AND PROCEDURAL SKILLS | Sample/Data Source | Target | Qtr 1 | Qtr 2 | Qtr 3 | Qtr 4 | ||
| Med Rec: % of Progress notes signed w/in 7 days | PSM Admin Assistant | HAS | 99% | |||||
| Encounter Closure: % of encounters closed w/in 7 days | PSM Admin Assistant | HAS | 99% | |||||
| Appropriate use & documentation of restraints/seclusion | ||||||||
| • Secure MH Inpatient Unit Building 115 | 100% Review of all episodes of restraint/seclusion by ICC QC's | 90% | ||||||
| MEDICAL/CLINICAL KNOWLEDGE | Sample/Data Source | Target | Qtr 1 | Qtr 2 | Qtr 3 | Qtr 4 | ||
| Clinical assessment is comprehensive (i.e., includes mandatory elements) and timely (i.e., meets specific timeframe and local requirements established in medical bylaws). | Clinical Pertinence Review/Colleague | Clinical Pertinence Review/Colleague (VHACO Level standard) | 80% | |||||
| Treatment plan is evidence-based (e.g., VA/DoD guidelines or other approved practice standards) and reflects shared decision-making between the practitioner and the Veteran. | Clinical Pertinence Review/Colleague (VHACO Level standard) | 80% | ||||||
| If indicated by policy, informed consent is completed and signed prior to a procedure or treatment, and the practitioner identified and discussed risks, benefits, and potential complications. | Clinical Pertinence Review/Colleague (VHACO Level standard) | 80% | ||||||
| Timely, appropriate, and guideline concordant (if applicable) empiric antimicrobial selection. | Clinical Pertinence Review/Colleague (Program Office standard) | 80% | ||||||
| Counseling on tobacco cessation prior to discharge. | Clinical Pertinence Review/Colleague (Program Office standard) | 80% | ||||||
| PRACTICE-BASED LEARNING AND IMPROVEMENT | Sample/Data Source | Target | Qtr 1 | Qtr 2 | Qtr 3 | Qtr 4 | ||
| Completed BLS within the past two years | COS Admin Asst. | Self-report to EDU Office. | ||||||
| Date: | Evidence of Compliance | |||||||
| INTERPERSONAL AND COMMUNICATION SKILLS | Sample/Data Source | Target | Qtr 1 | Qtr 2 | Qtr 3 | Qtr 4 | ||
| Patient complaints | Report of Contact, Communications to Pt Advocate Office, SLD, or COS office | Report of Contact, Patient Advocate Office, Chief of Staff, Office of the Director | ≤3 complaints in a quarter | |||||
| Colleague or other staff complaints | Report of Contact, Patient Advocate Office, Chief of Staff, Office of the Director | ≤3 complaints in a quarter | ||||||
| Patient compliments | Report of Contact, Patient Advocate Office, Chief of Staff, Office of the Director | NA | ||||||
| Colleague or other staff compliments | Report of Contact, Communications to Pt Advocate Office, SLD, or COS office | Report of Contact, Patient Advocate Office, Chief of Staff, Office of the Director | NA | |||||
| PROFESSIONALISM | Sample/Data Source | Target | Qtr 1 | Qtr 2 | Qtr 3 | Qtr 4 | ||
| Validated disruptive or unprofessional behavior with patients | Chief of Staff, Office of the Director | 0 | ||||||
| Validated disruptive or unprofessional behavior with staff | PSM SLD or PSM Nurse Administrator | Chief of Staff, Office of the Director | 0 | |||||
| SYSTEMS-BASED PRACTICE | Sample/Data Source | Target | Qtr 1 | Qtr 2 | Qtr 3 | Qtr 4 | ||
| Evidence of I-Med consent completed or documentation of Veteran's inability to sign | 100% review of all patient transfers out by ICC QC | 90% | ||||||
| Evidence of physician Co-signature on 10-2649A Form when completed by non-MD provider (NP/PA) | 100% review of all patient transfers out by ICC QC | 90% | ||||||
| Evidence the provider Inter-Facility Transfer form 10-2649A completed | 100% review of all patient transfers out by ICC QC | 90% | ||||||
| Transfer who are returned the same day had appropriate corresponding treatment/disposition based on reason for transfer | 100% review of all patient transfers out by ICC QC | 90% | ||||||
| Transfer to non-VA facility indicate the reason for transfer (acuity, testing, patient/family request, etc.) | 100% review of all patient transfers out by ICC QC | 90% |
&CQASP
Sheet3
| Evidence of chief complaint or reason for evaluation | PSM Quality Coord | 90% | 100% |
| Evidence of examination. If not, consult placed. | PSM Quality Coord | 90% | 98% |
| Evidence of impression | PSM Quality Coord | 90% | 98% |
| Evidence of plan | PSM Quality Coord | 90% | 98% |
| Evidence that evaluation addressed reason for visit | PSM Quality Coord | 90% | 100% |
| Documentation indicates results of test(s) done day of office visit were communicated to the patient | PSM Quality Coord | 90% | 100% |
| Documentation is free of administrative documentation and copy/paste is used appropriately | PSM Quality Coord | 90% | 100% |
| Documentation is free of unapproved abbreviations | PSM Quality Coord | 90% | 100% |
| Problem list is Up To Date | PSM Quality Coord | 90% | 98% |
| Medication Reconcilliation completed (5 components will be audited effective Q2-13) | PSM Quality Coord | 90% | 98% |
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