D.30 Quality Assurance Surveillance Plan.pdf

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: TBA

• Organization or Agency: Department of Veterans Affairs – New Mexico VA

Health Care System (NMVAHCS) 501.

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 Pamela Mayberry, Pamela.Mayberry@va.gov o Gary Hotovec, Gary.Hotovec@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.

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. 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: February 1, 2021.

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 PC Appointments Completed within 20 Days of Create Date New Primary Care Completed Appointments less than or equal to 20 days from create date (See the Appointments Cube in Pyramid Analytics for more information)

PWS

para.

4.13.1

Contractor shall provide completed appointments for new PC patients <=20 days from the create date

Contractor shall provide completed appointments for new PC patients <=20 days from the create date no less than 72% of the time

Contractor shall provide completed appointments for new PC patients <=20 days from the create date no less than 70% of the time

VA will monitor progress quarterly by 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 Average Wait Time in Days Established Primary Care Completed Appointments less than or equal to 20 days from Patient Indicated Date (patient desired date) or the clinically indicated date) (See the Appointments Cube in Pyramid Analytics for more information)

PWS

para.

4.13.2

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

Contractor shall provide completed appointments for established PC patients <=20 days from the patient indicated date no less than 94% of the time

Contractor shall provide completed appointments for established PC patients <=20 days from the patient indicated date no less than 94% of the time

VA will monitor progress quarterly by using data from the Appointments Cube. COR will send report to the Contractor and CO quarterly to notify them of

PCMHI Penetration

(PACT21)

The percent of assigned Primary Care patients seen in Primary Care- Mental Health Integration

(PCMHI)

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 progress COR will monitor progress quarterly using data from the

PACT

Compass.

COR will send report 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 medical question.

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 52%

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

VA will monitor progress COR will monitor progress biyearly using data from the

SHEP/PCMH

Report. COR will send report to the Contractor and CO to notify them of current

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

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 40%

Contractor’s

SHEP

question 7 score shall meet or exceed 40%.

VA will monitor progress quarterly based on data provided by VA performance data sources.

away? (Less is better) (See SHEP/PCMH Report for more information)

COR will send results 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.

4.13.6

Contractor shall provide same day appointments with primary care provider

Contractor’s same day appointments with PCP rate shall meet or exceed 66%

Contractor’s same day appointments with PCP rate shall meet or exceed 60%

VA will monitor progress quarterly by using data from the PACT Compass.

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

Appointment Cancellations Cancelled by clinic rate for all active clinic stop codes (mop13) (Lower is better) (See the Appointments Cube in Pyramid Analytics for more information)

PWS

para.

4.13.7

Contractor shall not unnecessarily cancel patient appointments

Contractor’s rate of appointments cancelled by clinic shall not exceed 8%

Contractor’s rate of appointments cancelled by clinic shall not exceed 7%

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

DOMAIN: QUALITY OF CARE

Composite - 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 sre1 -- (mdd41 and

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 94%

Contractor shall maintain a behavioral health composite score of at least equal to the VA National Average for that quarterly reporting period.

VA will monitor progress quarterly using

VA

performance data sources.

COR will send report to the Contractor and CO quarterly to notify them of ptsd52) aggregated scores for timely suicide evaluations

(See the CBOC Report for more information)

Composite – Diabetes Composite of dmg27h_ec DM: BP LT 140/90 ( eMeasure dmg34h_ec DM:

Medical attention for nephropathy - Renal Testing (OP)(eMeasure) statn7_ec Statin therapy for patients with diabetes ( eMeasure )

(See the CBOC Report for more information)

PWS

para.

4.13.9

Contractor shall manage patients with diabetes in accordance with VA standards

Contractor shall maintain a diabetes composite score of at least 79%

Contractor shall maintain a diabetes composite score of at least equal to the VA National Average for that quarterly reporting period.

VA will monitor progress quarterly using data from the eQM Provider Dashboard.

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

Composite - Ischemic Heart Composite of ihd53_ec and statn1_ec Statin Therapy for patients with cardiovascular disease (eMeasure)

(See the CBOC Report for more information)

PWS

para.

4.13.10

Contractor shall manage patients with ischemic heart disease in accordance with VA standards

Contractor shall maintain an ischemic heart composite score of at least 75%

Contractor shall maintain an ischemic heart composite score of at least equal to the VA National Average for that quarterly reporting period.

VA will monitor progress quarterly using

VA

performance data sources.

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

Composite – Prevention Composite of dmg31h DM: Retinal exam, timely by disease

(OP)

p61h Colorectal Cancer Screening Ages 50-75 p42 Cervical Cancer Screening Women age 21-29y p43h Cervical Cancer Screening Women

PWS

para.

4.13.11

Contractor shall provide preventive health care in accordance with VA standards

Contractor shall maintain a prevention composite score of at least 82%

Contractor shall maintain a prevention composite score of at least equal to the VA National Average for that quarterly reporting period.

VA will monitor progress quarterly using

VA

performance data sources.

COR will send report to the Contractor and CO quarterly to notify them of age 30-64 pvc11h Pneumococcal Immunizations (OP) EPRP sample p32h Breast Cancer Screening including tomography for Women 50-74y (OP)

HEDIS

(See the CBOC Report for more information)

Composite – Tobacco Composite of smg8 Pts using tobacco provided w/counsel

(OP)

smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds

(OP)

(See the CBOC Report for more information)

4.13.12

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

Contractor shall maintain a tobacco composite score of at least 99%

Contractor shall maintain a tobacco composite score of at least equal to the VA National Average for that quarterly reporting period.

VA will monitor progress quarterly using data from the

VA EHR

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

Progress Notes and Patient Care Encounter (PCE) Module Documentation

PWS

para.

4.13.13

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 include content

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

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

VA will monitor progress weekly using the Encounter Action Required Report. COR will notify Contractor and CO of any outliers.

as defined in

PWS.

DOMAIN: PANEL MANAGEMENT

Percent of Teams with Core Teamlet Staffing Ratio >=3 The total Core Primary Care Support Staff (clerical/administrative associate, RN care manager, and clinical associate) FTE divided by the total Primary Care Provider FTE entered in the PCMM Web Application.

(See PACT Compass for more information)

PWS

para.

4.13.14

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

100% 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 (Modeled Capacity PC Staffing Ratio).

COR will notify Contractor and CO quarterly to notify them of

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

4.13.15

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

Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 82%

Contractor’s percent of women assigned to Women’s

Health PACT or Designated

Women’s Health

Provider shall meet or exceed 80%

VA will monitor progress quarterly using data from the

PACT

Compass (panel management).

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

(See PACT Compass for more information)

Percent Primary Care Patients Enrolled in Home Telehealth Reflects the 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) (See PACT Compass for more information)

PWS

para.

4.13.16

Contractor shall offer and refer patients to home telehealth

Contractor shall exceed 1.2% of PC patients enrolled in Home Telehealth

(HT)

Contractor shall exceed 1.2% of patients enrolled in Home Telehealth

(HT)

VA will monitor progress quarterly using data from the

PACT

Compass (panel management).

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

PERCENT PRIMARY

CARE PATIENTS

DUE for TeleEye screening.

4.13.17 Contractor

shall offer and refer patients for TeleEye screening who are due now or within 90 days of their clinic visit.

Contractor shall screen 35% of scheduled PC patients monthly who have the clinical reminder for Eye Care at Risk Screen identified on either the clinical reminder due report or in CPRS at time of visit of due now or within 90 days.

Contractor shall exceed 35% of PC patients for TeleEye screening monthly.

COR will monitor progress quarterly using data from the Connected Care Section.

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 added to the sum of all incoming and outgoing secure messages, and video as the numerator.

PWS

para.

4.13.18

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

Contractor shall exceed 40% ratio of non-traditional encounters

Contractor shall exceed 35% ratio of non-traditional encounters

VA will monitor progress quarterly using data from the

PACT

Compass (non-traditional care). COR will send reports to the Contractor and CO quarterly to notify them of

The denominator is the total team assignments for the reporting period.

(See PACT Compass for more information)

DOMAIN: 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 4.13.19

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 73.5%

Contractor’s

SHEP

question 32 score shall meet or exceed 70%

VA will monitor progress by COR providing SHEP results and VSignals data when available with Contractor and CO. Any complaints or compliments 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: COORDINATION 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

(See PACT Compass for more information)

PWS

para.

4.13.20

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 61%

Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 61%.

VA will monitor progress quarterly using data from the

PACT

Compass.

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)

PWS

para.

4.13.21

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 shall meet or exceed 90%

VA will monitor progress by COR providing EOC result reports to the Contractor and CO when they are available /released by the inspectors.

DOMAIN: PHARMACY

Medication Storage Area Inspections

PWS

para.

4.13.22

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 documentation 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 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.

COR 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

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

10) COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP:

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE