D1 - Attachment - Quality Assurance Surveillance Plan.pdf

Attachment D.1 - QASP

Revision 04/04/2025

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 will monitoring take place?

• Who will conduct the monitoring?

• How will monitoring efforts and results 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.

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: Stephanie Keo Organization or Agency: Department of Veterans Affairs, Network Contracting Office 16 (NCO 16)

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: To be assigned at time of award ___________________ Organization or Agency: G.V. Sonny Montgomery VA Medical Center

3. CONTRACTOR REPRESENTATIVES

The following staff 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.

DASHBOARDS.

a. DIRECT OBSERVATION. Method not applicable

b. PERIODIC INSPECTION. Method not applicable

c. VALIDATED USER/CUSTOMER COMPLAINTS. Method not applicable

d. RANDOM SAMPLING. Method not applicable

VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR.

Applies to elements 4.13.1 - 4.13.21 of the QASP. COR will monitor Contractor performance monthly and quarterly using electronic report data from VSSC, Power BI, VISTA, and the CBOC Report. COR will verify submission of VA Form 10-0053 monthly.

6. MEASURES

VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template

As of: ________________________

NOTE: Any change to the level of performance (standard/AQL) after award of the contract must be conducted via bi-lateral modification.

Measure PWS Page#

Performance Requirement

Standard Acceptable Quality Level

(AQL)

Method of surveillance and frequency

Met AQL/Did Not Meet

AQL

(Add comment)

DOMAIN: ACCESS

New PC Appointments Completed within 20 Calendar Days of Reference Date

(RD)

New primary care appointments completed within 20 calendar days of the RD.

(See the Appointments Cube in Pyramid Analytics for more information. Note:

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

PWS

page

Contractor shall provide completed appointments for new PC patients within 20 calendar days of the RD.

Contractor shall provide completed appointments for new PC patients within 20 calendar days of the RD no less than 57% of the time.

Contractor shall provide completed appointments for new PC patients within 20 calendar days of the RD no less than 53 % of the time.

COR will monitor progress monthly using Access Summary data from the CPM Dashboard in Power BI.

COR will send reports to Contractor and CO quarterly to notify them of current performance.

Established PC Patient Appointments Completed within 20 calendar days of Patient Indicated Date

(PID)

PWS

page

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

Contractor shall provide completed appointments for established PC patients within 20 calendar days of the PID no

COR will monitor progress monthly using Access Summary data from the CPM Dashboard in Power BI.

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%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

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.)

of the PID no less than 94% of the time.

less than 93 % of the time.

COR will send reports to Contractor and CO quarterly to notify them of current performance.

PCMHI

Penetration

(PACT21)

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

(PCMHI)

(See PACT Compass for more information)

PWS

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 % progress monthly using data from the

PACT

Compass in

VSSC. COR

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

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

PWS

page 90-91

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 52% progress quarterly using data from the SHEP Patient Experiences Cube Reports in VSSC.

COR will send reports to the Contractor and 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%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 appointment as soon as needed, and 3) Get same day answer to your medical question.

(See SHEP/PCMH Report for more information)

CO quarterly to notify them of current performance.

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 information)

PWS

page

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% progress quarterly using data from the SHEP Patient Experiences Cube Reports in VSSC.

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

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP.

(See PACT Compass for more information)

PWS

provide same day appointments with primary care provider.

Contractor’s same day appointments with PCP rate shall meet or exceed 43%.

Contractor’s same day appointments with PCP rate shall meet or exceed 54%

COR will monitor progress monthly using data from the

PACT

Compass in

VSSC. COR

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

Appointment Cancellations

(MOP 13)

Cancelled by clinic rate for all active

PWS

page

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 % progress monthly using data from the Performance Measures 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 https://vaww.qps.med.va.gov/divisions/api/pm/shep/shepReporting.aspx 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 clinic stop codes (mop13) (Lower is better)

(See Performance Measure Report for more information)

Report in

VSSC. COR

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

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)

PWS

page

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

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

Contractor shall maintain a behavioral health composite score of at least 96%

COR will monitor progress monthly using data from the Outpatient Sites of Care Report in Poer BI. COR will send reports to the Contractor and CO quarterly to notify them of current

CVRM90_EC

Cardiovascular/D iabetes Risk

PWS

page

Contractor shall manage patients with diabetes and cardiovascular disease in

Contractor shall maintain a cardiovascular risk management

Contractor shall maintain a cardiovascular risk management composite score of at least 73%

COR will monitor progress monthly using data from the Outpatient https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=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 https://vaww.pbi.cdw.va.gov/PBI_RS/report/GPE/API_PMMAT/SSRS/ClinicalMeasurement/OutpatientSitesOfCare?rs:Embed=true

Management

(EQM)

Composite of 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))

(See the Outpatient Sites of Care Report for more information) accordance with VA standards.

composite score of at least 73%.

Sites of Care Report in Power BI.

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

Composite –

PRV90_EC

Prevention

Composite of bcs01_ec (Breast Cancer Screening for Women 50-74y (Electronic)) ccs01_ec (Cervical Cancer Screening (eMeasure)) col01_ec (Colorectal Cancer Screening Ages 45-75 (eMeasure)) psa1_ec (Non- Recommended PSA-Based Screening (eMeasure))

Contractor shall provide preventive health care in accordance with VA standards.

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

Contractor shall maintain a prevention composite score of at least 81% progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

(See the Outpatient Sites of Care Report for more information) Composite –

SMG90_1

Tobacco Use and Cessation

Composite of 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))

(See the Outpatient Sites of Care Report for more information)

PWS

page

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 composite score of at least 99%

COR will monitor progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

Composite -

FLU90_EC

Outpatient Influenza Immunization

Composite of p28h_ec (Influenza Immunizations 66 years of age and older (eMeasure)) p29h_ec (Influenza Immunization 19- 65 years of age (eMeasure))

PWS

page

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%

COR will monitor progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

(See the Outpatient Sites of Care Report for more information)

Composite – AIS90_EC Adult Immunization Status

Composite of ais01_ec Pneumococcal Immunization (eMeasure) ais10td_ec Tdap Immunization (eMeasure) ais20zos_ec Zoster Immunization (eMeasure)

(See the Outpatient Sites of Care Report for more

Contractor shall provide adult immunizations in accordance with VA standards.

Contractor shall maintain an adult immunization status composite score of at least 58%.

Contractor shall maintain an adult immunization status composite score of at least 58%

COR will monitor progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

DMG91_EC

Diabetes

Composite of 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))

PWS

page

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 72%

COR will monitor progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

(See the Outpatient Sites of Care Report for more information)

Clinical Reminders

PWS

page

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.

complete no less than 90% of all clinical reminders as indicated in the

VA EHR.

progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

Progress Notes and Patient Care Encounter (PCE) Module Documentation

PWS

page

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, 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.

progress monthly using data from the Outpatient Sites of Care Report in Power BI.

COR will send reports to the Contractor and CO quarterly to notify them 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 meet CMS guidelines, and include content as defined in

PWS.

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.

(See PACT Compass for more information)

PWS

page

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.

100% of contractor’s primary care teams shall have a core teamlet staffing ratio of 3 or more.

COR will monitor progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

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*

PWS

page

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 90%

COR will monitor progress monthly using data from the Outpatient Sites of Care Report in Power BI.

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

(See PACT Compass for more

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.

PWS

page

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.

progress monthly using data from the

PACT

Compass in

VSSC. COR

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

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

(See PACT Compass for more

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

page

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%

COR will monitor progress quarterly using data from the SHEP Patient Experiences Cube Reports in VSSC.

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

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

page

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 80%

COR will monitor progress quarterly using data from the SHEP Patient Experiences Cube Reports in VSSC.

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

DOMAIN: ENVIRONMENT OF CARE (EOC)

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://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

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)

PWS

page

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%

COR will monitor progress quarterly using data from the SHEP Patient Experiences Cube Reports in VSSC.

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

DOMAIN: PHARMACY

Medication Storage Area Inspections

PWS

page

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 VA parent facility form).

Inspection documentation will be sent to the COR within 10 calendar days of the end of each month.

Any issues discovered shall be resolved by the contractor

The contractor shall ensure that 100% of medication storage areas are inspected monthly and documented on VA Form 10- 0053 (or VA parent facility form). Inspection documentation will be sent to the COR within 10 calendar days of the end of each month. Any issues discovered are resolved by the contractor and reported to the COR within 15 calendar days of

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 https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

7. CPARS RATINGS ASSIGNED TO QASP ITEMS:

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/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).

and reported to the COR within 15 calendar days of the inspection date.

the inspection date.

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cpars.gov%2Fcparsweb%2Fassets%2Fdocuments%2FCPARS_User_Manual.pdf&data=05%7C02%7C%7C1299a8a1556647c9c9b208dd897915ec%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638817875334440754%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=6A9MQEEm9YUvO1cWqDUn1sC8wYUJvuCVqG%2F2AhW8s1E%3D&reserved=0

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

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).

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 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. See sample on following page.

9. FREQUENCY OF MEASUREMENT

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.

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:

COR will sign at time of award 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