Attachment J-17 QASP v1.docx

QUALITY ASSURANCE SURVEILLANCE PLAN

TRICARE Quality Monitoring Contract (TQMC)

Contract Number: HT9402-XX-D-XXXX Contract Description: This contract provides for services and materials to support the management of clinical quality in the Military Health System (MHS). The activities focus on the continuous assessment, analysis and reporting on the quality of direct and purchased healthcare provided in the MHS.

The purpose of the TQMC is to assist the Clinical Support Division (CSD) in assessing and improving the quality of care delivered under the TRICARE benefit across the direct and purchased care systems. This contract will assist DHA in decreasing unwarranted variation in the quality of medical care, implementing proven clinical and business practices, and creating an environment for learning and continuous improvement across the MHS. This contract will also support DHA with the management of clinical quality performance measurement to validate the quality of care.

TRICARE quality monitoring is accomplished through a variety of tasks supporting the direct care and purchased care systems. These tasks include external, third-party data collection, analysis and reporting of clinical quality measures, and comparison with national healthcare benchmarks; reviewing, evaluating, and reporting on published clinical care studies, evolving practices, and other data to identify superior quality healthcare services and recommend means to transfer successes; and conducting comprehensive, timely medical peer reviews to ensure medically-appropriate healthcare is provided per 32 CFR 199.

Contractor’s name: (hereafter referred to as the contractor).

1.0 PURPOSE:

1.1 This Quality Assurance Surveillance Plan (QASP) provides a systematic method for the Government to evaluate the contractor’s 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

1.2 The contractor is responsible for implementing and delivering performance that meets contract standards using its Internal Quality Management Plan (CDRL AP020). The QASP provides the structure for the government's surveillance of the contractor's performance to assure that it meets contract standards. It is the Government's responsibility to be objective, fair and consistent in evaluating contractor performance.

1.3 The QASP is not part of the contract nor is it intended to duplicate the contractor's quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

1.4 The Government may provide a copy of the QASP to the contractor to facilitate open communication. In addition, the QASP should recognize that unforeseen or Attachment J-17 Draft Quality Assurance Surveillance Plan (QASP)

TQMC HT940222R0002, Attachment J-17 uncontrollable circumstances might occur that are outside the control of the contractor. The QASP should ensure early identification and resolution of performance issues to minimize impact on mission performance.

1.5 Authority: Authority for issuance of this QASP is provided under Federal Acquisition Regulation (FAR) 46, Quality Assurance; which provides for inspection, acceptance and documentation of the service called for in the contract or order.

2.0 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.

Contracting Officer: Greg Stephens/Kristin Moore Organization or Agency: Defense Health Agency/COD-A, Aurora, CO Telephone: Greg Stephens 303.676.3634 (Kristin Moore: (303) 676-3905) Email: gregory.r.stephens3.civ@mail.mil/kristin.m.moore13.civ@mail.mil

b. Contracting Officer’s Representative (COR).The COR is responsible for the technical administration of the contract and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. At the conclusion of the contract or when requested by the CO, the COR shall provide documentation to the CO. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf. The contractor shall refer any changes it deems may affect contract price, terms, or conditions to the CO for action.

Assigned COR: Shana Flora Telephone:

240-606-5314 Email: shana.m.flora.cov@mail.mil

c. Other Key Government Personnel – Title: Program Manager, Dr. Daniel Ross Telephone: 703-681-6219 Email: daniel.j.ross81.civ@mail.mil

3.0 CONTRACTOR REPRESENTATIVES:

The following TQMC employees are the contractor’s designated point(s) of contact for contract performance:

a. Program Manager - Telephone:

Email:

b. Task Manager -

Telephone:

Email:

c. Other Contractor Personnel - Title:

Telephone:

Email:

4.0 PERFORMANCE STANDARDS:

4.1 The performance standards define the level of service required under the contract for the contractor to meet each performance objective in Part 5 TQMC Performance Work Statement (PWS). The contract and task orders will specify quality performance metrics and the Acceptable Quality Levels (AQLs) as the standards the Government requires from the contractor’s performance of services. The Government will perform surveillance to determine if the contractor exceeds, meets or does not meet these standards.

4.2 The Government shall compare the contractor’s performance to the minimum Acceptable Quality Levels (AQLs) in the Performance Standards Summary Matrix below.

Table 1, Performance Standards Summary Matrix

Task

Indicator

Standard

Section 1, Paragraph 1.10.1 The contractor provides a deliverable CDRL A010, Quality Control Plan.

Zero deviation from the standard.

100% inspection.

Observation and review of complet SOC/ QOC cases

Section 5, Paragraph 5.3.1 The contractor provides a deliverable CDRL A020, HEDIS® Compliance Audit.. The assigned task is completed by their due dates at least 95% of the time. (Adjustments may be made to due dates depending on changes to customer requirements).

Section 5, Paragraph 5.3.3.7.2

inspection. Review of spreadsheet by SME.

Oversight of annual HEDIS® audit and audit process

Task

Indicator

Standard

The contractor shall purchase the Leapfrog Hospital Survey, the Leapfrog Hospital Safety Grade, and the (stand-alone) Ambulatory Surgery Center (ASC) Survey Reports annually from the Leapfrog Group (CDRL A040 Leapfrog Group Reports).

PWS

Section 5, Paragraph 5.3.5.1 The contractor provides a deliverable CDRL A040 Leapfrog Group Reports.

Zero deviation from the standard.

100% inspection.

Monthly Clinical Measures Steering Panel reports and periodic inspections of secure web based site; customer feedback.

Validation by Services that ORYX® data is received on time.

Section 5, Para 5.3.5.3

Section 5, Para 5.3.5.5.2

Standard

Section 5, Para 5.3.5.5.3.1

The Autism Care Demonstration Quality Management Report CDRL (A080 Autism Care Demonstration Quality Management Report ) includes additional information with specific data elements required in the annual report. The Government reserves the right to modify the data elements required in the annual report.

The contractor shall audit claims data and medical records on a statistically valid sample of new and continuously enrolled ACD beneficiaries during each Fiscal Year. The contractor shall consult the COR or designee on the fiscal year included in each report.

PWS

Section 5, Para 5.6.2.2.8.1

Standard

The DFARS provision 252.204-7019 introduces the “NIST SP 800-171 DoD Assessment Methodology” requirement. This requirement enables a strategic assessment of a contractor’s implementation of the NIST SP 800-171 requirements as required in DFARS clause 252.204- 7012. The DoD Assessment Methodology requirement flows down to subcontractors (CDRL A090 System Security Plan and Associated Plans of Action for a Contractor’s Internal Unclassified Information System).

PWS

Section 6, Para 6.5.2 The contractor provides a deliverable CDRL A090 System Security Plan and Associated Plans of Action for a Contractor’s Internal Unclassified Information System.

Zero deviation from the standard 100% inspection.

Review of annual reports to ensure completeness.

Standard

For the initial submission: The contractor shall provide a bracketed copy of the original signed, executed contract with attachments and exhibits.

Indicate with brackets, the information proposed as exempt from release, if any, and cite the applicable FOIA Exemption(s) invoked within each bracketed area, pursuant to 5 USC § 552. The brackets may be made electronically or hand marked and the proposed FOIA Exemptions written in the margins.

For the subsequent submission: The contractor shall provide a copy of the original signed, executed contract, attachments, and exhibits, with the modifications incorporated into the original contract as a conformed contract. The contractor shall identify the last modification (P00NNN and date) incorporated into the contract. Indicate with brackets, the information proposed as exempt from release, if any, and cite the applicable FOIA Exemption(s) invoked within each bracketed area, pursuant to 5 USC § 552. The brackets may be made electronically or hand marked with the proposed FOIA Exemptions written in the margins.

Freedom of Information Act (FOIA) Releasable Contract. Zero deviation from the standard.

100%

Review of quarterly reports and analysis of data

Standard

The contractor shall submit letter of assurance representing that it has conducted its initial or annual Health Insurance Portability and Accountability Act (HIPAA) risk assessment and, if necessary, develop an action plan to address any deficiencies identified, in compliance with Department of Defense (DoD) HIPAA requirements applicable to the contractor.

Risk Assessment Letter of Assurance. Zero deviation from the standard.

100% inspection.

Observation and review of seminar material posted to website

Para 5.1.8 The contractor provides a deliverable CDRL AP010 – Program Management Plan. Zero deviation from the standard.

100%

Observation and interaction with PM

Standard

Section 5, Para 5.1.10.1 The contractor provides a deliverable CDRL AP020 - Internal Quality Management Program (IQMP) Plan. Zero deviation from the standard.

Section 5, Para 5.1.11 The contractor provides a deliverable CDRL AP030 – Continuity of Operations Plan (COOP). Zero deviation from the standard.

100%

Review of quarterly report and feedback from purchased care contractors

Standard

and customer any problems or issues

Monthly Progress feedback; review encountered, and specific

Report. The assigned of FAQs report information on workload task is completed by from contractor during the preceding month to their due date at least substantiate the monthly

98% of the time.

invoice and services rendered

(Adjustments may be in the previous month.

made to due to dates depending on changes to customer requirements).

Para 5.3.6.1.3

Surveillance.

identified harms by trigger and category. In addition, the contractor shall submit a consolidated control chart of progress over time to include

Adverse Events per 1,000

Patient Days; Adverse

Events per 100 Admissions;

and Percent of Admissions with an Adverse Event.

Global Trigger Tool DHA/Market/Service Level Report. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Periodic

Para 5.3.6.1.4

Surveillance.

Military Services. The contractor will list individual data for each site and aggregate data by trigger and category. In addition, the contractor shall include a control charts listing of

Adverse Events per 1,000

Patient Days; Adverse

Events per 100 Admissions;

and Percent of Admissions with an Adverse Event.

Standard

Para 5.3.6.1.5

Surveillance.

each inpatient MTF

(approximately 47 per month). The teleconference shall include a review the

MTFs’ data with the opportunity to ask questions, and further education regarding the GTT as needed. After the initial three months of teleconferences, the contractor shall conduct quarterly teleconferences

(approximately 47 per quarter) with the inpatient

MTFs. For Option Year 2 and beyond, the contractor shall conduct teleconferences on an as-needed basis in coordination with each inpatient MTF.

The contractor shall develop a “Frequently asked

Questions (FAQ)” report based upon the outcomes of these teleconferences.

Para 5.3.6.2.1.2

identified triggers and

Safety Reporting resultant harms with trigger

System MTF analysis.

Reports). The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Standard

Para 5.3.6.2.1.3 a deliverable CDRL M060 Quality and Safety Reporting Surveillance.

System DHA Reports.

The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Para 5.5.2.10

Surveillance.

requested medical records to the reviewer; the findings from the quality and utilization review criteria;

and each private sector care contractor’s responses to the issues (TOM Chapter 7, Section 3).

Para 5.5.2.11 a deliverable CDRL M080 DHA Private Sector Care Quality and Utilization Reviews Performance Report.

The assigned task is completed by their due date at least 98% of the time. (Adjustments Surveillance.

may be made to due to dates depending on changes to customer requirements).

Standard

The contractor shall design and conduct monthly, interactive, web-based seminars on clinical quality topics of interest to the direct and private sector care systems that promote the sharing of leading practices in healthcare quality and safety. The web-based seminars are generally one hour in length and include a chat capability, posting of resources, multiple presenters, and polling questions.

PWS

Section 5 Para 5.8.1.1

Section 5, Para 5.1.10.2 The contractor provides a deliverable CDRL Q010 Internal Quality Management Report.

The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Periodic Surveillance.

5.3.1.3 The contractor provides a deliverable CDRL Q020 HEDIS® Consultation and Education. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Periodic Surveillance.

Standard

5.3.2.1.4

The contractor shall develop a quarterly briefing with slides for presentation which includes a statistical comparative analysis with identification of top performing hospitals and those needing improvement based on DoD and CMS national performance rates for each quality measure complete with displays by MHS, direct care and private sector care.

PWS

Section 5, Para 5.3.2.2.2 The contractor provides a deliverable CDRL Q040 CMS Hospital/Care Compare Measures Report. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Periodic Surveillance.

Section 5, 5.3.2.2.4 The contractor provides a deliverable CDRL Q050 CMS Hospital/Care Compare Measures Raw Data File. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Periodic Surveillance.

Standard

Para 5.3.3.2.2

Surveillance.

The Joint Commission’s

Direct Data Submission

Platform (DDSP) or other designated Joint

Commission Platform according to Joint

Commission to support MTF

TJC accreditation. If the contractor fails to submit

ORYX® data on time, the

Government shall assess the performance guarantee identified in Section H, paragraph 1.

Para 5.3.3.6

Surveillance.

comparative analysis between TJC national performance rates and available benchmarks for each clinical performance measure. The analysis shall include performance comparisons with statistical significance, measure improvement or decline quarter over quarter, and comparison between like sized MTFs.

Standard

Para 5.3.4.2 a deliverable CDRL Q080 Administrative Measure Validation Report. The assigned task is completed by their due date at least Surveillance.

98% of the time.

(Adjustments may be made to due to dates depending on changes to customer requirements).

the results of the abstractions and validation of the data.

The contractor shall report Section 5, Para 5.3.5.4.5

Surveillance.

findings stratified by the

MHS, Market and MTF for each MTF participating in the Leapfrog Hospital

Survey, Leapfrog

Ambulatory Surgery Survey and Leapfrog Safety Grade.

Para 5.3.5.4.5.2 a deliverable CDRL Q100 Leapfrog Administrative Measure Validation Surveillance.

Data File. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Standard

Section 3, Para 3.4.1

Section 5, para 5.4.4

The contractor shall conduct medical necessity reconsideration reviews and issue decisions per TOM Chapters 12 and 24. These reviews and decisions shall be in accordance with the waiver of liability provisions in TPM Chapter 1, Section

4.1 These reviews shall include medical necessity appeals from the private sector care contractors identified in paragraph 1.3, and MTFs (including those from ADSMs).

PWS

Section 5, Para 5.5.3.1

Standard

Para 5.5.4.1

Surveillance.

(OGC) Appeals and

Hearings in accordance with

Section J, Attachment J-6, Appeals &

Hearings Internal and

External Reviews and

Hearing Support.

requirements).

Periodic

Para 5.5.4.1

Surveillance.

(OGC) Appeals and

Hearings in accordance with

Section J, Attachment J-6, Appeals &

Hearings Internal and

External Reviews and

Hearing Support.

Para 5.5.5.1 a deliverable CDRL R060 Standard of Care Review. The assigned task is completed by their due date at least Surveillance.

98% of the time.

(Adjustments may be made to due to dates depending on changes to customer requirements).

Standard

5.5.6.5 The contractor provides a deliverable CDRL R070 Ad HOC Medical Record Reviews Report. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Periodic Surveillance.

5.6.1.5 The contractor provides a deliverable CDRL R080 Quality Improvement Studies Report. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

100% Inspection.

Section 5, Para 5.7.3 The contractor provides a deliverable CDRL R090 Assessments of Evolving Practices, Devices, Medicines, Treatments and Procedures Report.

The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

100%

Standard

Section 5 Para 5.8.2.2 The contractor provides a deliverable CDRL R100 Meeting Support. The assigned task is completed by their due date at least 98% of the time. (Adjustments may be made to due to dates depending on changes to customer requirements).

Periodic Surveillance.

of the time.

100%

2.12.3 & TOM Ch. 1 Sec. 5 In a breach situation, the contractor provides a devliverable CDRL R120 Breach Report. The assigned task is completed as stipulated in Section H, paragraph 2.12.3 100%

The contractor shall complete the Declaration of Transfer and Destruction of Records in accordance with attached template.

completed by due date 100% of the time.

100%

Standard

The contractor shall develop and execute a transition-out plan to facilitate the accomplishment of a seamless transition from the incumbent to an incoming contractor/Government personnel at the expiration of the contract IAW CDRL 0T020 Transition-Out Plan.

The contractor shall keep the COR informed on its progress during transition-in via a weekly report including key transition milestones and issues submitted in an electronic format and by a method (e.g., email, fax) agreed to by the COR

Standard

Transition-Out Status Report. The assigned task is completed by due date 100% of the time.

100%

5.0 INCENTIVES:

5.1 As defined in the Section H, Special Contract Requirements, paragraph 1.0, Performance Guarantees, the government will assess performance guarantees to the Section C, tasks defined in paragraphs 6.3.3 and 6.5.

6.0 METHODS OF QA SURVEILLANCE:

6.1 Various methods exist to monitor performance. The COR may use the surveillance methods listed below in the administration of this QASP.

6.2 Regardless of the surveillance method, the COR will contact the contractor's designated point of contact when a defect is identified and inform the manager of the specifics of the problem. The COR shall be responsible for monitoring the contractor’s performance in meeting a specific performance standard/AQL.

a. Direct Observation: (Can be performed periodically or through 100% surveillance.)

· Study work products including methodology, IRB approval, Data Use Agreement, Reports, manuscript and educational materials provided to appropriate recipients in a complete and timely manner

· Meeting support for MHS Quality Forum, Risk Management, Clinical Measures Steering Panel, Scientific Advisory Panel, Perinatal Advisory Group, Infection Prevention and Control Panel, and Medical Directors’ Forum completed on time

· On-line educational materials from the studies developed and posted timely

· Behavioral Health Facility surveys complete and well-written with appropriate recommendations for certification, recertification or decertification

· Standard of Care reviews and reconsideration reviews performed by appropriate peer reviewers within prescribed timelines

b. Management Information Systems (MIS): (Evaluates outputs through the use of management information reports. Best used for general surveillance and may need to be supplemented by periodic inspections.) DHA E-Commerce Extranet Performance Assessment Tool

· Study work products including methodology, , Data Use Agreement, Reports, manuscript and educational materials provided to the Scientific Advisory Panel in a complete and timely manner

c. Periodic Inspection: (Uses a comprehensive evaluation of selected outputs. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

· Availability of secure web-based access

· ORYX® Data Submission to Joint Commission meets accreditation requirements

· Annual HEDIS® audit performed by certified auditor in appropriate manner

d. User Survey: (Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. Appropriate for high quantity activities that have historically been satisfactory. May also generate periodic and 100% inspections.)

· On-line educational materials from the studies develop and post timely.

e. Validated User/Customer Complaints and Compliments: (Relies on the user of the service to identify deficiencies. Complaints are then investigated and validated. Highly applicable to services provided in quantity and where quality is highly subjective.)

· Availability of secure web based access

· ORYX® Data Submission to Joint Commission meets accreditation requirements

f. Progress or status meetings:

· All tasks

g. Analysis of contractor's progress reports: (Evaluate cost, schedule, etc.)

· All tasks

h. Surveillance results may be used as the basis for actions (to include payment deductions) against the contractor: In such cases, the Inspection of Services clause in the Contract becomes the basis for the KO’s actions.

7.0 RATINGS:

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and AQL. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor was highly effective.

corrective actions taken by the contractor was effective.

actions taken by the contractor appear or were satisfactory.

implemented.

element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

8.0 DOCUMENTING PERFORMANCE:

a. Acceptable Performance: The Government shall document positive performance as part of its ongoing surveillance.

b. Unacceptable Performance: Unacceptable performance is contractor performance that is less than satisfactory or fails to meet the stated AQLs or other contract requirements. When unacceptable performance occurs, the COR shall notify the contractor in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion of unacceptable performance with a courtesy copy to the CO and place it in the COR file.

The COR 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 COR will also state how long after receipt the contractor has to present this corrective action plan to the COR. The Government shall review the contractor's corrective action plan to determine acceptability.

The contractor shall acknowledge receipt in writing of the COR’s notification of unacceptable performance. Any COR notifications of unacceptable performance may become a part of the supporting documentation for contract payment deductions, or other actions deemed necessary by the CO.

c. The COR and CO will use all performance documentation to complete the annual contractor’s performance evaluation in the Contractor Performance Assessment Report System (CPARS) per FAR 42.15, Contractor Performance Information.

9.0 FREQUENCY OF MEASUREMENT:

a. Frequency of Measurement:

During contract/task order performance, the COR shall take periodic measurements, as specified in the AQL column of the Performance Standards Summary Matrix, and shall analyze whether the negotiated frequency of measurement is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings:

The COR shall meet with the contractor as often as necessary to assess performance. If performance is less than satisfactory, the COR shall meet more frequently until the contractor’s performance is at least satisfactory. The COR shall document all performance assessment meetings, including the topics discussed, action items and their status until closed. The COR shall provide a copy of performance meetings to the CO

Prepared by:

Signature – Contracting Officer’s Representative

PERFORMANCE REPORT

1. CONTRACT NUMBER:

2. Prepared by: (COR)

3. Date and time of observation:

4. Observation:

Prepared by:

Signature – Contracting Officer’s Representative Date