P09 QASP.pdf

D. 1 QUALITY ASSURANCE SURVEILLANCE PLAN

1.1. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY

IMPROVEMENT(QI)

1.1.1. Quality Management/Quality Assurance Surveillance: Contractor’s physician(s) shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance: Focused Provider Practice Evaluation (FPPE) and Ongoing Provider Practice Evaluation (OPPE). Contractor performance will be monitored by the government using the standards as outlined in this Performance Work Statement (PWS) and methods of surveillance detailed in the Quality Assurance Surveillance Plan (QASP). The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted.

1.1.2. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. In the event that The Contractor is involved and named in a validated patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel. This does not preclude refusal in the event of incidents involving physical or verbal abuse.

1.1.3. The Government reserves the right to refuse acceptance of any Contractor personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care or interferes with the regular and ordinary operation of the facility. Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. The CO and COR shall deal with issues raised concerning Contractor’s conduct. The final arbiter on questions of acceptability is the CO.

1.1.4. Performance StandardsThe contract provider shall comply with the required standards as outlined in the Performance Work Statement (PWS) and the Quality Assurance Surveillance Plan (QASP). The QASP outlines required standards, defines the methods and frequency of surveillance, and will be a part of the resultant contract.

1.1.4.1. Measure: Provider Quality Performance

Performance Requirement: All Key Personnel shall perform in accordance with clinical standards of care.

Standard: OPPE documentation for all (100%) staf f providing services under the contract. All staf f (100%) meet clinical standards of care.

Acceptable Quality Level: 100% meet Standards Surveillance Method: Periodic Inspection or Random Sampling. OPPE data pertinent to care performed for each provider working under this contract. OPPE data will review the following elements:

A. Patient Care Performance

B. Medical/Clinical knowledge

C. Updated Licensing, registration and certif ication

D. Practiced Based Learning and Improvement

E. Interpersonal and Communication Skills

F. Professionalism

G. System Based Practice

Frequency: OPPE monitoring reports are every eight (8) months.

1.1.4.2. Measure: Qualif ications of Key Personnel

Performance Requirement: All Key Personnel shall be Board Certif ied Anesthesiologists in accordance with American Board of Anesthesiology Standards.

Standard: All (100%) Key Personnel are Board Certif ied Anesthesiologists Acceptable Quality Level: 100% Surveillance Method: Annual review of qualif ication documents Frequency: Reviewed annually

1.1.4.3. Measure: Time and Attendance

Performance Requirement: The Contractor shall provide Key Personnel in accordance with the operating hours and VA clinical schedule outlined in this PWS.

Standard: All (100%) Key Personnel are on time and available to perform services.

Acceptable Quality Level: Key Personnel is on-time and available to perform services 98% of the time Surveillance Method: Inspection of Time and Attendance Sheets Frequency: Monthly

1.1.4.4. Measure: Patient Safety

Performance Requirement: Patient safety incidents shall be reported using VA Patient Safety Reporting System. All incidents reported immediately (within 24 hours).

Standard: All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

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

Surveillance Method: Periodic inspections or random sampling Frequency: Reviewed every three (3) months

1.1.4.5. Measure: Mandatory Training

Performance Requirement: Contractor shall complete all required training on time per facility policy Standard: All (100%) of required training is complete on time by Key Personnel.

Acceptable Quality Level: 90% completions Surveillance Method: Periodic Inspection Frequency: Reviewed every three (3) months

1.1.4.6. Measure: Privacy, Conf identiality and HIPAA

Performance Requirement: Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Conf identiality and HIPAA and complies with all standards Zero breaches of privacy or conf identiality

Standard: All (100%) Key Personnel comply with all laws, regulations, policies and procedures relating to Privacy, Conf identiality and HIPAA Acceptable Quality Level: 100% compliance Surveillance Method: Random Sampling. Contractor shall provide evidence of annual training required by facility, reports violations per VA Handbook 6500.6.

Frequency: Reviewed annually

1.1.4.7. Measure: Clinical Information Documentation

Performance Requirement: Contract physician shall comply with all clinical documentation regulations, policies and procedures for complete and timely clinical documentation.

Standard: Contractor’s physician shall comply with all laws, regulations, policies and procedures relating to patient clinical information documentation.

Acceptable Quality Level: 95% compliance Surveillance Method: Random Sampling of patient records.

Frequency: Reviewed every three (3) months.

D. 1 QUALITY ASSURANCE SURVEILLANCE PLAN