Quality Assurance Surveillance Plan-NorCal.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

HOME OXYGEN SERVICES

This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contractor actions while implementing this Performance Work Statement (PWS). It is designed to provide an effective surveillance method of monitoring contractor performance for the objectives listed in this service contract.

The QASP is based on the premise the Government desires to maintain a quality standard in Home Oxygen services and that a contract to provide this service is the best means of achieving that objective.

The Contractor, and not the Government, is responsible for management and quality control actions to meet the terms of the contract. The role of the Government will be to monitor quality assurance to ensure contract standards are achieved.

In this contract, the quality control program is the driving force for product quality. The Contractor is required to develop a comprehensive program of inspections and monitoring actions. The first major step to ensuring a “self-correcting” contract is to ensure that the quality control program approved at the beginning of the contract provides the measures needed to lead the Contractor to success.

Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document will ensure a robust quality assurance program.

Category ID

PERFORMANCE

Indicator

MEASURES

Standard

Acceptable

Quality Level

Method of

Surveillance

Patient

Information

Return

(Timeliness)

Notification when

Patient refuses service

NUM: # reported to COR within

24 hours

DEN: Total # of refusals of service each quarter

90% or greater compliance with

COR notification within 24 hours

Electronic log kept by COR

PERFORMANCE

Indicator

MEASURES

Standard

Acceptable

Quality Level

Method of

Surveillance

Notification when

Patient Declines back up system

NUM: # reported to COR within

24 hours

DEN: Total # declinations for back-up services each quarter

90% or greater compliance with

COR notification within 24 hours

Electronic log kept by COR

For emergency service cases NOT provided within 6 hours of request, COR notified within

2 business days

NUM: # reported to COR within 2 days emergency services NOT provided within

6 hours of request quarterly

90% or greater compliance with

COR notification within 2 days

Electronic log kept by COR

90-Day assessment and report

NUM: # with current 90 Day assessment documented

DEN: # required for 90 Day assessment

90% or greater compliance with provision of 90

Day assessment

Electronic log kept by COR

Semi-annual reports provided

Semi-annual reports provided on or before the

8th calendar day of the 6th and 12th months each year

Met or Not Met

Vendor provision of semi-annual reports to COR

PERFORMANCE

Indicator

MEASURES

Standard

Acceptable

Quality Level

Method of

Surveillance

Access

(for all outpatient services)

(Volume)

Initial set-ups provided within 24 hours of request

NUM: #

provided within

24 hours of request

DEN: # of initial set-ups required with 24 hours of request

90% or greater compliance with initial set-up within 24 hours

Electronic log kept by COR

Emergency services provided within 6 hour of request

NUM: #

provided within

6 hours of request emergency services requested

95% or greater compliance

Electronic log kept by COR

Quality of

Care

All equipment has preventative maintenance (PM) performed at least once a year or more often in accordance with manufacturer recommendations.

NUM: # with completed PM

DEN: Total # equipment items on the inventory list due for PM

95% or greater

PM list provided to

COR by vendor

5%,10%,15%,20% reduction based on results

PERFORMANCE

Indicator

MEASURES

Standard

Acceptable

Quality Level

Method of

Surveillance

Evidence of initial and ongoing competency of all staff providing delivery/recovery and patient education services through this contract.

NUM: # with documented current competency contracted employees providing delivery/recovery and patient education services

95% or greater compliance with current competency record

Competency report provided by vendor to COR annually

Patient

Safety

A complete home safety assessment is performed at time of set-up and again during home visits, to include:

presence/functioning smoke alarm, fire extinguisher, education about smoking & oxygen use, no smoking signage, cognitive impairment that could affect oxygen use, electrical cords

/ outlets, proper storage of oxygen tanks & provision of tank holders, fall risks, education about fall prevention

NUM: # with current and complete home safety assessment

DEN: # of total patients requiring current and completed home safety assessment

90% or greater compliance with documented complete home safety assessment

COR random home visits

PERFORMANCE

Indicator

MEASURES

Standard

Acceptable

Quality Level

Method of

Surveillance

The patient has documented educated about

Emergency

Preparedness to include: escape route, back-up supply / equipment

NUM: # with documented education about

Emergency

Preparedness and home oxygen equipment

DEN: # total number of patients requiring

Emergency

Preparedness and

Home Oxygen equipment

90% or greater compliance with documented education related to Emergency

Preparedness

COR random home visits

Infection control reports will be sent to the COR on a semi-annual basis.

Semi-annual reports received on or before the

8th calendar day of the 6th and 12th months each year and analyzed by facility Infection

Control

Preventionist

(ICP).

There are no trends noted by facility ICP

Analysis of vendor-provided infection control report by facility ICP

Critical events reported to COR, including:

Sentinel events, observed /reported falls, patient abuse/neglect, and oxygen mishaps.

NUM: # reported to COR within

24 hours of the event

DEN: # known critical events quarterly

95% or greater compliance with reporting critical events within 24 hours

Electronic log kept by COR

PERFORMANCE

Indicator

MEASURES

Standard

Acceptable

Quality Level

Method of

Surveillance

Patient

Satisfaction

Customer

Satisfaction report results provided quarterly

Quarterly reports shall be received on or before the

8th calendar day of each quarter.

Trends identified.

Action plan implemented for any adverse trends.

Specific grievances reported and resolved within 5 days.

Quarterly reports of vendor to the COR

SURVEILLANCE: Contracting Officer’s Representative (COR) or authorized VA designee shall monitor the contractor performance through random home visits to ensure Contractor is providing service in accordance with the contract requirements. COR/designee will monitor equipment PM‘s at least on a quarterly basis and more frequently as needed. COR/designee will monitor set-ups and reports to ensure the Contractor has complied with the contract requirements. The VA and the Contractor will establish quarterly conference calls and/ or meet face to face or more frequently as needed to discuss and resolve non-performance issues and discuss ways to improve patient care and service.

STANDARD: The Contractor shall perform all work required in a satisfactory manner in accordance with the

Performance Work Statement (PWS). The COR or authorized VA designee shall not consider the services complete until all deficiencies have been corrected.

PROCEDURES: The COR or authorized VA designee will review all performance objectives at least quarterly and/or more frequently as needed to ensure Contractor compliance with the appropriate paragraphs of the PWS. The COR/designee will record results of review, noting the date and time of review. If the review indicates unacceptable performance, notify the contract manager or the Contractor’s Quality Control Inspector

(QCI) of the deficiencies for correction. The Contractor shall be given two (2) hours after notification to correct the unacceptable performance or the COR/designee may approve additional time if the COR/designee considers additional time appropriate. If the deficiencies are not corrected within the required time frame the

COR/designee shall notify the Contracting Officer for action.

HOME OXYGEN CONTRACT ROLES AND RESPONSIBILITIES

Scope/Type of Service VAMC Contracted Provider

1. Role and responsibilities of the organization and the contracted provider in:

a. Patient Admission

Process

Clinical coordinator or designee reviews, verifies medical need, obtains physician order, and contacts contracted oxygen provider.

Contractor will furnish oxygen supplies, equipment, and services to VA beneficiaries for the applicable VA

Medical Centers and Health Care

Centers during the period of the contract.

b. Patient Assessment

Process, initial and ongoing

Service provided solely by VA staff, Pulmonary/respiratory

Contractor, as part of the initial delivery protocol, completes the initial equipment assessment and provides education on equipment use and care, safety, patient rights and responsibilities, etc.

Contractor will provide ongoing assessment report related to equipment use, condition, and education every 3 months.

c. Plan of Care, development, review and revision

Service provided solely VA staff, pulmonary/respiratory.

d. Plan of Service, equipment, maintenance, refills

Service provided solely by Contractor. Contractor is responsible for developing, reviewing, and revising the patient's plan of service. The Plan of service will be maintained at the Contractor’s local office providing service to the VA beneficiary and will be developed, reviewed, and revised per contract.

e. Scheduling care or services

Clinical Coordinator and or COR will schedule with the contract vendor and home visits with the patient in keeping with the most current VHA Directive on

Home Oxygen Therapy.

Contractor is responsible for scheduling services with VA beneficiaries.

Scope/Type of Service VAMC Contracted Provider

f. Discharge Planning

(f.1) Discontinuing therapy

Clinical Coordinator or designee, either by direct notification from physician, death of the beneficiary, or reassessment no longer qualifies patient for therapy, will contact the contracted provider to discontinue therapy.

Contractor will notify patient/family and arrange time for pickup of equipment.

g. Patient Privacy and

IT Security

VA will abide by local policy related to patient privacy and record security

Contractor is responsible for maintaining the integrity of the VA Beneficiary’s patient records and compliance with The

Joint Commission Standard related to patient confidentiality and privacy.

2. Documentation requirements and time frames

Service provided solely by the

Contractor

Contractor will maintain a complete record of services provided to VA beneficiaries to meet current Joint

Commission Standards and as stipulated in the contract. The Contractor will maintain this documentation in the VA beneficiary’s folder.

3. Monitoring, evaluating, and auditing of contracted care and/or services.

Clinical COR and/or Administrative

COR will make scheduled and unscheduled on-site Contractor and home oxygen patient visits, on at least a quarterly basis, to monitor the contracted provider's performance under this contract.

Contractor agrees to make available all records and documentation necessary to perform these reviews.

4. Responsibility of contracted provider to comply with applicable organization policies and personnel qualifications

Policies: Clinical COR and/or

Administrative COR will review the

Contractor’s policies/procedures for compliance with VA policies/procedures and Joint Commission Standards.

Contractor agrees to make available all records and documents necessary per the

Contract.

Contractor is responsible for policy and personnel compliance with current Joint

Commission Standards.

5. Procedures for determining charges and reimbursement

VISN purchasing agents review monthly bills from the contracted provider for appropriate charges.

Contractor will submit billing reports monthly as stipulated in this contract.

Scope/Type of Service VAMC Contracted Provider

6. Terms of agreements and conditions for renewal or termination

Government may extend the term of this contract by written notice to Contractor.

The total duration of this contract, including the exercise of any options under this clause, shall not exceed 5 years.

Termination for the Government's convenience: Government reserves the right to terminate this contract for its sole convenience.

Termination for cause: Government may terminate this contract for cause in the event of any default by the

Contractor.

Reference: Comprehensive Accreditation Manual for Home Care (CAMHC,) current edition; LD.11