Attachment V Past Performance Questionnaire.pdf

ATTACHMENT V

PAST PERFORMANCE QUESTIONNAIRE

FOR

BUREAU OF PRISONS MEDICAL SERVICES CONTRACT

REFERENCE IDENTIFICATION

Name of Reference/Activity

(include point of contact)

Address

Phone

Fax

Date Questionnaire Completed

CONTRACT IDENTIFICATION

Contractor Name for whom questionnaire is completed

Contract Number

Contract Type

Period of Performance

Estimated Value of Contract, including all options

Description of Services

Number of BOP locations serviced by this contract

EVALUATION

Below are listed specific questions relating to the following four categories of contractor performance: quality of goods/services, timeliness of deliveries/performance, business relations, and customer satisfaction. Please rate the contractor for each question based on the guidelines provided for each element. There is a comment section provided below each question. Please provide comments for any responses receiving a rating of 2, 1, or 0.

QUALITY OF GOODS/SERVICES

Rating Guideline

+ - Plus The contractor has demonstrated an exceptional performance level that justifies adding a point to the score.

It is expected that this rating will be used in those rare circumstances when contractor performance clearly exceeds the performance levels described as “excellent.”

4 - Excellent There are no quality problems.

3 - Good Nonconformances do not impact achievement of contract requirements.

2 - Fair Nonconformances require minor agency resources to ensure achievement of contract requirements.

1 - Poor Nonconformances require major agency resources to ensure achievement of contract requirements.

0 - Unsatisfactory Nonconformances are compromising the achievement of contract requirements, despite use of agency resources.

Based upon a review of the medical record documentation, to what degree was the care provided to the inmates considered to be appropriate?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what extent did the inmates receive the services for which they were referred?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

To what degree were services provided that were not authorized by the Government?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what extent did the contractor submit invoices which were accurate, properly documented, and billed in accordance with the terms of the contract?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what extent was the evaluation and treatment completely documented, accurate, legible, and of the appropriate content?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what degree were the discharge instructions provided by the attending physicians in sufficient detail to allow subsequent care of the patients?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what degree was the contractor’ s assigned Point of Contact knowledgeable and available for consultation?

TIMELINESS OF DELIVERIES/PERFORMANCE

+ - Plus The contractor has demonstrated an exceptional performance level that justifies adding a point to the score.

It is expected that this rating will be used in those rare circumstances when contractor performance clearly exceeds the performance levels described as “excellent.”

4 - Excellent There are no delays.

3 - Good Delays do not impact achievement of contract requirements.

2 - Fair Delays require minor agency resources to ensure achievement of contract requirements.

1 - Poor Delays require major agency resources to ensure achievement of contract requirements.

0 - Unsatisfactory Delays are compromising the achievement of contract requirements, despite use of agency resources.

Based upon a review of the medical record documentation, to what degree was the medical care provided in a timely manner?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

If applicable, to what degree was the scheduling of appointments completed in a timely manner, given the urgency of the referrals?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what extent were appointments for specialty care generally available within 14 calendar days from date of referral to the specialty provider (or as specified in the contract)?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what degree were invoices received within 90 calendar days after an inmate’ s discharge or outpatient encounter (or as specified in the contract)?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

When improper invoices were rejected, to what extent were the revised invoices resubmitted within 30 calendar days from the date of rejection (or as specified in the contract)?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what degree were written reports by the attending physician documenting the circumstances of the inpatient treatment, outpatient procedure, or other consultation provided to the COTR within ten business days of the inpatient discharge, outpatient procedure, or other consultation (or as specified in the contract)?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what degree did the contractor’ s assigned Point of Contact provide prompt assistance and coordination in the provision of the contract services?

BUSINESS RELATIONS

Rating Guideline

+ - Plus The contractor has demonstrated an exceptional performance level that justifies adding a point to the score.

It is expected that this rating will be used in those rare circumstances when contractor performance clearly exceeds the performance levels described as “excellent.”

4 - Excellent Response to inquiries, technical/service/ administrative issues is effective and responsive.

3 - Good Response to inquiries, technical/service/administrative issues is usually effective and responsive.

2 - Fair Response to inquiries, technical/service/administrative issues is somewhat effective and responsive.

1 - Poor Response to inquiries, technical/service/administrative issues is marginally effective and responsive.

0 - Unsatisfactory Response to inquiries, technical/service/administrative issues is not effective and responsive.

To what extent did the contractor coordinate and integrate the provision of care while the inmate was in a community-based setting?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what degree did the attending physician or coordinator of care respond in a timely manner to requests for information from the HSA, Clinical Director, or other designated POC regarding the health status of the inmate?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what extent did the contractor cooperate with the Government in the review of invoices, answering questions as needed and providing clarifying information?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what extent did the contractor release inmate medical information in a timely manner, and in a manner consistent with applicable law or regulation?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what degree did the contractor facilitate open avenues of communication between the physician, hospital/facility, and the Government regarding patient care and/or administration issues?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

To what extent was the contractor effective in interfacing with BOP Health Services staff?

CUSTOMER SATISFACTION

+ - Plus The contractor has demonstrated an exceptional performance level that justifies adding a point to the score.

It is expected that this rating will be used in those rare circumstances when contractor performance clearly exceeds the performance levels described as “excellent.”

4 - Excellent Complete satisfaction with performance/end result/product.

3 - Good Infrequent performance issues cause overall satisfaction with performance/end result/product to be high.

2 - Fair Minor performance issues cause overall satisfaction with performance/end result/product to be moderate.

1 - Poor Frequent performance issues cause overall satisfaction with performance/end result/product to be low.

0 - Unsatisfactory Complete dissatisfaction with performance/end result/product.

What is the overall level of satisfaction with the hospital/facility services provided?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

What is the overall level of satisfaction with the physician services provided?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

What is the overall level of satisfaction with the invoicing/billing performed by the contractor?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

What is the overall level of satisfaction with the contractor’ s management of medical record information?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

What is the overall level of satisfaction with the contractor’ s communication efforts?

[ ] 4 [ ] 3 [ ] 2 [ ] 1 [ ] 0 [ ] N/A

Comment: ________________________________________________________________

Would you recommend this contractor for the award of additional contracts based on the contract services provided?

[ ] Yes [ ] No