S02 ATTACHMENT EIGHT 8 QASP.pdf

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 monitoring will take place.

• Who will conduct the monitoring?

• How monitoring efforts and results will be documented.

2. 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.

Assigned CO: Mechelle Reaser

Organization or Agency: Department of Veterans Affairs, Network Contracting Office 8

Phone: (813) 972-2000 Ext. 7541

Email: Mechelle.Reaser@va.gov

b. 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: Ruben Rivera-Rivera

Organization or Agency: Department of Veterans Affair, VA Caribbean Healthcare System

Phone: 787-641-7582 Ext/ 34997

Email: Ruben.Rivera-Rivera@va.gov

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary: TBD

Alternate: TBD

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.

mailto:Mechelle.Reaser@va.gov mailto:Ruben.Rivera-Rivera@va.gov

To be paid the full capitated rate on the schedule, the contractor shall provide services as required in the entire contract and to meet or exceed the acceptable quality level outlined in this section/sub-sections. 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 52.212-1.

Performance standards define desired services. The Government performs surveillance to determine the level of

Contractor performance to these standards.

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. The performance measures and goals are subject to change.

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.

a. DIRECT OBSERVATION. 100% surveillance

b. PERIODIC INSPECTION.

c. VALIDATED USER/CUSTOMER COMPLAINTS

d. RANDOM SAMPLING

6. Measures

PACT Outpatient Clinic QASP

TASK PWS Para Performance

Requirement

Standard Acceptable

Quality Level

Method of

Surveillance and frequency

1.CLINICAL

REMINDERS/

QUALITY

MEASURES

PWS para. 4.6.3;

4.6.26;

4.11.1.

VISTA/CPRS will automatically remind providers to complete clinical reminders during patients visits including but not limited to:

-Alcohol Use Screen

-Alcohol Audit-C Pos F/U

Eval

-Depression Screening

- Evaluation of Positive

Depression Screening

-PTSD Screening

-Evaluation of Positive

PTSD Screening

-Antipsychotic Med Side

Eff Eval

-MH High Risk No-Show

Follow-Up

-MHTC Needs Assignment

-MST Screening

-Breast Cancer Screening

-Clinical Review of

Mammogram Results and

Patient Notification

90% of the measures meet the

National Score.

75% of the measures meet the National

Score.

VA will monitor progress monthly thru automated reports: EPRP

Reviews, Clinical

Reminder Reports, eQM. Periodic

Sampling VA will monitor using

Electronic report using data from VA

VISTA/CPRS

system. VA will send these monthly reports to the contractor to notify them to their current performance

- Whether to Begin Breast

Cancer Screening In 40's Or to Wait Until Age 50

-Cervical Cancer Screening

-Clinical Review of Pap

Smear Results and Patient

Notification

-Tobacco Counseling by provider

-Tobacco Counseling

-Iraq & Afghan Post

Deploy

-Polytrauma Marker

-TBI /Polytrauma

Rehab/Reintegration

-TBI Screening

-AAA Screening

-Embedded Fragments

Screen

-Embedded Fragments Risk

Evaluation

-Project Arch

-Hep C Risk Assessment

-Homelessness Screening

-HTN Assessment Bp

>=140/90

-HTN Assessment Bp

>=160/100

-HTN Lifestyle Education

-IHD Lipid Profile

-Lipid Statin Rx Cvd/Dm

-Influenza Immunization

-Pneumovax

-Colorectal Ca Screening

-FOBT Positive F/U

-Diabetes Eye Exam

-Diabetes Foot Exam

2. PC 14:

NEW PC

PATIENT

WAIT TIME

PWS para.

4.11.2.

All new patients requesting an appointment for any clinic must receive an appointment in a timely manner.

New Patient Wait times 100% within

20 days from the preferred date.

90 % monthly new patient wait times within 20 days from the preferred date.

VHA SAIL or PACT

COMPASS Report http://reports2.vssc.m ed.va.gov/reportserve r?%2fMgmtReports

%2fVATR%2fSAIL_

Prod%2fSAIL&rs:Co mmand=Render, Periodic Sampling

VA will monitor using Electronic report using data from VA

VISTA/CPRS

system. Frequency:

Monthly

Contractor can check status of their performance by running reports in

VISTA/CPRS as frequently as needed.

3.

ESTABLISHED

PWS para. 4.11.3. Established Primary Care

Completed Appointments

Established

(100%) PC Patient

100 % monthly established PC

VHA SAIL Report http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render

PC PATIENT

WAIT TIME

(PC 17)

less than or equal to 20 days from Preferred Date

(patient desired date) or the clinically indicated date.

primary care appointments completed within twenty (20) days from Preferred

Date (patient desired date) or the clinically indicated date.

appointments completed no later than 20 days from Preferred

Date (patient desired date) or the clinically indicated date.

http://reports2.vssc.m ed.va.gov/reportserve r?%2fMgmtReports

%2fVATR%2fSAIL_

Prod%2fSAIL&rs:Co mmand=Render, Periodic Sampling

VA will monitor using Electronic report using data from VA

VISTA/CPRS

system.

Frequency:

Monthly. Contractor can check status of their performance by running reports in

VISTA/CPRS as frequently as needed.

4.SAME-DAY

APPTS W/ PCP

PWS para. 4.11.4.

Same day face-to-face appointments with primary care provider

70% completion of same day primary care appointments with PCP

70 % completion of same day primary care appointments with PCP

Periodic Inspection audit of PACT

Compass https://securereports2

.vssc.med.va.gov/Rep ortServer/Pages/Repo rtViewer.aspx?%2fP

C%2fPACTCompass

CubeSSRS%2fMain

Menu&rs:Command

=Render

5.CLINICAL

ENCOUNTERS

PWS para. 4.11.5. Providers must complete proper documentation for each patient visit.

100%

Documentation must be complete for all fields including whether the patient is service connected.

The CPT and provider codes must match, and codes must accurately reflect complexity of visit.

Complete documentation must be completed before the 18th of each month.

95% completion of clinical encounters each month.

Random Sampling

(auditing) VA will monitor using

Electronic report using data from VA

VISTA/CPRS

system.

VA will monitor progress weekly thru automated reports.

VA will send these weekly reports to the contractor to notify them to their current performance.

6.PHARMACY PWS para. 4.6.9;

4.6.10;

4.11.6.

Contractor shall submit a non-formulary and restricted drug request in

CPRS using the PBM consult option.

100% (zero disapproval ratings for non-formulary and restricted drug requests quarterly).

90% (no more than 10% disapproval ratings for non-formulary and restricted drug requests quarterly).

Random Sampling

VA will monitor using Electronic report using data from VA

VISTA/CPRS system

VA will monitor progress monthly thru automated reports. VA will send these monthly status reports to the contractor to notify http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render

7.PHARMACY

NEW DRUG

ORDER

REQUESTS

4.6.10.8.

Contractor shall submit new drug orders through

CPRS to VA

100% The contractor shall ensure that all new drug order requests follow all prescribing guidelines. This is including but not limited to ensuring all appropriate labs have been previously ordered and that the order is not a non-formulary drug

90% of new drug order requests follow all prescribing guidelines. This is including but not limited to ensuring all appropriate labs have been previously ordered and that the order is not a non-formulary drug

Random Sampling

VA will monitor using Electronic report using data from VA

VISTA/CPRS system

VA will monitor progress quarterly thru automated reports. VA will send monthly status reports to the contractor to notify

8.PATIENTS

ENROLLED IN

HOME

TELEHEALTH

4.11.7

The aggregate percentage of all patients enrolled in

Home Telehealth (HT) will exceed 1.6%

Contractor to maintain greater than 1.6% of required enrolled patients in HT.

1.2% of required enrolled patients enrolled in HT using Electronic report using data from PACT

Compass.

VA will monitor progress quarterly

(non-cumulative) thru automated reports.

9.RATIO OF

NON-

TRADITIONAL

ENCOUNTERS

PWS para. 4.11.8. The sum of all PC

Telephone encounters added to the sum of all PC

Group Encounters added to the sum of all incoming and outgoing secure messages as the numerator.

Contractor shall exceed 20% in the appropriate ratio of non-traditional encounters.

Contractor shall maintain at least

18% in the appropriate ratio of non-traditional encounters.

using Electronic report using data from the PACT

Compass.

VA will monitor progress quarterly

(non-cumulative)

10.POST

DISCHARGE

CONTACT BY

PACT TEAM

PWS para.

4.11.9.

Number of discharges with follow-up contact by a member of the assigned

PACT Team within 7 business days of discharge.

Contractor assigned PACT

Team member shall exceed 65% of patients within 7 business days of discharge.

Contractor assigned PACT

Team member shall contact at least 65% of patients within 7 business days of discharge.

VA will monitor using Electronic report using data from the PACT

Compass.

VA will monitor progress quarterly

(non-cumulative)

11.PCMH SHEP

ACCESS

COMPOSITE

PWS para.

4.11.10.

Composite % Based on 3

Questions: 1) Get an urgent care appointment as soon as needed, 2) Get a routine care appointment as soon as needed, and 3) Get same day answer to your medical question.

Exceed 50% 50% respond yes to PCMH

VHA SAIL Quarterly

Report or Patient

Experience Report http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed

7. Ratings:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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.

All AQL’s for the tasks in the QASP are met or exceeded.

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.

AQL for task # 1 is met and 11/13 of the remainder AQL’s are met or exceeded.

12.

APPOINTMEN

T

CANCELLATI

ON

PWS para.

4.11.11.

Contractor shall not unnecessarily cancel patient appointments and will reschedule cancelled appointments in a timely manner.

Cancelled appointments will be rescheduled with patient input and use the original clinically indicated date (CID) or preferred date

(PD) in the desired date

(DD) field. Wait time will be measured from the original CID/PD.

100% of patients seen within 20 days of their original CID/PD.

100% of patients seen within 20 days of their original CID/PD.

Periodic Sampling using Electronic report using data from VA

VISTA/CPRS

system.

VA will monitor progress through quarterly audits using automated reports. Contractor can check the status of their performance by running reports in

VISTA/CPRS

system.

13. PCP

CONTINUITY

4.11.12.

Patients see same PCP for

77% of provided with assigned PCP

75% of appointments provided with assigned PCP

VA will monitor using Electronic report using data from the PACT

Compass.

VA will monitor progress quarterly

(non-cumulative)

14.PCMH 4:

SHEP

PCMHQ38:

DISCUSSED

DIFFICULTIES

IN CARING

FOR SELF

4.11.13.

Weighted number of outpatients responding

"yes" to PCMH Q38

At least 51% respond yes to

PCMH Q38

At least 51% respond yes to

PCMH Q38

VHA SAIL Report or

Patient Experience

Report.

VA will monitor progress quarterly

(non-cumulative)

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.

AQL for task # 1 is met and 9/13 of the remainder AQL’s are met or exceeded.

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.

AQL for task # 1 is not met.

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.

AQL for task # 1 is not met and less than 7/13 of the remainder AQL’s are met or exceeded.

8. DOCUMENTING PERFORMANCE

a. 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 REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, 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.

c. The Government shall notify the Contractor within 60 days, any change in quality measures, quality measures goals or method and frequency of surveillance.

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.

9. FREQUENCY OF MEASUREMENT

a. 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.

b. 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 NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE