S02. Attachment D.6 - Franklin CBOC QASP-Final.pdf

ATTACHMENT D.6 – Franklin CBOC

Quality Assurance Surveillance Plan (QASP) Outpatient Site of Care Service (FRANKLIN CBOC)

Contract Number: (TBD)

Contractor’s name: (TBD)

Time Period (Quarter): (TBD)

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: Billy Morris, Contracting Officer Organization or Agency: Department of Veterans Affairs, Network Contracting Office 16 (NCO 16)

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: Richard Breaux Alternate POC: TBD

3. CONTRACTOR REPRESENTATIVES

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

Primary: (TBD – Contractor fill-in) ___________________ Alternate: (TBD – Contractor fill-in) ___________________

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.

To be paid the full capitated rate on the schedule, the contractor must 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.

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. Method not applicable

b. PERIODIC INSPECTION. Applies to 4.9.1, 4.9.2, 4.9.3, 4.9.4, 4.9.8, 4.9.9, 4.9.10, 4.9.11, 4.9.12, 4.9.13, 4.9.14, 4.9.15, 4.9.16 – VA will monitor using Electronic report using data from VA VISTA/CPRS system.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Method not applicable; however, they will be provided to contractor if report received.

d. RANDOM SAMPLING. Applies to 4.9.5, 4.9.6, 4.9.7 – VA will monitor using Electronic report using data from VA VISTA/CPRS system.

e. Verification and/or documentation provided by Contractor. Contractor may report to COR or CO has needed/required.

6. Measures- PACT CBOC

TASK PWS

Para

Performance Requirement Standard Acceptabl e Quality Level

Method of Surveillance and frequency

CLINICAL

REMINDERS

PWS

para.

4.9.1

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

- 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

90% Proper documentation and completion of all clinical reminders as they appear during a patient’s visit

90% completion of clinical reminders each month.

VA will monitor progress thru automated reports. (VHA SAIL report) Periodic Sampling VA will monitor using Electronic report using data from VA VISTA/CPRS system. VA will send these reports monthly to the contractor to notify them to their current performance

-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

NEW PC

PATIENT WAIT

TIME

PWS

para.4.

9.2

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

New Patient Wait times 100% within 30 days from the preferred date.

100% monthly new patient wait times within 30 days from the preferred date.

VHA SAIL or PACT COMPASS Report. (monthly) Periodic Sampling VA will monitor using Electronic report using data from VA VISTA/CPRS system.

Contractor can check status of their performance by running reports in

VISTA/CPRS as frequently as needed.

ESTABLISHED

PC PATIENT

WAIT TIME

PWS

para.4.

9.3

Established Primary Care Completed Appointments less than or equal to 30 days from Preferred Date (patient desired date) or the clinically indicated date.

Established

(100%) PC

Patient primary care appointments completed within thirty

(30) days from Preferred Date (patient desired date) or the clinically indicated date.

monthly established

PC

appointme nts completed no later than 30 days from Preferred Date (patient desired date) or the clinically indicated date.

VHA SAIL Report Frequency:

Monthly. Contractor can check status of their performance by running reports in VISTA/CPRS as frequently as needed.

SAME-DAY

APPTS W/ PCP

PWS

para.4.

9.4

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 appointme nts with

PCP

Periodic Inspection audit of PACT Compass (Quarterly)

CLINICAL

ENCOUNTERS

PWS

para.4.

9.5

Providers must complete proper documentation for each patient visit.

Documentatio n must be complete for all fields including whether or not 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.

100% 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 their current performance.

PHARMACY PWS

para.4.

9.6

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).

100% (no more than 10% disapprova l 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 them to their current performance.

PHARMACY

NEW DRUG

ORDER

REQUESTS

PWS

4.9.7

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

100% of new drug order requests follow all prescribing guidelines.

This is including but not limited to ensuring all appropriate labs have been previously

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 their current performance.

that the order is not a non-formulary drug ordered and that the order is not a non-formulary drug

PACT

PATIENTS

ENROLLED IN

HOME

TELEHEALTH

PWS

para.4.

9.8

The aggregate percentage of all patients enrolled in Home Telehealth (HT) will exceed

2.3%

Contractor to maintain greater than 2.3% of required enrolled patients in

HT.

2.3% of required enrolled patients enrolled in

HT

VA will monitor using Electronic report using data from PACT Compass.

VA will monitor progress quarterly (non-cumulative) thru automated reports.

PCMHI

PENETRATION

PWS

para.4.

9.9

Contractor reports PCMHI Penetration that uses patients assigned to a PACT team as the cohort (instead of core uniques with a primary care encounter).

Contractor to exceed 8.5 % of required enrolled patients in

PCMHI.

Contractor to maintain at least 8.5% of required enrolled patients in

PCMHI.

VA will monitor using Electronic report using data from the PACT Compass.

VA will monitor progress quarterly (non-cumulative) thru automated reports.

RATIO OF NON-

TRADITIONAL

ENCOUNTERS

4.9.10

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 25% in the appropriate ratio of non-traditional encounters.

Contractor shall maintain at least 25% in the appropriate ratio of non-traditional encounters.

VA will monitor using Electronic report using data from the PACT Compass.

VA will monitor progress

POST

DISCHARGE

CONTACT BY

PACT TEAM

PWS

para.

4.9.11

Number of discharges with follow-up contact by a member of the assigned PACT Team within two business days of discharge.

Contractor assigned PACT Team member shall exceed 78% of patients within two business days of discharge.

Contractor assigned

PACT

Team member shall contact at least 78% of patients within two business days of discharge.

VA will monitor using Electronic report using data from the PACT Compass.

VA will monitor progress

PCMH SHEP

ACCESS

COMPOSITE

PWS

para.

4.9.12

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% Exceed 50%

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

RATING OF PCP

by Patients per

SHEP [SHEP

Q32]-Provider rating

PWS

para.

4.9.13

Outpatients responding to the PCMH survey Question #32: “Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?” and answering 9 or 10.

Greater than 75% of patients need to answer 9 or

Greater than 75% of patients need to answer 9 or 10.

PCMH SHEP – Rating of PCP. VA will monitor progress monthly thru automated reports.

PACT 19:

PCP

CONTINUITY

4.9.14

Patients see same PCP for appointments

77% of appointments provided with assigned PCP

At least 77% of appointme nts provided with assigned

PCP

VA will monitor using Electronic report using data from the PACT Compass.

VA will monitor progress quarterly (non-cumulative) thru automated reports.

PCMH SHEP

Days Waiting for Urgent Appt (Q7)- Access Related

PWS

para.

4.9.15

Outpatients responding to the PCMH survey Question #7: “In the last 6 months, how many days did you usually wait for an appointment when you needed care right away?

Greater than 42% of patients need to answer 9 or

At least 42% of patients need to answer 9 or 10

PCMH SHEP – Days Waiting for Urgent Appointment. VA will monitor progress monthly thru automated reports.

PCMH SHEP

Staff Discuss Patient’s Stress (Q40)

PWS

para.

4.9.16

Outpatients responding to the PCMH survey Question #40: In the last 6 months, did you and anyone in this provider’s office talk about things in your life that worry you or cause you stress?

Greater than 62% of patients need to answer 9 or

Greater than 62% of patients need to answer 9 or 10

PCMH SHEP –

COMPRESHENSIVENESS

– Discussing patient stress.

VA will monitor progress monthly thru automated reports.

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.

Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the GOVERNMENT. However a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also there should have been NO significant weaknesses identified.

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.

Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the GOVERNMENT. Also there should have been NO significant weaknesses identified.

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.

Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also there should have been NO significant weaknesses identified.

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.

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g,. Management, Quality, Safety or Environmental Deficiency Report or letter).

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.

Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the GOVERNMENT. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g. Management, Quality, Safety or Environmental Deficiency Reports, or letters).

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 Report (CR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CR in writing. The CR 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 CR will also state how long after receipt the contractor has to 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 CRs 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

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY CONTRACTOR: c. ACTION COMPLETE

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER