Section D.1 - Quality Assurance Surveillance Plan.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: Yomika Brock, 972-708-0815, Yomika.Brock@va.gov Organization or Agency: Department of Veterans Affairs Central Texas Veterans Health Care System, VISN 17

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: Jennifer Martinez,254-743-2085, jennifer.martinez@va.gov

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Alternate

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs mailto:Yomika.Brock@va.gov mailto:jennifer.martinez@va.gov 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 52.212-4.

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. 100% surveillance: Performance Standards / Measures

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Monthly and random inspections of at least, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints will rely on patient to identify deficiencies.

d. RANDOM SAMPLING. Monthly and Random inspections of at le, ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. Verification and/or documentation provided by Contractor.

6. Measures VHA Contracted Outpatient Clinics Quality Assurance Surveillance Plan (QASP) Template

As of: January 2020

METRIC PWS

Para

Performance Requirement

Standard Acceptable Quality Level (tailor to meet your requirement s)

Method of Surveillance and frequency

Met AQL/Did Not Meet AQL (Add comment)

DOMAIN: ACCESS

New PC Appointments Completed within 20 Days of Create Date

New Primary Care Completed Appointments less than or equal to 20 days from create date

(See the

Cube in Pyramid Analytics for more information)

PWS

para.

4.13.

Contractor shall provide completed appointments for new PC patients <=20 days from the create date

Contractor shall provide completed appointments for new PC patients <=20 days from the create date no less than 61% of the time

Contractor shall provide completed appointments for new PC patients <=20 days from the create date no less than 95% of the time

VA will monitor progress monthly by Periodic Sampling 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.

PACT

COMPASS

https://reports.

vssc.med.va.g ov/ReportServ er/Pages/Repo rtViewer.aspx ?%2fPC%2fP ACTCompass CubeSSRS%2 fMainMenu&r s:Command= Render.

Established PC Patient Average Wait Time in Days

Established Primary Care Completed Appointments less than or equal to 20 days from Patient Indicated Date (patient desired date) or the clinically indicated date

PWS

para.

4.13.

Contractor shall provide completed appointments for established PC patients <=20 days from the patient indicated date

Contractor shall provide completed appointments for established PC patients <=20 days from the patient indicated date no less than 94% of the time

Contractor shall provide completed appointments for established PC patients <=20 days from the patient indicated date no less than 95% of the time progress

VHA SAIL

Report https://reports.

vssc.med.va.g ov/ReportServ er/Pages/Repo rtViewer.aspx ?/MgmtReport s/AdminSAIL/ AdminSAIL Periodic Sampling VA will monitor using Electronic report using data from VA https://pyramid.cdw.va.gov/direct/?id=6b5e3a7b-2720-4496-b9cd-84d50af0509f https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?/MgmtReports/AdminSAIL/AdminSAIL

Cube in Pyramid Analytics for more information)

VISTA/CPRS

system.

Contractor can check status of their performance by running reports in

VISTA/CPRS

as frequently as needed.

PCMHI

Penetration

(PACT21)

The percent of assigned Primary Care patients seen in Primary Care- Mental Health Integration

(PCMHI)

( (AS OF

OCTOBER 1,

2019 THIS

MEASURE

WILL APPLY

TO ALL SITES

REGARDLESS

OF THE

NUMBER OF

UNIQUE

PATIENTS

ASSIGNED).

(See PACT Compass for more information)

PWS

para.

4.13.

Contractor shall involve PCMHI staff in the care of patients with mental health needs

Contractor’s

PCMHI

penetration rate shall meet or exceed 8%

Contractor’s

PCMHI

penetration rate meets or exceeds 8% progress quarterly (non-cumulative) by using data from the

PACT

COMPASS.

COR will send reports to the Contractor and CO quarterly to notify them of current performance.

PCMH SHEP

Access Composite

Composite % based on 3 questions from the

SHEP/PCMH

report: 1) Get an urgent care appointment

PWS

para.

4.13.

Contractor shall provide: 1) urgent care appointments as soon as needed,

2) routine care appointments as soon as needed, and 3) same day answers to patients’ medical questions

Contractor’s SHEP access composite score shall meet or exceed 52%

Contractor’s SHEP access composite score shall meet or exceed 45% progress quarterly by periodic sampling using electronic report using date from

VISTA /

CPRS, EPRP

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

(See

SHEP/PCMH

Report for more information) reviews, and Clinical Reminder report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

https://bioffice .pa.cdw.va.go v/default.aspx ?bookid=e71e 8f03-6829- 403c-b002-b114ae1ac26f %7cispasFalse %7creport842 7c340-7848- 4f27-a2d1- 61dc7dfa3ea1 %7cws1%7cw sb0%7cisDisa bledAnalytics False%7cisDa shboardPanel OnTrue

SHEP

Question 7

In the last 6 months, how many days did you usually have to wait for an appointment when you needed care right away?

(Less is better)

(See

SHEP/PCMH

Report for more information)

PWS

para.

4.13.

Contractor shall provide timely appointments when patients need care right away

Contractor’s

SHEP

question 7 score shall meet or exceed 40%

Contractor’s

SHEP

question 7 score shall exceed 36%.

progress quarterly by Periodic Sampling of

VHA SAIL

Report or Patient Experience Report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.

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https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue 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403c-b002-b114ae1ac26f %7cispasFalse %7creport842 7c340-7848- 4f27-a2d1- 61dc7dfa3ea1 %7cws1%7cw sb0%7cisDisa bledAnalytics False%7cisDa

Same-Day Appts w/ PCP

Measures the percent of requested same day appointments with PCP

(See PACT Compass for more information)

PWS

para.

provide same day appointments with primary care provider

Contractor’s same day appointments with PCP rate shall meet or exceed 62%

Contractor’s same day appointments with PCP rate shall meet or exceed 60% progress quarterly (non-cumulative) by by Periodic Inspection audit of PACT

COMPASS.

https://reports.

vssc.med.va.g ov/ReportServ er/Pages/Repo rtViewer.aspx ?%2fPC%2fP ACTCompass CubeSSRS%2 fMainMenu&r s:Command= Render

Appointment Cancellations

Cancelled by clinic rate for all active clinic stop codes (mop13) (Lower is better)

(See Performance Measure Report for

PWS

para.

4.13.

Contractor shall not unnecessarily cancel patient appointments

Contractor’s rate of appointments cancelled by clinic shall not exceed 10%

Contractor’s rate of appointments cancelled by clinic shall not exceed 10% progress quarterly by Periodic Sampling of audits using automated reports. Contr actor can check the status of their performance by running reports in

VISTA/CPRS

system.

https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue 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://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render more information)

DOMAIN:

QUALITY OF CARE

Composite - Behavioral Health Screening

Composite of mdd40 -- Vets screened annually for major depression dx.

ptsd51 --

PTSD

screening using the PC- PTSD at required times sa17 -- Vets screened for alcohol misuse w/ score GE 5 w/ timely brief counselling sa7 -- Vets screened annually for alcohol misuse sre1 -- (mdd41 and ptsd52) aggregated scores for timely suicide evaluations

(See the CBOC Report for more

PWS

para.

4.13.

Contractor shall complete all behavioral health screenings and follow-up evaluations

Contractor shall maintain a behavioral health composite score of at least 96%

Contractor shall maintain a behavioral health composite score of at least 95% progress monthly by Periodic Sampling using electronic report using data from

VISTA /

CPRS

systems, EPRP reviews, Clinical Reminder Report, and eQM CBOC report. VA will send reports to the Contractor and CO quarterly to notify them of current performance.

https://eqm.va.

gov/COR/#/ho me

Composite – Diabetes

Composite of dmg27h_ec

DM: BP LT

140/90 ( eMeasure ) dmg34h_ec DM: Medical attention for

PWS

para.

manage patients with diabetes in accordance with VA standards

Contractor shall maintain a diabetes composite score of at least 79%

Contractor shall maintain a diabetes composite least 75% progress quarterly by Periodic Sampling using electronic report using data from

VISTA /

CPRS

http://vaww.car.rtp.med.va.gov/programs/pm/pmReportsCBOC.aspx https://eqm.va.gov/COR/#/home nephropathy - Renal Testing (OP)(eMeasur e) statn7_ec Statin therapy for patients with diabetes ( eMeasure )

(See the CBOC Report systems, EPRP reviews, Clinical Reminder report, and eQM CBOC report. VA will send these will send reports to the Contractor and CO quarterly to notify them of current performance.

https://eqm.va.

gov/COR/#/ho

Composite - Ischemic Heart

Composite of ihd53_ec and statn1_ec Statin Therapy for patients with cardiovascular disease (eMeasure)

(See the CBOC Report

4.13.

Contractor shall manage patients with ischemic heart disease in accordance with VA standards

Contractor shall maintain an ischemic heart composite score of at least 78%

Contractor shall maintain an ischemic heart composite least 75% progress monthly by Periodic Sampling using electronic report using data from

VISTA /

CPRS

systems, EPRP reviews, Clinical Reminder report, and eQM CBOC report. VA will send these monthly reports to the contractor to notify them of

Prevention

Composite of dmg31h DM:

PWS

para.

4.13.

Contractor shall provide preventive health care in accordance with VA standards

Contractor shall maintain a prevention composite

Contractor shall maintain a prevention composite

VA will monitor progress monthly by Periodic https://eqm.va.gov/COR/#/home

Retinal exam, timely by disease (OP) p61h Colorectal Cancer Screening Ages 50-75 p42 Cervical Cancer Screening Women age 21-29y p43h Cervical Cancer Screening Women age 30-64 pvc11h Pneumococcal Immunizations

(OP) EPRP

sample p32h Breast Cancer Screening including tomography for Women 50-74y (OP)

HEDIS

(See the CBOC Report least 78% least 74%

Sampling using electronic report using data from

VISTA /

CPRS

systems, EPRP reviews, Clinical Reminder report, and eQM CBOC report. COR will send reports to the Contractor and CO quarterly to notify them of current performance.h ttps://eqm.va.g ov/COR/#/ho

Tobacco

Composite of smg8 Pts using tobacco provided w/counsel

(OP)

smg9 Pts using tobacco offered referral (OP) smg10 Pts using tobacco offered meds

(OP)

4.13.

Contractor shall provide tobacco counseling and care in accordance with VA standards

Contractor shall maintain a tobacco composite score of at least 95%

Contractor shall maintain a tobacco composite least 95% progress monthly by Periodic Sampling using electronic report using data from

VISTA /

CPRS

systems, EPRP reviews, Clinical Reminder report, and https://eqm.va.gov/COR/#/home

CBOC Report eQM CBOC report. VA will send reports to the Contractor and CO quarterly to notify them of current performance https://eqm.v a.gov/COR/#/ home

Clinical Reminders

PWS

para.

4.13.

Contractor shall complete all clinical reminders as indicated in the

VA EHR.

Contractor shall complete no less than 90% of all clinical reminders as indicated in the VA EHR

Contractor shall complete no less than 90% of all clinical reminders as indicated in the VA EHR progress monthly by Periodic Sampling using data from VA EHR. VA will send these reports monthly to the contractor to notify them of their current

Progress Notes and Patient Care Encounter

(PCE)

Module Documentatio n

PWS

para.

4.13.

Contractor shall complete workload and encounter documentation as defined in the PWS within 2 business days.

Progress notes must be connected to the correct visit/encounter and location, entered into the VA EHR on the same day as the visit/encounter, meet CMS guidelines, and include content as defined in PWS.

shall properly complete documentatio n for each patient encounter 100% of the time

Contractor shall properly complete documentatio n for each patient encounter 99.9% of the time progress weekly by random sampling audit of automated reports. VA will send these weekly reports to the contractor to notify them of their current

PANEL MANAGEMENT

Percent of Teams with Core Teamlet Staffing Ratio >=3

The total Core Primary Care Support Staff (clerical/admin istrative associate, RN care manager, and clinical associate) FTE divided by the total Primary Care Provider FTE entered in the PCMM Web Application.

(See mPACT Dashboard for more information)

PWS

para.

4.13.

Contractor shall provide core teamlet staffing at a ratio of >=3 FTE core teamlet members (RN care manager, clinical associate, administrative associate) for each

PCP FTE

100% of Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

100% of Contractor’s primary care teams shall have a core teamlet staffing ratio of >=3

VA will monitor progress monthly by Periodic Sampling using data from the

PACT

Dashboard (Team Assignment Report). COR will send report monthly to the Contractor and CO to notify them of current performance.

https://reports.

vssc.med.va.g ov/ReportServ er/Pages/Repo rtViewer.aspx ?%2fPC%2fA lmanac%2fAl manacTeamA ssignments

Percent of Women Assigned to Women’s Health PACT or Designated Women’s Health Provider

(WH1)

The total number of female patients assigned to a Women’s Health PACT (identified by having *WH* in the team

PWS

para.

4.13.

Contractor shall ensure that an appropriate number of WH- PACTs or WH- PCPs are available at site of care to ensure that all VHA access goals are met for women Veterans who choose to be seen by a designated women’s health provider.

Contractor’s percent of women assigned to Women’s Health PACT or Designated Women’s Health Provider shall meet or exceed 85%

Contractor’s percent of women assigned to Women’s

Health PACT or

Designated Women’s

Health Provider exceed 85% progress quarterly by Periodic Sampling using electronic report using data from the

PACT

Compass. VA will send reports to the Contractor and CO quarterly to notify them of https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e97f10a0-94e2-4186-b157-3e30a33fb349|ispasFalse|reporta945bca6-c8d6-4239-9190-f20255341eb2|ws4|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e97f10a0-94e2-4186-b157-3e30a33fb349|ispasFalse|reporta945bca6-c8d6-4239-9190-f20255341eb2|ws4|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fAlmanac%2fAlmanacTeamAssignments name or a primary or secondary team focus of Women’s Health) OR to a provider with a team role of

DESIGNATE

D WH

PROVIDER

(WH-PCP)

divided by the total number of unique female patients assigned to

Teams

(See PACT Compass for https://reports.

vssc.med.va.g ov/ReportServ er/Pages/Repo rtViewer.aspx ?%2fPC%2fP ACTCompass CubeSSRS%2 fMainMenu&r s%3aComman d=Render

Percent

Patients Enrolled in Home Telehealth

Reflects the total number of unique PC patients enrolled in home telehealth (numerator) divided by the total number of unique patients assigned to primary care teams (denominator) offer and refer patients to home telehealth shall exceed 1.3% of PC patients enrolled in Home Telehealth

(HT)

shall exceed 1.2% of patients enrolled in Home Telehealth

(HT)

progress quarterly (non-cumulative) by by using data from the

PACT

COMPASS.

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://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render https://reports.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs%3aCommand=Render 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 http://vaww.reporting.oqp.med.va.gov/ReportServer?%2fPerformance+Reports%2fMeasure+Management%2fMeasure&measure=2744&rs%3aParameterLanguage=en-US&rc%3aParameters=Collapsed 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

Ratio of Non- Traditional Encounters

This is 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, and video as the numerator.

The denominator is the total team assignments for the reporting period.

4.13.

Contractor shall provide telephone encounters, group encounters, and secure messaging

Contractor shall exceed 26% ratio of non-traditional encounters

Contractor shall exceed 20% ratio of non-traditional encounters progress quarterly (non-cumulative) by using data from the

PACT

COMPASS.

VETERAN SATISFACTION

Veteran Satisfaction

Overall rating of Primary Care Provider on question 32 of the

SHEP/PCMH

survey

(See

SHEP/PCMH

Report for

PWS

para.

4.13.

The Contractor’s PCPs shall provide care that Veterans rate as a 9 or 10 on question 32 of the

SHEP/PCMH

survey

Contractor’s

SHEP

question 32 score shall meet or exceed 74%

Contractor’s

SHEP

question 32 score shall exceed 71% progress quarterly by Periodic Sampling using data from SHEP / PCMH report.

VA will send reports to the Contractor and CO quarterly to notify them of 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://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f|ispasFalse|report8427c340-7848-4f27-a2d1-61dc7dfa3ea1|ws1|wsb0|isDisabledAnalyticsFalse|isDashboardPanelOnTrue current performance.

https://bioffice .pa.cdw.va.go v/default.aspx ?bookid=e71e 8f03-6829- 403c-b002-b114ae1ac26f %7cispasFalse %7creport842 7c340-7848- 4f27-a2d1- 61dc7dfa3ea1 %7cws1%7cw sb0%7cisDisa bledAnalytics False%7cisDa

COORDINATION OF CARE

Post Discharge Contact by

PACT

Teamlet

The percent of assigned primary care patients discharged from any VA facility who have been contacted by PACT teamlet within two business days more information)

PWS

para.

4.13.

The Contractor’s PACT teamlets shall contact their assigned patients within 2 business days of discharge from any VA facility

Contractor’s rate of post discharge contact by PACT teamlet shall meet or exceed 60%

Contractor’s rate of post discharge contact by

PACT

teamlet shall exceed 60% progress quarterly by Periodic Sampling using electronic report using data from the

PACT

Compass. VA will send reports to the Contractor and CO quarterly to notify them of

ENVIRONMENT OF CARE (EOC)

https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue https://bioffice.pa.cdw.va.gov/default.aspx?bookid=e71e8f03-6829-403c-b002-b114ae1ac26f%7cispasFalse%7creport8427c340-7848-4f27-a2d1-61dc7dfa3ea1%7cws1%7cwsb0%7cisDisabledAnalyticsFalse%7cisDashboardPanelOnTrue 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

Percentage of Deficiencies Identified During EOC Rounds that are Closed Timely (e5eoc1)

Percentage of deficiencies identified during EOC rounds that are closed within 14-business days or have a documented Plan for Action (PFA)

(See Performance Measure Report for para 4.13.

Contractor shall address deficiencies identified in EOC rounds within 14 business days or have a documented Plan for Action

Contractor’s rate of EOC deficiencies that are closed within 14 business days or have a PFA shall meet or exceed 90%

Contractor’s rate of EOC deficiencies that are closed within 14 days or have a PFA exceed 90% progress quaretly by conducting periodic environment of care rounds and through electronic reports. VA will send reports to the Contractor and CO monthly to notify them of current performance.

Contractor has 14 days to correct or submit a plan of action to be put in place, monitor, and update VA until process is completed.

DOMAIN: PHARMACY

Medication Storage Area Inspections

PWS

para.

4.13.

Contractor shall inspect medication storage areas monthly

The Contractor shall ensure that 100% of medication storage areas are inspected monthly and documented on VA Form 10-0053 (or local VA medical center form).

Inspection documentatio n will be sent to the COR within 10 days of the end of each month.

The Contractor shall ensure that 100% of medication storage areas are inspected monthly and documented on VA Form 10-0053 (or local VA medical center form).

Inspection documentatio n will be sent to the COR within 10 days of the end of each month. Any issues

COR will monitor performance via receipt of VA Form 10- 0053 (or local medical center form) and documented resolution of any issues discovered during inspections.

COR will send reports to the Contractor and CO quarterly to notify them of http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPMR%2fPerformanceMeasures%2fPerformanceMeasureReport&rs:Command=Render

Any issues discovered shall be resolved by the Contractor and reported to the COR within 15 days of the inspection date.

discovered are resolved by the Contractor and reported to the COR within 15 days of the inspection date.

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 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.

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…