VA256-16-R-0542-028.pdf

Quality Assurance Surveillance Plan (QASP)

Community Based Outpatient Clinic

The contractor will 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.

This QASP does not detail how the contractor accomplishes the work. Rather, the QASP is created with the premise that the contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance.

This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

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 Agency: Department of Veterans Affairs, Network Contracting Office 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: Kristin Richardson

3. CONTRACTOR REPRESENTATIVES

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

3. CONTRACTOR REPRESENTATIVES

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

Primary: Kristin Richardson

Alternate:

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.

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.

b. PERIODIC INSPECTION/MONTHLY REVIEW. Inspections scheduled and reported quarterly per COR delegation or as needed.

c. VALIDATED USER/CUSTOMER COMPLAINTS.

d. RANDOM SAMPLING.

e. Verification and/or documentation provided by Contractor.

PACT PERFORMANCE

TASK PWS Para Indicator Standard Acceptable Quality Level

Method of Surveillance

PC 14:

New PC Patient Wait Time

4.6.2 VHA Access

% New patient wait times 30 days from create date

VHA Strategic Analytics for Improvement & Learning (SAIL)

99.7% monthly; New

PC

Appointments completed no later than 30 days

VHA SAIL

Report http://report s2.vssc.med.v a.gov/reports erver?%2fMg mtReports%2 fVATR%2fSAI

L Prod52fSAIL& rs:Command =Render

PCMH

SHEP

Access Composite

4.6.13 Composite %

Based on 2 Questions

1. Get an urgent care appointment as soon as needed

2. Get a routine care appointment as soon as needed

At least 55% 53.8% VHA SAIL Report http://report s2.vssc.med.v a.gov/reports erver?%2fMg mtReports%2 fVATR%2fSAI

L Prod52fSAIL& rs:Command =Render

PACT 7

Same-Day Appts w/

PCP

4.6.4 Same Day Appts

w/ Primary Care Provide

70% completion of same day primary care appointments with PCP

48% completion of same day primary care appointments with PCP

PACT

Compass & Dashboard https://secure reports2.vssc.

med.va.gov/R eportServer/P ages/ReportV iewer.aspx?% 2fPC%2fPC+ Medical+Ho me%2fMain Menu&rs%3a Command=R ender

PACT 8:

PCP

Continuity

4.6.15 Primary Care

Provider Continuity

77% of Appointments provided with assigned PCP

65% of Appointments provided with assigned PCP

PACT

Compass & Dashboard https://secure reports2.vssc.

med.va.gov/R eportServer/P ages/ReportV iewer.aspx?% 2fPC%2fPC+ Medical+Ho me%2fMain Menu&rs%3a Command=R ender

PACT 13:

PACT

Patients enrolled in

HT

4.6.8 % Primary Care Patients enrolled in HT The aggregate percentage of all

VISN PACT

Patients enrolled in Home Telehealth (HT) will exceed 1.6%.

Contractor to maintain 1.6% of required vested patients in HT

1.2% of required vested patients enrolled in HT

VHA

Performance Measure Report &

PACT

Dashboard

PACT 15:

PCMHI

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

4.6.9 % Primary Care Patients in Mental Health Integration

Contractor to maintain 6% of required vested patients in

PCMHI.

Contractor to maintain 4% of required vested patients in

PCMHI.

VHA

Performance Measure Report &

PACT

Dashboard

PACT 16:

Ratio of Non- Traditional Encounters

4.6.10 This is the sum

of all PC Telephone encounters added to the sum of all PC Group Encounters

Contractor shall maintain at least 20% in the appropriate ratio of non-traditional encounters

Contractor shall maintain at least 12% in the appropriate ratio of non-traditional encounters

VHA

Performance Measure Report &

PACT

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

PACT 17:

Post Discharge Contact by

PACT

Team

4.6.11 Number of

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

PACT

Improvement Data on Compass & Dashboard

Contractor

patients

VHA

Performance Measure Report &

PACT

Dashboard

PACT 18:

PACT

Staffing Ratio

4.6.12 Percent of

Divisions Meeting Staffing Ratio of 3:1 - (instead of the avg. ratio of staff per PC provider)

Division

time

Contractor

VHA

Performance Measure Report &

PACT

Dashboard

7. Ratings:

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

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 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 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 negotiated 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

COR DATE

CONTRACTOR NAME/TITLE DATE