VA257-17-R-0506-002.docx
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- Granbury CBOC Federal contract opportunity
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- VA25717R0506
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VA257-17-R-0506 D.1 Quality Assurance Surveillance Plan 02.docx
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D.1 VA257-17-R-0506
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: Valeria Gutierrez, Valeria.Gutierrez@va.gov Assigned CS: Marisela Galarza, Marisela.Galarza@va.gov Organization or Agency: Department of Veterans Affairs
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: Elizabeth Dannel, Elizabeth.Dannel@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 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. 100% surveillance: “Method not applicable”
b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. For example, 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 be collected from the responses given on the patient satisfaction survey.
d. RANDOM SAMPLING. VA will monitor using electronic report using data from VA Vista/CPRS system. VA will monitor progress weekly thru automated verification and/or documentation provided by the Contractor, with a sampling of 10 patients records. 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
PACT CBOC QASP
| TASK |
| PWS Para |
| Performance Requirement |
| Standard |
| Acceptable 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 -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
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 quarterly thru automated reports, EPRP Reviews, Clinical Reminder Reports). Periodic Sampling VA will monitor using Electronic report using data from VA VISTA/CPRS system. |
PC 14:
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. |
| 95 % monthly new patient wait times within 30 days from the preferred date. |
| VHA SAIL or PACT COMPASS Report |
http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=Render, 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 (PC 17) |
| 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. |
| 95 % monthly established PC appointments completed no later than 30 days from Preferred Date (patient desired date) or the clinically indicated date. |
| VHA SAIL Report |
http://reports2.vssc.med.va.gov/reportserver?%2fMgmtReports%2fVATR%2fSAIL_Prod%2fSAIL&rs:Command=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.
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 appointments with PCP
Periodic Inspection audit of PACT Compass https://securereports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fPC%2fPACTCompassCubeSSRS%2fMainMenu&rs:Command=Render
| CLINICAL ENCOUNTERS |
| PWS para. |
4.9.5.
Providers must complete proper documentation for each patient visit.
| 100% Documentation 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 contractor to notify them to 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). |
| 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 quarterly 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 para.
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 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 quarterly status reports to the contractor to notify them to their current performance.
PATIENTS ENROLLED IN HOME TELEHEALTH
PWS para.
4.9.8.
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.
1.6% 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.
PACT 15:
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). The percent of assigned primary care patients seen in a primary care mental health integration (PCMHI) clinic (primary stop code 534 or 539) or by a HBPC mental health provider (primary stop code 156 and 157) or when primary stop code is either 338 or 527 and secondary stop code is 534. Only required divisions are included in this measure which consist of large (5,000 or more core uniques) and very large (10,000 or more core uniques) divisions. Core uniques include all patients except those whose interaction with the facility is limited only to laboratory and telephone triage episodes of care. Numerator for Primary Care Patients in PCMHI – The total number of assigned primary care patients seen in primary care mental health integration (PCMHI) during the past 12 months. Denominator for Primary Care Patients in PCMHI – The total number of primary care patients assigned to a primary care provider on the last day of the month. |
| Contractor to exceed 6% of required enrolled patients in PCMHI. |
| Contractor to maintain at least 6% of required enrolled patients in PCMHI. |
| VA will monitor using Electronic report using data from the PACT Compass. |
RATIO OF NON-TRADITIONAL ENCOUNTERS
PWS para.
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 20% in the appropriate ratio of non-traditional encounters. |
| Contractor shall maintain at least 20% in the appropriate ratio of non-traditional encounters. |
VA will monitor using Electronic report using data from the PACT Compass.
| 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 65% of patients within two business days of discharge. |
| Contractor assigned PACT Team member shall contact at least 65% of patients within two business days of discharge. |
| VA will monitor using Electronic report using data from the PACT Compass. |
| 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% |
| 55% |
| VHA SAIL Report or Patient Experience Report |
| APPOINTMENT CANCELLATIONS |
| PWS para. |
4.9.13.
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 30 days of their original CID/PD. |
| 95% of patients seen within 30 days of their original CID/PD. |
Periodic Sampling VA will monitor 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.
PCP CONTINUITY
PWS para.
4.9.14.
Patients see same PCP for appointments
| 77% of appointments provided with assigned PCP |
| 77% of appointments provided with assigned PCP |
| VA will monitor using Electronic report using data from the PACT Compass. |
PCMH 4:
SHEP PCMHQ38: DISCUSSED DIFFICULTIES IN CARING FOR SELF
PWS para.
4.9.15.
Weighted number of outpatients responding "yes" to PCMH Q38
| At least 51% respond yes to PCMH Q38 |
| 51% respond yes to PCMH Q38 |
| VHA SAIL Report or Patient Experience Report. |
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 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 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
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