Home Oxygen Services and Ventilation - VA Central California Healthcare System (VACCHCS)

Page 1 of 9 QUALITY ASSURANCE SURVEILLANCE PLAN FOR HOME OXYGEN SERVICES This Quality Assurance Surveillance Plan (QASP) has been developed to evaluate contractor actions while implementing this Performance Work Statement (PWS). It is designed to provide an effective surveillance method of monitoring contractor performance for the objectives listed in this service contract. The QASP is based on the premise the Government desires to maintain a quality standard in Home Oxygen services and that a contract to provide this service is the best means of achieving that objective. The Contractor, and not the Government, is responsible for management and quality control actions to meet the terms of the contract. The role of the Government will be to monitor quality assurance to ensure contract standards are achieved. In this contract, the quality control program is the driving force for product quality. The Contractor is required to develop a comprehensive program of inspections and monitoring actions. The first major step to ensuring a “self-correcting” contract is to ensure that the quality control program approved at the beginning of the contract provides the measures needed to lead the Contractor to success. Once the quality control program is approved, careful application of the process and standards presented in the remainder of this document will ensure a robust quality assurance program. Category ID PERFORMANCE Indicator MEASURES Standard Acceptable Quality Level Method of Surveillance Patient Information Return (Timeliness) 1 Notification when Patient refuses service NUM: # reported to COR within 24 hours DEN: Total # of refusals of service each quarter 90% or greater compliance with COR notification within 24 hours Electronic log kept by COR -- 1 of 9 -- Page 2 of 9 Category ID PERFORMANCE Indicator MEASURES Standard Acceptable Quality Level Method of Surveillance 2 Notification when Patient Declines back up system NUM: # reported to COR within 24 hours DEN: Total # declinations for back-up services each quarter 90% or greater compliance with COR notification within 24 hours Electronic log kept by COR 3 For emergency service cases NOT provided within 6 hours of request, COR notified within 2 business days NUM: # reported to COR within 2 days DEN: Total # of emergency services NOT provided within 6 hours of request quarterly 90% or greater compliance with COR notification within 2 days Electronic log kept by COR 4 90-Day assessment and report NUM: # with current 90 Day assessment documented DEN: # required for 90 Day assessment 90% or greater compliance with provision of 90 Day assessment Electronic log kept by COR 5 Semi-annual reports provided Semi-annual reports provided on or before the 8th calendar day of the 6th and 12th months each year Met or Not Met Vendor provision of semi-annual reports to COR -- 2 of 9 -- Page 3 of 9 Category ID PERFORMANCE Indicator MEASURES Standard Acceptable Quality Level Method of Surveillance Access (for all outpatient services) (Volume) 1 Initial set-ups provided within 24 hours of request NUM: # provided within 24 hours of request DEN: # of initial set-ups required with 24 hours of request 90% or greater compliance with initial set-up within 24 hours Electronic log kept by COR 2 Emergency services provided within 6 hour of request NUM: # provided within 6 hours of request DEN: Total # of emergency services requested 95% or greater compliance Electronic log kept by COR Quality of Care 1 All equipment has preventative maintenance (PM) performed at least once a year or more often in accordance with manufacturer recommendations. NUM: # with documented completed PM DEN: Total # equipment items on the inventory list due for PM 95% or greater PM list provided to COR by vendor 5%,10%,15%,20% reduction based on results -- 3 of 9 -- Page 4 of 9 Category ID PERFORMANCE Indicator MEASURES Standard Acceptable Quality Level Method of Surveillance 2 Evidence of initial and ongoing competency of all staff providing delivery/recovery and patient education services through this contract. NUM: # with documented current competency DEN: Total # of contracted employees providing delivery/recovery and patient education services 95% or greater compliance with current competency record Competency report provided by vendor to COR annually Patient Safety 1 A complete home safety assessment is performed at time of set-up and again during home visits, to include: presence/functioning smoke alarm, fire extinguisher, education about smoking & oxygen use, no smoking signage, cognitive impairment that could affect oxygen use, electrical cords / outlets, proper storage of oxygen tanks & provision of tank holders, fall risks, education about fall prevention NUM: # with current and complete home safety assessment documented DEN: # of total patients requiring current and completed home safety assessment 90% or greater compliance with documented complete home safety assessment COR random home visits -- 4 of 9 -- Page 5 of 9 Category ID PERFORMANCE Indicator MEASURES Standard Acceptable Quality Level Method of Surveillance 2 The patient has documented educated about Emergency Preparedness to include: escape route, back-up supply / equipment NUM: # with documented education about Emergency Preparedness and home oxygen equipment DEN: # total number of patients requiring Emergency Preparedness and Home Oxygen equipment 90% or greater compliance with documented education related to Emergency Preparedness COR random home visits 3 Infection control reports will be sent to the COR on a semi-annual basis. Semi-annual reports received on or before the 8th calendar day of the 6th and 12th months each year and analyzed by facility Infection Control Preventionist (ICP). There are no trends noted by facility ICP Analysis of vendor- provided infection control report by facility ICP 4 Critical events reported to COR, including: Sentinel events, observed /reported falls, patient abuse/neglect, and …