QASP.pdf

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TABLE OF CONTENTS

Quality Assurance Surveillance Plan (QASP)

DIABETES CASE MANAGER/GPRA SERVICES

Page

1.0 Introduction 2

2.0 Method of Surveillance 3

3.0 Roles and Responsibilities 3

4.0 Surveillance 3-4

5.0 Standards 4-5

6.0 Procedures 5

7.0 Contract Performance Evaluation 5-6

Tab 1 Performance – based Matrix 7-9 Tab 2 National Institute of Health Report 10-15 Tab 3 Customer Evaluation Form 16-17 Tab 4 COR Monthly Evaluation Report 17-18 Tab 5 Nonconforming Deliverables 19

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Quality Assurance Surveillance Plan (QASP)

1.0 Introduction

1.1 Since this is a performance-based contract, the Government must effectively validate in a timely manner the performance of the Contractor in meeting the services required. This QASP provides a systematic surveillance method for the services, and describes the methodology by which the Contractor’s performance will be monitored.

1.2 The principal focus of the surveillance system is the Contractor’s performance of the indicators identified in the Performance-based Matrix of the Performance Based Work Statement (PBWS). Therefore, the QASP surveillance standards are identical to those in the Performance-based Matrix. See Tab 1 for a copy of the Performance-based Matrix.

1.3 All task orders will comply with this Quality Assurance Surveillance Plan

(QASP).

1.4 The plan contains a National Institutes of Health (NIH) Contractor Performance Report. This document will be utilized in documenting contracting performance, and can be used to motivate the contractor on the current contract; and will serve as a data base for past performance evaluations for future contracts. See Tab 2 for a copy of the NIH Report.

1.5 For the purpose of this plan, California Area Indian Health Service (CAIHS) considers the FAR Clause 52.212-4(a), Contract Terms and Conditions, to meet the FAR Part 37.601 criteria for establishing a procedure for reduction of price or fee of a contract. The Government may request re-performance in lieu of a monetary deduction.

1.6 The QASP:

1.6.1 Identifies the services and products that will be measured.

1.6.2 Establishes the specific standards of performance for each required output.

1.6.3 Establishes the responsibilities for performing the measurement.

1.6.4 Defines the Government role in overseeing the performance.

1.6.5 Provides for feedback to the Contractor regarding quality, quantity, and timeliness of the service outputs.

1.6.6 Establishes timeframes for communicating performance improvements.

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2.0 Methods of Surveillance

2.1 The Performance-based Matrix at Tab 1 lists the services to be monitored and the standards to be applied.

2.2 This QASP is based on the premise the government desires to maintain a quality standard for diabetes data/case management services.

2.3 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 is quality assurance to ensure contract standards are achieved.

2.4 In this contract the Contractor’s quality control program is the basis for service quality. The Contractor is required to only deliver diabetes data/case management service that conforms to the requirements of the contract.

3.0 Roles and Responsibilities

3.1 It is the Contractor’s primary responsibility to ensure all contract requirements meet required quality levels. The Government shall ensure this responsibility has been met before payment is made to the Contractor. The primary Government team members are the Contracting Officer’s Representative (COR) and the Contracting Officer (CO).

3.1.1 The Contracting Officer has the overall responsibility for overseeing the

Contractor’s performance. The CO will be responsible for monitoring the contractor’s performance in the areas of contract compliance, contract administration, and the resolution of all issues relative to the language of the contract.

3.1.2 The COR is responsible for direct monitoring, assessing, recording, and reporting on the technical performance of the contractor. The COR will have primary responsibility for signing off on all invoices and documenting the inspection and evaluation of the Contractor’s performance.

3.1.3 The COR will work closely with patients, CAIHS staff, and the Contractor to ensure good communication and resolve any problems not requiring the CO’s authority.

4.0 Surveillance

The COR will evaluate the performance objectives through periodic inspections during each service period. The COR will also use customer evaluation forms to evaluate the contractor’s performance. See Tab 3 for a copy of the Customer Evaluation Form. The COR may develop a

4 | P a g e local form to record both outstanding and deficient performance. (See Tab 4 for a sample of a COR Monthly Evaluation Report).

4.1 The following information will be included:

4.1.1 Contract paragraph number referencing the requirement

4.1.2 Short description of the requirement being surveilled

4.1.3 Date, time, and location of surveillance

4.1.4 Results of surveillance

4.1.5 Signature of individual accomplishing the surveillance

4.2 All performance must be documented, whether acceptable or unacceptable. When unacceptable performance is documented, the COR shall take the following actions:

4.2.1 If government actions caused the unacceptable performance, take steps to prevent it in the future.

4.2.2 If the unacceptable performance was not government caused, inform the contractor’s on-site representative of the unacceptable performance and the reasons why it is unacceptable.

4.2.3 If the contractor wants to dispute the results of the surveillance, refer them to the CO for resolution.

4.3 Performance should not be determined unacceptable until all possible contributing factors have been considered.

4.4 For required tasks not shown on the Performance-based Matrix, the government still retains the right to inspect any item included in the contract. These services will be inspected periodically and the results provided to the Contracting Officer.

5.0 Standards

All standards in the Performance-based Matrix shall be met. All deliverable dates and other contractual completion dates shall also be met. If any of the standards are not met, the Government may receive consideration from the Contractor for breach of contract.

5.1 Late performance is un-excusable unless the Contractor can justify all of the following:

5.1.1 The delay was not the Contractor’s fault.

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5.1.2 The delay was not foreseeable.

5.1.3 It was beyond the Contractor’s control to avoid the delay.

5.2 All work shall be performed in accordance with the PBWS. The COR will not consider the services complete until all deficiencies have been corrected.

5.3 The COR will determine whether the failure was a minor non-conformance or a substantive non-conformance. (See Tab 5 for a list of Non-conforming Deliverables) If it was a minor non-conformance, the COR may accept the work once without consideration. If the consideration is greater than the cost of modifying the contract, the COR must accept the work with consideration from the Contractor in accordance with the Inspection Clause.

6.0 Procedures

The Government will inspect performance requirements to ensure contractor compliance; and record results of inspection, noting the date and time of inspection.

6.1 Unacceptable performance and customer input will be referred to the COR for investigation/validation. The COR will investigate/validate the unacceptable performance or customer complaint and notify the Contractor’s Quality Control representative. The Contractor will be given a reasonable amount of time to correct the unacceptable performance and notify the COR that the deficiency has been corrected. If deficiencies are not corrected, the COR will notify the CO and recommend a course of action.

7.0 Contract Performance Evaluation

7.1 FAR 42.15 – Contractor Performance Information establishes the Government responsibility for recording and maintaining contractor performance information.

This requirement does not apply to procedures used in determining incentive awards or other incentive systems, although the two systems should be mutually supporting.

7.2 FAR 42.1501 states: Past performance information is relevant information, for future source selection purposes, regarding a contractor's actions under previously awarded contracts. It includes, for example, the contractor's record of conforming to contract requirements and to standards of good workmanship; the contractor's record of forecasting and controlling costs; the contractor's adherence to contract schedules, including the administrative aspects of performance; the contractor's history of reasonable and cooperative behavior and commitment to patient satisfaction; the contractor’s record of integrity and business ethics, and generally, the contractor's businesslike concern for the interest of the patient.

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7.3 The general procedures to be used are addressed in the following FAR section:

42.1503 Procedures.

(a) Agency procedures for the past performance evaluation system shall generally provide for input to the evaluations from the technical office, contracting office and, where appropriate, end users of the product or service. (b) Agency evaluations of contractor performance prepared under this subpart shall be provided to the contractor as soon as practicable after completion of the evaluation. Contractors shall be given a minimum of 30 days to submit comments, rebutting statements, or additional information. Agencies shall provide for review at a level above the contracting officer to consider disagreements between the parties regarding the evaluation. The ultimate conclusion on the performance evaluation is a decision of the contracting agency. Copies of the evaluation, contractor response, and review comments, if any, shall be retained as part of the evaluation. These evaluations may be used to support future award decisions, and should therefore be marked “Source Selection Information”.

7.4 The National Institutes of Health (NIH) form at Tab 2 will be completed at least annually and more frequently if necessary to motivate or reward the contractor.

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Tab 1. Performance-based Matrix Performance-based Indicator Standard Quality Incentives

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Task Assurance State the end results or outputs that you, the customer will formally accept or reject.

For the requirement state the feature(s) of end result that will be surveilled.

For each “indicator,” state a performance level that, when met, means the task has been performed satisfactorily.

This Standard describes “What Success Looks Like.”

For each “Standard”, state the method used to check performance (i.e. random sampling, 100% inspection, periodic inspection, customer complaints).

List Positive and Negative Incentives.

Address method of linking payment to quality of service.

Contractor shall provide Diabetes Management/GPRA Services to include chronic disease management, RPMS, CRS and Data Improvement Services.

Competency

Compliance

Customer Support

On-site Training

Service Quality

Perform 100% required tasks at 100% of the required competencies. (refer to 5.1

PBSW)

Perform 100% compliance with IHS Service Diabetes Standards of Care and American Diabetes Association Standards of Care.

Perform 100% compliance with Paragraph 5.2 requirements/PBSW.

with Paragraph 5.3

Satisfaction with quality of services is evidenced by customer completed surveys.

Surveillance systems will include customer satisfaction survey;

periodic on-site inspections;

and customer complaints.

Monthly reports provided to CAO within 30 days of site visit by the Contractor

Payment of contract price for satisfactory service.

The Contractor will assist the Tribal/Urban Indian Health program sites

Perform 100% required tasks at 100% of the required competencies. (refer to 5.1

Surveillance systems will include

Payment of contract price for

9 | P a g e using RPMS to provide the Annual Diabetes Outcomes Audit through the IHS Web Audit and produce Government Performance and Results Act (GPRA) reports using the Clinical Reporting System (CRS).

PBSW)

with IHS Service Diabetes Standards of Care and American Diabetes Association Standards of Care.

with Paragraph 5.2 with Paragraph 5.3

Satisfaction with quality of services is evidenced by customer completed surveys.

customer satisfaction survey;

periodic on-site inspections;

and customer complaints

Reports provided by Contractor will include the programs progress

Monthly reports provided to CAO within 30 days of site visit by the Contractor

The Contractor will assist clinics in identifying patients with a diagnosis of pre-diabetes and establishing Pre- Diabetes Registers by 3/31/2011.

Number of clinics with a Pre-Diabetes Register by 3/31/2011.

b. Number of patients in Pre- Diabetes Registers 3/31/2011.

c. Number of clinics instituting evidence-based prevention programs (such as Diabetes Prevention Project - DPP) by 3/31/2011.

d. Number of programs adopting a clinical protocol for the management of

Surveillance systems will include customer satisfaction survey;

periodic on-site inspections;

and customer complaints

Monthly reports provided to CAO within 30 days of site visit by the

Payment of contract price for

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Tab 2: NIH Report

Pre-Diabetes by 3/31/2011.

Recommend the IHS Guidelines for Care of Adults with Pre-diabetes and/or the Metabolic Syndrome in Clinical Settings (April 2006).

Contractor

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National Institutes of Health Contractor Performance Report

Standard Evaluation Contract Data

Evaluation Type: Interim _ Final _ (check one) Evaluating Organization: Reporting Period: From to Contracting Office: Contract Number: Order Number:

Contractor Name: Contractor Address:

DUNS: City: State:

Additional or Alternate Contractor Name:

Zip/Postal Code: Country:

TIN: Industrial Code (NAICS): Commodity Code: Contract Type:

Contract Award Date: Contract Expiration Date: Contract Value:

Requirement Description:

Ratings

Summarize contractor performance and check the number which corresponds to the rating for each rating category (See attached Rating Guidelines).

Quality of Product or Service

_0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent _5=Outstanding

Government Comments for Quality of Product or Service (2000 characters maximum):

Cost Control (Rating and Comments for Cost Control are not required if contract type is Fixed- Price)

_0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent

Government Comments for Cost Control (2000 characters maximum):

Timeliness of Performance

_0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent

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Government Comments for Timeliness of Performance (2000 characters maximum):

Business Relations

_0=Unsatisfactory _1=Poor _2=Fair _3=Good _4=Excellent

Government Comments for Business Relations (2000 characters maximum):

Additional Information

Subcontracts

Are subcontracts involved? __Yes __No (Check one) Government Comment on subcontracts (2000 characters maximum):

Contractor Key Personnel

Contractor Manager/Principal Investigator (name):

Government Comment on Contractor Manager/Principal Investigator (2000 characters maximum):

Contractor Key Person (name):

Government Comment on Contractor Key Person (2000 characters maximum):

Contractor Key Person (name):

Government Comment on Contractor Key Person (2000 characters maximum):

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Small Business Subcontracting Plan

Did the contractor make a good faith effort to comply with its subcontracting plan consistent with the goals and objectives, reporting and other aspects of the plan? _Yes _No _N/A (Check one)

If this is a bundled contract, did the contractor meet the goals and objectives for small business participation?

_Yes _No _N/A (Check one)

Government Comments on Small Business Subcontracting Plan (2000 characters

Small Disadvantaged Business Goals

Did the contractor make a good faith effort to comply with its subcontracting plan consistent with the goals and objectives, for small disadvantaged business (SDB) participation, monetary targets for SDB participation, and required notifications? _Yes _No _N/A (Check one)

Government Comments on Small Disadvantaged Business Goals (2000 characters

Customer Satisfaction

Is/was the contractor committed to customer satisfaction? _Yes _No (Check one)

Would you recommend the selection of this firm again? _Yes _No (Check one) – FINAL

REPORT ONLY

Government Comments on Customer Satisfaction (2000 characters maximum):

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Rating Guidelines

Quality of Product or Service

0 = Unsatisfactory 1 = Poor 2 = Fair 3 = Good 4 = Excellent 5 = Outstanding Unsatisfactory Non-conformances are jeopardizing the achievement of contract requirements, despite use of Agency resources. Recovery is not likely. If performance cannot be substantially corrected, it constitutes a significant impediment in consideration for future awards containing similar requirements.

Poor Overall compliance requires significant Agency resources to ensure achievement of contract requirements.

Fair Overall compliance requires minor Agency resources to ensure achievement of contract requirements.

Good There are no, or very minimal, quality problems, and the Contractor has met the contract requirements.

Excellent There are no quality issues, and the Contractor has substantially exceeded the contract performance requirements without commensurate additional costs to the Government.

Outstanding The contractor has demonstrated an outstanding performance level that was significantly in excess of anticipated achievements and is commendable as an example for others, so that it justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Excellent".

Cost Control

Unsatisfactory Ability to manage cost issues is jeopardizing performance of contract requirements, despite use of Agency resources. Recovery is not likely. If performance cannot be substantially corrected, this level of ability to manage cost issues constitutes a significant impediment in consideration for future awards.

Poor Ability to manage cost issues requires significant Agency resources to ensure achievement of contract requirements.

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Fair Ability to control cost issues requires minor Agency resources to ensure achievement of contract requirements.

Good There are no, or very minimal, cost management issues and the Contractor has met the contract requirements.

Excellent There are no cost management issues and the Contractor has exceeded the contract requirements, achieving cost savings to the Government.

Outstanding The contractor has demonstrated an outstanding performance level that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances where the contractor achieved cost savings and performance clearly exceeds the performance levels described as "Excellent".

Timeliness of Performance

0 = Unsatisfactory 1 = Poor 2 = Fair 3 = Good 4 = Excellent 5 = Outstanding Unsatisfactory Delays are jeopardizing the achievement of contract requirements, despite use of

Agency resources. Recovery is not likely. If performance cannot be substantially corrected, it constitutes a significant impediment in consideration for future awards.

Poor Delays require significant Agency resources to ensure achievement of contract requirements.

Fair Delays require minor Agency resources to ensure achievement of contract

Good There are no, or minimal, delays that impact achievement of contract

Excellent There are no delays and the contractor has exceeded the agreed upon time schedule.

Outstanding The contractor has demonstrated an outstanding performance level that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Excellent".

Business Relations

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Unsatisfactory Response to inquiries and/or technical, service, administrative issues are not effective. If not substantially mitigated or corrected it should constitute a significant impediment in considerations for future awards.

Poor Response to inquiries and/or technical, service, administrative issues are marginally effective.

Fair Response to inquiries and/or technical, service, administrative issues are somewhat

Good Response to inquiries and/or technical, service, administrative issues are consistently

Excellent Response to inquiries and/or technical, service, administrative issues exceed Government expectation.

Outstanding The contractor has demonstrated an outstanding performance level that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances where contractor performance clearly exceeds the performance levels described as "Excellent".

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TAB 3 CUSTOMER EVALUATION FORM

CUSTOMER EVALUATION

Our goal is to deliver quality services provided by our contractors. We know that customer satisfaction is the key to fulfilling our goal. Please share your thoughts and concerns by completing this Customer Satisfaction Survey. Your feedback is very important to us.

DIABETES CASE MANAGEMENT/GPRA SERVICES

How would you rate the performance of our contractor(s)?

AREA

EXCELLENT

GOOD

SATISFACTORY

NEEDS

IMPROVEMENT

UNSATISFACTORY

N/A

5 4 3 2 1 Competency Compliance Knowledge of Diabetes Knowledge of RPMS/CRS and Diabetes Data System

Knowledge of Epi-Info Service Quality On-site Service Quality Remote Knowledge of GPRA measures

What Do You Think We Do Well?

What Could We Do To Improve Our Service?

Additional Comments:

Completed By PLEASE RETURN COMPLETED FORM

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TO

Date California Area Diabetes Consultant Telephone Number Contracting Officer’s Representative

TAB 4: COR MONTHLY EVALUATION REPORT

1.0 Contract Paragraph Number(s)

Identify the contract paragraph surveilled.

2.0 Review Interval

Indicate the review period covered by this report.

3.0 Date

Identify the date of report.

4.0 Contact Information

Identify the name and phone number of the individual to contact for follow-up information on the report.

5.0 Recommendations

Identify the high priority recommendations for this reporting period. Use a supporting document to supplement this summary information.

6.0 Current Interval QA Activities

Describe the major quality assurance activities accomplished during this reporting period.

Sample:

Reviewed 100 percent of invoices submitted for the month.

Reviewed 100 percent of patient complaints for the quarter.

Verified accuracy and timeliness of reports submitted for the month.

7.0 Planned Activities for Next Review Period

Describe Planned Activities for the Next Review Interval, Sample:

Will review compliance with Position Description next month.

8.0 Task Order or Basic Contract Risk Assessment and Trends

Describe the observed and identified risk areas within the project and the trend of that risk (improving, worsening, no change) as well as impacts of the risks.

8.1 Risk Mitigation Recommendations

Identify the steps or actions to address the trends.

9.0 Outstanding QA Issues

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Describe the new and unresolved issues from previous reports. Issues should be documented in the Issues Log.

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Tab 5: Non-conforming Deliverables

NON-CONFORMING DELIVERABLES

MINOR NON-CONFORMANCE

If Then Consideration Consideration would be less than the cost of modifying the contract

Accept as is (once)

None

Consideration would be greater than the cost of modifying the contract

Accept as is (once)

Consideration comparable to the value of the loss sustained by the Government

SUBSTANTIVE NON-CONFORMANCE

If Then Consideration The contractor agrees to correct the deliverable (or re-perform the service) within the delivery schedule

Withhold acceptance until receipt of the corrected deliverable

Cost to re-inspect or retest

The contractor agrees to correct the deliverable (or re-perform the service) but needs an extension of the delivery date

Withhold acceptance until receipt of the corrected deliverable

Cost to re-inspect or retest

Appropriate consideration for the delay

Acceptance:

• Would not affect safety or performance, and

• Is justified on the basis of economy or urgency

Accept as is

Consideration comparable to the value of the loss sustained by the Government

The contractor refuses to make repair or provide appropriate consideration.

Either:

• Correct the product or service through other means (contract or in-house), or

• Terminate for default and re-procure.

Contractor to pay all costs for the correction or re-procurement.

Quality Assurance Surveillance Plan (QASP)