Attachment F - QASP.docx

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

DEPARTMENT OF VETERANS AFFAIRS

Veterans Health Administration Digital Health Office

Office of Clinical Informatics (OCI) Integration & Operations (I&O)

Interoperability Pledge Program Support_Convener

Date: TBD

QASP Version Number: 0 i

TABLE OF CONTENTS

QUALITY ASSURANCE SURVEILLANCE PLAN

(QASP)

For: Interoperability Pledge Program Support_Convener

Contract/Order Number: Blank until contract awarded

Contractor’s Name: Blank until contract awarded.

Contract/Order Description: The contractor shall establish a Community of Practice (CoP) that will reside outside of VA/VHA firewall and managed by the vendor, that will be accessible by all stakeholders, managed by professional facilitators under an organization supporting a growing membership dedicated to supporting the Pledge. This approach will allow the broader ecosystem involved in supporting both Veteran care and providing for similar communities to come together to provide information regarding solution approaches to take on the biggest challenges they face. A forum to provide comments and insight on existing laws, regulations, and constraints affect the Community.

INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled Interoperability Pledge Program Support. This plan sets forth the procedures and guidelines Office of Clinical Informatics (OCI) Integration and Operations (I&O) will use in ensuring the required performance standards or services levels are achieved by the contractor.

Purpose The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the PWS and the contractor’s quality control plan (QCP), and to ensure that the government pays only for the level of services received. The QASP describes:

What will be monitored.

How monitoring will take place.

Who will conduct the monitoring.

How monitoring efforts and results will be documented.

Copies of the original QASP and revisions shall be provided to the Contractor and Government officials responsible for surveillance activities. The Government can change the method of surveillance at any time without the approval of the contractor.

This QASP defines the roles and responsibilities of all members of the integrated project team (IPT), if applicable, identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

Performance Management Approach The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by [insert name of program office/monitoring activity] to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

Performance Management Strategy The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the government to take advantage of the contractor’s QC program.

The government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The government will make determination regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively. The Contractor will be monitored and assessed throughout the period of performance of the contract/order as to either meeting or not meeting the performance thresholds stated in the Performance Metrics Section of the Performance Work Statement (PWS). The Contracting Officer’s Representative (COR) will perform quarterly assessments. The Performance Based Service Assessment, or other method, may be used to document this assessment. A Performance Based Service Assessment is provided at the end of this document. When Contractor performance is unacceptable, the COR will notify the Contractor Program Manager (CPM) and the Contracting Officer (CO). Unacceptable performance is defined as; “the contractor is not meeting the Acceptable Levels of Performance (ALPs) as defined in the PWS or is in violation of any contract clause or terms and conditions. Notification of unacceptable performance issues shall be immediately provided to the CPM and shall not remain un-addressed until the end of an assessment period. To remediate performance issues in a timely manner, the COR should work collaboratively with the CPM. The COR/CO will engage the CPM to resolve the discrepancy.

For instances where immediate notification of performance issues is not required, the COR should review the assessment in accordance with the quarterly reviews with the CPM and provide the assessment to CO. The COR/CO will notify the Contractor of the results for a rating of 3 or less, no later than 15 working days after the end of the assessment period.

GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel shall oversee and coordinate surveillance activities:

The Contracting Officer (CO) The contracting officer is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the "COR and/or program manager (PM)" and the contractor. The CO will designate one full-time COR as the government authority for performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the CO. The CO shall also assure that the Contractor receives impartial, fair, and equitable treatment under this contract/order. The CO is ultimately responsible for the final determination of the level of acceptability of the Contractor’s performance.

Assigned CO: Tawana M. Young, tawana.young@va.gov, (202) 227- 8964 Organization: Department of Veterans Affairs, Office of Procurement, Acquisition, and Logistics, Strategic Acquisition Center-Virginia (SAC-V)

The Contracting Officer’s Representative The contracting officer’s representative (COR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR shall revise the QASP to meet the specifics of the submitted QCP and keep a quality assurance file including (but not limited to) quality assessment reports, quarterly quality review details and annual CPARS. At the conclusion of the contract or when requested by the CO, the COR shall provide documentation to the CO. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

Other Key Government Personnel

Program Manager: Nicole Wilson, Nicole.Wilson3@va.gov, 805-295-9676

Contractor Representatives

Program Manager: To be completed at award

Other Contractor Personnel: To be completed at award

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary. If the contractor meets the required service or performance level, it will be paid the monthly amount agreed on in the contract. Failure to meet the required service or performance level will result in a deduction from the monthly amount.

METHODOLOGIES TO MONITOR PERFORMANCE

Surveillance Techniques To minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are:

· Random monitoring, which shall be performed by the COR designated inspector.

· 100% Inspection – Each month, the COR shall review the generated documentation and enter summary results into the Surveillance Activity Checklist.

· Periodic Inspection – COR typically performs the periodic inspection on a monthly basis.

Customer Feedback The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems, but the customer always has the option to communicate complaints to the COR, as opposed to the contractor.

Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form – Customer Complaint Investigation, identified in Attachment 3.

Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

Acceptable Quality Levels The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for contractor performance are structured to allow the contractor to manage how the work is performed.

INCENTIVES

The Government shall consider the Contractor’s performance when deciding to exercise any options.

QUALITY ASSURANCE DOCUMENTATION

The Performance Management Feedback Loop The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and are assessed using the performance monitoring techniques shown in Attachment 1.

Monitoring Forms The government’s QA surveillance, accomplished by PM, will be reported using the monitoring forms in Attachments 2 and 3. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results [service levels] are being achieved.

The PM will retain a copy of all completed QA surveillance forms.

ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

Determining Performance Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. The Government shall document all performance as provided below.

a. ACCEPTABLE PERFORMANCE

The Government shall document acceptable performance accordingly. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR shall inform the CO. This will always be in writing although when circumstances necessitate immediate verbal communication, that communication will be followed up in writing. The COR shall document the discussion and place it in the COR file.

When the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the Contractor's program manager.

The Contractor shall acknowledge receipt of the CDR in writing to the CO. The CDR will state how long after receipt the Contractor has to take corrective action. The CDR will also 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 CO shall review the Contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

Reporting At the end of each month, the PM will prepare a written report for the COR summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the contractor’s submitted monthly report and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

Reviews and Resolution The PM may require the contractor’s project manager, or a designated alternate, to meet with the PM and other government IPT personnel as deemed necessary to discuss performance evaluation. The PM will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the PM as often as required or per the contractor’s request. The agenda of the reviews may include:

· Monthly performance assessment data and trend analysis

· Issues and concerns of both parties

· Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

· Recommendations for improved efficiency and/or effectiveness

· [Insert if appropriate: Issues arising from the performance monitoring processes]

The COR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

The contractor’s PM should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the PCO/ACO.

Frequency of Measurement

a. Frequency of Measurement.

During contract/order performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed, and at a minimum shall be quarterly.

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment to the CO.

Quality of submission should also be considered. See examples below. Error rates or resubmits for content flaws would be the measures associated with these standards.

· Accuracy ‑ Work Products shall be accurate in presentation, technical content, and adhere to accepted elements of style.

· Clarity ‑ Work Products shall be clear and concise. Any/All diagrams shall be easy to understand and be relevant to the supporting narrative.

· Consistency to Requirements ‑ All work products must satisfy the requirements of this PWS.

· File Editing ‑ All text and diagrammatic files shall be editable by the VA in Windows-based or Adobe environments/platforms.

· Format - Follow specified VA Directives or Manuals and/or best business practices.

· Presentations - Presentations shall be clear, concise, executive-focused, and written in plain, clear English with minimal jargon, understandable by lay persons. The quality of deliverables directly contributes to organizational communications.

· Project Plan - Project Plan shall be comprehensive; recognize and address authority, perceptions, and concerns of stakeholders; incorporate scope of requisite requirements across the organization and/or agency.

· Reports - There shall be no omissions in the reports, documents, or functional requirements.

· Publications and other documents - Deliverables shall be in formats appropriate to target audiences, user friendly, clear, thorough, and comprehensive.

· Meeting support - Pre-meeting preparations and logistics demonstrate smooth meeting operations; complete comprehensive post-meeting summaries to include but not limited to: Minutes, Action Items, Attendees, Program Objectives and Milestones and major decision points.

· Analyses and Assessments - Analyses and assessments are performed with accuracy, completeness, and adherence to industry best practices.

Obtain stakeholder input. Deliverables shall consist of the timely implementation of input mechanisms and shall consist of an accurate and comprehensive synthesis of results and recommendations. Integration of relevant stakeholder input documented for each deliverable.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Required Services (Tasks) Performance Standards Acceptable Quality Levels Methods of Surveillance

2. Notifies customer in advance of problems with meeting the deliverable due date.

1. Deliverables are on time 95% of the time.

2. Customer notified no later than 7 business days before the due date.

As provided above in 4.1

b. Knowledge of Access, Excel spreadsheets, macros, effective written and oral communication, presentation, and facilitation skills at an executive level.

c. Knowledge of SharePoint Online, Office 365, Power Apps, Power Automate and Power BI at an expert level.

Demonstrated proficiency in the skills required to execute the defined deliverables independently and at high quality.

As provided above in 4.1

Complaints No more than 3 valid complaints from the government per quarter on, but not limited to,

· Professionalism

· Response time

· Effective communication

· Project deliverable quality

· Engagement/participation during team collaboration

· Resource availability 100% of the time.

As provided above in 4.1

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE

MONITORING FORM

PERFORMANCE BASED SERVICE ASSESSMENT

CONTRACTOR: ________________________

GOVERNMENT REQUIRING ACTIVITY: _____________________

CONTRACT/ORDER NUMBER/ TITLE: _____________________

PERFORMANCE PERIOD COVERED: _____________________________________

NAME AND TITLE OF COR: _______________________________

DATE: __________________________

SURVEILLANCE METHOD (Check):

r Random Sampling r 100% Inspection r Periodic Inspection r Customer Complaint LEVEL OF SURVEILLANCE (Check):

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

EVALUATION RATINGS FOR ASSESSMENT

EXCEPTIONAL

VERY GOOD

SATISFACTORY

MARGINAL

UNSATISFACTORY

All value ratings must be supported, objective and explained in the Narrative Section for each Performance Objective.

PERFORMANCE OBECTIVES:

A. TECHNICAL/QUALITY OF PRODUCT OR SERVICE: Rating: <Value>

How well does the contractor meet your Technical Requirement IAW the performance metrics in the PWS?

NARRATIVE: (enter narrative in box)

B. PROJECT MILESTONES AND SCHEDULE: Rating: <Value>

How well does the contractor meet the established schedule IAW the performance metrics in the PWS?

NARRATIVE: (enter narrative in box)

C. COST & STAFFING: Rating: <Value>

Are the staffing levels and expertise appropriate for accomplishing the mission IAW the performance metrics in the PWS?

Were the invoices current, accurate and complete?

D. MANAGEMENT: Rating: <Value>

How well did the contractor integrate/coordinate all activities needed to execute the contract IAW the performance metrics in the PWS?