36C24420Q0437-002.pdf

Quality Assurance Surveillance Plan (QASP)

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:

Organization or Agency:

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: Debrah Mentzer Organization or Agency: Lebanon VA Medical Center

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. INCENTIVES/DEDUCTS

The Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards on the following Indicators:

Credentialing/OSHA Requirements – if 100% compliance is not maintained, a 10% monthly deduction from any pending invoices, and services will be discontinued until once again in compliance.

Patient Complaints regarding quality of care: If more than one substantiated patient complaint per quarter, a 10% deduction will be applied to the first monthly invoice in the following quarter of service .

Service Cancellation – If there is more than one occurrence of service cancellation without 90 days prior notice per quarter a 10% reduction in the first monthly invoices of the following quarter will be implemented.

Mandatory Training/PIV Maintenance/Computer Access: If there is a lapse in Mandatory Training, PIV Maintenance, or Computer Access, a 10% reduction in monthly invoices will be implemented until such is rectified.

6. 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:

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. This will be conducted by reviewing random documentation via Peer Review associated with the clinical indicators per quarter. (All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)

c. VALIDATED USER/CUSTOMER COMPLAINTS. This data will be reported via the Patient Advocate, and or facility staff in direct contact with the patients served.

d. RANDOM SAMPLING. Ten (10) randomly selected patient files will be reviewed per quarter for patient related documentation, and . All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

e. Verification and/or documentation provided by Contractor. This documentation will be reviewed and inspected by the Credentialing process, as well as by the COR for PIV and Security/Training mandated.

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Incentive Disincentive/ Deduction

Credentialing Section 3 Paragraphs 1.a.viii, 1.a.xiii, and 3.a.i - ii

Contractor dependent healthcare professionals shall be responsible for completion of online entry of his or her credentials into the VetPro electronic database.

Licensing and registration information kept current.

All (100%) providers must be credentialed in accordance with Department of Veteran Affairs and Local.

100% compliance required. No acceptable deviation.

Periodic Inspection and Random Sampling.

Favorable performance evaluation.

No deduction in invoices.

A 10% reduction to monthly invoices until back in compliance.

Removal from contract until such time the contract physician (s) meet qualification standard.

Mandatory VA Training Section 1 Paragragh 5.b and Section 3 Paragraph 8.a.vi

Contractor shall complete all required training per VAMC policy.

VHA Privacy Policy, VHA Information Security Training (Cyber Security), Ethics Training, VA Privacy and Information Security Awareness and Rules of Behavior, and Privacy and HIPAA Focused Training must be completed on an annual basis.

100% compliance required. No deviations.

Periodic Inspection and Random Sampling.

Favorable performance evaluation.

No deduction in invoices.

Suspension or termination of all physical and/or electronic access privileges until such time as the training is complete, and a 10% reduction in monthly invoices will be implemented until such is rectified.

OSHA Requirement Section 3 Paragraph 1.a.xi

PPD/TB screening current, and evidence of having been offered Hep-B

All (100%) providers required to have annually PPD/TB screening;

100% compliance required prior to commencement of work. No deviations.

Periodic Inspection and Random Sampling.

Favorable performance evaluation.

No

Immediate removal from contract until in compliance, and a 10% reduction in vaccine prior to

EOD.

current immunizations and evidence of having been offered the HEP- B vaccine prior to commencement of work.

deduction in invoices.

monthly invoices until such is rectified.

Patient complaints about the quality of care reported to the Patient Advocate and/or received by the

COR.

Section 1 Paragraph 7.e

Contractor is to treat patients with ethical and respectful behavior and with high standard of care.

All patient complaints are reported immediately (within 24 hours).

No more than one substantiated patient complaint per quarter.

Substantiated complaints reported via staff, Patient advocate or other will be investigated.

Favorable performance eval.

10% deduction from monthly invoice following quarter in which more than one complaint was received.

Unfavorable performance evaluation.

Joint Commission Standards

Section 1 Paragraph 6.b and Section 3 Paragraph 15.a - f

Compliance with all industry Joint Commission Standards.

All (100%) providers comply with the Joint Commission Standards.

100% compliance, no deviations.

Periodic Inspection and Random Sampling.

Favorable performance evaluation.

Unfavorable performance evaluation.

Monthly Invoices

Section 1 Paragraph 7.g

Invoices should be submitted within two weeks of completion of billing month, using correct PO#.

Monthly invoices of billed services will be forwarded to the Surgery Service Office COR for tracking.

No more than one occurrence of non-compliance per 6 months.

COR shall collect and monitor monthly billing statements.

Favorable performance evaluation.

Unfavorable performance evaluation.

Service Cancellation Section 1 Paragraph 8.c.

Cancellations should be communicated 90 days prior.

Cancellations should be communicated 90 days prior.

No more than one occurrence of non-compliance per quarter.

COR will monitor this on a monthly basis via clinic cancellation or other pertinent method.

Favorable performance evaluation, and no deduction from invoice.

10% reduction to invoice in month following quarter compliance was not met.

The table below is a sample that can be tailored – note that the table must identify where in the PWS the standards are found for monitoring performance. Check the MSO Customer Resource Center for approved mandatory QASPs.

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 perparing 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.

See Sample CDR below.

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED

b. RETURNED BY CONTRACTOR: c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE.

(Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

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