D3. QASP - On-Call Thoracic Services.docx

QUALITY SURVEILLANCE PLAN (QASP)

On-Call Thoracic Surgery Services

Contract Number: TBD Contractor’s name: TBD Contract Description: Contractor shall provide Thoracic Surgery staff, as qualified registered health care professionals to the VA Medical Center, 1700 S. Lincoln Avenue, Lebanon, PA 17042.

PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

1. What will be monitored.

2. How monitoring will take place.

3. Who will conduct the monitoring.

4. 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. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

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.

1. Assigned CO: Mark Knorr, mark.knorr@va.gov

2. Assigned Contract Specialist: Robert Neal, Robert.neal2@va.gov

3. Organization or Agency: Department of Veterans Affairs, Lebanon VAMC, Lebanon, PA

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.

1. Assigned COR: Debrah Mentzer, Debrah.mentzer@va.gov C. CONTRACTOR REPRESENTATIVES: The following employees of the contractor serve as the contractor’s program manager for this contract.

2. Program Manager: Carl T. Reese, M.D./ACOS, Surgery Care Line

PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets, or does not meet these standards.

The Performance Requirements Summary Matrix, paragraph B (General Requirements) in the Performance Work Statement (PWS) includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Clinical Information;

Quality; Patient safety

INCENTIVES

The Government shall use Past Performance, and avoidance of reduction of monthly bill as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

METHODS OF QA SURVEILLANCE

1. Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. The following Numbers from the matrix apply to this method: 1, 2.

b. PERIODIC INSPECTION: The following Numbers from the matrix apply to this method: 8, 10.

c. USER SURVEY: N/A.

d. VALIDATED USER/CUSTOMER COMPLAINTS: The following Numbers from the matrix apply to this method: 4.

e. 100% INSPECTION. The following number from the matrix apply to this method: 6, 9, 11.

f. PERIODIC SAMPLING. N/A.

g. RANDOM SAMPLING. The following numbers from the matrix apply to this method: 3, 4, 5, 7.

h. Progress or status meetings: N/A.

i. Analysis of contractor's progress reports: The following number from the matrix apply to this method: 6.

RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

DOCUMENTING PERFORMANCE

a. Acceptable Performance: The Government shall document positive performance. 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 contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the COR 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. 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 must present this corrective action plan to the COR. The Government 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.

SERVICE SUMMARY – PERFORMANCE MEASURES:

1. The Government will evaluate the Contractor’s performance to ensure services are performed in accordance with this Contract. The Government may evaluate the quality of professional and administrative services provided, but retains no control over the medical, professional aspects of services rendered. The Government may inspect each task as completed or increase the number of quality assurance inspections if deemed appropriate because of repeated failures or because of repeated customer complaints. Likewise, the Government may decrease the number of quality assurance inspections if performance dictates. Lebanon VAMC will validate any complaints and report to the Government Contracting Officer who will then take necessary action to enforce contract compliance.

2. If any of the services do not conform to contract requirements, the Government may require the Contractor to perform the services again in conformity with contract requirements, at no additional cost to the Government. When the defective services cannot be corrected by re-performance, the Government may:

a. Obtain the service from another source and charge the Contractor with any resultant charges plus actual administrative costs.

b. Require the Contractor to take necessary action to ensure that future performance conforms to contract requirements; and

c. Reduce the Contract price to reflect the reduced value of the services performed.

d. Take other actions as appropriate, including but not limited to termination of this Contract.

FREQUENCY OF MEASUREMENT

1. Frequency of Measurement: During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

2. Frequency of Performance Assessment Meetings: The COR shall meet with the contractor on a regular basis to assess performance and shall provide a written assessment.

[After award, both the contractor’s Program Manager and the COR shall sign this document.]

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative