P09.QUALITY ASSURANCE SURVEILLANCE PLAN.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

TRANSPLANT SERVICE

Transplant Patient, Donor and Caregiver Lodging

NCO9 Contracting Office

1639 Medical Center Parkway

Suite 400

Murfreesboro, TN 37129

Quality Assurance Surveillance Plan

Lodging for Transplant Patients, Donors, and Caregivers (Transplant Service)

For: Lodging for Transplant Patients, Donors, and Caregivers

Contract Number:

Contract Description: Lodging for Transplant Patients, Donors, and Caregivers

Contractor’s name: To Be Determined (hereafter referred to as the contractor).

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. 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: Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville Campus.

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: Kim West

c. Other Key Government Personnel: _______________-

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Hotel/Motel Manager -

4. 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 D.1 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).

Task ID Indicator Standard Acceptable

Quality Level Method of

Surveillance Incentive

Furnished Rooms

1 Facility to provide rooms requested by VA authorized agent.

Within 24 hours of receipt of the referral or as soon as possible in event of same day referral.

95% Observation and random inspection (auditing)

Exercise of Option Year and Past Performance

Quality Care

Patient Safety

2 Facility to provide clean, safe, pleasant environment in compliance with all federal, state, local and VA requirements.

95% Observation and random inspection (auditing)

Exercise of Option Year and Past Performance

3 Agency will report to the VA of any incidents of patient death, accident, injury.

Immediately upon incident.

95% Customer Complaints

Exercise of Option Year and Past

Task ID Indicator Standard Acceptable

Quality Level Method of

Surveillance Incentive

Patient Satisfaction

Patient complaints about the quality of service are reported to the VISN Patient Advocate, the COR, and the Contractor Patient for resolution.

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

95% Validate Patient Complaints

Exercise of Option Year and Past Performance

Facility to submit Performance Improvement report including a patient satisfaction report.

At least annually 95% Annual Submittal of Report

Exercise of Option Year and Past Performance

Billing 6

Submit certified invoice with patient’s name and date of service

Monthly or in accordance with period of service on purchase order

95% Review of invoice/date received

Exercise of Option Year and Past

5. INCENTIVES

The Government shall use Exercise of Option Period and past performance as an incentive.

Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

a. Performance Measures Review: The COR shall use the surveillance methods listed below. See scale in paragraph 7 for rating/rating methodology.

(1) Observation and Random Sampling

(2) Monthly Submittal of Pest Inspection Report

(3) Quarterly Environmental Health inspections by VA team.

(4) Customer Complaints

(5) Validate Customer Complaints

(6) Review of Invoice/Date Received

7. 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:

ting Methodology scale for performance measures review

RATING RATING METHODOLOGY

Met All elements within the standard were met

Partially Met At least half the required elements within the standard were met or partially met

Not Met Less than half the required elements within the standard were met

8. DOCUMENTING PERFORMANCE. In conjunction with the quarterly performance measure reports prepared by the COR, this data will also be used for documentation for a request to renew/not to exercise option period or renew of a contract.

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action. In order for a contractor to receive an “Acceptable” Performance rating, contractor must:

(1) Receive “Met” or “Partially Met” on all performance measures (see rating scale above).

AND

(2) Receive “Outstanding” or “Satisfactory” rating for all other Contract Requirements items.

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.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

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

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor twice during the contract period: (1) middle of contract period and (2) end of contract period to assess performance and shall provide a written assessment. This written assessment will be forwarded to the Contracting Officer as documentation of contractor’s performance and/or for a request to exercise option period, renewal of a contract or termination of a contract.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative