36C25019Q0835-006.pdf

36C25019Q0835

Attachment D5 - QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

The contractor shall 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.

2. GOVERNMENT ROLES AND RESPONSIBILITIES: The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer/Contract Specialist (CO/CS): The CO/CS 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/CS shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO/CS is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned CO/CS: Lisa Bailey Organization or Agency: Department of Veterans Affairs, Network Contracting Office 10

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: Janice Fries

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. METHODS OF QA SURVEILLANCE: Various methods exist to monitor performance. The COR will use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. 100% surveillance: (if this method is used, define how surveillance will be accomplished.)

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. (Define what and how often it will be inspected. For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)

c. VALIDATED USER/CUSTOMER COMPLAINTS. If this method is used, explain how data will be collected and reported.

d. RANDOM SAMPLING. If this method is used, define what and how often it will be sampled. (For example, ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. Review PWS and if this method of surveillance is selected, define how documentation will be verified and how assessment will be conducted. (For example, off-site contracts may require the contractor to provide information on services provided to patients).

6. MEASURES:

METRIC PWS Para Performance Requirement Standard Acceptable Quality Level (tailor to meet your requirements)

Method of Surveillance and frequency

Met AQL/Did Not Meet

AQL

(Add comment)

1 - Scope of Practice/Privileging

PWS

para.

4.4.2.

Contract physician(s) perform within their individual scopes of practice/privileging.

All (100%) contract physician (s) perform within their scope of practice/privileges 100% of the time.

All (100%) contract physician (s) perform within their scope of practice/privileges 100% of the time. No deviations accepted.

Random Inspection of records.

2- Patient Access PWS para.

3.3.

Contract physician (s) shall be available and in location as needed to properly perform tasks as specified.

All (100%) contract physician (s) are on time and available to perform services.

Contract physician (s) are on-time and available to perform services 95% of the time.

Periodic Sampling of Time and Attendance Sheets.

3 - Patient Safety PWS para.

8.1.3.

8.1.5.

8.1.9.

Patient safety incidents shall to be reported using Patient Safety Report. All incidents reported immediately (within 24 hours).

All (100%) of patient safety incidents are reported using Patient Safety Report within 24 hours of incident.

All (100%) of patient safety incidents are reported using Patient Safety Report within 24 hours of incident. No acceptable deviation.

Direct Observation

4 – Mandatory Training PWS para.

2.1.6.

7.10.

8.1.10

Contract physician(s) shall complete all required training on time per VAMC policy.

All (100%) of required training is complete on time by contract physician(s).

100% completions, no deviations.

Periodic Sampling

5 - Privacy, Confidentiality and

HIPAA

PWS

para.

2.1.12.

4.3.

7.7.

7.9.

7.10.

Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality.

All (100%) contractor physician (s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA.

100% compliance; no deviations.

Contractor shall provide evidence of annual training required by VAMC, reports violations per VA Directive 6500.6.

6 – Medical/Clinical Knowledge

PWS

para.

5.1.4.8.

Provide acceptable medical care and services and uses evidence-based guidelines.

Compliance is met on the Ongoing Professional Practice Evaluations (OPPEs).

95% Observation/Record Review

7 – Medication Reconciliation

PWS

para.

4.4.

8.1.

Complete appropriate medication reconciliation on admission/discharge.

Compliance is met on the Ongoing Professional Practice Evaluations (OPPEs).

95% Observation/Record Review

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: The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR). If contractor performance does not meet the Acceptable Quality level, the CO/CS shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO/CS shall document the discussion and place it in the contract file. When the COR and the CO/CS determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to CO/CS. The CO/CS 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/CS.

The Government shall review the contractor's corrective action plan to determine acceptability. The CO/CS shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO/CS 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/CS.

9. FREQUENCY OF MEASUREMENT: The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO/CS) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

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:

Janice Fries DATE

Administrative Officer & COR

SIGNED:

CONTRACTOR NAME/TITLE DATE