Conformed__Atch 2 Quality Assurance Surveillance Plan 21R0002.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 will coordinate changes with the contractor. Copies of the original QASP and revisions will be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel willl oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO will ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and will safeguard the interests of the United States in the contractual relationship. The CO will 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: Michael Cumins, (913) 946-1122, michael.cumins@va.gov Organization or Agency: Network Contracting Office 15, Healthcare Branch, Leavenworth, Kansas (VISN 15)

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and will assure proper Government surveillance of the contractor’s performance. The COR will keep a quality assurance f ile. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: To Be Determined and Delegated at the Time of Contract Award Organization or Agency: Robert J. Dole VAMC Radiology Department, Wichita, Kansas (VISN 15, Station 589A7)

A. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract. The contractor’s program manager(s) should be a person(s) other than the contractor’s physicians assigned to perform services under the contract.

Primary:

, Phone: , E-mail:

Alternate:

, Phone: , E-mail:

Conformed to RFP Amendment 0003 - revised pages 5 and 6 by Amend. 0003.

B. 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 willl 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 will use these standards to determine contractor performance and will 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.

C. 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.

i. DIRECT OBSERVATION. 100% surveillance: The delegated COR and/or the Radiology Service Chief will verify contractor’s physician(s) are on-site and in location as needed to properly perform tasks as specified in the PWS.

The COR and/or Radiology Service Chief or VA or Service Line Representative will utilize the Talent Management System (TMS) to verify training status, make certain safety issues are reported in JPSR, and verify that privacy is maintained based on HIPAA standards. The delegated COR and/or the Radiology Service Chief will receive verif ication from VAMC Human Resources / Credentialing information regarding licenses, registrations, and certif ications are updated and copies provided as they are provided and renewed and licensing and registration information is kept current. Direct obersvation includes OPPE evaluations reviews, verification with ABR or

AOBR.

ii. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. The delegated COR and/or the Radiology Service Chief or VA or Service Line Representative will verify contractor’s physician(s) meet measures as defined in Section 6 by performing audits using, but not limited to: participation in performing peer reviews, VistA/CPRS Management Reports. Credentialing will periodically review licenses, relevant certifications, and participation in Board MOC. The delegated COR and/or the Radiology Service Chief, Service Line Representative, or other VA or designated personnel will periodically review logs regarding report timeliness and regarding overdue EHR alerts. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards. Periodic inspection includes OPPE evaluations reviews.

iii. VALIDATED USER/CUSTOMER COMPLAINTS. Compaints or information received from customers, such as VA benef iciaries or VA staff. Complaints or information may be received in writing, electronic methods or orally/personal contact to any VA staff, the delegated COR and/or the Radiology Service Chief, or other VA or Service Line representative.

iv. RANDOM SAMPLING. Randomly selected patient files will be reviewed as needed to verify measures as defined in Section 6 are being met. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards. Random Sampling includes OPPE evaluations reviews.

VA or Service Line Representatives include, but are not limited to pariticipation and information from other VA staff such as radiology department personnel, Human Resources/Credentialing, and Patient Safety Representatives and Service Line Administrative personnel.

D. SAMPLE QASP PERFORMANCE REPORT DATE: __________________

No. Measures PWS

Location

Performance

Requirement

Standard Acceptable Quality Level Surveillance

Method

Frequency Met AQL/DID

NOT MEET

AQL-

CPAR

RATING/ADD

COMMENTS

1 Provider Quality

Performance B.3 – 4.1., 4.4., 6.

Satisfactory overall rating on OPPE evaluations for individual contractor physicians; as well as satisfactory line-items on the OPPE evaluation.

Ratings are categorized as satisfactory vs. needs improvement

vs. unsatisfactory. Expectation is a satisfactory rating on each OPPE evaluation for each contractor physician.

At least 80% of the total contractors shall be deemed satisfactory in a rating period.

Direct Observation Periodic Inspection Random Sampling

Every six (6) Months

2 Provider Quality Performance

B.3 – 4.1., 4.4., 6.

No Line-item rating on an OPPE evaluations shall receive a rating below satisfactory in successive rating periods for an individual contractor physician.

Ratings are categorized as satisfactory vs. needs improvement

vs. unsatisfactory. Expectation is that NO contractor physician will EVER receive OPPE ratings of “needs improvement” or “unsatisfactory” on successive OPPE evaluations for the same OPPE line-item.

No more than 0% of all individual contractor physician shall EVER receive OPPE ratings of “needs improvement” or “unsatisfactory” on successive OPPE evaluations for the same OPPE line-item.

Direct Observation Periodic Inspection Random Sampling

At the time of the OPPE and then every six

(6) months

3 Qualifications of Key Personnel

B.3 – 1., 2.1., 2.9., 2.10., 4.4.

Contractor physicians shall be board eligible or board certified with the American Board of Radiology (ABR) or American Osteophathic Board of Radiology (AOBR).

Contractor physicians are board certified/board eligible with either the American Board of Radiology (ABR) or American Osteophathic Board of Radiology (AOBR).

100% of all contractors shall be Board Certified/Board eligible. No deviations.

Direct Observation

At the time of initial appointment or reappointment (every two (2) years)

4 Qualifications of Key Personnel

B.3 – 2.1., 4.4..

Board certified contractor physicians with time-limited or continuous American Board of Radiology (ABR) or American Osteophathic Board of Radiology (AOBR) certificates shall be enrolled in and meet the requirement of MOC.

Board certified contractor physicians with time-limited or continuous American Board of Radiology (ABR) or American Osteophathic Board of Radiology (AOBR) certificates shall be enrolled in and meet the requirement of

MOC.

100% of all board certified contractors (American Board of Radiology (ABR) or American Osteophathic Board of Radiology (AOBR)) with time-limited or continuous certificates shall be enrolled in MOC and meet the requirements of MOC. Those contractor physicians with a lifetime board certificate are exempt. No deviations.

Periodic Inspection

Annually

5 Patient access B.3. – 3.2., 4.3., 4.4., 6.1.

The Contractor shall provide physicians in accordance with the operating hours and VA clinical schedule outlined in this

PWS.

Physicians are present during duty hours.

All: 100% of the time, at least one contractor radiologist is on-site at the RJD during normal duty hours, except when excused by the Government. The Government may adjust the times when contractor physicians are required to be on-site from time to time at the Government’s sole discretion. 100% of the time, the contractor must be compliant.

Direct Observation

Intermittently

6 Patient access B.3 – 2.1., 2.10., 4.4., 6.1.

The Contractor shall provide appropriately credentialed physicians in accordance with the operating hours and VA clinical schedule outlined in this

PWS.

Physicians are available to perform services.

At least 95% of the time an appropriately credentialed contractor radiologist is available for scheduled procedures during duty hours, unless they are involved in another procedure.

Direct Observation Validated User/Customer Complaints

Intermittently

7 Patient Safety B.3 – 4.3., 4.4.

Patient safety incidents shall be reported using JPSR module. All incidents reported immediately (within 24 hours.)

Patient safety incidents are reported using JPSR within 24 hours of incident.

At least 90 % of patient safety incidents are reported using JPSR within 24 hours of incident.

Direct Observation Validated User/Customer Complaints

Intermittently

8 Maintains licensing, registration, and certification

B.3 – 1.4., 1.5., 2.1., 2.9., 4.4., 6.1.

Updated licenses, registrations, board certification, and educational certification shall be provided to, and when required by, VA credentialing or HR, and kept current.

Any materials required by VA credentialing or HR shall be provided when requested and kept current.

All: 100% of any materials required by VA credentialing or HR shall be provided when requested and kept current. No deviations.

Direct Observation

At the time of initial appointment or reappointment then intermittently

9 Maintains licensing, registration, and certification

B.3 – 1.4., 1.5., 2.1., 2.9., 4.4., 6.1.

All forms and materials required for the VA shall be completed in a timely fashion.

Materials required shall be provided in a timely fashion when needed by VA credentialing HR.

At least 90% of materials requested by VA credentialing or HR must be returned within 45 days of reappointment date. The Government may extend the number of days requirement at its discretion.

Direct Observation Validated User/Customer Complaints

At the time of initial appointment or reappointment then intermittently

10 Mandatory Training

B.3 – 1.5., 2.1., 2.9., 2.10., 4.4., 6.1.

Mandatory BLS certification.

Mandatory ACLS certification for those physicians with moderate sedation privileges.

All contractor physicians shall have current certification in BLS. Any contractor physician who is privileged with moderate sedation privileges, shall have current certification in ACLS.

100% of all contractor physicians shall be current with BLS certification. 100% of contractor physicians with moderate sedation privileges shall be current with ACLS certification. No deviations.

Direct Observation Periodic Inspection

Monthly

11 Mandatory Training

B.3 – 2.1., 4.4.

Contractor shall be current with the TMS module, ““VA Privacy and Information Security Awareness and Rules of Behavior.”

Contractor physicians shall complete the TMS module, “VA Privacy and Information Security Awareness and Rules of Behavior” (or its successor) before its due date.

100% of contractor physicians shall complete the TMS module, “VA Privacy and Information Security Awareness and Rules of Behavior” (or its successor) before its due date. No deviations.

Direct Observation Periodic Inspection

Monthly

12 Mandatory Training

B.3 – 2.1., 2.9., 4.4.

Contractor shall complete all required TMS training on time per VAMC policy

TMS required training is completed on time by the contractor physician.

There are stricter guidelines for BLS, ACLS, and VA Privacy and Information Security Awareness and Rules of Behavior TMS modules; see table in section 2.1.7.

No more than 0% of TMS courses shall be greater than 30 days overdue by any contractor physician. The Government may extend the number of days requirement at its discretion.

Direct Observation Periodic Inspection

Monthly

13 Privacy, Confidentiality and HIPAA

B.3 – 1.5, 2.1., 4.3., 4.4., 6.6

Contractor shall comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

All (100%) contractor physicians comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA.

100% compliance with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA.

Direct Observation Validated User/Customer Complaints

14 Report preparation

B.3 – 3.3., 4.3., 4.4.

Timeliness of reporting non-routine cases

STAT/emergency department diagnostic studies shall have final interpretations within one (1) hour from the time these diagnostic studies are made available to the contract radiologist for interpretation during normal weekday duty hours {8:00 AM-4:30 PM Monday-Friday).

At least 95% STAT/ emergency department diagnostic studies shall have final interpretations within one (1) hour from the time these diagnostic studies are made available to the contract radiologist for interpretation during normal weekday duty hours {8:00 AM-4:30 PM Monday-Friday).

Periodic Inspection Validated User/Customer Complaints

Intermittently

15 Report preparation

B.3 – 3.3., 4.3., 4.4.

Timeliness of reporting in-patient cases Routine inpatient exams shall be given priority over outpatient exams and shall have final interpretations within four (4) hours from the time these diagnostic studies are made available to the contract radiologist for interpretation during normal weekday duty hours {8:00 AM-4:30 PM Monday-Friday).

At least 95% of routine inpatient exams shall have final interpretations within four (4) hours from the time these diagnostic studies are made available to the contract radiologist for interpretation during normal weekday duty hours {8:00 AM-4:30 PM Monday-Friday).

Periodic Inspection Validated User/Customer Complaints

Intermittently

16 Report preparation

B.3 – 3.3., 4.3., 4.4., 6.1.

Timeliness of reporting routine cases It is expected that most routine outpatient diagnostic exams obtained during weekday duty hours will have final interpretations by midnight the same day.

At least 90% of routine outpatient diagnostic exams obtained during weekday duty hours will have final interpretations by midnight the same day and 100% of exams will have final interpretations within 48 hours (excluding weekends/holidays).

Periodic Inspection

Intermittently

17 Report preparation

B.3 – 4.3., 4.4., 6.1.

Timeliness of reporting interventional radiology cases

It is expected that most interventional radiology cases obtained at any time will have final interpretations within 48 hours of the exam.

At least 90% of interventional radiology exams obtained at any time will have final interpretations within 48 hours of the exam.

Periodic Inspection

Intermittently

18 Electronic Health Record (EHR)

B.3 – 1.5., 4.3., 4.4., 6.1.

Adequacy of reporting in EHR Patients requiring hospitalization for an interventional radiology complication require an initial EHR note detailing the procedure, any complications, hand-off, and plan;

as well as daily notes (excluding weekends/holidays) until the complication is successfully managed.

100% of patients requiring hospitalization for an interventional radiology complication require an initial EHR note detailing the procedure, complication, hand-off, and plan; as well as daily notes (excluding weekends/holidays) until the complication is successfully managed.

Validated User/Customer Complaints

Intermittently

19 Electronic Health Record (EHR)

B.3 – 1.5., 4.3., 4.4., 6.1.

EHR alert management It is expected that each contractor physician review EHR alerts, each time they work at the RJD VA. No alerts shall be over 30 days old.

Furthermore, they must maintain access to the EHR by logging in at least once every 30 days.

At least 95% compliance with no alerts greater than 30 days, and at least 95% compliance with maintaining EHR access.

Periodic Inspection Validated User/Customer Complaints

CPAR RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/help.htm Guides option):

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).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

E. DOCUMENTING PERFORMANCE

i. 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).

ii. 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 Report (CR), 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 CR in writing. The CR 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 CR 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 CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

See Sample CR below.

F. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS ISSUE

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

5. DATES

a. CR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. Issue Identified (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 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.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER