D.3 ATTACHMENT 3 QASP.pdf

Attachment D.3 Quality Assurance Surveillance Plan (QASP)

36C25521R0020

Quality Assurance Surveillance Plan (QASP)

Health Care Resources (HCR)

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: Colleen Donahue-MacDonald

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: Geoffrey Gibson Organization or Agency: Kansas City, MO VAMC

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 shall use the surveillance methods listed below in the administration of this QASP.

a. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. 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.

b. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints are registered in the patient advocate system.

c. RANDOM SAMPLING. 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.

6. QASP PERFORMANCE REPORT DATE: __________________

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT MEET AQL-

CPAR RATING/ADD COMMENTS

1-Provider Quality Performance 4.9.5.1. All Contractor’s physician (s) shall perform in accordance with clinical standards.

OPPE

documentation for all (100%) staff providing services under the contract.

95% OPPE, a.

Patience Care Performance b.

Medical/Clinical knowledge c.

Practiced Based Learning & Improvement d.

Interpersonal & Communication Skills e.

Professionalism

f. System Based Practice

2 - Qualifications of Key Personnel

4.9.5.2. Perfusionist shall

have only a certification as a Perfusionist

All (100%) Contractor’s physicians (s) are Board Certified /Board Eligible

100% Random Inspection of qualification documents

3 - Scope of Practice/Privileging 4.9.5.3. Contract personnel

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

All (100%) Contractor’s physicians (s) perform within their scope of practice/privileges 100% of the time.

100% Random Inspection of records.

4- Patient Access 4.9.5.4.

Perfusionist shall be available and be in location as needed to properly perform tasks as specified.

Perfusionist shall be onsite during all scheduled OR hours.

95% Contractor’s physician (s) perform within their scope of practice/privileges.

Periodic Sampling of Time and Attendance Sheets

5 - Patient Safety 4.9.5.5. All 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.

Contractor’s physician

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

Direct Observation and periodic inspection

6 - Maintains licensing, registration, and certification

4.9.5.6.

Updated Licensing, registration and certification shall be provided as they are renewed.

All licensing, registration(s) and certification(s) for contract personnel

(s) shall be provided as they are renewed.

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

Periodic Sampling and Random Sampling

7 - Mandatory Training 4.9.5.7. Contractor personnel

(s) shall complete all required training on time per VAMC policy. Contractor personnel (s) 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%) of required training is complete on time by Contractor’s physician (s).

95% All contractor personnel (s) shall comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality, and

HIPAA.

Periodic sampling.

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

8 - Clinical Information Return 4.9.5.8. Perfusionist shall be responsible to check and compute all calculations of perfusion, autotransfusion and cell saver treatments.

95% of required training is complete on time by Contractor’s physician (s).

95% completions, Direct observation and random sampling.

9 -Documentation/timesheet 4.9.5.10. Time Sheet Documentation to be completed weekly and turned in to COR for concurrence.

100% completion 97% Periodic inspection and random sampling.

7. 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 preparing 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 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 on the following page.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE