Attachment A Updated Quality Assurance Surveillance Plan QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Pond Restoration and Stewardship For JC & JB VAMCs

Table of Contents

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)……………………………………………2

(a). INTRODUCTION……………………………………………………………………………………...2

(b). ROLES AND RESPONSIBILITIES………………………………………………………………….3

(c). IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS……3

(d). METHODOLOGIES TO MONITOR PERFORMANCE……………………………………………3

(e). QUALITY ASSURANCE DOCUMENTATION……………………………………………………..4

(f). ANALYSIS OF QUALITY ASSURANCE ASSESSMENT …………………………………………5

ATTACHMENT 1: SAMPLE QUALITY ASSURANCE MONITORING FORM……………………..9

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

(a). INTRODUCTION:

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the Performance Work Statement (PWS). This plan sets forth the procedures and guidelines the Wichita VA Medical Center will use in ensuring the required performance standards or services levels are achieved by the contractor.

(1). Purpose

(A). The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the PWS and the contractor’s quality control plan (QCP), and to ensure that the government pays only for the level of services received.

(B). This QASP defines the roles and responsibilities of all members of the contracting team , identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

(2). Performance Management Approach

(A). The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by the VA Medical Centers to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

(B). Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

(3). Performance Management Strategy

(A). The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the government to take advantage of the contractor’s QC program.

(B). The government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The government will make determination regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

(b). ROLES AND RESPONSIBILITIES:

(1). The Contracting Officer

The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the contracting officer's representative (COR) and the contractor. The CO will designate one full-time COR as the government authority for performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the Contractor.

(2). The Contracting Officer’s Representative

The contracting officer’s representative (COR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

(c). IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS:

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary” to this document. If the contractor meets the required service or performance level, it will be paid the amount agreed on in the contract. Failure to meet the required service or performance levels may be documented in the contractor’s performance evaluation and will be used in considering a determination of suitability for future contract extensions of services.

(d). METHODOLOGIES TO MONITOR PERFORMANCE:

(1). Surveillance Techniques

In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are:

(A). Random monitoring, which shall be performed by the COR or his designated inspector.

(B). Periodic Inspection – COR typically performs the periodic inspection on a monthly or quarterly basis.

(C). Feedback from facilities being served by the contract, satisfaction or complaints.

(D). Monthly review of invoices, reports, and documents.

(E). Contractor quality assurance reports.

(2). Customer Feedback .

(A). The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction.

Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

(B). Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems but the customer always has the option to communicate complaints to the COR, as opposed to the contractor.

(C). Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form identified in Attachment 2.

(D). Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

(3). Acceptable Quality Levels

The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. For certain critical activities such as those involving delivery time frames and, the desired performance level is established at 100 percent.

Other levels of performance are keyed to the relative importance of the task to the overall mission performance at the VA Medical Centers.

(e). QUALITY ASSURANCE DOCUMENTATION:

(1). The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes.

Performance standards are expressed in the PWS.

(2). Monitoring Forms

(A). The government’s QA surveillance, accomplished by the COR, will be reported using the monitoring form in Attachments 1. The form, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results are being achieved.

(B). The COR will retain a copy of all completed QA surveillance forms.

(f). ANALYSIS OF QUALITY ASSURANCE ASSESSMENT:

(1). Determining Performance

Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

(2). Reporting

(A). Semi-annually the COR will prepare a written report summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the monthly report and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

(3). Reviews and Resolution

(A). The COR may require the contractor’s project manager, or a designated alternate, to meet with the CO, COR, and other government personnel as deemed necessary to discuss performance evaluation.

The COR will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the COR as often as required or per the contractor’s request. The agenda of the reviews may include:

(i). Monthly performance assessment data and trend analysis

(ii). Issues and concerns of both parties

(iii). Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

(iv). Recommendations for improved efficiency and/or effectiveness

(B).The COR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

(C). The COR and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the CO.

Performance Requirements Summary:

Acceptance Quality Level (AQL) Summary Table

Performance Requirement

Performance Standard

Surveillance Method

Frequency AQL Corrective Action Process

Removal of Invasive/Weedy Species

100% removal in designated areas per MSD specs

Site Inspection

/ COR

Observation

Monthly 0% CDR issued for any missed areas; CAP required within 5 business days

Debris, Trash, and Silt Removal

100% removal from all identified zones

Field Inspection / Photo Documentation

Monthly 0% Immediate rework required; CDR if recurring

Herbicide Application & Weed Control

100% compliance with label, SDS, and licensing

SDS Review / Applicator License Check / Site Inspection

Per Application

0% CDR for non-compliance;

suspension of chemical use until resolved

Mulch Maintenance

95% of designated areas properly mulched

Visual Inspection

Monthly 5% CDR if >5% of areas are bare; re-mulching required

Underdrain Inspection & Flushing

100% of cleanouts inspected and flushed as needed

COR

Inspection / Field Report Review

Quarterly 0% CDR for missed inspections or sediment buildup

Pruning & Plant Maintenance

100% compliance with horticultural standards

COR

Observation / Site Walkthrough

Monthly 0% CDR for improper pruning or plant damage

Annual Flower Replacement

100% of approved flowers

COR Approval / Site Inspection

Annually 0% CDR for unapproved or missing plantings

Performance Requirement

Performance Standard

Surveillance Method

Frequency AQL Corrective Action Process planted and maintained

Field Report Submission

100% of visits documented with signed reports

Document Review

Per Visit 0% CDR for missing/incomplete reports

Off-Hours Maintenance (Bldg. 55)

100% compliance with schedule

COR

Verification / Time Logs

Quarterly 0% CDR for any work during restricted hours

Quarterly COR Walkthroughs

100% contractor participation and correction of noted issues

COR

Inspection / Follow-up Review

Quarterly 0% CDR for missed walkthroughs or uncorrected issues

Personnel Identification &

PPE

100% of staff properly identified and equipped

Visual Inspection / VA Police Reports

Ongoing 0% CDR for violations;

removal from site if repeated

Contractor Qualifications

100% of staff meet BMP and stewardship experience requirements

Resume Review / License Verification

At Award & As Needed

0% CDR for unqualified personnel;

replacement required

Corrective Action Process Summary

• Unacceptable performance is identified through:

• Observation of actual performance

• Inspection of services

• Review of documentation and complaints

• COR Actions:

• Notify contractor (verbal or written)

• Document all communications

• Issue Contract Discrepancy Report (CDR) when formal action is needed

• Contractor Actions:

• Acknowledge CDR in writing

• Submit Corrective Action Plan (CAP) within specified timeframe

• Implement corrective measures at no additional cost to the Government

• Government Rights:

• Increase or decrease surveillance based on performance

ATTACHMENT 1: SAMPLE QUALITY ASSURANCE MONITORING FORM

Contract #:____________________________________

Contractor:____________________________________

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

[__] Periodic Inspection [__] Customer Complaint [__] Review of documents

LEVEL OF SURVEILLANCE (Check):

[__] Monthly [__] Quarterly [ ] As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: ______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (Check): [__] Meets Standards

[__] Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: _________________

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)