ATTACHMENT D.3 QASP.docx
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- Solicitation number
- 36C25622R0001
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT D.2 - CONTRACTOR KEY PERSONNEL AND COI.docx | DOCX document | |
| ATTACHMENT D.1 -CONTRACTOR CERTIFICATION IMMIGRATION.docx | DOCX document | |
| S02 36C25622R0001_1.docx | DOCX document | |
| ATTACHMENT D.4 - PAST PERFORMANCE QUESTIONNAIRE.pdf | ||
| ATTACHMENT D.2 - CONTRACTOR KEY PERSONNEL AND COI.docx | DOCX document | |
| ATTACHMENT D.4 - PAST PERFORMANCE QUESTIONNAIRE.pdf | ||
| ATTACHMENT D.3 QASP.docx | DOCX document | |
| ATTACHMENT D.1 -CONTRACTOR CERTIFICATION IMMIGRATION.docx | DOCX document | |
| 36C25622R0001_1.docx | DOCX document |
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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: Billy Morris / billy.morris@va.gov / Thomas Kovarovic (CS) / thomas.kovarovic@va.gov 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: Susan L. Fetzer-Bova, BS MT(ASCP) Organization or Agency: VHSO
3. Contractor Representatives The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.
Primary:
Alternate:
Quality Assurance Surveillance Plan (QASP)
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. Incentives/Deducts The Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards
6. 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. Look at notes and talk to patient
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.
d. Verification and/or documentation provided by Contractor. On Site contracts will be reviewed by Quality and Performance to insure completeness of notes and encounter.
| Measures |
| PWS |
Reference Performance Requirement
| Standard |
| Acceptable Quality Level |
| Surveillance |
Method
| Incentive |
| Disincentive/Deduct |
| 1 - Provider Availability |
| 2.9.2 |
3.8.4.1.
| Presence of Board-Certified Pathologists during normal business hours. |
| Presence of Pathologists (Anatomical & Clinical) during normal business hours (8:00 am – 4:30 pm M-F, (exclusive of federal holidays) |
| Contractor’s physician is on-time and available to perform services 100% of the time |
| Sign-in Sheets / VistA Log In |
| Favorable contactor performance evaluation. |
| Unfavorable contractor performance evaluation. |
| 2 - Qualifications of Key Personnel |
| 2.1.1. |
2.1.2.
3.8.4.2.
| All Contractor physicians shall be Board Certified by the College of American Pathologists (CAP) in both Anatomical & Clinical Pathology in accordance with PWS requirements. |
| All (100%) Contractor’s physicians are Board Certified, Anatomical & Clinical Pathology. |
| 100% |
| Initial and then random Inspection of qualification documents |
| Favorable contactor performance evaluation. |
| Unfavorable contractor performance evaluation. |
| 3 - Maintains licensing, registration, and certification |
| 5.1.1. |
3.8.4.3.
| Updated Licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current. |
| All (100%) licensing, registration(s) and certification(s) for Contractor’s physicians shall be provided as they are renewed. Licensing and registration information kept current. |
| 100%, no acceptable deviation. |
| Periodic Sampling and Random Sampling |
| Favorable contactor performance evaluation. |
| Unfavorable contractor performance evaluation. |
| 4 - Mandatory Training |
| 2.1.6. |
3.8.4.4.
| Contractor shall complete all required training per VHSO policy |
| All (100%) of required training is complete on time by Contractor’s physicians. |
| 100% |
| TMS records |
| Favorable contactor performance evaluation. |
| Unfavorable contractor performance evaluation |
| 5 – Pathology Consultations |
| 3.7.2.1. |
3.7.2.2.
3.8.4.5.
| Emergent pathology consultations, including but not limited to, unexpected frozen section; blood bank, compatibility and blood bank transfusion reaction interpretations. |
| Response time of one-half hour |
| 95% |
| Review critical value report. |
| Favorable contractor performance evaluation |
| Unfavorable contractor performance evaluation. |
| 6 – New Malignancy Notification |
| 3.8.4.6. |
| Provider notification of all new malignancies |
| Within 24 hours of diagnosis |
| 95% |
| Review PLMS QPI Minutes |
| Favorable contractor performance evaluation |
| Unfavorable contractor performance evaluation. |
| 7 – Surgical Pathology report completion |
| 3.8.4.7. |
| Completion time of Surgical Pathology reports |
| Routine within 2 working days of specimen receipt, complicated within 5 working days of specimen receipt. |
| 90% |
| Review PLMS QPI Minutes |
| Favorable contractor performance evaluation |
| Unfavorable contractor performance evaluation. |
| 8 – Surgical Pathology 10% Review |
| 3.8.4.8. |
| Review of data on cases submitted as part of the random 10% surgical pathology review program. |
| Agreement of reviewing pathologist with the initial interpretation of the case. No major discrepancies will occur between the initial interpretation and the reviewing interpretation resulting in a significant clinical impact. |
| 100% |
| Review PLMS QPI Minutes |
| Favorable contractor performance evaluation |
| Unfavorable contractor performance evaluation. |
| 9 – Cytopathology 10% Review |
| 3.8.4.9. |
| Review of data on cases submitted as part of the random 10% Non-GYN review program. |
| Agreement of reviewing pathologist with the initial interpretation of the case. No major discrepancies will occur between the initial interpretation and the reviewing interpretation resulting in a significant clinical impact. |
| 100% |
| Review PLMS QPI Minutes |
| Favorable contractor performance evaluation |
| Unfavorable contractor performance evaluation |
| 10 – Provisional Autopsy Diagnosis |
| 3.8.4.10. |
| Entry of provisional diagnosis into VistA |
| Within 24 hours of post. |
| 100% |
| Review of autopsy report |
| Favorable contractor performance evaluation |
| Unfavorable contractor performance evaluation |
| 11 – Final Autopsy Report |
| 3.8.4.11 |
| Entry of final autopsy report into VistA |
| Within 30 calendar days of post |
| 100% |
| Review of TAT report/ |
| Favorable contractor performance evaluation |
| Unfavorable contractor performance evaluation |
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
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 determine formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), 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 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. 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CDR below.
CONTRACT DISCREPANCY REPORT
| 1. CONTRACT NUMBER |
| 2. REPORT NUMBER FOR THIS DISCREPANCY |
| 3. TO: (Contracting Officer) |
| 4. FROM: (Name of COR) |
5. DATES
a. CDR PREPARED
| b. RETURNED BY CONTRACTOR: |
| c. ACTION COMPLETE |
6. DISCREPANCY OR PROBLEM (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, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)
13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)
14. CLOSE OUT
| NAME |
| TITLE |
| SIGNATURE |
| DATE |
CONTRACTOR NOTIFIED
COR
CONTRACTING OFFICER
9. Frequency of Measurement
| a. | Frequency of Measurement. The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed. |
| b. | 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:
COR NAME/TITLE DATE
SIGNED:
CONTRACTOR NAME/TITLE DATE
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