S02 Attachment D.1 FINAL QASP-ANATOMICAL AUTOPSY SERVICES .pdf

ATTACHMENT D. 1 – 36C25624Q0705

Quality Assurance Surveillance Plan

PATHOLOGY AND LABORATORY MEDICINE SERVICES

For: Pathology and Laboratory Medicine Services

Contract Number:

Contract Description: An agreement to provide Pathology and Laboratory Medicine Services.

Contractor’s name:

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. 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: Stephanie Keo Organization: NCO 16

b. Contracting Officer’s Representative (COR) - The COR is responsible for 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: Darby Matthews Organization or Agency: New Orleans VA (NOLA VAMC)

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

Program Manager – __________________________

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Performance Requirements Summary Matrix of the contract includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

CONTRACT PERFORMANCE METRICS

PROFESSIONAL SERVICES

Task Id Indicator Standard Acceptable

Quality Level

Method Of

Surveillance

Incentive

Clinical

Info

Return

1 Presence of Pathologist staffing during normal business hours (7:30 a.m. – 4:30 p.m. M-F, exclusive of federal holidays)

100%

Clinical

Pathology Staff

Anatomic

Pathology Staff

Sign-in

Sheets/VISTA log-in

Past performance

2 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.

Past performance

3 Physician notification for typical single frozen sections

Initial frozen section is 20 minutes; 10 minutes for each additional

90% with notification documented on final report

Review critical value report.

Past performance

Method Of

Surveillance

Incentive specimen -specimen receipt to physician notification

4 Second review of all new malignancies not previously established

(excluding skin squamous and basal cell carcinoma)

Review PLMS QA

Management

Minutes.

Past performance

5 Provider notification of all new malignancies

(excluding skin squamous and basal cell carcinoma)

Within 24 hours of diagnosis

Minutes.

Past performance

6 Correlation of frozen section and final diagnoses

98% correlation

Minutes.

Past performance

Surgical Pathology report completion

Routine within 3 working days of specimen receipt, complicated within 5 working days of specimen receipt.

90%

Minutes.

Past performance

8 Provisional Autopsy

Diagnosis

Within 24 hours of post

Review monthly report.

Past performance

Final Autopsy Report

Within 30 calendar days of post

Print TAT report monthly.

Misc. 10 Miscellaneous

Pathologist review of referral testing requested after technologist screening.

80% Attendance at monthly

P&LMS Meeting

Random sampling

Meeting Minutes

Method Of

Surveillance

Incentive

Medical

Records

11 CPRS Requirements:

-Consults

-Electronic consent form

Contract requirements

95% Monitored by

HIMS using reports from the dictation system and VistA.

Medical Records to alert COTR of any provider who is non-compliant with these requirements.

TECHNICAL SERVICES

Id Indicator Standard Acceptable

Quality Level

Method Of

Surveillance

Incentive

Tests/

Reports

1 % of specimen slides mislabeled

None 0% Documentation when slides are received

Past performance

5. INCENTIVES

The Government shall use Exercise of Option Period and past performance as an incentive. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE - CHANGE TO MATCH ACTUAL METHOD IN

CONTRACT

a. Performance Measures Review: The COR shall use the surveillance methods listed below. See scale in paragraph 7 for rating/rating methodology.

(1) Sign-in Sheets/VISTA log-in

(2) Review critical value report.

(3) Review PLMS QA Management Minutes

(4) Review monthly report.

(5) Print TAT report monthly.

(6) Random sampling.

(7) Meeting minutes.

(8) Monitored by HIMS using reports from VistA. Medical Records to alert AO/COR of any provider who is non-compliant with these requirements.

(9) Documentation when slides are received.

b. Performance on Other Contract Requirements: The following items will also be monitored. See scale in paragraph 7 for rating/rating methodology. Ratings for these items will be achieved by random sampling, inspections, observation and customer complaints.

(1) Contractor conforms to contract requirements

(2) Contractor meets quality patient care standards

(3) Administrative matters handled appropriately (reports, credentialing, etc.)

(4) Contractor’s personnel are responsive and cooperative.

7. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

ting Methodology

SCALE FOR PERFORMANCE MEASURES REVIEW

RATING RATING METHODOLOGY

Met All elements within the standard were met

Partially Met At least half the required elements within the standard were met or partially met

Not Met Less than half the required elements within the standard were met

SCALE FOR PERFORMANCE ON OTHER CONTRACT REQUIREMENTS

RATING RATING METHODOLOGY

Outstanding Contractor provides exceptional quality of work. Work performance always achieves expectations and frequently exceeds them. Demonstrates a very high level of performance in all areas of responsibility.

Satisfactory Work performance consistently fulfills expectations and periodically may exceed them. Work is of high quality in all significant areas of responsibility.

Unsatisfactory Contractor does not meet most of the basic expectations and/or has failed to meet agreed upon performance measures. Significant improvement is needed in most aspects of this contract and contractor’s performance.

8. DOCUMENTING PERFORMANCE. In conjunction with the quarterly performance measure reports prepared by the COR, this data will also be used for documentation for a request to renew/not to exercise option period or renew of a contract.

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action. In order for a contractor to receive an “Acceptable” Performance rating, contractor must:

(1) Receive “Met” or “Partially Met” on all performance measures (see rating scale above).

AND

(2) Receive “Outstanding” or “Satisfactory” rating for all other Contract Requirements items.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the contractor's program manager.

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 COR. The Government shall review the contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COR shall visit/correspond, at a minimum, with the contractor twice during the contract period: (1) middle of contract period and (2) end of contract period to assess performance and shall provide a written assessment. This written assessment will be forwarded to the Contracting Officer as documentation of contractor’s performance and/or for a request to exercise option period, renewal of a contract or termination of a contract.

c. Semi-Annual Performance Measure Reports. COR will provide CO with semi-annual reports (due 45 days after the end of each performance period). CO will forward these reports to the Contractor. In turn, the Contractor will review the reports and acknowledge receipt of report by returning a signed copy, along with any comments, to the Contracting Officer within 30 days of receipt of the report.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative