36C25719R0002-008.pdf

D1 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 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: To be Determined 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: To be Determined Organization or Agency Organization or Agency: VANTHCS Dallas, TX 75216

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. MANAGEMENT INFORMATION SYSTEMS (MIS). Evaluates outputs through the use of management information reports. Will be supplemented with periodic sampling.

Measure: Timeliness of Reports – Standard: 100% of reports are delivered per the requirements of the performance work statement.

Measure: Provider Quality Performance – Standard: 100% of care provided within clinical standards of care.

b. PERIODIC INSPECTION. Uses a comprehensive evaluation of selected outputs. Inspections may be scheduled daily, weekly, monthly, quarterly, or annually or unscheduled.

Measure: Timeliness of Reports – Standard: 100% of reports are delivered per the requirements of the performance work statement.

Measure: Provider Quality Performance – Standard: 100% of care provided within clinical standards of care.

c. RANDOM SAMPLING. Designed to evaluate the output of the award requirement by randomly selecting and inspecting a statistically significant sample. Sampling may schedule daily, weekly, monthly, quarterly, or annually or unscheduled.

Measure: Qualifications of Key Personnel – Standard: 100% (All) contractor physician(s) are board certified.

Measure: Scope of Practice/Privileging – Standard: 100% (All) contractor physician(s) perform within their scope of practice/privileges 100% of the time.

Measure: Patient Access – Standard: 100% (All) contract physician(s) are on time and available to perform Teleradiology Physician Services to include BPE connection.

Measure: Maintains Licensing, Registration, and Certification – Standard: 100% (All) licensing, registration(s), and certification(s) for contract physician(s) shall be provided as they are renewed as they should be current at all times.

Measure: Mandatory Training – Standard: 100% (All) require training is complete on time by contract physician(s).

d. SELF MONITORING. The contractor is responsible to report any breach and/or violation of laws, regulations, policies, and procedures relating to Privacy, Confidentiality and HIPAA within 24-hours to the COR and CO.

Measure: Privacy, Confidentiality and HIPAA – Standard: 100% (All) contractor physician(s) comply with all laws, regulations, policies, and procedures relating to Privacy, Confidentiality and HIPAA.

6. QUALITY ASSURANCE AND PERFORMANCE MONITORING:

(a) The Government will periodically evaluate the Contractor’s performance by appointing a representative(s) to monitor performance to ensure services are received. The Government may inspect each task as completed or increase the number of quality assurance inspections if deemed appropriate because of repeated failures or because of repeated customer complaints. Likewise, the Government may decrease the number of quality assurance inspections if performance dictates. VAMC Quality Assurance Personnel will validate any complaints and report to the Government Contracting Officer who will then take necessary action to enforce contract compliance.

(b) If any of the services do not conform to contract requirements, the Government may require the Contractor to perform the services again in conformity with contract requirements, at no additional cost to the government. When the defects in services cannot be corrected by re-performance, the Government may -

(1) Require the Contractor to take necessary actions to ensure that future performance conforms to contract requirements; and

(2) Terminate the contract.

Table 7 - PERFORMANCE MEASURES

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID

NOT MEET

AQL-

CPAR

RATING/ADD

COMMENTS

Maintains licensing, 4.5.3.6 Updated All (100%) All (100%) Periodic registration, and Licensing, licensing, licensing, Sampling certification registration and registration(s) registration(s) and and certification shall and certification(s) for Random be provided as certification(s) contract physician Sampling they are renewed. for contract (s) shall be Licensing and physician (s) provided as they registration shall be are renewed.

information kept provided as Licensing and current. they are registration renewed. information kept Licensing and current. No registration acceptable information kept deviation.

current.

Qualifications of Key 4.5.3.3

All contract All (100%) 100% No Random

Personnel physician(s) shall contract deviations inspections have current physician(s) of board certified in perform within qualification accordance with their scope of the ACR practice documents Standards for Radiology

Scope of 4.5.3.4 Contract All (100%) All (100%) Random Practice/Privileging physician(s) contract contract physician Inspection perform within physician (s) (s) perform within of records.

their individual perform within their scope of scopes of their scope of practice/privileges practice/privileging practice/ privileging 100% of the time.

100% of the time. No deviations accepted.

Patient Access 4.5.3.5 Contract physician (s) shall be available and in location as needed to properly perform tasks as specified.

All (100%) contract physician

(s) are on time and available to perform services.

Contract physician (s) are on-time and available to perform services 98 % of the time

VISTA/Mont age turnaround time

Privacy, Confidentiality Contractor is All (100%) 100% compliance;

Contractor and HIPAA 4.5.3.8 aware of all laws, contractor no deviations. shall regulations, physician

(s) provide policies and comply with all evidence of procedures laws, annual relating to regulations, training Privacy, policies and required by Confidentiality procedures VAMC, and HIPAA and relating to reports complies with all Privacy, violations standards Zero Confidential ity per VA breaches of and HIPAA Directive privacy or 6500.6.

confidentiality

Timeliness of Reports : Prompt delivery 100% of reports

98% VISTA/Montage turnaround time

4.5.3.1 (timeliness) of are delivered interpretations per the and return for requirement s of routine/stat/immedi ate the PWS

Provider Quality 4.5.3.2 All contract 100% of care

100% OPPE

Performance physician (s) shall provided within perform in clinical accordance with standards of clinical standards care

1. 7. 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/pdfs/CPARS- Guidance.pdf p. A2-1):

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

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 determines 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: SIGNED:

COR NAME/TITLE DATE CONTRACTOR NAME/TITLE DATE