S02 D.1 QASP PLAN After Hours Pharmacy.docx

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

For: After Hours Pharmacy Services – Amarillo Texas

Contract Number:

Contract Description: The contractor shall provider Amarillo VA Medical Center after hours medication order processing to include but not limited to all management, supervision, manpower, materials, supplies, and equipment in accordance with the requirements of this contract.

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.

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: Jacob Yang Phone: 806-355-9703 x7581 Email: jacob.yang@va.gov

6010 Amarillo Blvd. West Amarillo, TX 79106-0238

c. Other Key Government Personnel – Chief of Pharmacy

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. DIRECT OBSERVATION: 100% surveillance: Staff and management’s direct observation of methods, process adherence, and quality during the performance of contractual duties.

b. PERIODIC INSPECTION: Inspections scheduled and reported quarterly per COR delegation or as needed. Clinical or operational reports randomly selected will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS: Each customer complaint will be investigated by the Pharmacy Supervisor/COR. Methods of investigation include the examination of records, and statements provided by the patient, other staff/patients, and the contract personnel. Final determination on the validity of the complaint rests with the Chief of Pharmacy.

d. RANDOM SAMPLING: Randomly selected patient files will be reviewed on an as-needed basis to validate other quality indicators.

e. Verification and/or documentation provided by Contractor. Supplied documentation will be reviewed and verified by the COR.

6. QASP PERFORMANCE REPORT

Frequency

Quarterly

98%

Direct Observation

Annually

100%

Periodic Inspection

Quarterly

7. CPAR RATINGS ASSIGNED TO QASP ITEMS

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:

Per the performance standard grid above, a calculation of percent goal will be made during the random sampling/observation. For example, a random sampling of progress notes will be conducted to ensure 95% or better are actually entered for veteran participants as well as 95% or better within time-frame.

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/documents/CPARS-Guidance.pdf:

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.

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.

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.

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).

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 on the following page.

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

CONTRACT DISCREPANCY REPORT

5. DATES

a. CDR PREPARED

6. DISCREPANCY OR PROBLEM (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

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.)

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

a. CONTRACTOR NOTIFIED

b. COR

c. ONTRACTING OFFICER

9. CONTRACTOR AND COR ACKNOWLEDGEMENT OF QASP

SIGNED:

CONTRACTOR NAME/TITLE DATE

SIGNED:

COR NAME/TITLE DATE