36C25918R0573-004.docx

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Copy of (M) 635-Inpatient Dialysis: ATTN Kevin Pollard (VA-18-00082608)
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36C25918R0573
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This document contains a Quality Assurance Surveillance Plan (QASP) for a medical services contract to provide dialysis nurses, technicians, equipment, and limited supplies. The contract will be awarded by the Department of Veterans Affairs Network Contracting Office and overseen by a Contracting Officer and Contracting Officer's Representative.

The QASP outlines 13 performance standards for clinical information provision, care plan compliance, check-in times, accreditation and qualifications, provider credentialing, patient safety incident reporting and resolution, patient complaint reporting, preventative equipment maintenance, water and dialysate quality, medication and chemical storage, and frequency of performance assessments. Methods for monitoring include direct observation, periodic inspection, user surveys, validated complaints, and random sampling. Performance will be rated as meeting or exceeding standards, or failing to meet standards. Acceptable and unacceptable performance will be documented.

36C25918R0573 ATTACHMENT C- QUALITY ASSURANCE SURVEILLANCE PLAN - Rev.docx

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Quality Assurance Surveillance Plan For: Medical Services

Contract Number: TBD

Contract Description: Contractor to provide Dialysis Nurses and Technician services along with equipment and limited supplies

Contractor’s name: TBD

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: Kevin Pollard Organization or Agency: Department of Veterans Affairs, Network Contracting Office 16

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:

c. Other Key Government Personnel –

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – TBD

b. Other Contractor Personnel - TBD

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.

There is no separate Performance Requirements Summary Matrix. Below are the areas from the Performance Work Statement (PWS) that are being monitored and the performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Task
ID
Indicator
Standard
Acceptable Quality Level
Method of Surveillance

Rating

Clinical Information Return
1
Inpatient care: clinical information provided to the authorizing VA medical center through CPRS documentation.
Within 24 hours after treatment.(Paragraph 21)
100%
Random review of CPRS documentation.
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

2
Patient Care Plan Compliance.
Contractor to provide treatment as per protocols for Dialysis as referenced in Paragraph 6 &11
100%
Direct Observation and random review of documented care plans.
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Check in/Initial Access
3
Patient must be seen by the provider in a timely manner. Nurse must sign in/out.
Within time frames established in Paragraph 5 Contractor must fax this within 30 minutes of completion of treatment to Medicine Service. Sign in/out (Paragraph 18)
90%
100% inspection
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Quality Care

4
Accreditation and Qualifications
Competency file must be kept current with Nurse’s license, training, TB, etc as in Paragraph 12 & 14
90%
Files will be reviewed quarterly for completeness.
Incentive: Favorable contractor performance evaluation
5
Provider credentialing.
All nurses must be credentialed in accordance with VA policy (new) and kept current throughout contract period. Paragraph 1 &12
100%
Files will be reviewed quarterly for compliance.
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Patient Safety
6
Patient safety incidents must be reported to the authorizing VA medical center and the COR.
All incidents reported immediately (within 24 hours.) Paragraph 24.
90%
100% inspection
Incentive: Favorable contractor performance evaluation
7
Patient safety incidents must be investigated, confirmed and resolved.
All incidents are investigated, confirmed and resolved. Paragraph 24
85%
100% inspection
Incentive: Favorable contractor performance evaluation
8
Patient safety incident investigations, conclusions and findings must be reported to the authorizing VA medical center and the COR.
Updates and findings of patient safety incident investigations are provided continuously (at least once a week.) Paragraph 24
90%
100% inspection
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Patient Satisfaction
9
Patient complaints about the quality of care are reported to the VISN Patient Advocate, the COR, and the Contractor Patient for resolution.
All patient complaints are reported immediately (within 24 hours.) Paragraph 25
90%
100% inspection
Incentive: Favorable contractor performance evaluation
10
Providers and staff are familiarized with the process outlined in contractor’s grievance procedures as well as patient rights.
All providers and staff are educated. Paragraph 25
85%
Direct observation and random review of customer surveys.
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Equipment
11
Preventive and Emergency Equipment Maintenance
Contractor must meet safety and quality checks for dialysis machines as indicated in Paragraph 1 & 10.
100%
Analysis of reports provided by Contractor and random checks by VA Env. Rounds team.
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Water and dialysate quality reports
12
Positive Outcome from the Dept. of Health.
Contractor shall not receive 2 consecutive negative outcomes in a one year period. Shall provide reports in timely fashion as indicated in Paragraph 19
100%
Contractor shall provide the COR with a copy of each report for Infection Control Dept.
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Storage/ Handling of Medications

13
Correct storage of medications.
There shall be no storage of medications in assigned space; any unused shall be returned to Pharmacy, especially expired medications. Paragraph 19
100%
Random inspection by COR and by VA Env. Rounds team.
Incentive: Favorable contractor performance evaluation

Disincentive: Unfavorable contractor performance evaluation

Storage/ Handling of chemicals

14
Correct storage of chemicals needed for dialysis.
There shall be no storage of chemicals without being dated nor any expired products. Paragraph 1 & 10
90%
Random inspection by COR and by VA Env. Rounds team.
Incentive: Favorable contractor performance evaluation

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. (Can be performed periodically or through 100% surveillance.)

10, 2

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

14, 13, 12, 11, 5, 4, 1

c. USER SURVEY. (Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. May also generate inspections and sampling.) 12, 10, 9

d. VALIDATED USER/CUSTOMER COMPLAINTS. (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.) 10, 9

e. 100% INSPECTION. (Evaluates all outcomes.)12, 9, 8, 7, 6, 3

f. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases. 14, 13, 11, 10, 5, 4, 1

6. 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:

1) Meeting or exceeding acceptable quality level as defined in the above mentioned survey plan will be considered satisfactory.

2) Failure to meet the defined quality levels will be considered unsatisfactory.

All survey results will be presented to the Quality Management Board on a quarterly basis.

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

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.

8. 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 meet with the contractor monthly to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative

File details come from the government source that posted it. Updated .