36C25918R0596-0002001.docx

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Orthopedic Long Term Contract Federal contract opportunity
Solicitation number
36C25918R0596
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 19

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36C25918R0596 0002 Attachment D.1 Onsite ORTHOPEDICQASP_Denver.docx

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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: Assigned CO:

Kevin Pollard, Contracting Officer Department of Veterans Affairs Network Contracting Office 19 950 NE 13th Street Oklahoma City, OK 73104 Phone: 405-456-1896 Email: kevin.pollard2@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:

MaryEllen Winkler, Administrative Officer Department of Veterans Affairs VA Eastern Colorado Health Care System 1055 Clermont Street (112) Denver, Colorado 80220 Phone: 303-399-8020 x 2912 Email: maryellen.winkler@va.gov

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)

Page 5 of 8 Revised10/1/2015

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: (if this method is used, define how surveillance will be accomplished.)

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. (Define what and how often it will be inspected. For example, 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.)

c. VALIDATED USER/CUSTOMER COMPLAINTS. If this method is used, explain how data will be collected and reported.

d. RANDOM SAMPLING. If this method is used, define what and how often it will be sampled. (For example, 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.)

e. Verification and/or documentation provided by Contractor. Review PWS and if this method of surveillance is selected, define how documentation will be verified and how assessment will be conducted. (For example, off-site contracts may require the contractor to provide information on services provided to patients).

SAMPLE PERFORMANCE MEASURES

Measures
PWS

Reference Performance Requirement

Standard
Acceptable Quality Level
Surveillance

Method

1-Provider Quality Performance
4.5.5.1.
All Contractor’s physician (s) shall perform in accordance with clinical standards
100% of care provided within clinical standards of care
95%
OPPE
2 - Qualifications of Key Personnel
4.5.5.1
Contractor’s physician (s) Board Certified in accordance with PWS requirements.
All (100%) Contractor’s physician (s) are Board Certified
100%
Verification and/or documentation provided by Contractor.
3 - Scope of Practice/Privileging
4.5.5.2
Contractor’s physician (s) perform within their individual scopes of practice/privileging
All (100%) Contractor’s physician (s) perform within their scope of practice/privileges 100% of the time.
100%
Random Inspection of records.
4- Patient Access
3.1;

3.2;

4.4.6.2;

4.5.5.3.

Contractor’s physician (s) shall be available and in location as needed to properly perform tasks as specified.
All (100%) Contractor’s physician (s) are on time and available to perform services as scheduled.
Contractor’s physician (s) are on-time and available to perform services 90% of the time
Periodic Sampling of Time and Attendance Sheets & Review of Encounter Report
5 - Patient Safety
4.4.7.4.;

4.5.3.4.

Patient safety incidents shall to be reported using Patient Safety Report. All incidents reported immediately (within 24 hours.)
All (100%) of patient safety incidents are reported using Patient Safety Report within 24 hours of incident.
100% of patient safety incidents are reported using Patient Safety Report (electronic) within 24 hours of incident.
Direct Observation as notified
6 - Maintains licensing, registration, and certification
2.2.1;

4.5.5.5.

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 physician (s) (s) shall be provided as they are renewed. Licensing and registration information kept current.
100% licensing, registration(s) and certification(s) for Contractor’s physician (s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation.
Periodic Sampling and Random Sampling
7 - Mandatory Training
6.3;

4.5.5.6

Contractor shall complete all required training per VAMC policy
All (100%) of required training is complete on time by Contractor’s physician (s).
80% of the training courses are completed on time.
Periodic Sampling
8 - Privacy, Confidentiality and HIPAA
4.4.2;

4.5.5.7.

Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality
All (100%) Contractor’s physician (s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA
100% of the time in compliance
Contractor shall provide evidence of annual training required by VAMC, reports violations per VA Directive 6500.6.
9 – Operating Room Efficiency
4.6.4.9
The pre-operative note will be written in the patient’s electronic health record 15 minutes prior to the scheduled time of the case.
90% of the cases will meet this timeliness standard.
90%
Quarterly review of the operative report.
10- Patient Record Management / Post-operative note completion.
4.5.5.9
This note will be documented immediately after the operation/procedure. This note will describe the procedure, operative findings, and condition of the Veteran. This note is to include the name of the staff physician responsible for the procedure and the post-procedure care. It will be written or countersigned by the staff physician. Before the Veteran is discharged, the procedure(s) should be reviewed with the Veteran by the staff physician regarding results and the Veteran’s progress and the prognosis. This review may be recorded by either a staff entry in the progress notes or countersignature of a house officer

entry stating the staff performed this function. Discharge notes must be dictated or entered directly into CPRS 24 hours prior to Veteran’s discharge from the hospital (when applicable).

90% of the dictated notes are signed within 24 hours after dictating.

Acceptable Quality Level: 90% compliance.

90%
Periodic Sampling as reviewed by the unsigned notes report.

The table below is a sample that can be tailored – note that the table must identify where in the PWS the standards are found for monitoring performance. Check the MSO Customer Resource Center for approved mandatory QASPs.

7. RATINGS

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)”.

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:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

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