36C26118Q0132-003.pdf

VA Sierra Nevada Health Care System

ATTACHMENT A

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Per Diem Nursing Staff (080)

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:

a. What will be monitored?

b. How monitoring will take place.

c. Who will conduct the monitoring?

d. 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 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:

Organization or Agency: VISN 21 Network Contracting Office

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: Andrew Mahoney 775-788-6849

Alternate COR: Randy G Wehnes 775-788-6847

Alternate COR: Dawn Lafferty 775-786-7200 x 6851

Organization or Agency: VA Sierra Nevada Health Care System, Reno, NV

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary:

Alternate:

Organization or Agency:

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. INCENTIVES / DEDUCTS

The Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards.

6. 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. The Chiefs of Acute Care Nursing Service, Extended Care &

Mental Health Nursing Service, Sterile Processing, Primary Care and/or his/her designee will regularly observe the work performance of the vendor or vendor’s employee during normal work hours and at dates and times consistent with operational efficiency.

b. PERIODIC INSPECTION. The Chiefs of Acute Care Nursing Service, Extended Care &

Mental Health Nursing Service, Sterile Processing, Primary Care and/or his/her designee will perform periodic inspection of notes, encounters and other standard documentation of clinics, procedures and follow up to ensure both completion of the documentation and completion to the established standards.

c. PATIENT/CUSTOMER COMPLAINTS. The Chiefs of Acute Care Nursing Service, Extended Care & Mental Health Nursing Service, Sterile Processing, Primary Care and/or his/her designee will review and investigate as necessary any patient complaints, with results to be discussed with the CO and vendor as required.

Measure

PWS

Reference

Performance

Requirement Standard

Acceptable

Quality

Level

Surveillance

Method Incentive Disincentive

Provide professional services in support of

Nursing

Services

4.5.2.1

4.5.2.2

4.5.2.3

4.5.2.4

Employees from contract provide care to patients by determining priority level and assessments using organizational and observational skills

Per floor charge nurse instructions 100%

Direct

Observation, Records Review

Favorable

Contractor

Performance

Unfavorable

Contractor

Performance

Provide assistance to physician during procedures

4.5.2.6

Proper clinical procedures and specimen collection followed. Equipment cleaned as directed.

Per Physician performing procedure and supervisory nursing staff

100% Direct

Observation

Favorable

Contractor

Performance

Unfavorable

Contractor

Performance

Equipment properly assembled for procedures

4.5.2.5

Equipment will be properly cleaned, sterilized and prepared for distribution

Established department procedures

100% Direct

Observation

Favorable

Contractor

Performance

Unfavorable

Contractor

Performance

Clinical

Effectiveness

4.2

4.5.2.1

4.5.2.2

4.5.2.3

4.5.2.4

Assure proper patient outcomes based on indicators

Meet clinical standards 100%

Direct

Observation, Records Review

Favorable

Contractor

Performance

Unfavorable

Contractor

Performance

Present for scheduled clinics

3.3

3.4

3.5

3.6

Meets performance measures and other quality assurance measures

Per schedule and contract 95%

Direct

Observation, Records Review

Favorable

Contractor

Performance

Unfavorable

Performance

Measure

PWS

Reference

Performance

Requirement Standard

Acceptable

Quality

Level

Surveillance

Method Incentive Disincentive

Meeting

Participation

3.3

3.4

3.5

3.6

Participate in scheduled staff/team meetings

Present at meetings as required

95% Records Review

Favorable

Performance

Unfavorable

Contractor

Performance

Work Hours 3.1

4.1.1

On as needed per diem basis

Meet requirements in

PWS

95%

Direct

Observation, Records Review

Favorable

Contractor

Performance

Unfavorable

Contractor

Performance

Qualifications Section 2

4.3

Provide fully trained and competent staff

Meet all qualification criteria

100% Records Review

Favorable

Contractor

Performance

Unfavorable

Contractor

Performance

Billing for services

VISN

and/or GSA

Contract

Bill properly and on time

Acceptable

Business Practice 95% Records Review

Favorable

Contractor

Performance

Unfavorable

Performance

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

EXCEPTIONAL:

Performance meets contractual requirements (AQL) 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 (AQL) 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:

(Acceptable Quality

Level)

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

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).

a. 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.

b. 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.

c. 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.

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:

ANDREW MAHONEY, AO/COR DATE CONTRACTOR NAME/TITLE DATE

SIGNED:

RANDY G WEHNES, AA/COR DATE

SIGNED:

DAWN LAFFERTY, AA/COR DATE