36C26118Q0536-0001010.doc

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

640-18-4-097-0012 – MAGNETIC RESONANCE IMAGING TECHNOLOGIST (MRI)

For: Diagnostic Radiologic Technologist, Magnetic Resonance Imaging – Palo Alto Division

Contract Number:

Contract Description:

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.

*Note. The QASP is not a part of the contract. Its sole use is to monitor contractor performance.

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: Organization or Agency: Department of Veterans Affairs, Network Contracting Office, VISN 21

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 Primary: Valeriano L. Sia, Chief Radiology Administrator Organization or Agency: Department of Veterans Affairs, VAPAHCS, Radiology Service

c. Other Key Government Personnel - Upon award, Government will enter name, if applicable. This may include Performance Monitors, Clinical Quality experts, etc. who act on behalf of the COR to monitor performance.

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Secondary:

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. 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.

The Performance Requirements Summary Matrix in the Performance Work Statement (PWS), includes performance measures. The Government shall use these measures to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Task

Measures

PWS

Ref#

Deduct

Key Personnel

Unfavorable

Contractor performance evaluation.

Unfavorable

Contractor performance evaluation

Licensing and registration information kept current.

Unfavorable

Contractor performance evaluation

Contractor completes all mandatory required training

Contractor will complete all required training in accordance with VAPAHCS policy.

100%

Contractor to provide documented evidence.

Suspension or termination of all physical and/or electronic access privileges and removal from contract until training is completed.

Privacy, Confidentiality and HIPPA

5. INCENTIVES AND DEDUCTS

The Government shall use past performance as incentives. Disincentives shall be based on ratings received on the performance standards. The Government shall use the scoring methods above for continuing contract performance. MONETARY INCENTIVES: NONE

6. METHODS OF QUALITY ASSURANCE SURVEILLANCE

Various methods exist to monitor performance. The COR may use any surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION: Attendance is monitored continuously using the Vista electronic messaging system through daily signing in and out.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

· For all outpatient and inpatient services, patient must have their radiographic procedure done in a timely manner. We expect all (100%) of our patients to be provided service within 25 minutes of scheduled appointment/walk in or notified within that time of when a study can be performed and/or to explain any reason for delays.

· Staff must maintain an acceptable level on image quality monitoring measure.

As images will be reviewed before the patient is released, 100 % of the studies are expected to be within acceptable threshold of established QC criteria or otherwise deemed acceptable by the reviewing radiologist.

· Staff must adhere to the Radiology Service quality assurance program in providing patient care. Shall be 100 % in compliance with the program, including competencies and routine daily QA expectations.

c. USER SURVEY: This method combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. The COR may also generate inspections and sampling.

d. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints are to be reported to the COR and the Service Chief. All complaints are reviewed and discussed at the monthly staff meetings.

e. INSPECTION. The COR may evaluate all outcomes of procedures, spot check the work area, and discuss performance with physicians and allied health personnel at any time but at least once per quarter.

7. 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:

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.

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.

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 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 be 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:

Valeriano L. Sia, Chief Radiology Administrator, COR Date

SIGNED: