36C26319R0132-004.doc

Quality Assurance Surveillance Plan

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 agreement 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 agreement. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned CO: Dan Vagts Organization or Agency: NCO-23 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(S): Linda Beem

Organization or Agency: Minneapolis VA Health Care

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 Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

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; direct observation will not be performed by the COR.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. On-call services will be checked on a monthly basis by COR by checking the on-call schedule and speaking with the Colon-Rectal Service to see if provider was providing required on-call services.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Discussion with individuals involved in patient care and who are familiar with the provider’s work will be randomly polled quarterly or as needed by the COR.

d. RANDOM SAMPLING. Patient charts will be randomly sampled semi-annually by COR reviewing up to 10 randomly selected CPRS records to verify required documentation and for resident supervision. (All reviews and reports will be conducted in compliance with VA Privacy and Information Security Standards).

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. COR will work with the Medical Staff Office to verify maintenance of valid license & other credentialing

6. QASP PERFORMANCE REPORT

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:

8. DOCUMENTING PERFORMANCE

a. Acceptable Performance

The Government shall document positive OR NEGATIVE 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 work with the Contracting Officer (CO) to 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. In order to assure that the contractor receives impartial, fair, and equitable treatment under this agreement, the COR will work with the contractor to increase performance to an acceptable level.

When the COR and CO determines formal written communication is required, the COR and CO 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.

9 . 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 as needed to assess performance and shall provide a written assessment.

Signature – Contractor

Signature – Contracting Officer Representative See above Acceptable Quality Level & Method of Surveillance located in QASP