36C26319R0153-004.pdf

Quality Assurance Surveillance Plan (QASP)

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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 Contracted performance.

Assigned CO: Medical Sharing Office Team 1, CO will be assigned upon receipt of procurement package.

Organization or Agency: Medical Sharing Office Team 1

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the Contracted 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: Kim Bielicki Organization or Agency: Minneapolis VAHCS

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3. 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.

4. 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: Cardiology staff will directly monitor a ECHO while it is being performed.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Five (5) patient files will be randomly selected and reviewed quarterly. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Customer complaints will be reviewed and an in-depth fact finding will be initiated by the Cardiology Nurse Manager with all parties involved. Fact finding will then be reviewed with Primary Care Leadership team and Chief Experience Officer and an outcome will be documented.

d. RANDOM SAMPLING. Five (5) 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. Timecards will be reviewed on a weekly basis for accuracy.

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5.SAMPLE QASP PERFORMANCE REPORT DATE:1/18/2018

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Frequency

Provider Quality Performance 4.5.4.1. All Contracted MITs (Echocardiographers) shall perform non-invasive examinations of the heart in accordance with clinical standards at

MVAHCS.

Contracted MITs (Echocardiographe

rs) independently perform and access non-invasive examinations of the heart in accordance with section 4.4 of

PWS.

100%Contracted MITs (Echocardiographers) perform within their scope of practice/privileges 100%of the time. No Deviations.

Direct Observation, daily reports and chart reviews

Monitor throughout the term of contract by Cardiology staff.

Qualifications of Key Personnel 4.5.4.2. All Contracted MITs (Echocardiographers) shall be Certified in echocardiography imaging by the ARDMS and/or CCI in accordance with Standards.

100% Contracted MITs (Echocardiographe

rs) are certified.

100% Contracted MITs (Echocardiographers) are certified by ARDMS and/or CCI.

No deviations.

Credentialing Onboarding/Credentialing and throughout the term of the contract.

Scope of Practice/Privileging 4.5.4.3 Contracted MITs (Echocardiographers) perform within their individual scopes of practice/privileging

100% Contracted MITs (Echocardiographe

rs) perform within their scope of practice/privileges 100% of the time.

100%Contracted MITs (Echocardiographers) perform within their scope of practice/privileges 100%of the time. No Deviations

Direct observation

Randomly throughout the term of the contract by Cardiology staff.

Patient Access 4.5.4.4. Contracted MITs (Echocardiographers) available in accordance with the operating hours.

Contracted MITs (Echocardiographe

rs) shall be available and in location as needed to properly perform tasks as needed.

Contracted MITs (Echocardiographers) are on-time and available to perform services 95% of the time.

Periodic sampling of time and attendance sheets.

Randomly throughout the term of contract.

Patient Safety 4.5.4.5. Patient safety incidents shall be reported using Patient Safety Report. All

Patient safety incidents are reported using Patient Safety

100% of patient safety incidents are reported using Patient Safety

Direct Observation

Randomly throughout the term of the contract

Page 4 of 8 Version 0002 1/20/2018 incidents within 24 hours.

Report within 24 hours of incident.

Report within 24 hours of incident.

Maintains licensing, registration, and certification

4.5.4.6. Updated Licensing, registration and certification shall be provided as they are renewed. Licensing, registration and certification information kept current.

(100%) registration(s) and certification(s) for Contracted MITs (Echocardiographe

rs) shall be provided as they are renewed.

Licensing and registration information kept current.

100% registration(s) and certification(s) for Contracted MITs (Echocardiographers) shall be provided as they are renewed.

Licensing and registration information kept current.

Periodic and random sampling.

Randomly throughout term of contract.

Mandatory Training 4.5.4.7. Contractor shall complete all required training per MVAHCS policy.

(100%) of required training is complete on time by Contracted MIT (Echocardiographe rs)

95% completions. Periodic Sampling

Randomly throughout term of contract.

Privacy, Confidentiality and

HIPAA

4.5.4.8. 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

(100%) Contracted MITs (Echocardiographe

rs) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

95% compliance. Contractor shall provide evidence of annual training required by

MVAHCS

reports violations per VA Directive 6500.6.

Randomly throughout term of contract.

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7. CPAR RATINGS ASSIGNED TO QASP ITEMS:

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):

EXCEPTIONAL: Performance meets contractual requirements 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 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:

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 Contracted 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 Contracted 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).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

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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 Report (CR), and present it to CO. The CO will in turn review and will present to the Contracted program manager for corrective action.

The contractor shall acknowledge receipt of the CR in writing. The CR 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 CR will also state how long after receipt the contractor has to present this corrective action plan to the CO. The Government shall review the Contracted 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 Contracted performance and the acceptability of the Contracted corrective action plan.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

See Sample on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Kim Bielicki, COR II and Program Analyst DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

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CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS

DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. Issue Identified (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 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.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

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CONTRACTING

OFFICER