7. QASP - Injury Prevention Academic Advisor Services - Final.docx

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Injury Prevention Academic Advisor Services

May 29th, 2024 i

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Injury Prevention Academic Advisor Services

INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled Injury Prevention Academic Advisor Services. This plan sets forth the procedures and guidelines for the inspection of services in ensuring the required performance standards or services levels are achieved by the contractor.

Purpose The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the PWS and the contractor’s quality control plan (QCP), and to ensure that the government pays only for the level of services received.

This QASP defines the roles and responsibilities of all members of the integrated project team (IPT), identifies the performance objectives, defines the methodology used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

Performance Management Approach The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by the Division of Environmental Health Servics to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

Performance Management Strategy The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the government to take advantage of the contractor’s QC program.

The government representative(s) will monitor performance and review performance reports furnished by the contractor on a quarterly basis to determine how the contractor is performing against communicated performance objectives. The government will make determinations regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

ROLES AND RESPONSIBILITIES

The Contracting Officer The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the assigned contracting officer's representative (COR), program manager (PM) and the contractor. The CO will designate one full-time COR as the government authority for performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the CO.

The Contracting Officer’s Representative The contracting officer’s representative COR is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for the technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect the contract price, terms, or conditions shall be referred to the CO for action. The COR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract. The COR will conduct a final review of deliverables and recommend approval of invoices.

2.3 The Program Manager

The program manager (PM) will work with the contractor to provide technical and programmatic oversight of the contract. The PM will review all deliverables to ensure performance standards and quality levels have been reached in accordance with the performance requirements summary in Attachment 1. The PM will participate in weekly conference calls with the contractor and/or contractor’s staff. Purpose of communications is to review project progress, discuss issues or problems, and develop recommendations.

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary.” If the contractor meets the required service or performance level, it will receive a positive CPARS report. Failure to meet the required service or performance level will result in a negative CPARS report.

METHODOLOGIES TO MONITOR PERFORMANCE

Surveillance Techniques In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are (include those that apply).

· 100% Inspection – For each deliverable, the PM and/or COR, shall review the generated documentation and enter summary results into the Surveillance Activity Checklist.

Customer Feedback The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer-focused through initially and internally addressing customer complaints and investigating the issues and/or problems but the customer always has the option to communicate complaints to the CO or COR, as opposed to the contractor.

Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR will accept those customer complaints and investigate.

Acceptable Quality Levels The acceptable quality levels (AQLs) included in PWS for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. Levels of performance are keyed to the relative importance of the task to the overall mission.

QUALITY ASSURANCE DOCUMENTATION

Monitoring Forms The government’s QA surveillance, accomplished by the PM or COR, will be reported using the monitoring form in Attachment 2. The form, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results are being achieved.

The COR will retain a copy of all completed QA surveillance forms.

ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

Determining Performance Government shall use the monitoring methods cited to determine whether the performance standards/ AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels. Failure to meet the AQL may result in a deduction from the monthly payment, using the deduction percentages shown in Attachment 1.

Reporting At the end of each Quarter, the PM will prepare a written report for the COR summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the contractor’s submitted quarterly report and will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

Reviews and Resolution The COR may require the contractor’s project manager, or a designated alternate, to meet with the CO, PM and other government IPT personnel as deemed necessary to discuss performance evaluation. The CO will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the PM or COR as often as required or per the contractor’s request. The agenda of the reviews may include:

· Performance assessment data and trend analysis

· Issues and concerns of both parties

· Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

· Recommendations for improved efficiency and/or effectiveness

The COR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

The PM and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the CO.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Required Services (Tasks) Performance Standards Acceptable Quality Levels Methods of Surveillance Impact on Contractor CPARS

· Perform as the coordinator and advisor, for academic review and revisions, of the injury and violence prevention courses

· Coordinate meetings/calls of the IHS Injury Prevention ARC to determine if content and teaching modalities for the Fellowship, the core courses [Injury and Violence Prevention Course 1, 2, and 3] require updating, including the existing distance-learning delivery/instructional methods that support synchronous and asynchronous learning environments

· Revise documents and materials such as teaching curriculums, training outlines, data collection methods and other resources materials as needed

· Coordinate pilot course(s) and conduct secondary revisions to curriculum, outlines, resource materials, and delivery as needed;

· Design the curriculum, conduct, and record a train-the-trainer course that includes 2-hours of on-demand webinar(s) covering material that will prepare instructors to host any of the three injury and violence prevention courses (e.g. become a confident IHS IVP short course instructor)

Materials shall be reviewed upon receipt; the reviewer will report any flaws in the document and categorize the flaws (editorial, format, and/or substance) Posivtive or negative CPARS report

· Implement the existing Fellowship curriculum, course structure, learning methods, and prepare the schedule for the IHS Injury and Violence Prevention Fellowship

· Plan the 12-18 month experience for each Fellowship class/cohort, organize speakers, ensure effective curriculum design and delivery, and provide evaluation for the Fellowship experience, including implementing and coordinating up to seven classes (in-person or virtual), the graduation and presentation of final projects, and assist the Fellows prepare for additional advanced training (e.g. complete a course at a university)

· Assist and support mentors assigned to each Fellow

· Monitor Fellow progress through phone calls, email, letters and/or face-to-face meetings to assure timeline and completion of Fellow’s research projects

· Assist in the design, implementation and analysis of individual Fellow projects

· Provide oversight in Fellow progress during the training period

Materials shall be reviewed upon receipt; the reviewer will report any flaws in the document and categorize the flaws (editorial, format, and/or substance) Posivtive or negative CPARS report

· Advise on clinical and public health aspects of injury prevention

· Assist with developing reports, information summaries and presentations

· Assist with design, implementation, and evaluation of Area IVP Projects

· Justify why the IHS Injury Prevention Program should be renamed as the Injury and Violence Prevention Program and assist with the official name change

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE

MONITORING FORM (Quarterly)

SERVICE or STANDARD: submitted report and it was agreeae

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint LEVEL OF SURVEILLANCE (Check):

ANALYSIS OF RESULTS:

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: _________________

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