A0001_Attachment 02 - QASP_Clean.pdf

Quality Assurance Surveillance Plan

The QASP provides a performance requirement and an Acceptable Quality Level (AQL) for select activities in the PWS and the contract itself. A performance requirement describes a required element of contractor performance. An AQL defines the minimum level of performance that is deemed satisfactory. The contract requires the contractor to perform all work as specified.

AQLs take into account that, in some instances, an allowable level of deficiency (deviation) is possible while overall performance continues to meet ICE’s desired level of service. AQL’s define that level or number of performance deficiencies tolerable under this contract. They take into account the difference between an occasional defect and a gross number of defects. AQLs are expressed as a percentage as calculated per the performance measure. The AQLs directly relate to the performance requirement and are a direct percentage of the performance requirement percentage. There may be instances where 100% compliance is necessary, and no deviation is acceptable.

AQLs for contractor performance are structured to allow for the contractor to manage how it performs work while providing negative incentives for performance shortfalls which may have a serious impact on mission performance. If the quality level does not meet or exceed the AQL, the Government may consider the contractor’s performance unsatisfactory.

Functional Area Performance Requirements

Performance Measure Frequency Method of

Surveillance

Acceptable Quality Level /

Critical Threshold

(as % of Perf. Req.)

Reporting/ Deduction Criteria

Overall Staffing

100% of contractually required FTEs are fully qualified and working.

The number of FTEs working as a percentage of the total contractually required number of FTEs.

(# of working staff / # of required positions) x 100

Monthly • Site Status Report.

92% / 80%

Note: This number will not be rounded when begin calculated

All QASP Metrics will be reported in

CPARS.

Site Staffing Levels

100% of contract FTEs are fully qualified and working on site at each IHSC location.

The number of fully qualified FTEs working on site as a percentage of the total contractually required number of FTEs monthly by site.

• The Site Status

Report containing the last day of each month will

Large Site:

92% / 80%

Small Site:

80% / 60%

The monthly amount invoiced per site will be reduced by the sum of deductions applicable to each labor category at

Performance Measure Frequency Method of

Surveillance

Acceptable

Deduction Criteria

(# of working staff / # of required positions for each location) x 100

Unfilled position codes due to a contract modification, will be exempt from assessment for 45 days from the effective date of the signed modification.

For classification within this document only the following definitions are used

Large Site: ≥ 30 FTE

Small Site: < 29 FTE be used to assess this monthly metric.

that site.

Large Sites:

LVN/LPNs < 85% = 0.25% < 80% = 0.50% < 75% = 1.00% < 60% = 3.00%

RNs < 88% = 0.25% < 83% = 0.50% < 78% = 1.00% < 65% = 3.00%

APPs < 90% = 0.25% < 83% = 0.50% < 78% = 1.00% < 65% = 3.00%

BHPs < 90% = 0.25% < 83% = 0.50% < 78% = 1.00% < 65% = 3.00%

Techs/Assistants < 92% = 0.25% < 87% = 0.50% < 82% = 1.00% < 65% = 3.00%

MD/DO-DDS-

PharmD-CC

Performance Measure Frequency Method of

Surveillance

Acceptable

Deduction Criteria

< 75% = 0.25% < 50% = 3.00%

Small Sites:

RN/LVN/LPN

< 75% = 0.25% < 67% = 0.50% < 60% = 1.00% < 50% = 3.00%

All Other Positions:

< 75% = 0.25% < 67% = 0.50% < 60% = 1.00% < 50% = 3.00%

Contract Medical Staff

Qualifications

100% of candidates submitted for e-QIP initiation shall be fully qualified according to the position description.

The number of candidates submitted for e-QIP initiation receiving a wavier as a percentage of the total number submitted.

((total # of submitted staff for eQIP - #staff with active waivers) / total submitted staff for eQIP) x

Monthly • Site Status Report.

• Waiver request submitted and approved to the government.

95%

(Less than 5% contractor staff receive waivers when submitted)

All QASP Metrics will be reported in

CPARS.

Retention

90% of employees that start each quarter shall remain employed at the end of that quarter.

# of individual employees who employed at the end of the quarter divided by the # of employees which were on contract or started at the start of the quarter

Quarterly • Site Status Report. 100% All QASP Metrics

Performance Measure Frequency Method of

Surveillance

Acceptable

Deduction Criteria

(Total staff at end of quarter / (# total staff at the start of quarter – those working after start of quarter)) x 100

Sites closing, conversions to GS and positions removed during a contract year will not be included.

Turnover

No more than 18% of the employees who start each quarter shall leave the contract by the end of the same quarter.

# of separations during the measurement period divided by the average # of employees during the measurement period

(# of staff which left during quarter / ((total working staff month 1 + total working staff month 2 + total working staff month

3) / 3)) x 100

Sites closing, conversions to GS and positions removed during a contract year will not be included.

Quarterly • Site Status Report. 100% All QASP Metrics will be reported in

CPARS.

Backfill for RN and LVN Callouts

100% of RN and LVN/LPN shifts shall be backfilled by the contractor.

The number of RN and LVN/LPN shifts backfilled as a percentage of the total RN and LVN/LPN shift call outs each month.

(Required backfill shifts covered / Total backfill

Monthly • Site Status Report.

• Assessment from local GTMs.

85% / 40% All QASP Metrics

Performance Measure Frequency Method of

Surveillance

Acceptable

Deduction Criteria shifts required) x 100

Successful back-fill is defined as having worked:

6 of an 8-hour shift 8 of a 10-hour shift 10 of a 12-hour shift

Start Dates

100% of contract staff start within 30 calendar days of receiving a preliminary favorable fitness determination.

The number of staff that start within 30 calendar days of receiving a preliminary favorable fitness determination as a percentage of the total starting each month.

(total staff that started within 30 days of favorable determination / total staff which started during period) x 100

• Assessment from local GTMs.

95% All QASP Metrics

Competency Assessment

100% of staff shall successfully complete their competency assessment* within 90 calendar days of start date.

The number of staff that successfully complete competency assessment* within 90 calendar days of their start date as a percentage of the staff that started within the previous 90 days.

(total staff that completed competency assessment within 90 / total staff that were required to complete assessment within the

Monthly • Site Status Report.

• Assessment from local GTMs.

95% All QASP Metrics

Performance Measure Frequency Method of

Surveillance

Acceptable

Deduction Criteria month) x 100

Collaborative Practice and Prescriptive Authority Agreement

(CP&PA

Agreement)

100% of APP staff are covered under an

IHSC CP & PA

Agreement with a contract collaborating physician within 90 calendar days of their start date.

The number of APP staff covered under an IHSC CP & PA Agreement with a contract collaborating physician within 90 calendar days of their start date as a percentage of the total APP staff.

(total APP staff that have an agreement in place within 90 days / total APP staff required to have an agreement in place within 90 days)) x 100

Monthly • Site Status Report.

• Assessment from local GTMs.

• Assessment from

IHSC

Credentialing.

95% All QASP Metrics will be reported in

CPARS.

Credentialing (Non-Licensed Independent Practitioners)

100% of complete credentialing packets shall be submitted to the government no less than 7 business days before their start date.

APPs – 12 business days.

Number of complete credentialing packets submitted to the government no less than seven business days before their start date as a percentage of the total submitted monthly.

APPs-12 days

(total # of complete packets submitted within timeline / total # of packets required to be submitted) x

Monthly • Site Status Report.

• Assessment from local GTMs.

• Assessment from

IHSC

Credentialing.

95% All QASP Metrics will be reported in

CPARS.

Privileging 100% of complete privileging packets shall be submitted to the government no

Number of complete privileging packets submitted to the government no less than

Monthly • Site Status Report.

• Assessment from local GTMs.

• Assessment from

95% All QASP Metrics

Performance Measure Frequency Method of

Surveillance

Acceptable

Deduction Criteria

(Non-Licensed Independent Practitioners) less than 14 business days before the start date.

fourteen business days before their start date as a percentage of the total submitted monthly.

(total # of complete packets submitted within timeline / total # of packets required to be submitted) x

IHSC

Credentialing.

Deliverables

100% of deliverables listed in the Deliverables Table are provided to the government according to the Deliverable Table schedule.

Number of deliverables as listed in the Deliverables Table provided to the government according to the Deliverable Table schedule, as a percentage of the total.

(total # of deliverables submitted on time / total # of deliverables required) x

Annually Email receipt by the government.

100% All QASP Metrics will be reported in

CPARS.

*as applicable

Note: The contractor is responsible for performance of ALL terms and conditions of the contract. The contractor will provide progress reports quarterly to the CO and CORs reflecting QASP performance according to the QASP table above. The performance measures outlined in this QASP shall be used to determine Contractor performance in each Functional Area. All metrics will be reported in