A07 - QASP Dental Locums Contract.docx

Quality Assurance Surveillance Plan (QASP) 5/30/2025

Contract Number: Pending Contract Description: FBSU FY2026 6-month Dental Locums Services Contract Contractor’s Name: Pending

1. Vision To raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

2. Mission The Indian Health Service, an agency within the Department of Health and Human Services , is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally-recognized tribes grew out of the special government-to-government relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level. The IHS provides a comprehensive health service

3. Purpose

This Quality Assurance Surveillance Plan is a government-developed document used to determine if the contractor’s performance meets the performance standards contained in the contract. The QASP establishes procedures on how this assessment/inspection process will be conducted. It provides the detailed process for a continuous oversight process:

· What will be monitored

· How monitoring will take place

· Who will conduct the monitoring

· How monitoring efforts and results will be documented

The contractor is responsible for implementing and delivering performance that meets contract standards using its Quality Control Plan. The QASP provides the structure for the government’s surveillance of the contractor’s performance and their Quality Assurance/Quality Control (QA/QC) actions to assure they meet contract standards. It is the government’s responsibility to be objective, fair and consistent in evaluating contractor performance.

The QASP is not part of the contract nor is it intended to duplicate the contractor’s quality control plan. This QASP is a living document. Flexibility in the QASP is required to allow for an increase or decrease in the level of surveillance necessary based on contractor performance.

The government may provide a copy of the QASP to the contractor to facilitate open communication. In addition, the QASP should recognize that unforeseen or uncontrollable circumstances might occur that are outside the control of the contractor.

Bottom line, the QASP should ensure early identification and resolution of performance issues to minimize impact on mission performance.

FBSU will monitor and ensure the following:

1. Contractor will be evaluated to ensure that locums providers meet the performance and quality standards. These are outlined in the Performance Work Statement.

a. Patient Care and Professional Practice:

i. Contractors follows current guidelines and/or established Service Unit Policy & Procedures.

ii. Medical/clinical knowledge: Contractors use of current guidelines and scientific evidence to evaluate and to improve patient care.

iii. Contractors must work with the medical records department throughout each week to complete required documentation, including identified deficiencies. Prior to assignment completion the contractor must ensure, with the Health Information Management department, completion of all documentation and medical records.

iv. Contractors complete all required documentation, paperwork, communications and records in a timely manner, within timelines established by FBSU and Billings Area IHS Medical Staff Bylaws

b. Contractor Standards:

i. Contractors are compassionate, empathetic and culturally sensitive.

ii. Contractors present promptly, in professional appearance, dressed in professional attire for clinic,

iii. Contractors demonstrate exceptional ethical conduct

iv. Contractors demonstrate effective communication

v. Contractors demonstrate appropriate interpersonal skills that promote multidisciplinary teamwork and mutual respect

vi. Contractors exhibit high quality internal and external customer service

vii. Contractors exhibit exemplary attitude by being flexible and being adaptable.

viii. Contractors exhibit ethical conduct, attitude, appearance

ix. Contractor upholds all professional expectations and standards of conduct of Indian Health Service, Billings Area IHS Medical Staff, Billings Area IHS Medical Staff Bylaws, and Fort Belknap Service Unit

x. Contractors respond promptly and professionally to professional oversight of supervisors designated by IHS, Billings Area IHS, Billings Area IHS Medical Staff and Fort Belknap Service Unit

1. This includes oversight of the Service Unit CEO, the Service Unit Clinical Director or their designee, Department supervisor, Billings Area Chief Medical Officer, and Billings Area Medical Staff Chief of Staff,

xi. Contractors follows and upholds all FBSU Policies, Protocols and Procedures in an appropriate and timely manner.

c. Vendor will provide replacement candidate(s) if one or more candidate is not able to be present or is not qualified, or is removed or loses privileges.

d. Vendor will provide replacement candidate(s) if one or more candidate does not, in the judgment of FBSU Dental Department Supervisor, Clinical Director or CEO, perform duties adequately, or does not fulfill expectations as outlined above, in terms of medical professional practice, standards or conduct.

e. Vendor will provide a monthly report of contractor hours expended.

f. Vendor will provide accurate and timely invoices.

4. Authority

Authority for issuance of this QASP is provided under Part 46 of the Federal Acquisition Regulation, Inspection of Services clauses, which provides for inspection, acceptance and documentation of the service called for in the contract or order. This acceptance is to be executed by the contracting officer or a duly authorized representative.

5. Roles and Responsibilities

The following personnel shall oversee and coordinate surveillance activities.

Program/Project Manager (PM) or Functional Services Manager (FSM) – The PM/FSM provides primary program oversight, nominates the COR, ensures the COR is trained before performing any COR duties and supports the COR’s performance assessment activities. While the PM/FSM may serve as a direct conduit to provide Government guidance and feedback to the Contractor on technical matters, they are not empowered to make any contractual commitments or any contract changes on the government’s behalf.

Assigned PM/FSM: Eric C. Chenworth, D.O., Clinical Director Organization or Agency: Fort Belknap Service Unit Telephone: 406-353-3143 Email: eric.chenworth@ihs.gov

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 KO shall also ensure that the contractor receives impartial, fair, and equitable treatment under this contract. Determine the final assessment of the contractor’s performance.

Assigned KO: DeeAndra Salabye, Chief Contracting Officer Organization or Agency: IHS Telephone: (406) 208-8857 Email: DeeAndra.Salabye@ihs.gov

Contracting Officer’s Representative (COR) The COR is responsible for providing continuous technical oversight of the contractor’s performance. The COR uses the QASP to conduct the oversight/surveillance process. The COR shall keep a Quality Assurance file that accurately documents the contractor’s actual performance. The purpose is to ensure that the contractor meets the performance standards contained in the contract. The COR is responsible for reporting early identification of performance problems to the KO. The COR is required to provide an annual performance assessment to the KO which will be used in documenting past performance. The QASP is the primary tool for surveillance of the contractor’s quality program and help the COR to document contractor performance. The COR is not empowered to make any contractual commitments or to authorize any contractual change on the Government’s behalf.

Contractor Representatives

The following employees of the contractor serve as the contractor’s Program Manager and Task Manager for this contract. (Complete this section after the contract award)

Contractor Program Manager - <upon award, enter name> Telephone: <enter number> Email: <enter address>

Contractor Task Manager - <upon award, enter name> Telephone: <enter number> Email: <enter address>

Other Key Contractor Personnel - <upon award, enter name or delete these lines if not applicable> Title: <enter title> Telephone: <enter number> Email: <enter address>

6. Performance Requirements and Method of Surveillance

6.1. Contract Surveillance

The goal of the QASP is to ensure that contractor performance is effectively monitored and documented. The COR’s contribution is their professional, non-adversarial relationships with the KO, PM and the contractor, which enables positive, open and timely communications. The foundation of this relationship is built upon objective, fair, and consistent COR evaluations of contractor performance against contract requirements. The COR uses the methods contained in this QASP to ensure the contractor is in compliance with contract requirements. The COR function is responsible for a wide range of surveillance requirements that effectively measure and evaluate the contractor’s performance. Additionally, this QASP is based on the premise that the contractor, not the government, is responsible for management and QC/QA actions to successfully meet the terms of the contract.

6.2. Surveillance Matrix

The Surveillance Matrix (see sample at Attachment 1) is the list of performance objectives and standards that must be performed by the contractor. This matrix details the method of surveillance and frequency the COR will use to validate and inspect these performance elements. Inspection of each element will be documented in the COR file.

DFARS 222.17 mandates including surveillance for ensuring compliance with Combatting Trafficking in Persons (CTIP) in the QASP. Use the CTIP sample checklist from PGI 222.17. See the DoD CTIP website.

Performance objectives define the desired outcomes. Performance Standards define the level of service required under the contract to successfully meet the performance objective. The inspection methodology defines how, when, and what will be assessed in measuring performance. The Government performs surveillance, using this QASP, to determine the quality of the contractor’s performance as it relates to the performance element standards. The Performance Requirement Summary (PRS) should be used to form the foundation of the COR’s inspection checklist.

6.3. Performance Rating Definitions

The performance ratings below reflect definitions at FAR 42.1503 Table 42-1. The COR will use these rating to evaluate the quality of contractor’s performance. [If your organization requires that you use a different rating mechanism, insert it here.]

Performance Rating Definition

Note 1: Plus or minus signs may be used to indicate an improving (+) or worsening (-) trend insufficient to change the evaluation status.

Note 2: N/A (not applicable) should be used if the ratings are not going to be applied to a particular area for evaluation.

6.4. Methods of Surveillance include but are not limited to:

* 100% Inspection - This is an inspection method whereby all outputs are monitored. This method provides the best indication of contractor performance and the most documented basis for determining contract payment actions. However, it requires extensive COR resources, and therefore, is not practical for most service requirements. 100 percent inspection is preferred when the PWS requirement is so critical that nonperformance would pose a direct risk to the safety of personnel or property, or when the work occurs infrequently and the output population is small.

* Random Sampling - When a service is performed relatively frequently and a statistically valid sample can be selected for audit. The most appropriate method for frequently recurring tasks. Random Sampling is a means of evaluation by observing or inspecting some part (a sample), but not all, of a population or lot of the contract requirements to assist the government with determining whether standards set forth in the contract have been met. This tool is not the Contracting Officer’s only option nor is the tool usage mandatory. When performing random sampling, use a current version of Military Standard 105E Tables/ANSI/ASQC Z1.4 to determine the sample size and the acceptance and rejection numbers.

* Periodic Sampling - This method, sometimes called "planned inspection," consists of the evaluation of tasks selected on other than a 100 percent or random basis. It may be appropriate for tasks that occur infrequently, and where 100 percent inspection is neither required nor practical. A predetermined plan for inspecting part of the work is established using subjective judgment and analysis of agency resources to decide what work to inspect and how frequently to inspect it.

* Customer Feedback – Not necessarily a valid method of surveillance, but a good indicator for areas surveillance should be conducted or intensified. The COR may design a customer survey questionnaire to be used as an essential part of a well-publicized customer complaint program. In time of resource constraints, the use of customer surveys provides an effective and efficient means of monitoring contractor performance. Customer surveys should only supplement other surveillance efforts and be analyzed by surveillance personnel trained in validating customer complaints. Customers should be made aware of minimal contractor performance requirements to be sure that customer responses to surveys are valid indicators of actual contractor performance. The COR must investigate each customer complaint and validate the accuracy before any action is taken.

7. Performance Reporting

7.1. Corrective Action Report (CAR)

Describes how discrepancies are reported and resolved (see sample CAR below).

7.2. Customer Complaint Form

(See sample Customer Complaint Form below)

7.3. Performance Assessment Report (PAR) (See sample customer PAR below)

7.4. Contractor (Vendor) Evaluation Form (see sample Contractor Evaluation Form below)

Appendix 1 - Surveillance Matrix

C.3.1 Provide Dental locums services for FBSU.

C.3.1.1 The Contractor shall be licensed, qualified, credentialed, privileged and cleared Dentists for Dental locums services.

Deliverables:

Dental services, monthly statements, include amount billed and hours owed, as well as cumulative contract hours utilized.

a) High quality Dental locums services for care of routine and emergency dental procedures, including emergency/acute dental care as well as preventative and restorative dental care.

What: Dental locums services for direct dental care of patients at FBSU How: Case and chart reviews, Continuous observation, and Customer feedback reports Who: Service unit POC and COR, as well as Dental Department Supervisor and Clinical Director Incentive: $100 deduct for out of compliance documentation Standard(s ): Incentive applies to standard (a)

C.3.1.2 The Contractor shall participate in Dental Department and Medical Staff meetings and required trainings/orientations, as well as required service unit and IHS trainings.

a) The contractor will participate in the Dental Department activities and meetings, Medical Staff activities and meetings, as well as required trainings/orientations, as well as service unit and IHS trainings.

b) Maintains appropriate licensure, as well as credentialing and privilegings with Billings Area IHS Medical Staff, and appropriate security clearance(s).

What: Participation in required department and medical staff meeting attendance records and direct observation, verification of required orientations and trainings.

How: Inspection, direct observation and review of records, certificates and reports.

Who: Dental Department Supervisor and Clinical Director Incentive: $100 deduct for each absence at required meetings, trainings and orientations.

Standard(s): Inspection, observation and review applies to all expected standards, meetings, trainings and orientations.

C.3.1.3 The Contractor shall assure that locums dentist is appropriately licensed and trained to provide appropriate, high quality and efficient dental care services.

Deliverables:

A02 will deliver appropriate information on prospective locums dentists, ensure that all necessary information is available for credentialing, privileging and clearance, as well as updates in licenses and registrations

a) High quality locums dentist provided in order to provide exceptional dental care services AQL: Quality dental locums provider provided to provide exceptional dental care services at FBSU

What: Verification of education, training, licensures and registrations as well as work history and malpractice history How: Records and Visual Inspection of qualifications, education, licensures, registrations, work and malpractice history and ongoing quality care.

On-site periodic inspections Frequency: After completion of each inventory Who: AO credentialing and PSR staff to review qualifications for credentialing, privileging and clearance.

Standard(s): Inspection and review of all provided information and records to assure qualifications and competence.

Compliance

100% compliance with IHS Service Units and/or Health Centers published Policies; Procedures; Standards of Care; and hospital protocols.

To be reviewed and confirmed by Clinical Director as part of Contractor Orientation and maintained per FBSU policy.

To be reviewed and confirmed by Clinical Director as part of Contractor Orientation and maintained per FBSU policy.

To be reviewed and confirmed by Clinical Director as part of Contractor Orientation and maintained per FBSU policy.

Monthly reporting of continual evaluation by Clinical Director

Clinical Director to review continuously and at the end of each module

Inspection Methodologies: Documentation of participations, observations, and chart reviews maintained by Clinical Director, with monthly review of performance by contractor and contract dentist to document required monthly evaluation.

M1: Inspection of Reports. All reports shall be reviewed upon receipt. The reviewer will report any flaws in the document and categorize the flaws (Editorial, Format, and/or Substance).

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY |_| MAJOR |_| MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. QUALITY ASSURANCE PERSONNEL (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. COR DETERMINATION

|_| ACCEPTED |_| REJECTED

12. CLOSE DATE

CUSTOMER COMPLAINT RECORD

DATE/TIME OF COMPLAINT

SOURCE OF COMPLAINT

ORGANIZATION

BUILDING NUMBER

INDIVIDUAL

PHONE NUMBER

NATURE OF COMPLAINT

CONTRACT REFERENCE

VALIDATION

DATE/TIME CONTRACTOR INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR

RECEIVED/VALIDATED BY

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Billings Area Indian Health Services (IHS) Quality Assurance Monitoring Form

The information collected on this form is to determine the overall performance of the Contractor in meeting the requirements of the contract. This form will be kept confidential and will be reported onto the Contractor’s Performance Assessment Report (CPAR).

CONTRACTOR INFORMATION

Contractor’s Name (First, MI, Last):

Specialty:

Vendor Name:

Purchase Orde Appraisal Peri

STANDARD: Con procedures that m

1. Patient Car & Procedu

2. Medical/cl evidence to

3. Patient Car

4. Timely com with effective comm

5. Profession

6. Flexibility

7. Interperson respect.

STANDARD: No r Hospital Protocols

8. Have any q

Risk

9. Has contra r Number:

od: From: To:

tractors provided fully successful or excellent patient care. No reports of breached safety or other ay have adversely affect patient outcomes.

e Practice: Follows current guidelines and/or established Service Unit Policy res.

inical knowledge: Use of most recently recommended guidelines and scientific evaluate and improve patient care.

tractors were compassionate and culturally sensitive.

e Practice: Compassion and culturally sensitivity.

tractors completed required documentation in clear and legible form in a timely manner.

pletion of required paperwork/records: documents visits clearly and legibly.

tractors presented promptly in professional appearance for clinic, demonstrated exceptional ethical conduct unication, and exhibited exemplary attitude by being flexible and being adaptable.

alism: Ethical conduct, attitude, appearance, and prompt for clinic.

– Adaptability.

al/communication skills that promote multidisciplinary teamwork and mutual eprimands or disciplinary actions for violations of published Policies; Procedures; Standards of Care or (includes timely completion of mandatories).

uality of care issues or disciplinary actions been brought forth by:

Management Evaluations Tort Claims ctor been reprimanded for compliance violations?

Submitted by: _________________________________________

REVISED 07/2021

Contractors Name First MI Last:

Vendor Name:

Purchase Order Number:

Question 1: [Exceptional]

Question 2: [Exceptional]

Question 3: [Exceptional]

Question 4: [Exceptional]

Question 5: [Exceptional]

Question 6: [Exceptional]

Question 7: [Exceptional]

Risk: [No]

Tort: [No]

Reprimand: [No]

Name of Chief:

CHIEF OF:

From_af_date:

To_af_date:

Specialty: