ALBANY IONM QUALITY ASSURANCE SURVEILLANCE PLAN.pdf

Quality Assurance Surveillance Plan (QASP)

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 contractor’s performance.

Assigned Contract Specialist: Tiffany Vazquez-Simon Network Contracting Office 2 130 west Kingsbridge Road Bronx, NY 10468 Phone: 914-737-4400 Email: tiffany.vazquez-simon@va.gov

Assigned Contracting Officer: Natalie Acevedo Network Contracting Office 2 130 west Kingsbridge Road Bronx, NY 10468 Phone: 718-584-9000 Email: Natalie.acevedo@va.gov

Organization or Agency: U.S. Department of Veterans Affairs

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: Scott A. Brooks Department of Veterans Affairs, Albany Stratton VA Medical Center 113 Holland Ave Albany, NY 12208 Phone: 518-626-5000 ext. 66302 Email: Scott.Brooks3@va.gov

Organization or Agency: U.S. Department of Veterans Affairs

3. CONTRACTOR REPRESENTATIVES: The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Primary –

b. Alternate –

4. 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.

5. RATING STANDARDS: Ratings shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE: Various methods exist to monitor performance:

a. DIRECT OBSERVATION

b. PERIODIC INSPECTION AND/OR VISIT

c. VALIDATED USER/CUSTOMER COMPLAINTS

d. PERIODIC SAMPLING

e. RANDOM SAMPLING

f. PROGRESS OR STATUS MEETINGS

g. ANALYSIS OF CONTRACTOR’S PROGRESS REPORTS

7. SAMPLE QASP PERFORMANCE REPORT` DATE: __________________

MEASURES PWS

REFERENC

E

PERFORMANCE

REQUIREMENT

STANDARD ACCEPTAB

LE QUALITY

LEVEL

SURVEILLAN

CE

METHOD

1- Patient Access

4 (All) 7.3.1

Contractor’s Technologist(s) shall be available and in location as needed to properly perform tasks as specified.

All (100%) Contractor’s Technologist(s) are on time and available to perform services.

100% Direct Observation, as scheduled for procedures

2 – Patient Safety

4 (All) 7.3.2

Contractor’s Technologist(s) report patient incidents using Patient Safety Report. All incidents reported immediately (within 24 hours.)

All (100%) Contractor’s patient safety incidents are reported using Patient Safety Report within 24 hours of incident.

100% Direct Observation, Random

3 - Maintains licensing, registration, and certification

2 (All) 7.3.3

Contractor’s Technologist(s) maintain licensing, registration, trainings, and certifications

All (100%) licensing, registration(s) and certification(s) for Contractor’s Technologist(s) shall be provided as they are renewed. Licensing and registration information kept current.

100% No acceptable deviation.

Periodic Inspection or Random Sampling of records.

4- Medical Records

6 (All) 7.3.4

Contractor shall make all medical records concerning the veteran’s surgical care readily accessible to VA and VA surgeons.

100% all medical records shall be made readily accessible to VA and VA surgeons by Contractor’s Technologist(s)

100% Direct Observation or Random Sampling of records.

5 - Privacy, Confidentiality and HIPAA

6.2 6.3 6.4 7.3.5

Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero

All (100%) Contractor’s Technologist(s) comply with all laws, regulations, policies and procedures relating to Privacy, 100% compliance;

Periodic Inspection or Random Sampling.

Contractor shall provide evidence of annual training required by breaches of privacy or confidentiality

Confidentiality and

HIPAA

VAMC, reports violations per VA Handbook 6500.6.

6- Billing for Services

9.3 9.4 9.5 9.6 7.3.6

Contractor shall submit invoices in a timely manner.

All (100%) of invoices should be submitted timely by the 7th business day of the following month after services performed.

100% Periodic or Random sampling of invoices submitted to the VA electronic invoicing system.

8. 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/documents/CPARS-Guidance.pdf):

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 contractor’s 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 https://www.cpars.gov/documents/CPARS-Guidance.pdf 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 contractor’s 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).

9. 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 contractor's 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 contractor's 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 contractor’s performance and the acceptability of the Contractor’s corrective action plan.

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

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE