Atch 1 - Quality Assurance Surveillance Plan _ENT.docx

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Q514--Otolaryngology (ENT) Physician Services for Columbia VA Health Care System
Solicitation number
36C24721Q1079
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About this file

This document includes a Quality Assurance Surveillance Plan and related federal contract opportunity for otolaryngology physician services. The Quality Assurance Surveillance Plan outlines monitoring methods and performance standards for a contract to provide one full-time equivalent ear, nose and throat physician for the Columbia VA Health Care System. Monitoring will include direct observation, inspections, validated complaints, and random sampling. Performance will be evaluated on clinical quality, qualifications, scope of practice, patient access, safety reporting, licensing and training. The federal contract opportunity involves solicitation number 36C24721Q1079 to provide otolaryngology physician services at the Columbia VA on a firm-fixed-price basis. The services include both regular and on-call hours, and the period of performance is 12 months. Qualifications require the physicians to be licensed, board certified in otolaryngology, and credentialed and privileged at the Columbia VA. The solicitation is expected to close on September 9, 2021 for services from September 22, 2021 to September 21, 2022.

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36C24721Q1079 0001.docx DOCX document
Atch 4 IMMIGRATION CERTIFICATION.docx DOCX document
36C24721Q1079.docx DOCX document
Atch 3 CONTRACTOR RULES OF BEHAVIOR.docx DOCX document
Atch 2 - MCM 544-11-13 Ordering and Reporting of Test Results.docx DOCX document

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QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

CONTRACT # _________________________

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 CO: Valeria Murray Organization or Agency: Network Contracting Office (NCO) 7

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: Brenda S. Currier, Lead Vascular Technologist Organization or Agency: Surgery Service, Columbia VA Health Care System

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary:

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. 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. Performance standard Number 1.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Performance Standard numbers 1,2,3,4,7.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Performance Standard Numbers 4.

d. RANDOM SAMPLING. Performance Standard Numbers 2,3.

e. Verification and/or documentation provided by Contractor. The Performance Requirements Summary Matrix of the Performance Work Statement includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality level.

Atch 1

6. SAMPLE QASP PERFORMANCE REPORT DATE: __________________

Measures
PWS

Reference Performance Requirement

Standard
Acceptable Quality Level
Surveillance

Method Met AQL/DID NOT MEET AQL-

CPAR RATING/ADD COMMENTS

Provider Quality Performance
4.6.4.1.
All Contractor’s physician(s) shall perform in accordance with clinical standards
100% of care provided within clinical standards of care
100%
OPPE
Qualifications of Key Personnel
4.6.4.2.
Contractor’s physician(s) shall have Board Certified /Board Eligible Otolaryngology Physician in accordance with PWS requirements
All (100%) Contractor’s physician(s) are Board Certified /Board Eligible Otolaryngology Physician
100%
Random Sampling of qualification documents
Scope of Practice/Privileging
4.6.4.3
Contractor’s physician(s) perform within their individual scopes of practice/privileging
All (100%) Contractor’s physicians (s) perform within their scope of practice/privileges 100% of the time.
100% Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time.
Random Sampling of records.
Patient Access
4.6.4.4.
Contractor’s physician(s) shall be available and in location as needed to properly perform tasks as specified.
All (100%) Contractor’s physicians (s) are on time and available to perform services.
Contractor’s physician(s) are on-time and available to perform services 100% of the time
Periodic Inspection of Time and Attendance Sheets
Patient Safety
4.6.4.5.
Patient safety incidents shall be reported using Patient Safety Reporting System. All incidents reported immediately (within 24 hours.)
All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.
100% of patient safety incidents are reported using Patient Safety Reporting System within 24 hours of incident.
Reviews reported
Maintains licensing, registration, and certification
4.6.4.6.
Updated Licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current.
All (100%) licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current.
100% licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation
Periodic Inspection and Random Sampling
Mandatory Training
4.6.4.7.
Contractor shall complete all required training per VAMC policy
All (100%) of required training is complete on time by Contractor’s physician(s).
100%. completions
Periodic Inspection
Privacy, Confidentiality and HIPAA
4.6.4.8.
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
All (100%) Contractor’s physician(s) comply with all laws, regulations, policies, and procedures relating to Privacy, Confidentiality and HIPAA
100%
Contractor shall provide evidence of annual training required by VMC, reports violations per VA Handbook 6500.6

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 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 management tool that notified the contractor of thecontractual 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).

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 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. See Sample on following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Brenda S CurrierApril 20th, 2021
Brenda S. CurrierDATE

Lead Technologist

SIGNED:

CONTRACTOR NAME/TITLE DATE

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

CONTRACTING OFFICER

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