Atch 2c QASP.docx

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 will coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions will be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel will oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO will ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and will safeguard the interests of the United States in the contractual relationship. The CO will 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: Michael Cumins Organization or Agency: Dept. of Veterans Affairs NCO-15, Leavenworth, KS

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and will assure proper Government surveillance of the contractor’s performance. The COR will 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: TBD Organization or Agency: Robert J. Dole VAMC, Wichita, KS

3. CONTRACTOR REPRESENTATIVES

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

Primary:

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 will 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 will use these standards to determine contractor performance and will 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 will use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION - 100% surveillance.

1. Patient Records Reviews – review of patient records for diagnosis, follow-up, medications, lab and clinical orders for appropriate documentation, orders, and diagnosis information.

2. Interpersonal skills and communications observed by VAMC between contractor and patients/family, between contractor and VAMC providers and clinicians, including oral and written communications; and professionalism during performance of work.

3. Observation of physician’s use and navigation of EHR/CPRS, to include entry of patient visit notes, orders, assessments, and orders creation – submit & receive – and follow-up notes and actions, and addendums.

4. Reviews of privileging and credentialing information and documents for periodic recredentialing.

5. OPPE documentation for all data pertinent to care performed for each provider working under the contract. OPPE data will review the following elements:

i. Patient Care Performance

ii. Medical/Clinical knowledge

iii. Practiced Based Learning & Improvement.

iv. Interpersonal & Communication Skills

v. Professionalism

vi. System Based Practice

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

1. Patient Records Reviews – review of patient records for diagnosis, follow-up, medications, lab and clinical orders for appropriate documentation, orders, and diagnosis information.

2. Observation of physician’s use and navigation of EHR/CPRS, to include entry of patient visit notes, orders, assessments, and orders creation – submit & receive – and follow-up notes and actions, and addendums.

3. Reviews of privileging and credentialing information and documents for periodic recredentialing.

4. Reviews of OPPE audits performed by physician, e.g. 5 patients per monthly OPPE.

5. Reviews of OPPE audits performed on physician, e.g. 5 patients per monthly OPPE.

6. Review of Contractor physician’s evidence of annual Privacy and HIPAA training required by VAMC, reports of violations per VA Directive 6500.6.

c. VALIDATED USER/CUSTOMER COMPLAINTS.

1. Interpersonal skills and communications observed by VAMC between contractor and patients/family, between contractor and VAMC providers and clinicians, including oral and written communications; and professionalism during performance of work.

2. Complaints issued by patients/family and VAMC personnel, including other contractor physicians performing under separate contracts, related to any aspect of nephrologist’s performance, diagnosis, professionalism, or other matters. Complaints would be collected individually as presented to the VAMC, including by surveys completed by patients/family and/or VAMC or contractor personnel.

d. RANDOM SAMPLING.

1. Patient Records Reviews – review of patient records for diagnosis, follow-up, medications, lab and clinical orders for appropriate documentation, orders, and diagnosis information.

2. Observation of physician’s use and navigation of EHR/CPRS, to include entry of patient visit notes, orders, assessments, and orders creation – submit & receive – and follow-up notes and actions, and addendums.

3. Random sampling of time and attendance sheets.

e. Verification and/or documentation provided by Contractor.

1. Patient Records Reviews – review of patient records for diagnosis, follow-up, medications, lab and clinical orders for appropriate documentation, orders, and diagnosis information.

Quality Assurance Surveillance Plan (QASP)

6.SAMPLE QASP PERFORMANCE REPORT DATE:__________________

Reference Performance Requirement

Method Met AQL/DID NOT MEET AQL-

CPAR RATING/ADD COMMENTS

7. DOCUMENTING PERFORMANCE

a. The Government will 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 will inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO will document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR will 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 an action plan to document how the contractor shall correct the identified issue and avoid a recurrence. The CR will also state how long after receipt the contractor has to present this action plan to the CO. The Government will review the contractor's action plan. The CO will 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 action plan.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CR on following page.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

SHARON WILBUR, COR DATE

SIGNED:

(Offeror/Contractor) DATE

CONTRACT REPORT

5. DATES

a. CR PREPARED

6. Issue Identified: (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

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.)

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER