ATT 2 QASP FOR MRI SERVICES - Updated - 5-28-25.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 will monitoring will take place?

• Who will conduct the monitoring?

• How will monitoring efforts and results 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 the 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: Thomas M. Kovarovic Contract Specialist (850) 226-1921

Organization or Agency: Department of Veterans Affairs, South Central Veterans Administration Health Care Network (SCVAHC) P&C

b. Contracting Officer’s Representative (COR) – The COR is responsible for the technical administration of the contract and shall ensure 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: Cassandra L. Sibley, Administrative Officer (318) 990-5354

Organization or Agency: Overton Brooks VA Medical Center – Radiology Service

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager:

Alternate Program Manager:

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:

• Utilize remote diagnostic tools software to rack equipment performance

• Ensure that preventive maintenance activities are conducted as per contract

• Review MRI images produced to ensure they meet the required diagnostic standards

• Regular consultation with medical staff on the quality and effectiveness of MRI scans

• Conduct regular audits of contractor operations to verify compliance with contract terms (e.g., reporting, staffing levels, and performance)

• Review service logs, maintenance records, and other reports submitted by the contractor to ensure they are complete and accurate

• Ensure that MRI safety protocols are being followed, such as patient screening for contraindications and radiation safety procedures (if applicable)

• Verify that the contractor employees maintain appropriate accreditation or certification

b. PERIODIC INSPECTION. Inspections are scheduled and reported quarterly per COR delegation or as needed. Five to ten randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)

c. VALIDATED USER/CUSTOMER COMPLAINTS. Data for customer complaints will be received and validated through the Patient Advocate Tracking System (PATS). The Patient Advocacy Office will forward PATS submissions to the COR for processing and resolution.

d. RANDOM SAMPLING. Samplings are scheduled and reported quarterly per COR delegation or as needed. Five to ten randomly selected patient files will be reviewed per sampling period. All samplings and reports will be conducted in compliance with VA Privacy and Information security standards.)

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. Performance matrix not utilized at this time, but may be added in the future.

6. SAMPLE QASP PERFORMANCE REPORT DATE: __________________

Measure ID Performance Requirement

Standard Acceptable

Quality Level Method of

Surveillance

Met AQL/DID NOT MEET AQL-

CPARS RATING/ADD COMMENTS

Patient Access 1

Patients must receive subsequent treatment in a timely manner.

The provider is on-site and available during all scheduled clinic hours.

98%

Direct Observation and random inspection

Quality Care 2

Contract employee qualifications and competency assessments.

All employees must have appropriate qualifications, training, and annual competency assessments in line with OBVAMC standards.

100%

Direct Observation

Patient Safety

Patient safety incidents must be reported to the authorizing VA medical center and the COR.

All incidents are reported immediately (within 24 hours.) 100%

Direct Observation and random Inspection

Patient safety incidents must be investigated, confirmed, and resolved.

All incidents are investigated, confirmed, and resolved.

100%

Direct Observation and random inspection

Reference SOW - Section 3, page 1 Section 13b, page 12

Reference SOW - Section 3, page 1 Section 13b, page 12

Reference SOW - Section 6, page 2;

Section 13b, page 12

Reference SOW - Section 10(1), page 6 Section 13b, page 12

Measure ID Performance Requirement

Standard Acceptable

Quality Level Method of

Surveillance

Met AQL/DID NOT MEET AQL-

CPARS RATING/ADD COMMENTS

Patient safety incident investigations, conclusions, and findings must be reported to the authorizing VA medical center and the COR.

Updates and findings of patient safety incident investigations are provided continuously (at least once a week.)

100%

Direct Observation and random inspection

Patient Satisfaction

Patient satisfaction with MRI services

All cases.

99%

Direct Observation and communication from Veterans

Documentation of Services

MRI cases are documented in the Radiology VISTA package.

Exams completed for all services rendered

98%

Periodic inspection

Maintains applicable certification

Updated registration and certification shall be provided as they are renewed.

Licensing and registration information are kept current.

All (100%) registration(s) and certification(s) for contractor’s employees shall be provided as they are renewed.

Licensing and registration information are kept current.

100% registration(s) and certification(s) for contractor’s employees shall be provided as they are renewed.

Licensing and registration information are kept current.

No acceptable deviation.

Periodic Inspection or Random Sampling of training/competen cy folders maintained by the contractor.

Copies shall be maintained on the trailer.

Reference SOW - Section 3, page 1 Section 13b, page 12

Reference SOW - Section 6, page 3 Section 13b, page 12

Reference SOW - Section 10, page 6 Section 13b, page 12

Reference SOW - Section 13a, page 11

Measure ID Performance Requirement

Standard Acceptable

Quality Level Method of

Surveillance

Met AQL/DID NOT MEET AQL-

CPARS RATING/ADD COMMENTS

Mandatory Training

The contractor employees shall complete all required training on time per facility policy.

All (100%) of required training is completed on time.

100% completions, no deviations.

Periodic Inspection or Random Sampling

Privacy, Confidentiality , and HIPAA

The contractor and all employees are aware of all laws, regulations, policies, and procedures relating to Privacy, Confidentiality, and HIPAA and comply with all standards Zero breaches of privacy or confidentiality

All (100%) contractor employees comply with all laws, regulations, policies, and procedures relating to Privacy, Confidentiality, and

HIPAA

100% compliance

Periodic Inspection; The Contractor shall provide evidence of annual training required by the facility, and reports violations per VA Handbook 6500.6.

Reference SOW - Section 7, page 4 Section 13b, page 12 Section 13h, page 12 Section 15h, page 14

Section 19e, page 17

7. CPARS 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 management tool that notified the contractor of the contractual deficiency (e.g.

Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTO

RY:

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 https://www.cpars.gov/documents/CPARS-Guidance.pdf https://www.cpars.gov/documents/CPARS-Guidance.pdf 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 REPORTING SYSTEM (CPARS).

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 CR below.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Cassandra L. Sibley, Administrative Officer_______

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER

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