Attachment 06 - QASP.pdf

Quality Assurance Surveillance Plan (QASP)

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Eyeglasses and Optical Shop Services For

Veteran Integrated Services Network (VISN) 15 Facilities

Table of Contents

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

(a). INTRODUCTION

(1). Purpose

(2). Performance Management Approach

(3). Performance Management Strategy

(b). ROLES AND RESPONSIBILITIES

(1). The Contracting Officer

(2). The Contracting Officer’s Representative

(c). IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS ... 5

(d). METHODOLOGIES TO MONITOR PERFORMANCE

(1). Surveillance Techniques

(2). Customer Feedback

(3). Acceptable Quality Levels

(e). QUALITY ASSURANCE DOCUMENTATION

(1). The Performance Management Feedback Loop

(2). Monitoring Forms

(f). ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

(1). Determining Performance

(2). Reporting

(3). Reviews and Resolution

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

ATTACHMENT 3: SAMPLE CONTRACTOR DISCREPANCY REPORT FORM

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

(a). INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the statement of work (SOW) entitled Eyeglasses and Optical Shop Services. This plan sets forth the procedures and guidelines the VA Medical Centers will use in ensuring the required performance standards or services levels are achieved by the contractor.

(1). Purpose

(A). The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the SOW and the contractor’s quality control plan (QCP), and to ensure that the government pays only for the level of services received.

(B). This QASP defines the roles and responsibilities of all members of the contracting team , identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

(2). Performance Management Approach

(A). The SOW structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by the VA Medical Centers to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the SOW are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management;

this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

(B). Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

(3). Performance Management Strategy

(A). The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the staffing and procedures for self- inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the SOW. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the SOW. This QASP enables the government to take advantage of the contractor’s QC program.

(B). The government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The government will make determination regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

(b). ROLES AND RESPONSIBILITIES

(1). The Contracting Officer

The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the contracting officer's representative (COR) and the contractor. The CO will designate one full-time COR as the government authority for performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the Contractor.

(2). The Contracting Officer’s Representative

The contracting officer’s representative (COR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

(c). IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY

LEVELS

The required performance standards and/or quality levels are included in the SOW and in Attachment 1, “Performance Requirements Summary” to this document. If the contractor meets the required service or performance level, it will be paid the monthly amount agreed on in the contract. Failure to meet the required service or performance levels may be documented in the contractor’s performance evaluation and will be used in considering a determination of suitability for future contract extensions of services.

(d). METHODOLOGIES TO MONITOR PERFORMANCE

(1). Surveillance Techniques

In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are:

(A). Random monitoring, which shall be performed by the COR or his designated inspector.

(B). Periodic Inspection – COR typically performs the periodic inspection on a monthly or quarterly basis.

(C). Feedback from Beneficiaries, satisfaction or complaints. (D). Monthly review of invoices, reports, and documents. (E). Contractor quality assurance reports.

(2). Customer Feedback .

(A). The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

(B). Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems but the customer always has the option to communicate complaints to the COR, as opposed to the contractor.

(C). Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form identified in Attachment 2.

(D). Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

(3). Acceptable Quality Levels

The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. For certain critical activities such as those involving delivery time frames and, the desired performance level is established at 100 percent. Other levels of performance are keyed to the relative importance of the task to the overall mission performance at the VA Medical Centers.

(e). QUALITY ASSURANCE DOCUMENTATION

(1). The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the SOW and are assessed using the performance monitoring techniques shown in Attachment 1.

(2). Monitoring Forms

(B). The government’s QA surveillance, accomplished by the COR, will be reported using the monitoring form in Attachments 2 . The form, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results are being achieved.

(B). The COR will retain a copy of all completed QA surveillance forms.

(f). ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

(1). Determining Performance

Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

(2). Reporting

(A). Semi-annually the COR will prepare a written report summarizing the overall results of the quality assurance surveillance of the contractor’s performance.

This written report, which includes the monthly report and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

(3). Reviews and Resolution

(A). The COR may require the contractor’s project manager, or a designated alternate, to meet with the CO, COR, and other government personnel as deemed necessary to discuss performance evaluation. The COR will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the COR as often as required or per the contractor’s request. The agenda of the reviews may include:

(i). Monthly performance assessment data and trend analysis (ii). Issues and concerns of both parties (iii). Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis (iv). Recommendations for improved efficiency and/or effectiveness

(B).The COR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

(C). The COR and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the CO.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Performance Objective

Acceptable Quality Level

(AQL)

Method of Performance Assessment

Incentive / Disincentive

1 - Performance Requirement:

Patient Satisfaction

Performanc e criteria equals 98% or better

Patient satisfaction/ complaints, and documentation submitted Numerator is the total number of validated complaints for the month and the denominator is the total number of orders for the month.

When AQL is not met: 1st offense is written notice to the contractor to correct the deficiency. 2nd offense will result in an other than positive CPARS evaluation.

2 - Performance Requirement:

Number of remakes and timeliness of remaking and providing to Veteran within 72 hours

Performanc e criteria equals 98% or better

Patient satisfaction / complaints, monthly review of invoices for accuracy, accuracy of required documentation submitted.

When AQL is not met: 1st offense is written notice to the contractor to correct the deficiency. 2nd offense will result in an other than positive CPARS evaluation

3 - Performance Requirement:

Accuracy of required documentation submitted

Performanc e criteria equals 98% or better

Review of invoices for accuracy, timeliness of report submission, and accuracy of required documentation submitted.

When AQL is not met: 1st offense is written notice to the contractor to correct the deficiency. 2nd offense will result in an other than positive CPARS evaluation

4 - Performance Requirement:

Timeliness of eyeglass fabrication.

Performanc e criteria met in 98% or greater of the cases

Patient complaints.

Invoice documentation.

When AQL is not met: 1st offense is written notice to the contractor to correct the deficiency. 2nd offense will result in an other than positive CPARS evaluation

5 - Performance Requirement:

Number of eyeglass fabrication / prescription errors.

Performanc e criteria equals 98% or better

Patient satisfaction / complaints, monthly review of invoices for accuracy, accuracy of required documentation submitted and ANSI Standards. Numerator is the total number of identified fabrication/prescription errors and the Denominator is the total number of orders for the month.

When AQL is not met: 1st offense is written notice to the contractor to correct the deficiency. 2nd offense will result in an other than positive CPARS evaluation

6 Performance Requirement:

Activity, Quality Assurance & Patient Satisfaction Reports

Performanc e criteria equals 80% or better

COR receipt and review of reports.

Numerator is the total number of reports received and the

When AQL is not met: 1st offense is written notice to the contractor to correct the deficiency. 2nd offense will result in an other than positive CPARS evaluation.

Denominator is the total number of reports due for the month.

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

Contract #:

Contractor:

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

[ ] Periodic Inspection [ ] Customer Complaint [ ] Review of documents

LEVEL OF SURVEILLANCE (Check):

[ ] Monthly [ ] Quarterly [ ] As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD:

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: %

Service Provider’s Performance (Check): [ ]Meets Standards [ ]Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY: DATE:

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 f ile. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), 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 CDR in writing. The CDR 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 CDR 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CDR below.

ATTACHMENT 3: SAMPLE CONTRACTOR DISCREPANCY REPORT

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. Report Number for this Discrepancy

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED b. Returned by Contractor: c. Action Complete

6. DISCREPANCY OR PROBLEM (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, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

Contractor notif ied

COR

Contracting Officer