Attachment 1 36C25522Q0001 D.1 QASP.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 CO: Kayla Haas Organization or Agency: Network Contracting Office (NCO) 15

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: Kristen Galler Organization or Agency: VA St. Louis Health Care System

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) 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. 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: Surveillance will be accomplished through site visits; interviews with the veterans, the veteran families, and staff; record review and will be done by COR and assigned VA staff, to evaluate all reports provided.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. COR will evaluate evaluations and treatment through documentation and/or contractor’s therapist’s notes; randomly selected files will be reviewed and conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. The Patient Safety Report will be utilized to maintain and track patient complaints; Information from the patient advocacy office will assist in validating the complaints.

d. RANDOM SAMPLING. Periodic Sampling will be taken when a problem and/or deficiency is suspected. Sample results are applicable only for the specific work being inspected. This will occur either on a monthly and/or quarterly basis. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

6. QASP Matrix /Quarterly Report Format

Quarterly Report is due no later than the 15th of the beginning of each new quarter

"FOR Official USE ONLY"

1) Task Order #: 2) Contractor:

3) COR: 4) Surveillance Period:

Contracting Officer’s Representative Overall Comments:

Task PWS Reference Acceptable Quality Level

Method of Surveillance

COR Observation

All technologists are responsible for recording exam information in the patient’s file.

10.1.13 No more than 10 failures

to complete within one hour on annual basis

>15 failed attempts to case edit within 15 minutes on an annual basis

Direct Observation

Patient Safety incidents shall be reported using JPSR.

All incidents reported immediately (within 24 hours)

9.6.4.1 100% of patient safety incidents are reported using the Joint Patient Safety Reports within 24 hours of incident.

Validated User/Customer Complaints

Safety Policy Compliant

2.1.7.3 <2 violations on an annual basis

Direct Observation

Room Procedures 2.1.8 < 3 failed attempts to properly set up assigned room, clean equipment and room, stock supplies, and properly dispose of expended linens on an annual basis.

Direct Observation

Exposure Control Plan 2.1.8.3 <3 violations of policies on an annual basis

Direct Observation

Diagnostic Quality Radiographs

10.1.12 Does not exceed one

poor image for every 10 images taken.

Random Sampling

Minor Errors 10.1.14 Not more than 15 minor errors on an annual basis

Direct Observation

Major Errors 10.1.15 Not more than 5 major errors on an annual basis

Direct Observation

Returned Images 10.1.16 Not more than 3 returned sets of radiographs on an annual basis

Direct Observation

Courtesy 10.1.17 Not more than one (1) valid complaint towards patient or visitor on an annual basis.

Not more than three (3) valid complaints towards medical staff on an annual basis.

Validated User/Customer Complaints

Scheduling 3.4.6 Shall not miss more than three (3) shifts per year

Shall not be tardy more than three (3) times per quarter

Periodic Inspection

Attendance 7.1.1 100% compliance with signing attendance log upon reporting and departing for work.

Periodic Inspection

Updated licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current.

2.1.1.1 100% licensing, registration (s) and certification (s) for Contractor’s technologist (s)shall be provided as they are renewed.

Licensing and registration information kept current. No acceptable deviation.

Periodic Inspection

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 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).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

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 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.

CONTRACT DISCREPANCY REPORT 1. CONTRACT NUMBER

Report Number: Date:

2. TO: (Contractor and Manager Name)

3. FROM: (Contracting Officer’s Representative Name)

DATES

CONTRACTOR

NOTIFICATION:

RESPONSE DUE BY:

RETURNED BY

CONTRACTOR:

ACTION COMPLETE:

4. DISCREPANCY OR PROBLEM (Describe in detail; Include reference in PWS / Directive. Attach continuation sheet if necessary.)

5. SIGNATURE OF CONTRACTING OFFICER’S REPRESENTATIVE (COR)

6. TO: (COR)

7. FROM: (Contractor)

8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION, AND ACTIONS TO PREVENT

RECURRENCE (Attach continuation sheet if necessary.)

9. SIGNATURE OF CONTRACTOR REPRESENTATIVE

10. DATE

11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN (Acceptable response/plan, partial acceptance of response/plan, rejection. Attach continuation sheet if necessary)

12. GOVERNMENT ACTIONS (Payment withholding, cure notice, show cause, other.)

CLOSE OUT

NAME AND TITLE SIGNATURE DATE

NOTIFIED

COR

CONTRACTING

OFFICER

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE