Attachment 1 Quality Assurance Surveillance Plan Ground Ambulance.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Ground Ambulance Transportation Services

Contract Number: <Government will enter number upon award>

Contract Description: The contractor shall provide legal representation for veterans who are guardianship cases and are referred by the VA Southern Nevada Healthcare System. Services will only be furnished to veteran beneficiaries for whom such representation is specifically authorized by the VA.

Contractor’s name: _________________<Government will enter name upon award>

1. PURPOSE

a. 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

b. 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.

c. 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. 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: <Government will enter name upon award>

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: Chervil Tatum

c. Other Key Government Personnel – <Upon award Government will enter name, if applicable. This may include Performance Monitors, Clinical Quality experts, etc. who act on behalf of the COR to monitor performance.>

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager ‐ James L. Andrews II, Service Chief>

b. Other Contractor Personnel ‐ <Offeror will enter name(s) upon award>

4. PERFORMANCE STANDARDS

a. Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets, or does not meet these standards.

b. The Performance Requirements Summary Matrix below includes performance standards. The

Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL) on a quarterly basis.

c. Contractor will be held to the same standard as VA personnel through quality assurance and performance monitoring to ensure compliance under this Contract. The Quality Assurance and

Performance Monitoring will be governed by the appointed COR who will be responsible for verifying compliance with the terms and conditions of the contract. After the contract is awarded, any incidents as evidenced by the monitoring procedures will be forwarded immediately to the Contracting Officer. In addition, the COR will forward the summary evaluation of the contractor performance to the

Contracting Officer once performance ends.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Task PWS Reference

Standard Acceptable Quality Level

Method of Surveillance

Provide on‐ time ambulance services

Section 4.5.1.8.3

Scheduled patient pick‐ups shall not deviate more than 15 minutes past scheduled pick‐up time for scheduled orders

97% Customer Feedback

Incident Reporting

Section 4.8 The contractor shall notify the Program Manager, Beneficiary Travel Department, of any accidents and/or safety problems that occur while the patient is being transported. This notification shall occur within one (1) hour by telephone. A written report of the incident shall be delivered to the Program Manager, Benefits Management, by the close of business of the next working day.

97% Customer Feedback

Invoice Reports

Section 4.9 Provide a monthly invoice including secondary documentation in accordance with Section 4.10 of the PWS

95% 100% inspection of monthly invoices/reports

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint 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: _________________