Attachment 1 -QUALITY ASSURANCE SURVEILLANCE PLAN -QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

1. INTRODUCTION

This QASP is pursuant to the requirements listed in this PWS. This plan sets forth the procedures and guidelines the requiring office's COR will use in ensuring the required performance standards or services levels are achieved by the contractor.

1.1 Purpose

1.1.1 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 PWS and the contractor's QCP, and to ensure that the government pays only for the level of services received.

1.1.2 This QASP 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.

1.2 Performance Management Approach

1.2.1 The PWS 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 COR to monitor and manage the contractor's performance to ensure the expected outcomes or performance objectives communicated in the PWS 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.

1.2.2 Performance management represents a significant shift from the more traditional quality assurance 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.

1.3 Performance Management Strategy

1.3.1 The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor's own QCP. 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 PWS.

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 PWS. This QASP enables the government to take advantage of the contractor's QCP.

1.3.2 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.

2. ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer (CO)

The CO is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the 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 CO.

2.2 The Contracting Officer's Representative (COR)

The contracting officer's representative 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.

3. IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in PWS and in the QASP.

Positive incentives as a result of performance that continually exceeds the performance objectives as outlines in the PWS may result in favorable Contractor Performance Assessment Reports (CPAR). Negative performance incentives include re-performance of the defective services negative CPAR reporting and/or increased surveillance.

4. METHODOLOGIES TO MONITOR PERFORMANCE

4.1 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. Inspection — Documented evidence received by COR.

b. Customer Feedback — COR randomly corresponds with VCCC personnel

4.2 Customer Feedback

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.

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.

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 as necessary.

Customer feedback may also be obtained either from the results of formal customer satisfaction survey post inspection or from random customer complaints.

4.3 Acceptable Quality Levels.

The acceptable quality levels (AQLs) included in the QASP, 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 accreditation decisions, 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 VHA.

5. QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and are assessed using the performance monitoring techniques listed in the QASP.

6. ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1Determining Performance

6.1.1 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.

6.2 Reporting

6.2.1 At the end of each quarter, 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 contractor's submitted monthly report and the completed quality assurance monitoring forms, 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 objective

6.3 Reviews and Resolution

6.3.1 The CO may require the contractor's project manager, or a designated alternate, to meet with the COR and other government personnel as deemed necessary to discuss performance evaluation. The CO 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:

Monthly performance assessment data and trend analysis

Issues and concerns of both parties

Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

Recommendations for improved efficiency and/or effectiveness

Issues arising from the performance monitoring processes

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

6.3.3 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 PCO/ACO.

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

The following minimum Quality Assurance Surveillance Plan applies. The Government may modify inspection methods in accordance with site specific requirements.

Performance Objective

Performance Standard

Ref.

PWS

Method of Assessment

Remedy

Facility demographics

Within 30 miles of George E.

Wahlen VA Medical Center;

has indoor or outdoor arenas available for therapy

2a, 2b Documentation None

Equines available For individual therapy, at least 1 equine per patient available with adequate training and temperament

3c(ii) Observation and qualitative assessment by VA therapists

If training and temperament is inadequate, facility will provide other equines that adequately meet the need. If quantity, training, or temperament is not achievable, government has the option to stop services.

Equines available For group therapy, at least 3 equines available with adequate training and temperament

2c, 3c(iii)

Observation and qualitative assessment by VA therapists

If three equines are not available, facility will provide more, to a minimum of three. If training and temperament is inadequate, facility will provide other equines that adequately meet the need. If quantity, training, or temperament is not achievable, government has the option to stop services.

Equine professional availability

At least one equine professional to work with VA staff; possesses

2d Observation and qualitative assessment by VA therapists

If one equine professional is not available, facility will provide at least one. If professional cannot work with VA staff adequately, supervisors from the facility and VA will discuss solutions. If solutions cannot be determined, government has the option to stop services.

Facility Hours Facility will provide uninterrupted 60-or 90-minute session based on government need

3b Observation and qualitative assessment by VA therapists

COR will notify facility of shortcoming.

Supervisors from the facility and VA will discuss solutions. If solutions cannot be determined, government has the option to stop services.

Facility accessories

Facility will provide equipment to be used during therapy, to include:

grooming tools, arena props, halter and lead ropes, private discussion area

3c(v), 3c(vi), 3c(vii), 3c(viii)

Observation and qualitative assessment by VA therapists

COR will notify facility of shortcoming.

Supervisors from the facility and VA will discuss solutions. If solutions cannot be determined, government has the option to stop services.

Facility operations VA and facility will coordinate to schedule and reserve blocks of times

3d Observation and qualitative assessment by VA therapists;

may be supported by documentation logs at either facility

COR will notify facility of shortcoming.

Supervisors from the facility and VA will discuss solutions. If solutions cannot be determined, government has the option to stop services.

Equine specialist performance

VA and facility to discuss needs of patient, equine specialist role, therapist’s expectations and other issues

3e, 3f Observation and qualitative assessment by VA therapists;

may be supported by documentation logs at either facility; debrief after therapy

COR will notify facility of shortcoming.

Supervisors from the facility and VA will discuss solutions. If solutions cannot be determined, government has the option to stop services.

2.1 The Contracting Officer (CO)