ATTACHMENT 2 QUALITY ASSURANCE SURVIELANCE PROGRAM (QASP).pdf

Attachment D.2

RFQ

36C24822Q0477

Quality Assurance Survielance Program (QASP)

Board Certified Chief Therapeutic Medical Physicist/Therapeutic Medical Physicist

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: Cyrouse Himid Houshyani

Organization or Agency: Department of Veterans Affairs, Network Contracting Office 8, VISN 8

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: Lauren Cochran , Administrative Officer, Radiation Oncology

Organization or Agency: Department of Veteran Affairs, Bay Pines VA Healthcare System, Radiation Oncology

3. CONTRACTOR REPRESENTATIVES

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

Primary:

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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:

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Ten

(10) 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

d. RANDOM SAMPLING. Ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. Verification and/or documentation provided by Contractor. May require the contractor to provide information on services provided.

6. THERAPEUTIC MEDICAL PHYSICS QASP PERFORMANCE REPORT

DATE: ______ _

MetAQL/DID

Acceptable

NOT MEET

PWS Performance Surveillance AQL- Measure

Requirement Standard Quality

Method CPAR Para.

Level

RATING/ADD

COMMENTS

Qualifications and 9.1.1. Physicists shall be Board Certified All (100%) of Physicists 100% Periodic Sampling Annually Availability of Key in accordance with ACR Standards. shall be Board Certified of qualification

Personnel The Contractor shall provide in accordance with ACR documentation evidence that workload is Standards and available and medical distributed between 2 or more to provide the required records submitted providers within the group and scheduled services to in accordance that treatment is provided in veterans 100% of the with contractor compliance within standard of time. reporting care outlined in this PWS. requirements

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Patient Reports and 9.1.2. All notes must be electronically Compliance with VA 90% Periodic Bi- Documentation signed, and all encounters closed Rules and Regulations Inspection and Annually within 24 hrs. Random Sampling

Standard Operating 9.1.3. Reviewable documentation of all 100% of procedures are 100% Random Annually Procedures {SOP) for all SOPs shall be maintained. documented and inspection of radiotherapy techniques Radiotherapy techniques such as reviewed and updated procedure

3DCRT, IMRT, IGRT, SBRT, SRS, annually. documentation Brachytherapy have written and medical procedures. records submitted in accordance with facility reporting requirements.

Quality 9.1.4. Reviewable records of device 100% of QA/QI 100% Periodic sampling. Quarterly Assurance/Quality quality assurance shall be documents complete in Improvement (QA/QI) maintained. Daily, monthly and accordance with ACR Documentation annual QA documentation for standards and reported linear accelerators and CT Sim are as required to Tumor accessible. The Contractor shall Board and/or VA have an operational performance Radiation Oncology improvement process in Service QA Committee.

accordance with ACR Standards;

including data collection, measurement, assessment and improvement. Data shall be required on processes, outcomes, patient satisfaction, and quality control. Appropriate statistical quality control techniques in compliance with ACR standards must be utilized. Results of performance improvement activities must be reported quarterly to the VA Radiation Oncology Service Quality Assurance Committee

Radiation Safety 9.1.5. CTMP is responsible for the �II {100%) Radiation safety 100% Periodic Inspection Annually Policy and Standards Radiation Safety Program (RSP) of �tandards and external for ACR Accreditation the Radiation Oncology review requirements shall

Service/Section. The RSP shall lbe met. Quality meet the accreditation standards Management reports shall of the ACR Radiation Oncology be submitted quarterly to Program for Accreditation he Orlando VAMC

(ROPA). RSP shall meet the Radiation Safety radiation safety standards, �ommittee.

policies and procedures set by NRC, NHPP and the ACR. The RSP status, to include the correction plan for all radiation safety related deficiencies noted by site surveys from ACR, NHPP or Imaging and Radiation Oncology Core (IROC) shall be reported quarterly as a part of the quarterly medical physicist report to the Orlando VAMC Radiation Safety Committee.

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Patient safety incidents, including 100% of incidents

Quarterly

Patient Safety/ medical events involving reported promptly Direct

Radiation Safety

9.1.6. radioactive material and

(within 24 hours of 100%

Observation misadministrations, must be reported.

discovery.)

Report issued by Bi-

Chart Review/Physics Completion deadlines met as Chart Review/Physics Chief Radiation Annually

Check/Consults

9.1.7. assigned by Radiation Oncology Check/Consu Its a re 100% Therapist as well

Service Administration/COR completed weekly. as Billing and Coding Service

Contractor's Medical All (100%) of required Periodic Sampling Quarterly Therapeutic Physicists therapeutic medical and Random shall develop and physicist reports Sampling maintain a quality documenting the management program successful evaluation of

Therapeutic Medical (QMP) for the dosimetry equipment performance

Physicist Reports system(s) and all (meeting or exceeding demonstrate ACR 9.1.8. applications pertinent ACR Standards) to 100%

Standards thereto. Said QMP shall include therapy define explicit machines, radiation evaluation criteria sources, and simulators intended to ensure that for proper working the prescribed dose is order is required. All delivered in a safe, external review consistent and accurate requirements per ACR

Version 11/30/2020 Page 4 of7 manner. Contractor shall Standards are met, provide the VA Radiation including those of TJC Oncology Service, with written reports of these activities. Quality management of radiation therapy equipment is primarily an ongoing evaluation of functional performance characteristics.

Maintains licensing, 9.1.9. Updated Licensing, registration 100% Licensing and 100% Periodic Sampling Annually registration, and and certifications will be provided registration information and Random certifications as they are renewed. kept current. Sampling

Mandatory Training 9.1.10. Contractor completes all All Training (100%) 100% Contractor to Annual mandatory required training completed as required provide per VAMC policy documented evidence

Privacy, Confidentiality 9.1.11. Contractor is aware of all laws, Zero breaches of privacy 100% Contractor to Annually and HIPAA regulations, policies and or confidentiality provide evidence procedures relating to Privacy, of annual training Confidentiality and HIPAA and required by complies with all standards VAMC, reports violations per policy

Professionalism/Conduct 9.1..12 Contractor employees maintain Zero complaints from 100% COR notification Annually excellent relationships with VA Medical Center staff of complaints patients, Radiation Oncology staff members related to the members, VA Medical Center staff contractor's employee members, and vendors. interfering with patient care or the ordinary operation of the facility.

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.

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Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

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