Attachment 3 - QASP.doc

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

IHS Hospital Leadership and Management Support (HLMS) for Readiness

TABLE OF CONTENTS

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the Performance Work Statement (PWS) entitled Hospital Accreditation Compliance Assessments and Leadership Support. This plan sets forth the procedures and guidelines the IHS will use in ensuring the required performance standards or services levels are achieved by the contractor.

Purpose 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 quality control plan (QCP).

This QASP defines the roles and responsibilities and 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.

Performance Management Approach 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 World Trade Center Health Program 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.

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.

Performance Management Strategy 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 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 QC program.

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 contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

ROLES AND RESPONSIBILITIES

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 CO.

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.

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Quality Assurance and Performance Matrix.” If the contractor meets the required service or performance level, it will be considered for additional awards. Failure to meet the required service or performance level will result in a performance evaluation that documents such failures. That information will be used to determine future awards for similar services.

METHODOLOGIES TO MONITOR PERFORMANCE

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:

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 CO and 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 and must be forwarded to the CO or COR. The CO or COR will accept those customer complaints and investigate in accordance with the PWS.

Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints. Customer feedback does NOT include feedback directly from patients. Customers are considered to be hospital staff.

Acceptable Quality Levels The acceptable quality levels (AQLs) Is included in the Quality Assurance and Performance Matrix, 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 quarterly reporting, 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.

QUALITY ASSURANCE DOCUMENTATION

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 shown in Matrix.

Monitoring Forms The government’s QA surveillance, accomplished by the COR, will be reported using the monitoring form. 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.

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

ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

Determining Performance The 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.

Reporting At the end of the 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 form (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.

Reviews and Resolution The CO may require the contractor’s project manager, or a designated alternate, to meet 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:

ATTACHMENT 1: QUALITY ASSURANCE AND PERFORMANCE MATRIX

The Contractor shall meet the following performance objectives, standards, thresholds, and surveillance methods.

Performance Objective Performance Standard Acceptable Quality Surveillance/Monitoring Incentives / Remedies

PO 1 – Accreditation Support: Provision of accreditation support enabling facilities to meet complex high‑risk regulatory challenges.

Detailed CAP outlining steps and strategy to move the facility from current to future state.

100% acceptable upon COR and facility/Area Office leadership review, with receipt of CAP to include the gap analysis report within 10 business days of Contractor being provided with findings.

Validated CAP received by COR.

Ongoing dialogue with facility leadership and staff to achieve compliance with accreditation and CMS CoPs.

≥90% of actions met under the approved CAP by defined due dates and deliverables; overall compliance with CMS CoPs and accreditation standards facility‑wide.

Weekly review through 100% inspection of CAP progress and adherence to due dates; validated monthly progress reports received by COR.

PO 1a Continuity of core team of three (3) SMEs: Continuity, stability, and reliability of a core team of three (3) primary SMEs at each facility including one lead SME.

SMEs are available as scheduled; advice is accurate, relevant, and actionable.

COR reviews staffing rosters and facility/Area/HQ feedback; Contractor limits turnover and retains assigned SMEs/Key Personnel.

COR monitoring of rosters and feedback channels.

1. Mentor, guide, and coach executive, medical, and managerial staff to support compliance with CMS CoPs and accrediting-body requirements.

Coaching and mentoring sessions delivered as scheduled.• Guidance aligns with CMS CoPs, TJC standards, and facility policies.• Staff demonstrate improved understanding and application of standards.

95% of scheduled coaching sessions completed on time with satisfactory feedback from Government COR.

Review of monthly contractor reports.• Direct observation.• Interviews with IHS leadership and participants.• Feedback surveys.

Positive: CPARS recognition for exceptional performance. Negative: Corrective Action Request (CAR) for missed sessions.

2. Develop or enhance facility QAPI Programs aligned with CMS regulatory requirements.

QAPI plan submitted within required timeframe.• QAPI activities include performance indicators, data collection methods, and PDSA cycles.• QAPI plan is functional, actively used, and demonstrates measurable quality improvement.

100% of QAPI deliverables submitted on time; 90% accuracy/completeness on first submission.

Document reviews (QAPI plans, dashboards).• QAPI committee attendance audits.• Measurement of PDSA cycle implementation.

Positive: Recognition of high compliance in QASP evaluation.Negative: Rejection and resubmission required within Government-specified timeframe.

3. Establish or strengthen Patient Safety Programs to reduce risk and ensure CMS/TJC compliance.

Patient safety program components (event reporting, root cause analysis, risk mitigation) implemented timely.• Training provided to appropriate staff.• Event reporting and analysis meet regulatory timelines.

95% of required components implemented.90% staff trained by deadline.

Review of program documentation.• Audit of event-reporting logs.• Observation of RCA processes.

CAR issued for deficiencies; repeat non-compliance may lead to withholding of payment if applicable.

4. Provide accreditation support (CMS, TJC) including preparation, readiness assessments, and corrective-action guidance.

Completion of gap analyses within established schedule.• Action plans developed to close identified gaps.• Mock surveys conducted with written findings and recommendations.

100% of gap analyses and action plans delivered by due date.95% of recommendations accepted with minimal revision.

Review of gap analyses and corrective-action plans.• Mock survey observation and document review.• Interviews with facility leadership.

Incentive: Positive past performance reference. Remedy: Government may require re-performance at no additional cost.

5. Deliver timely reports, assessments, and documentation as required in the PWS.

Reports are accurate, complete, and submitted by required deadlines.• Reports meet contract formatting and quality requirements.

100% on-time submission; 95% accuracy.

COR review of monthly, quarterly, and special reports.• Direct monitoring of deliverables.

Potential incentive for consistent timeliness. CAR for late or incomplete submissions.

PO 2 – Education for Staff Delivery of training/education to staff in accordance with gap analysis and CAP.

≥90% of staff demonstrate application of new/improved skills consistent with job descriptions/assignments.

Weekly CAP inspection; monthly progress reports; pre/post knowledge checks; departmental evaluations via direct observation and performance evaluations (including JCR tracers, as applicable).

1. Provide education, training, and skill-set enhancement for clinical and administrative staff.

Training content aligns with CMS CoPs, TJC EPs, and IHS requirements.• Training delivered per approved training schedule.• Participants achieve minimum passing scores

(if applicable).

95% of training sessions delivered on time.90% participant completion rate.

Attendance logs.• Training evaluations.• Testing or post-training assessments.

Positive: Government commendation for enhanced outcomes. Negative: CAR or requirement for make-up sessions at no cost.

PO 3 – Education for Executive & Departmental Leaders Development of custom educational curriculum meeting needs identified in survey reports and through interviews/observations.

100% acceptable upon COR and facility/Area Office leadership review, with receipt of tailored curriculum within 15 business days of approved CAP.

Weekly review of CAP progress; validated monthly progress reports received by COR.

Application of learned skills resulting in improved job and leadership performance.

≥90% of leaders demonstrate application of new/improved skills consistent with job descriptions/assignments.

Weekly CAP inspection; monthly progress reports; pre/post knowledge checks; evaluation via direct observation and written/verbal performance evaluations (including JCR tracers, as applicable).

ATTACHMENT 2: QUALITY ASSURANCE MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

LEVEL OF SURVEILLANCE (Check):

Monthly Quarterly As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: %

ANALYSIS OF RESULTS:

Narrative of Performance During Survey Period:

PREPARED BY: DATE: