Attachment 3 - QASP HCHV.pdf

Quality Assurance Surveillance Plan (QASP) Community Based Residential Treatment Services at the Oklahoma

City VA Medical Center

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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: ________________________________

Organization or Agency: _______________________

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: __________________________________

Organization or Agency: Oklahoma City VA Medical Center

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3. CONTRACTOR REPRESENTATIVES

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

Primary: ____________________________________

Alternate: ___________________________________

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports annually 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. INCENTIVES/DEDUCTS

The Government shall use favorable contractor performance evaluation and exercise of option period as an incentive. Incentives shall be based on meeting or not meeting performance standards.

6. 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.

DIRECT OBSERVATION: COR and OKC VAMC staff will directly monitor performance of Contractor.

VALIDATED USER/CUSTOMER COMPLAINTS: Patient complaints regarding quality of care are reported to the Patient Advocate and the COR. OKC VAMC staff will meet with Contractor for resolution.

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RANDOM SAMPLING: Patient treatment records will be randomly selected and cover the period of service.

VERIFICATION/DOCUMENTATIOM: Medical records will be reviewed for proper documentation of service performed by Contractor.

7. PERFORMANCE MEASURES

ID Indicator Standard Acceptable

Quality Level

Method of Surveillance

Incentives

Licensing and Accreditation

All licensing and Accreditation is complete and up to date in accordance with State and Federal laws

100% Viewing of licensing and accreditation

Favorable contractor performance evaluation and exercise of option year

Food Service

Food services meet applicable standards of State and Federal laws. Food and Nutrition staff and or appropriate staff to inspect annually. Any noted deficiencies will be cleared within one week.

100% Annual inspection by VA nutrition staff

Favorable contractor performance evaluation and

Patient Complaints

Formal patient complaints regarding quality of care are reported using the grievance form located in the patient handbook &/or reporting to the OKC VA Medical Center Patient Advocate.

100%

Patient advocate, Program Coordinator or the COR will maintain all formal complaints.

Favorable contractor performance evaluation and

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ID Indicator Standard Acceptable

Quality Level

Method of Surveillance

Incentives

Performance Review

Contractor shall be required to meet with VA Homeless Program staff when requested by Contracting Officer at Oklahoma City VA Medical Center unless otherwise arranged, on an annual basis to review performance, or as needed to address any performance problems.

100%

COR monitoring of contract management standards

Favorable contractor performance evaluation and exercise of option year

5 SOW

standards

Contractor meets all SOW and contract requirements.

90% Homeless

Program/staff Monitoring

Favorable contractor performance evaluation and exercise of option year

Fire, safety and sanitation

Contractor meets all fire, safety and sanitation standards

95% Homeless

Program/staff Monitoring

Favorable contractor performance evaluation and exercise of option year

7 Positive discharges

Negative Exits as defined by VA national homeless program are within an acceptable range, not to exceed 20% of discharges quarterly.

75%

Monitoring of VA Homeless Programs Score Card by VA staff

Favorable contractor performance evaluation and exercise of option year

8 Participant satisfaction

All participants will report satisfaction of the contractor-provided services.

85% USPEQ Survey. COR will maintain surveys

Favorable contractor performance evaluation and

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8. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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).

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9. 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.

10. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement. The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting.The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

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11. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

COR

NAME: __________________________________

TITLE: __________________________________

SIGNED:_________________________________

DATE

CONTRACTOR

NAME: __________________________________

TITLE: __________________________________

SIGNED:_________________________________

DATE

CONTRACTOR WAS FOUND ______________________________________