Attachment 4 Quality Assurance Surveillance Plan.pdf

Neil A. Armstrong Flight Research Center (AFRC)

Edwards, California 93523

OCCUPATIONAL HEALTH SERVICES

(OHS)

SOLICITATION No. 80AFRC20R0003

QUALITY ASSURANCE SURVEILLANCE PLAN

(QASP)

February 28, 2020

80AFRC20R0003

Attachment 4

1 INTRODUCTION

This Government Quality Assurance Surveillance Plan (QASP) is pursuant to the requirements listed in the Performance Work Statement (PWS) entitled Occupational Health Services. This plan sets forth the procedures and guidelines NASA Armstrong Flight Research Center (AFRC) will use in ensuring the required performance standards or services levels of work performed under this contract are achieved by the OHS Contractor.

This plan is applicable to all services performed by the OHS Contractor(s). Throughout this QASP, the term OHS Contractor is used. In terms of this plan, it should be known that unless explicitly stated, this term is applicable to both the OHS Contractor and any and all subcontractors.

Under fixed price contracts, the contractor assumes more responsibility and greater risk in exchange for more flexibility and less direct Government involvement in contract activities.

However, the Government still has a responsibility to monitor the contractor’s performance over the course of the contract to ensure its acceptability. To meet this responsibility, the Government needs sufficient information on contractor performance to be assured contract requirements are being satisfied.

The QASP is a Government-developed surveillance tool prepared in accordance with FAR

46.601 and NFS 1846.401. It is not part of the contract, per NFS 1846.401, but provided to the Contractor for informational purposes only.

1.1 Purpose

The purpose of the QASP is to provide an effective surveillance method of monitoring contractor performance in accordance with the PWS. The QASP provides a systematic method to evaluate the services the Contractor is required to furnish. The Contractor, and not the Government, is responsible for management and quality control actions to meet the terms of the contract.

This QASP defines the roles and responsibilities of all members of the surveillance team, defines the process the Government expects to follow to obtain data, evaluate the Contractor, and determine if Contractor’s performance conforms to the contract requirements.

The QASP is intended to be a “living” document from which resources and activities will evolve during the life of the contract, and can be updated and changed unilaterally by the Government at any time during the contract.

1.2 Contract Goals and Objectives:

The purpose of this Firm-Fixed Price contract is to provide OHS to the AFRC. The specific services covered are Occupational Medicine (to include Occupational Health Nursing and Fitness Center Management), as well as Industrial Hygiene and Health Physics (i.e. Radiation Safety). Services specifically EXCLUDED from this PWS are: Employee Assistance Program (EAP), Workplace Drug-Testing (including Specimen Collection and/or Medical Review), Workers’ Compensation Case Management, and Environmental Management.

https://www.acquisition.gov/content/part-46-quality-assurance https://www.acquisition.gov/content/part-46-quality-assurance https://www.hq.nasa.gov/office/procurement/regs/NFS.pdf

The Contractor’s primary requirement under this contract is to ensure the safety and health of workers through compliance with all applicable laws, regulations, policies and standards related to occupational health.

NASA has defined the requirements for an Occupational Health Program under NASA Procedural Requirement (NPR) 1800.1, entitled, “Occupational Health Program Procedures”.

Many of these requirements reflect or expand upon other Federal requirements, as promulgated through the Occupational Safety and Health Administration (OSHA), the Federal Aviation Administration (FAA), the Federal Motor Carrier Safety Administration (FMCSA), and various other organizations responsible for establishing industry standards such as the American Conference on Governmental Industrial Hygienists (ACGIH). More NASA-specific procedures for implementing these requirements are found in various AFRC Operational Procedures, Standards, Plans and Policies. California OSHA requirements are also applicable to all contractors working at the Building 703 site (Palmdale, CA). The PWS outlines what objectives the Contractor shall accomplish to fulfill the specific elements of NPR 1800.1 and related Center documents. For the purposes of this requirement, the term ‘Occupational Medicine’ shall include the functions of Occupational Health Nursing and Fitness Center Management, unless otherwise noted. The term ‘Environmental Health’ shall include the function of Health Physics (Radiation Safety) and Industrial Hygiene, unless otherwise noted.

2 FORMS OF SURVEILLANCE

Surveillance Strategy Definitions

Insight

Insight is an assurance process that uses performance requirements and performance metrics to ensure process capability, and quality of deliverables. Insight relies on gathering a minimum set of deliverable or process data that provides adequate visibility into the integrity of the deliverable or process. The data may be acquired from Contractor records or report deliverables, usually in a non-intrusive parallel method.

Insight as applied to this contract will result in lower levels of Government surveillance and allow the Contractor to assume increased responsibility and accountability for the integrity of processes. Insight will rely heavily on evaluating planned contract deliverables, performance standards, and existing Contractor procedures and working documents. The Government’s goal is to follow an insight-driven surveillance strategy.

Oversight

Oversight results in higher levels of Government surveillance. The Government gathers information pertaining to the Contractor's process through involvement and/or inspection in the process and monitors the process itself.

Oversight is an assurance process that uses customer-imposed specification and process controls, such as performance specifications and mandatory inspections, to direct the development and production of the deliverable. Oversight entails very detailed monitoring of the process itself.

Oversight is an in-line involvement in an activity, principally through inspection, with review and approval authority implicit to the degree necessary to assure that a process or deliverable’s key characteristics are stable and in control. The Government's involvement in the Contractor's performance, through oversight, will be determined necessary by the Contracting Officer's Representative.

AFRC will strive to use an insight-driven surveillance approach through the performance period of the OHS contract. However, the Government reserves the right to use am oversight approach to monitor questionable areas or areas of poor contract performance.

3 ROLES AND RESPONSIBILITIES

General organization and responsibilities of the Surveillance Team are as follows:

3.1 General

The activities detailed in this plan will be supported and performed by a group of individuals, many with differing levels of responsibilities, but all maintaining a level of consistency in terms of the surveillance strategy, approach, and activities in general. The specific entities and their associated responsibilities/input to the surveillance activities on the contract are described in the following paragraphs.

3.2 Surveillance Team

3.2.1 Contracting Officer/Contract Specialist

The NASA AFRC Contracting Officer (CO) and/or Contract Specialist (CS) is responsible for monitoring contract compliance, contract administration, and for resolving any differences between the observations documented by the NASA AFRC 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 Task Monitors (TMs) depends on the number and complexity of the services, as well as the Contractor’s performance, and must be identified and designated by the COR.

As required by FAR 42.1502(b), the CO will complete an annual Contractor performance assessment report for work performed under this contract using the Contractor Performance Assessment Reporting System (CPARS) evaluation, which will also be reviewed by the Contractor.

3.2.2 Contracting Officer’s Representative

The NASA AFRC COR is designated in writing by the NASA CO to act as his or her authorized representative to assist in administering the contract. The COR’s limitations of authority are contained in the NASA Form 1634, COR Delegation. 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, authorize any contractual changes on the Government’s behalf, or in any way direct the Contractor to operate in conflict with the contract. 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 monitoring, inspecting, and evaluating the Contractor’s work performance. Government surveillance may occur under the inspection of services clause for any services provided under this contract.

The COR will assist the CO in the completion of the annual performance assessment report for work performed under this contract using CPARS.

3.2.3 Task Monitors

The NASA AFRC Task Monitors (TMs) are individuals appointed by the COR for the surveillance of specific areas under the contract. TMs provide detailed technical surveillance of the Contractor’s performance and report findings to the COR in a timely, complete and impartial fashion. While the TMs may serve as a direct conduit to provide Government guidance and feedback to the Contractor on technical matters, the TMs are not empowered to make any contractual commitments, authorize any contractual changes on the Government’s behalf, or in any way direct the Contractor to operate in conflict with the contract.

3.2.4 Other Surveillance Team Support

Other Government personnel such as the AFRC Safety, Health and Environmental Office, Defense Contract Audit Agency (DCAA), Defense Contract Management Agency (DCMA), and local contract support personnel, as required may assist in surveillance activities.

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

In an effort to minimize the performance management burden, simplified surveillance methods will be applied to the insight areas described in Section 5 of this document to evaluate Contractor performance to determine whether the performance standards/service levels required have been met. The primary methods of surveillance are described below.

4.1.1 Communications

Communications is a general surveillance activity. Communications is a two-way process and includes both written and oral communication. Examples of written communications activities that may be used in conducting surveillance include:

a. Exchanges from the OHS Contractor to the Government of plans, procedures, quality records, reports, etc., and/or provision of read-only access to repositories which retain these items.

b. Exchanges from the Government to OHS Contractor of letters, reports, review results, etc.

c. Ad hoc information submitted by NASA AFRC COR and/or TM(s) to the CO related to the OHS Contractor’s electronic mail.

Examples of oral communications activities that may be used in conducting surveillance include:

a. Informal telephone calls, teleconferences.

b. Informal verbal inquiries, discussions.

c. Working group meetings, technical/status briefings, progress reviews, technical information meetings, and formal and informal reviews.

d. Informal discussions.

4.1.2 Management Reviews and Reporting

Examples of management review and reporting activities that may be used in conducting surveillance include:

a. Formal, process, and progress reviews

b. Review of contract deliverables (e.g., Monthly Reports) and documentation

c. Documentation of problems, issues and concerns

d. Data collection reporting

4.1.3 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 or 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, perform an investigation, and notify the CO and Contractor, accordingly. Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints and feedback.

5. SURVEILLANCE ACTIVITIES

5.1 General

There exist specific insight areas that the Government and the OHS Contractor shall concentrate on during applicable stages of work being performed. Each of these insight areas and the Government’s expectations for these areas are described in Table 1.

Table 1. Surveillance Insight Areas

Area of Risk Identified Impact to Government Surveillance Team Activity Information Technology (IT) Security

Computer Security: Potential corruption and loss of data;

disruption of schedule

Review of IT security plans and contingency test results and controls.

Review compliance with policies, firewalls, protection software, vulnerability scans and external systems.

Property Management, Control, and Maintenance

Loss of or damage to equipment;

potential schedule impact

Review Contractor property management techniques, compliance with policies, and record-keeping.

Safety Loss of work-time or equipment, with schedule impact

Evaluate compliance with the Contractor's Safety, Health and Environmental Management Plan (SHEMP) and safety requirements.

Continuous Risk Management Technical, schedule, safety, and program success

Periodically ensure that the Contractor is performing a Continuous Risk Management program that identifies, analyzes, tracks, mitigates, controls and reports on related risks.

Quality Management Technical, schedule, safety, and program success

Monitor the Contractor’s internal and external audits for compliance with the Contractor’s established QCP.

Organizational Conflicts of Interest (OCI) Avoidance

Potential restrictions, ineligible to perform, and/or unfair competitive advantage on future work

Monitor submittal, enforcement and compliance with Contractor OCI Avoidance Plan.

Environmental Environmental damage to local and remote sites

Conduct periodic inspections to ensure compliance with environmental requirements.

5.2 Surveillance Team Activities

The surveillance team members will participate in review meetings. They will provide support, as necessary, with the review of technical requirements, and flow-down of requirements. They will also maintain insight into the Contractor’s compliance with relevant deliverables submitted under the contract and services performed. When the Government has concerns regarding Contractor performance, surveillance team members may conduct independent audits of the Contractor’s activities, processes, documentation, and data in order to provide assurance that the program is being implemented according to all requirements and performance standards. These audits will normally be conducted with advance notification and coordinated with the Contractor.

However, the Government reserves the right to conduct unscheduled audits when evidence indicates that Contractor performance is deficient.

The following selected surveillance team activities will be performed by various surveillance team members during applicable stages of work being performed (as provided in Table 2):

Table 2: Surveillance Performance Requirement Summary:

Performance Objectives

Performance Requirement

Acceptable Quality/Timeliness

Standards

Monitoring Methods

Deduction Schedule, per the Total Contract Value

Contract Staffing PWS 8.0 Number of days per year without key personnel.

Government quarterly review of documents

# Days per Year 0-10 Events = No deduction 11-20 Events = 1% deduction 20-30 Events = 2% deduction 31+ Events = 3% deduction

Required Licenses and Certifications

PWS 4.1.2

Number of days any Licensed Medical Professional (LMP) expired on license

Government quarterly review of documents

0-30 Days = No deduction 30-60 Days = 1% deduction 60-180 Days = 3% deduction 181+ Days = 5% deduction

Required Licenses and Certifications

PWS 2.1.2 Number of days MD’s Federal Aviation Administration Senior Aviation Medical Examiner designation is expired, or MD is without.

Government quarterly review of documents

0-30 Days = No deduction 30-60 Days = 1% deduction 60-180 Days = 3% deduction 181+ Days = 5% deduction

Required Licenses and Certifications

PWS 2.1.12;

4.1.10.5

Number of days any LMP expired on Advanced Cardiovascular Life Support (ACLS) certification

Government quarterly review of documents

0-30 Days = No deduction 30-60 Days = 1% deduction 60-180 Days = 3% deduction 181+ Days = 5% deduction

Automated External Defibrillator (AED) Monitoring

PWS 4.1.14.3 Number of AEDs not checked within 180 days

Government quarterly review of documents

# Events per Year 0-2 Events = No deduction 3-4 Events = 1% deduction 4-6 Events = 2% deduction 7+ Events = 3% deduction

Exposure Assessment

PWS 4.3.1 Number of worksite Exposure Assessments greater than six

(6) months behind schedule

Government quarterly review of documents

# Events per Year 0-4 Events = No deduction 5-8 Events = 1% deduction 9-12 Events = 2% deduction 13+ Events = 3% deduction

Internal Assessments:

PWS 4.3.4 Number of Program Self- Review (i.e. Internal Assessments) not accomplished within twelve

(12) months of schedule

Government quarterly review of documents

# Events per Year 0-4 Events = No deduction 5-8 Events = 1% deduction 9-12 Events = 2% deduction 13+ Events = 3% deduction

Performance Objectives

Performance Requirement

Acceptable Quality/Timeliness

Standards

Monitoring Methods

Deduction Schedule, per the Total Contract Value

Equipment Calibration

PWS 4.3.5 Number of equipment/instrument items expired on calibration

Monthly Metrology Report from Code M

# Expired per Year 1 Expired = 0% deduction 2 Expired = 1% deduction 3 Expired = 2% deduction 4+ Expired = 5% deduction

Document & Chemical Reviews

PWS 4.3.8 Number of chemical/document reviews per year not accomplished within 10 days

Government quarterly review of documents, and customer input

# Events per Year:

0-10 Events = No deduction 11-15 Events = 1% deduction 16-20 Events = 3% deduction 21+ Events = 5% deduction

Permitting PWS 4.3.10.11

Number of radiofrequency, microwave and laser permits not acted upon within 10 days of request

Government quarterly review of documents, and customer input

# Events per Year:

0-4 Event = No deduction 5-8 Events = 1% deduction 9-11 Events = 3% deduction

12+ Events = 5% deduction Surveys & Sampling

PWS 4.3.2 Number of validated ROUTINE sampling/survey requests not accomplished within thirty (30) days

Government quarterly review of documents and customer input

# Events per Year 0-6 Events = No deduction 7-12 Events = 1% deduction 13-18 Events = 2% deduction 19+ Events = 3% deduction

Surveys and Sampling

PWS 4.3.10 Number of events late on completing required ionizing surveys. (e.g. incoming mailed sources, leak test, X-ray cabinets, x-ray producing devices, and vault)

Monthly reviews of documents at the Metrics meeting.

# Events per Year 1 Events = 1% deduction 2 Events = 2 % deduction 3 Events = 3% deduction 4+ Events = 5% deduction

Surveys and Sampling

PWS 4.3.2 Number of URGENT sampling/survey requests not accomplished within one (1) day

Government quarterly review of documents and customer input

# Events per Year 0-2 Events = No deduction 3-4 Events = 1% deduction 4-6 Events = 2% deduction 7+ Events = 3% deduction

Required Certifications

PWS 4.3.17.2 Number of days IH’s Asbestos Certification (State of California) is expired or IH is without

Monitoring of Certification expiration dates by

COR

0-30 Days = No deduction 30-60 Days = 1% deduction 60-180 Days = 3% deduction 181+ Days = 5% deduction

Required Certifications

PWS 4.3.17.3 Number of days IH’s Lead Assessor/Inspector Certification is expired or IH is without

Monitoring of Certification expiration dates by

COR

0-30 Days = No deduction 30-60 Days = 1% deduction 60-180 Days = 3% deduction 181+ Days = 5% deduction

Sampling And Survey Reports

PWS 4.3.2.1 Number of personal monitoring reports (chemical and noise) that were not submitted to NASA within 5 business days from the time the sampling results were received.

Government quarterly review of documents and customer input

# Events per Year 0-7 Events = No deduction 8-15 Events = 1% deduction 16-30 Events = 2% deduction 31+ Events = 3% deduction

5.2.1 Work Area/Floor Checks

The surveillance team members will make a physical inspection of the Contractor's onsite work semi-annually. In addition, the COR may make informal inspections, as required. These inspections are made to assure compliance with NASA AFRC regulations regarding:

a. All Contractor employees have an AFRC identification badge.

b. The total number of Contractor employees provided onsite office space.

c. The Contractor knows who the building's Facilities Operation Manager (FOM) is, and what his/her functions are.

d. The Contractor is familiar with the building emergency evacuation procedures.

e. The Contractor employees are aware that work area checks may be conducted at any time.

The Contractor is familiar with NASA and AFRC Policy Directives and Procedural Requirements as it pertains to ANSI/ISO/ASQ Q9001 or AS 9100 governing onsite performance. These procedures can be accessed via the following NASA Online Directive Information System Website: https://odie.ndc.nasa.gov/SitePages/Home.aspx

f. The Contractor is aware of the appropriate protection procedures for handling Government planning data, private medical information, Sensitive but Unclassified (SBU) data, and other Contractor confidential or financial data.

g. The Contractor employees are aware that the use of Government telephones is for official business only.

h. The Contractor employees are following the proper Checkout Procedures when out processing from AFRC (e.g., returning PIV card (badges)).

i. The Contractor employees are aware of the AFRC IT Security compliance requirements.

j. The Contractor employees are aware of the Contractor’s Organizational Conflict of Interest

Plan and the appropriate Non-Disclosures.

In addition to checking conformance with NASA AFRC regulations listed above, the COR may make periodic checks of the Contractor's workspace to assess adequacy of facilities, equipment, and materials.

5.2.2 Work Review and Performance Monitoring

The COR, with the assistance of the TMs, will perform the following functions to evaluate the Contractor's performance:

a. Reviews the Contractor's monthly Progress Report for accuracy and completeness.

Consult with TM, as necessary, to assess the fidelity of reports.

b. Meets monthly, or more often if required, with the Contractor's Program Manager/Site

Manager to discuss overall management and performance, and review staffing and schedule issues.

c. Certifies the Contractor’s invoices for payment in accordance with AFRC procedures.

d. In the event of a discrepancy in the Contractor's performance, the COR promptly notifies both the CO and the Contractor's Program Manager and arranges a meeting to rectify the situation.

5.2.3 Government Property Administration

https://odie.ndc.nasa.gov/SitePages/Home.aspx

The COR will carry out the following functions.

a. Validate that all Installation-Accountable Government Property (IAGP) is being properly utilized and maintained.

b. Conduct periodic inspection of equipment and its location, compared to the data on the property records.

c. Validate that all existing and new equipment is properly tagged.

d. Validate that Government property is made available in accordance with the terms of the contract.

e. Validate that the Contractor does not modify or provide additional facilities, plant equipment, or real property at NASA AFRC, except as specifically required by the contract, or as directed or approved in writing by the CO.

5.2.4 Performance Monitoring

The COR will ensure that employer–employee relationships do not occur between Government and Contractor personnel. This is achieved if the following is adhered to:

a. Only the Contractor interviews prospective employees.

b. Only the Contractor’s Program Manager assigns work directly to the employees.

c. Only the Contractor approves timecards and absences.

d. Government personnel do not interfere with the Contractor regarding personnel and administrative activities.

e. Government Physician will not be the supervising Physician (Physician of Record) for the Contractor Nurse Practitioner (NP) or Physician Assistant (PA).

5.2.5 Safety

The responsibility for meeting all safety requirements rests with the Contractor. Surveillance team safety engineers and technical personnel will review Contractor-generated hazard analyses, safety compliance data packages or other safety-related documentation, as appropriate, to help ensure all safety requirements have been satisfied. Surveillance team personnel will also maintain insight into the Contractor’s safety activities through the review of the Contractor’s submitted Safety, Health and Environmental Management Plan (SHEMP), and updates, as required by this contract.

6.0 SUMMARY

This QASP describes the approach AFRC intends to use to monitor the OHS contract and assure that the Contractor performs in accordance with the terms and conditions of the contract. AFRC anticipates using an insight surveillance approach. The goal is to balance the level of Government surveillance with the perceived impacts and risks of mission failure.

Quality Assurance Office Signature Date

Contracting Officer’s Representative Signature Date

Contracting Officer Signature Date

APPENDIX A –CONTRACT SURVEILLANCE REPORT

CONTRACT SURVEILLANCE REPORT

(If more space is needed, use reverse and identify by number)

1. CONTRACT/TASK ORDER NUMBER 2.CONTRACTOR 3. AREA OF REVIEW/DATE

4. QAS/COR/TASK MONITOR/REVIEWER, PRINT NAME &

SIGNATURE

5. PHONE 6. RATING

Acceptable Unacceptable

I. PERFORMANCE

7. DEFICIENCY (CHECK ALL

BOXES THAT APPLY)

8. SOW PARAGRAPH ITEM REVIEWED

NEW _____

REPEAT _____

NO DEFICIENCY NOTED _____

9. BRIEF DESCRIPTION OF DEFICIENCY (IF DEFICIENCY BOX WAS CHECKED)

II. CONTRACTOR VALIDATION

11. CONTRACTOR REPRESENTATIVE

CONCUR_____

NON-CONCUR_____

12. CORRECTIVE ACTION ESTIMATED

COMPLETION DATE

13. CONTRACTOR REPRESENTATIVE CORRECTIVE ACTION AND PREVENTION OF RECURRENCE

OR REASON FOR NON-CONCURRENCE OF QAS CITED DEFICIENCY

III. ACTION CORRECTED

14. CONCUR NON-CONCUR QAS/COR/TASK MONITOR/REVIEWER SIGNATURE AND

DATE

15. QAS/COR/TASK MONITOR/REVIEWER REMARKS (REQUIRED)

16. CONTRACTOR REPRESENTATIVE REMARKS

NOTE: After completion of report, send report and comments to the Contract COR

4 METHODOLOGIES TO MONITOR PERFORMANCE