Attachment 5 -Quality Assurance Surveillance Plan.docx

QUALITY ASSURANCE SURVEILLANCE PLAN

Home Oxygen Services Orlando VA Healthcare System

STATION NAME:

Vendor being surveyed: _______________________________

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 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. 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.

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. CORs will be designated upon contract award.

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 assess the level of contractor performance in the elements defined.

Performance standards define desired services. The Government performs surveillance to assess the level of Contractor performance to these standards.

The Performance Requirements are listed below. 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 evaluate the past performance of the contractor on the contract.

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. Contractor shall facilitate the direct observation visits by VA personnel during over site visits to work centers, warehouse facilities and Veteran homes.

b. Periodic Inspection. Inspections will be conducted both scheduled and unscheduled.

c. Customer Feedback. Complaints received from customers reported to contractor and VA will be logged and submitted to the contractor for immediate resolution and corrective action. Contractor will monitor complaints monthly and provide written reports to the COR no less than quarterly.

d. Random Sampling. Random sampling may be used in reviewing vendor employee and Veteran files to ensure that proper contractor documentation is being maintained.

e. Documentation. The contractor shall provide requested information immediately (within 1 hour or as specified) upon request for verification of required documentation, such as receipts and evaluation of reports as required in the SOW.

f. Other. Patient home inspection, patient satisfaction, and/or complaints, monthly review of invoices for accuracy, timeliness of equipment delivery, accuracy of required documentation submitted, and adherence to Joint Commission Standards.

Numerator and Denominator Quantity of Surveillance

Number (N)=# of VA patients (pts) delivered

Random Sampling

N=# of VA pts satisfied with contractor’s service Satisfaction survey developed by vendor, but approved by VA.

N=# of VA patients audited for pt. satisfaction.

100% Review

N=# of VA pt. files with documentation of pt. and/or caregiver signing for receipt of DME equipment.

N=# of VA pts receiving DME equipment.

Page 41 - Inventory GFE Report (if applicable) N=# of GFE on Vendor property ready for issue.

N=# of GFE signed for as issued.

N=# of VA pts who had an incident related to DME equipment to include fires, accidents, malfunctions, injuries, deaths, and sentinel events.

N=# of VA pts receiving DME equipment

N=# of patients who received the packet the first visit.

Randomly pull 10% of files

Patient’s Plan of Service File N=# of VA pt. files with doc of pt. and caregiver education to include return demonstration of equipment use equip.

N=# of VA pt. files

Random Sampling

Page 34, Qualifications of an offeror Page 45 and 47 Methods of surveillance, Site visits N=# of deficiencies observed in infection control protocol in warehouse and delivery vehicles, employees.

Periodic Inspection

Discontinuation of Service ***Review Monthly Invoice.

Page 20, Discontinuation of Service

N=# Contractor notifications received within the next day a patient death or upon finding a patient has moved out of the service area.

N=# timely submitted lists of discontinued VA patients and whether they included VA patient’s full name, last SSN, date of equipment pick up, type, quantity and serial numbers of equipment picked up.

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. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled monthly or unscheduled, as required.)

b. USER SURVEY. (Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. May also generate inspections and sampling.)

c. VALIDATED USER/CUSTOMER COMPLAINTS. (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.)

d. 100% INSPECTION. (Evaluates all outcomes.)

e. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.)

f. Progress or status meetings. Quarterly meetings with Contractor as needed.

g. Analysis of contractor's progress reports. (Evaluate cost, schedule, etc.)

6. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

7. DOCUMENTING PERFORMANCE

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).

Performance will be either ACCEPTABLE PERFORMANCE or UNACCEPTABLE PERFORMANCE.

When unacceptable performance occurs, the COR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.

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 COR. The Government shall review the contractor's corrective action plan to determine acceptability.

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

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor quarterly to assess performance and shall provide a written assessment.

Signature – Contracting Officer’s Representative

Signature – Contracting Officer