ATTACHMENT D.1 - QUALITY ASSURANCE SURVEILLANCE PLAN.docx

36C24924Q0296

D.1. QUALITY ASSURANCE SURVEILLANCE PLAN

FOR: Contract PICC Line Nursing Staff at the Nashville and York VA Medical Centers

CONTRACT NUMBER: ______________________________

DESCRIPTION: Furnish services of PICC Line nursing support in accordance with the PWS

CONTRACTOR: ______________________________

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 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. 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.

ASSIGNED COR: Morgan Hadley

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract:

a. PROGRAM MANAGER: ______________________________

b. OTHER PERSONNEL: ______________________________

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Skills Required in the Performance Work Statement includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Individual will follow and meet all medical center and clinical policies, procedures, rules and regulations. Individual will be provided with and will follow all Tennessee Valley Health System (TVHS) Medical Center memorandums, VHA Directives, Policies and Procedures, as well as specific direction from VA Nurse Managers or designees.

PATIENT CARE

QUALITY OF CARE

-Assessing the services that are provided must be made accessible when clinically needed to patients receiving care at TVHS

- Service must be delivered within four hours from the time the need is identified -Documentation in CPRS

PATIENT CARE

QUALITY OF CARE

-Patient education -Collaborates with team members, MDs, other disciplines, includes giving report

PATIENT CARE

QUALITY OF CARE

PATIENT CARE

QUALITY OF CARE

5. INCENTIVES

The Government shall use incentives based on exceeding, meeting or not meeting performance standards.

6. METHODS OF SURVEILLANCE

Various methods exist to monitor performance. The COR or designee shall use the surveillance methods listed below in the administration of this QASP:

· DIRECT OBSERVATION

IDs 1 – 4. Observation and random inspection (auditing); surveys.

· VALIDATED USER / CUSTOMER COMPLAINTS

ID 5. Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. Inspections and sampling may also be generated.

7. RATINGS

Metrics and methods are designed to determined if performance exceeds, meets, or does not meet a given standard and Acceptable Quality Level. A rating scale shall be used to determine positive neutral, or negative outcomes. The following ratings shall be used:

· Exceeds

· Meets

· Does Not Meet

8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

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

The Government reserves the right to dismiss any contractor employee for unacceptable performance without need for a corrective action plan.

9. FREQUENCY OF MEASUREMENT

a. MEASUREMENT

Measurements will be accomplished quarterly. During contract performance, the COR or designee will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. ASSESSMENT

Assessment Meetings will be accomplished monthly. The COR shall meet with the contractor monthly (or as deemed necessary by the COR) to assess performance and shall provide a written assessment quarterly or as necessary.

By signing this, each party understands and agrees to the Quality Assurance Surveillance Plan.