ATTACHMENT D.2 - QUALITY ASSURANCE SURVEILLANCE PLAN.docx

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Q515--MO - HLA Testing - 626 Tennessee Valley Healthcare System HLA Transplant Testing Services POP: 10/1/2026-9/30/2032
Solicitation number
36C24926R0076
Issued by

About this file

This is a Quality Assurance Surveillance Plan (QASP) for HLA Transplant Testing Services under contract number 36C24926R0076 with the Department of Veterans Affairs' Tennessee Valley Healthcare System, effective October 1, 2026 through September 30, 2032.

The QASP establishes systematic monitoring procedures to evaluate contractor performance against three primary performance standards: (1) Safety and Integrity of Specimens—maintaining 100% specimen integrity with no loss, degradation, or destruction; (2) Turnaround Time for Test Results—delivering results within the contractor's laboratory reference test manual TAT with a 90% acceptable quality level and 100% inspection of six randomly selected test codes monthly; and (3) Emergency Response Time—completing urgent/emergency specimens within four hours at 100% compliance through direct observation. The Contracting Officer is Olonzo Haynes (olonzo.haynes@va.gov, 615-225-6959) at the Network Contracting Office 9 in Murfreesboro, Tennessee, with Contracting Specialist Rebecca Espinoza providing support. The Contracting Officer's Representative is Shannon Skillern, Administrative Officer at Tennessee Valley Healthcare System Pathology and Laboratory Service in Nashville, responsible for technical administration and quality assurance file maintenance. Performance monitoring includes quarterly periodic inspections reviewing 25% of laboratory reports, monthly random testing of designated test codes, and direct observation of emergency response times. Contractor performance ratings—Exceptional, Very Good, Satisfactory, Marginal, or Unsatisfactory—are documented in Contractor Performance Assessment Reports (CPAR) and inform past performance evaluations. Non-conformances trigger Contract Reports requiring contractor corrective action plans reviewed by the Contracting Officer for acceptability and implementation verification.

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D.2 QUALITY ASSURANCE SURVEILLANCE PLAN

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:Olonzo Haynes
Assigned CS:Rebecca Espinoza
Organization or Agency:Network Contracting Office (NCO) - 9

1639 Medical Center Parkway Murfreesboro, TN 37129 Olonzo.Haynes@va.gov Rebecca.Espinoza@va.gov (615)-225-6959 (Olonzo) (615)-225-6998 (Rebecca)

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:Shannon Skillern, Administrative Officer
Organization or Agency:Tennessee Valley Healthcare System
Pathology and Laboratory Service

24 Avenue South Nashville, TN 37212-2637 shannon.skillern@va.gov (615)873-7589

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager: _____________________ Phone Number / Email Address: _____________________________________ Alternate Program Manager: ____________________ Phone Number / Email Address: _____________________________________

4. PERFORMANCE STANDARDS

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 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. 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. Inspections scheduled and reported quarterly per COR delegation or as needed. 25% of all laboratory reports will be randomly selected for review per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

b. RANDOM TESTING. 6 random test codes will be selected for inspection each month for timeliness.

c. DIRECT OBSERVATION. COR will monitor timeliness of emergency response time through direct observation to ascertain if results are obtained within the required turn-around-times.

36C24926R0076 – HLA Transplant Testing – Tennessee Valley Healthcare System

36C24926R0076 – HLA Transplant Testing – Tennessee Valley Healthcare System

QASP PERFORMANCE REPORTDATE:__________________
Measures
PWS

Reference Performance Requirement

Standard
Acceptable Quality Level
Surveillance

Method Met AQL/DID NOT MEET AQL-

CPAR RATING/ADD COMMENTS

1 – Safety and Integrity of Specimens
15.2.1
Maintain integrity of all specimens provided for testing with no loss, degradation, or destruction of specimens
No loss or destruction of specimens.
100%
Periodic Inspection of reporting documentation.
2- Turnaround Time for Test Results
15.2.2
Reports of lab testing results shall be provided within the TAT listed in the contractor’s laboratory reference test manual per test
Results per test will be reported within the TAT listed in the contractor’s laboratory reference test manual.
90%
100% inspection of 6 randomly selected test codes per month.

3 – Emergency Response Time

Specimens provided for testing on an emergency/ urgent basis shall be completed within four (4) hours
Contractor responds within 4 (four) hours.
100%
Direct observation.

CPAR RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/documents/CPARS-Guidance)

EXCEPTIONAL:
Contractor always meets the standard. 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:
Contractor almost always meets the standard, always performs over the Acceptable Quality Level. 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:
Contractor occasionally meets the standard, but more often meets the Acceptable Quality Level. 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:
Contractor most often meets the Acceptable Quality Level, occasionally does not meet the Acceptable Quality Level and CDRs have been reported. 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 thecontractual deficiency (e.g. Management, Quality, Safety or Environmental Deficiency Report or letter).
UNSATISFACTORY:
Contractor has history of not meeting Acceptable Quality Level. Significant efforts have been made to bring Contractor into performance. 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).

6. 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 Report (CR), 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 CR in writing. The CR 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 CR 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 CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample CR below.

7. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR: Shannon Skillern DATE Contracting Officer Representative

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER
2. REPORT NUMBER FOR THIS ISSUE
3. TO: (Contracting Officer)
4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY CONTRACTOR:
c. ACTION COMPLETE

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR
Date:
8. SIGNATURE OF CONTRACTING OFFICER
Date:
9a. TO (Contracting Officer)
9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE
Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME
TITLE
SIGNATURE
DATE

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER

END OF QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

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