ATTACHMENT D.2 QUALITY ASSURANCE SURVEILLANCE PLAN - Tumor Registrar Services.pdf

Quality Assurance Surveillance Plan (QASP) Tumor Registrar Services

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. lt 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: CYROUSE H. HOUSHYANI

Organization or Agency: Network Contracting Office (NCO) 08

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: JAIME G. DILLARD

Organization or Agency: Malcom Randall VA Medical Center (VAMC)

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Name (Print) Phone # Email Address

Alternate:

Name (Print) Phone # 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. Five

(5) randomly selected abstracted files and five (5) randomly selected case findings will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information

Security standards.

b. RANDOM SAMPLING. Five (5) randomly selected abstracted files and five (5) randomly selected case findings will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and

Information Security standards.

c. Verification and/or documentation provided by Contractor.

6. QASP PERFORMANCE REPORT DATE: ___________________

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Timeliness of Reports 4.7.6.1.1. The Contractor shall return a monthly list of case abstracts completed along with the Contractor's monthly invoice to the COR and POC.

Delivery 100% of the time.

98% Verification and/or documentation provided by Contractor.

Abstracting Timeliness 4.7.6.1.2. There is no performance requirement for back logged cases. The Contractor will work the back log in sequential FY order beginning with FY18. Once the back log of cases is abstracted new cases will be abstracted within 6 months of diagnosis.

Once the current back log of cases have been processed new cases will be abstracted 6 months of diagnosis.

90% Verification and/or documentation provided by Contractor.

Accuracy of Abstracted Data

4.7.6.1.3. The Contractor shall abstract

oncology cases with 100% accuracy and shall ensure that all Commission on Cancer requirements/standards are met.

The Contractor shall abstract oncology cases with 100% accuracy and shall ensure that all Commission on Cancer requirements/ standards are met.

100%

No deviations accepted.

Random Sampling

Qualifications of Key Personnel

4.7.6.1.4. All contract CTR (s) shall be

board certified in accordance with NCRA Standards.

All (100%) contract Registrars are Certified Tumor Registrars (CTRs).

100%

No deviations accepted.

Verification and/or documentation provided by Contractor

Mandatory Training 4.7.6.1.5.

Contractor shall complete all required training per VAMC policy.

All (100%) of required training is complete on time by contractor CTR(s).

100% completion.

No deviations accepted.

Verification and/or documentation provided by Contractor.

7. 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/pdfs/CPARS-Guidance.pdf p. A2-1):

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).

https://www.cpars.gov/pdfs/CPARS-Guidance.pdf

8. 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 (CAP) 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 the CAP 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 CAP.

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

See Sample CDR on the following page.

1. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED: ___________________________________________

COR NAME/TITLE: _______________________________________ Date: __________

SIGNED: ___________________________________________

CONTRACTOR NAME/TITLE: _____________________________________ Date: __________

Jamie G. Dillard / COR

Appendix A: Contract Discrepancy Report (CDR)

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (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, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

a.

CONTRACTO

R NOTIFIED

b. COR c.

CONTRACTI

NG OFFICER

VHAPM Part801.603-70 COR SOP Revision 07 Page 1 of 1 Original Date: 05/20/2011 Revision 08 Date: 05/07/2021