Attachment F QASP.pdf

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 will monitoring take place.

• Who will conduct the monitoring?

• How will monitoring efforts and results 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: Tawana Young

Organization or Agency: Department of Veterans Affairs.

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: Lisa C. Wall

Organization or Agency: Veterans Health Administration

CONTRACTOR REPRESENTATIVES

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

Contractor Program Manager: TBD

3. 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.

4. 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. 100% surveillance: VA NTP will be able to monitor directly the cases being completed through referencing the case number and following the patient exam. Evaluation of The Contractor’s performance will be completed by assigning a representative to monitor performance to ensure services are received. NTP may inspect each task as completed or increase the number of quality assurance inspections if deemed appropriate because of repeated failures or because of repeated customer complaints. Likewise, the Government may decrease the number of quality assurance inspections if performance dictates. NTP Quality Assurance Personnel will validate any complaints and report to the Government Contracting Officer who will then take necessary action to enforce Contract compliance.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. The Contractor will provide quarterly volume reports by radiologist. The peer review and volume information by contract radiologist will be available to the National Teleradiology Program (NTP) through an electronic web-based portal with appropriate security protections. The National Teleradiology Program will be given access to the web portal to access the quality data and reports. The electronic web-based portal will be available for use by NTP on the first day of the contract. Reports will be available for NTP to print from the electronic web-based portal to utilize for Ongoing Professional Practice Evaluation (OPPE) for each privileged contract radiologist.

VALIDATED USER/CUSTOMER COMPLAINTS. Each quarter, the COR shall review the Contractor’s performance and/or generated documentation corresponding to a validated stakeholder complaint or validated inability to perform in accordance with the Acceptable Level of Performance (ALP) in a specific area. The results of this review shall be documented and placed in the COR’s QA file.

c. RANDOM SAMPLING. Each quarter, the COR shall review a random sampling of the Contractor’s performance and generated documentation. The results of this review shall be documented and placed in the COR’s QA file.

QASP PERFORMANCE REPORT DATE: ___________________

Measures PWS Reference

Performance Requirement

Standard Acceptabl e Quality

Level

Surveillance Method

Met AQL/DID NOT

MEET AQL-

CPARS

RATING/ADD

COMMENTS

Timeliness of Reports 5.1.5 Prompt delivery (timeliness) of interpretations and return for routine/stat/immediate:

- STAT exam turnaround time: Read within 60 minutes

100% of reports are delivered

98%

The Contractor shall provide detailed time log data for each case. Data shall include Radiology Accession Number, Time/Date of Radiology Image receipt by vendor, Time/Date of Final Report sent to VA CPRS/Vista HIS, and Time between Image Receipt and Final Report Transmission. Data shall also include the Time of the beginning of image transmission from NTP, since this is when the Turnaround Time Data begins to document the timeliness of vendor performance.

Timeliness of Reports 5.1.5 - Routine exam turnaround time: Read within 48 hours.

are delivered

90% The Contractor shall provide detailed time log data for each case. Data shall include Radiology Accession Number, Time/Date of Radiology Image receipt by vendor, Time/Date of Final Report sent to VA CPRS/Vista HIS, and Time between Image Receipt and Final Report Transmission. Data shall also include the Time of the beginning of image transmission from NTP, since this is when the

Turnaround Time Data begins to performance.

Timeliness of Reports 5.1.5 - Routine exam turnaround time: Read within 72 hours.

are delivered

98% The Contractor shall provide detailed time log data for each case. Data shall include Radiology Accession Number, Time/Date of Radiology Image receipt by vendor, Time/Date of Final Report sent to VA CPRS/Vista HIS, and Time between Image Receipt and Final Report Transmission. Data shall also include the Time of the beginning of image transmission from NTP, since this is when the Turnaround Time Data begins to performance.

Provider Quality Performance

3.0 All contract physicians

shall perform in accordance with clinical standards

OPPE

document ation for all (100%) staff providing services under the contract.

All staff (100%) meet Standards

98% OPPE data pertinent to care performed for each provider working under this contract. OPPE data will review the following elements:

A. Patient Care Performance

B. Medical/Clinical Knowledge

C. Practiced Based Learning and Improvement

D. Interpersonal and Communication Skills

E. Professionalism

F. System Based Practice

Network Uptime Metric 5.1.9 Network downtime calculation* excludes hours of preventive and scheduled maintenance of the system.

99% Uptime

95% of the time

Validated User/Customer Complaints

Privacy, Confidentiality and HIPAA

5.1.6

Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality

All (100%) Contractor ’s physician(

s) comply with all laws, regulation s, policies and procedure s relating to Privacy, Confidenti ality and

HIPAA

98% compliance

Periodic Inspection: Contractor shall provide evidence of annual training required by the facility, reports violations per VA Handbook 6500.6.

*Downtime calculation

5. CPARS 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/cparsweb/assets/documents/CPARS_User_Manual.pdf)

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).

UNSATISFACTO

RY: Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.cpars.gov%2Fcparsweb%2Fassets%2Fdocuments%2FCPARS_User_Manual.pdf&data=05%7C02%7C%7C1299a8a1556647c9c9b208dd897915ec%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638817875334440754%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=6A9MQEEm9YUvO1cWqDUn1sC8wYUJvuCVqG%2F2AhW8s1E%3D&reserved=0 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 VA 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 REPORTING SYSTEM (CPARS).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This shall 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 shall in turn review and shall present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall also state how long after receipt the contractor has to present this corrective action plan to the CO. The VA 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.