ATTACHMENT ONE- Quality Assurance Surveillance Plan (QASP).pdf

Quality Assurance Surveillance Plan (QASP)

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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: To be determined

Organization or Agency:

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 f ile. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: Son Nguyen 3801 Miranda Avenue (111C) Palo Alto, CA 94304 650-493-5000 ext. 67199 Son.Nguyen1@va.gov

3. CONTRACTOR REPRESENTATIVES

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

Contractor employee: To be determined mailto:Son.Nguyen1@va.gov

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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. INCENTIVES/DEDUCTS

The Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards

6. 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 and verification of all documentation.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Submitted invoices will be compared to CPRS records. Licenses, registrations, VA-required training certifications will be periodically inspected.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Customer complaint data will be reviewed as an issue arises and is escalated to the level of the facility Patient Advocate or Medical Center Director. Complaints will be reviewed by the COR, Section Chief, and Service Chief. Any validated complaints against a contracted personnel that are not resolved within the required seven day period will be further investigated and may require administrative action.

d. RANDOM SAMPLING. Board certifications, licenses, registrations will be randomly inspected.

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Measures PWS

Reference

Performance

Requirement

Standard Acceptable Quality

Level

Surveillance

Method

Incentive Disincentive/Deduct

Provider Quality Performance 4.2, 4.4.4.1.

All contract personnel shall perform in accordance with clinical standards

100% of care provided within clinical standards of care

100% Random inspection

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation.

Qualifications of Key Personnel 2.1.1 –

2.1.2;

2.1.4, 4.4.4.2.

All contract personnel shall be certified in accordance with national Nursing

Board standards

All (100%) contract personnel are certified by ARDMS or CCI.

100% No deviations accepted.

Direct

Observation

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation.

Removal from contract until such time the contract personnel meet qualification standard.

Scope of Practice/Privileging 4.3.6.1 –

4.3.6.10;

4.4.4.3

Contract personnel shall perform within their individual scopes of practice/privileging

All (100%) contract personnel perform within their scope of practice/privileges

100% of the time.

All (100%) contract personnel perform within their scope of practice/privileges

100% of the time. No deviations accepted.

Random

Inspection of records.

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation.

Patient Access 3.1.1 – 3.1.3, 3.2, 3.3, 4.4.4.4.

Contract personnel shall be available and in location as needed to properly perform tasks as specified.

All (100%) contract personnel are on time and available to perform services.

Contract personnel are on-time and available to perform services 100% of the time

Direct Observation, Periodic

Sampling of

Time and

Attendance

Sheets

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation;

Contractor will be paid for actual hours worked.

Patient Safety 4.3.7.4, 4.4.4.5.

Patient safety incidents shall be reported using Patient

Safety Report. All incidents reported immediately (within

24 hours.)

All (100%) of patient safety incidents are reported using Patient Safety

Report within 24 hours of incident.

All (100%) of patient safety incidents are reported using Patient

Safety Report within 24 hours of incident.

No acceptable deviation.

Direct

Observation, Validated

Patient Complaints

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation

Maintains licensing, registration, and certification

2.1.1.1 - , 2.1.1.3, 4.4.4.6.

Updated Licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current.

All (100%) licensing, registration(s) and certification(s) for contract personnel shall be provided as they are renewed. Licensing and registration

All (100%) licensing, registration(s) and certification(s) for contract personnel shall be provided as they are renewed.

Licensing and registration information kept

Periodic

Sampling and

Random

Sampling

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation.

Removal from contract until such time the contract personnel meet qualification standard.

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current. No acceptable deviation.

Mandatory Training 2.1.5, 4.4.4.7.

Contract personnel shall complete all required training per

VAMC policy

All (100%) of required training is complete on time by contract personnel.

100% completions, no deviations.

Periodic

Sampling and

Random

Inspection of records

Favorable contactor performance evaluation.

Suspension or termination of all physical and/or electronic access privileges and removal from contract until such time as the training is complete

Timely Invoice 4.3.7.6, 4.4.4.8.

Contractor shall submit monthly invoices within 30 days.

Monthly invoices shall be submitted within 30 days

75% compliance Periodic

Sampling

Favorable contractor performance evaluation.

Unfavorable contractor performance evaluation.

Privacy, Confidentiality and

HIPAA

4.3.2, 4.3.3, 4.3.5, 4.4.4.9.

Contract personnel 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%) contract personnel comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

100% compliance; no deviations.

Contractor shall provide evidence of annual training required by

VAMC,

reports violations per

VA Directive

6500.6.

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation.

Immediate removal from contract

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The table below is a sample that can be tailored – note that the table must identify where in the PWS the standards are found for monitoring performance. Check the MSO Customer Resource Center for approved mandatory QASPs.

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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-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).

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

See Sample CDR below.

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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

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

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9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement. The f requency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting. The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

_Son Nguyen - COR______________5/16/19_________________

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE