Attachment QASP.pdf

QASP Registered Vascular Technologists

PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY IMPROVEMENT(QI)

1.1.1. Quality Management/Quality Assurance Surveillance: Contract personnel shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance: Contractor performance will be monitored by the government using the standards as outlined in this Performance Work Statement (PWS) and methods of surveillance detailed in the Quality Assurance Surveillance Plan (QASP). The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted.

1.1.2. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints.

In the event that the Contractor is involved and named in a validated patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel.

This does not preclude refusal in the event of incidents involving physical or verbal abuse.

1.1.3. The Government reserves the right to refuse acceptance of any Contractor personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care or interferes with the regular and ordinary operation of the facility. Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction, or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. The CO and COR shall deal with issues raised concerning Contracted conduct. The final arbiter on questions of acceptability is the CO.

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

1.1.4.1. Measure: Provider Quality Performance

Performance Requirement: All contracted RVTs shall perform a variety of complex physiological and radiological procedures in accordance with clinical standards at MVAHCS.

Standard: Contracted RVTs independently performs Ultrasound procedures according to Imaging protocols.

Acceptable Quality Level: 97% Contracted RVTs perform within their scope of practice/privileges 97% of the time. No Deviations.

Surveillance Method: Direct observation, and reviews.

Frequency: Monitor throughout the term of contract by Imaging staff.

1.1.4.2. Measure: Qualifications of Key Personnel

Performance Requirement: Contracted RVTs shall be Registered with ARDMS in accordance with standards.

Standard: 100%Contracted RVTs are certified.

Acceptable Quality Level: 100% Contracted RVTs are registered with ARDMS Surveillance Method: Human Resources/Credentialing Frequency: Onboarding/credentialing throughout the term of the contract.

1.1.4.3. Measure: Scope of Practice/Privileging

Performance Requirement: Contracted RVTs perform within their individual scopes of practice/privileging.

Standard: (100%) Contracted RVTs perform within their scope of practice/privileges 100% of the time.

Acceptable Quality Level: 100% Contracted RVTs perform within their scope of practice/privileges 100% of the time. No deviations.

Surveillance Method: Direct observation.

Frequency: Randomly throughout term of contract by Imaging staff.

1.1.4.4. Measure: Patient Access

Performance Requirement: Contracted RVTs available in accordance with the operating hours.

Standard: Contracted RVTs available and in location as needed to properly perform tasks as specified.

Acceptable Quality Level: Contracted RVTs are on-time and available to perform services 95% of the time.

Surveillance Method: Periodic sampling of time and attendance sheets.

Frequency: Randomly throughout term of contract by COR and/or Supervision.

1.1.4.5. Measure: Patient Safety

Performance Requirement: Patient safety incidents shall be reported using Patient Safety Report. All incidents reported within 24 hours.

Standard: Patient safety incidents are reported using Patient Safety Report within 24 hours of incident.

Acceptable Quality Level: 100% of patient safety incidents are reported using Patient Safety Report within 24 hours of incident.

Surveillance Method: Report monitoring Frequency: Randomly throughout the term of the contract.

1.1.4.6. Measure: Maintains licensing, registration, and certification Performance Requirement: Updated Licensing, registration and certification shall be provided as they are renewed. Licensing, registration, and certification information kept current.

Standard: (100%) registration(s) and certification(s) for Contracted RVTs shall be provided as they are renewed. Licensing and registration information kept current.

Acceptable Quality Level: 100% registration(s) and certification(s) for Contracted RVTs shall be provided as they are renewed. Licensing and registration information kept current.

Surveillance Method: Periodic and random sampling.

Frequency: Randomly throughout term of contract.

1.1.4.7. Measure: Mandatory Training

Performance Requirement: Contractor shall complete all required training on time per MVAHCS policy.

Standard: (100%) of required training is complete on time by Contracted RVTs Acceptable Quality Level: 100% completions, no deviations Surveillance Method: Periodic Sampling Frequency: Randomly throughout term of contract

1.1.4.8. Measure: Privacy, Confidentiality and HIPAA

Performance Requirement: 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.

Standard: (100%) Contracted RVTs comply with all laws, regulations, policies, and procedures relating to Privacy, Confidentiality and HIPAA Acceptable Quality Level: 97%compliance, no deviations.

Surveillance Method: Contractor shall provide evidence of annual training required by VAMC, reports violations per VA Directive 6500.6.

Frequency: Randomly throughout term of contract.