Attachment Three (3) - Quality Assurance Surveillance Plan.pdf

ATTACHMENT THREE (3) -

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:

• MRI scans, Images transfer to PACS, Case close out, patient complication, number of scans completed.

• Monitoring will be physically periodically, Computer Data transfer.

• Monitoring conducted by COR

• Monitoring will be saved electronically.

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 will oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO will ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and will safeguard the interests of the United States in the contractual relationship.

The CO will 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.

ATTACHMENT FOUR (4) -

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Assigned CO: Cyrouse Houshyani Network Contracting Office 8 (NCO 8 8875 Hidden River Pkwy Tampa, FL 33637 Ph: 813-631-2816 E-mail:

Cyrouse.houshyani@va.gov

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Organization or Agency:

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and will assure proper Government surveillance of the contractor’s performance. The COR will 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:

Michael Wright Miami VA Healthcare System 1201 NW 16th Street Miami, FL 33125 Ph: 305-575-7000 ext. 13778 Cell: 954-675-6341 E-mail: Michael.wright9@va.gov

3. CONTRACTOR REPRESENTATIVES

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

Primary:

Alternate:

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 will 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 will use these standards to determine contractor performance and will 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

At the time of contract award, the Contracting Officer will appoint a Contracting Officer Representative (COR) to assist with the contract monitoring requirements. The COR will monitor such items as quality of service, timeliness of performance, customer service, cost control business relations. In accordance with FAR 1.601 (a) “Contracts may be entered into and signed on behalf of the Government only by contracting officers.” A COR is not authorized to modify the stated terms of the contract, including extending the length of the contract period. Quality of service will be monitored through a continuous review of requested studies vs. performed studies, the appropriateness of images produced and morbidity and mortality figures. These factors will be rated by a consensus of radiologists interpreting the MRI studies and through a radiologist or resident in the MRI unit setting protocols for scan and observing patients and procedures through the study process. Timeliness of performance will be measured through daily workload counts compared to daily number of studies ordered. Customer service will be monitored through periodic unannounced visits to the MRI unit and through patient satisfaction surveys completed by MRI patients.

Cost control will be monitored through a comparison of overtime hours worked and the type and number of studies completed per day. Appropriate regulatory and accrediting standards will apply, and all adverse events will be reported in accordance with medical center and other applicable guidelines.

mailto:Michael.wright9@va.gov

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Various methods exist to monitor performance. The COR will use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. Periodic Inspection of facility, Annual Staff License checks.:

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. COR will review monthly the technician surgical notes in CPRS pertaining to each of the surgical cases done on the corresponding month. All inspection and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. COR will receive quarterly reports showing any valid user/customer complaint.

d. PERIODIC SAMPLING. Random review will be conducted quarterly of quality reports; attendance records; customer satisfaction, medical records, training compliance cancelations; operating room and clinic reports. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

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e. Verification and/or documentation provided by Contractor. Contractor shall provide evidence of required training and qualifications such as TMS training certificates, license and certification copies.

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6. QASP PERFORMANCE REPORT DATE: _8/13/2021

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT MEET

AQL-

CPAR RATING/ADD

COMMENTS

1 –Documentation 4.3.4

4.4.2.10 4.4.2.14 4.5.4.1

Contractor’s MRI Technologist (s) shall complete all required notes for every procedure into the computerized medical record as required by Medical Center Policy and JC policies & procedures.

All (100%) documentation completed within stablished /required time frames.

95% Monthly Inspection of records.

2 – Outpatient Care Documentation

4.3.4 4.4.2.10 4.4.2.14 4.5.4.2

Contractor’s MRI Technologist (s) shall conduct procedures on outpatients as requested by physicians, close out case, transfer images to PACS, notify physician on incidental findings, and document pertinent information (note) in Computerized Patient Record System (CPRS).

All (100%) Case close out/image transfer/ documentation completed within stablished required time frames.

3- Clinic Consults and Documentation

4.3.4 4.4.2.10 4.4.2.14 4.5.4.3

Outpatient consults/orders will be performed by MRI Technologist as scheduled, All scheduled MRI Orders to be completed within 24 hours of the end of procedure.

All (100%) documentation completed within stablished /required time frames.

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4- Patient Access 1.1.

1.2 3.1.1 3.1.2 3.1.2.1 3.1.2.2 4.5.4.4

Contractor’s MRI Technologist (s) shall be available and in location as needed to properly perform tasks as specified.

All (100%) Contractor’s MRI Technologist (s) are on time and available to perform services.

100% Contractor’s MRI Technologist (s) perform within their scope of practice/privileges 100% of the time.

Periodic Sampling of Time and Attendance Sheets

5 - Patient Safety 4.4.2.11 4.4.2.16 4.4.2.17 4.4.4.2 4.4.5 4.5.4.5

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.

Contractor’s MRI Technologist reports incidents within 24 hours 100% of the time

Direct Observation .

6 - Maintains certification 2.1.1 2.1.2 2.1.3 4.2.1 4.4.1.1 4.5.4.6

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

All (100%) licensing, registration(s) and certification(s) for Contractor’s MRI Technologist (s) (s) shall be provided as they are renewed.

Licensing and registration information kept current.

100% completions, No acceptable deviation.

Contractor shall provide evidence of current license, registration and certification

7 - Mandatory Training 2.1.3 2.1.4 4.2.1 4.4.4.1.

4.5.4.7 6.2.3.

6.8.4.1.

7.6.

Contractor shall complete all required training per VAMC policy.

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%) of required training is complete on time by Contractor’s MRI Technologist (s).

100% completions, No acceptable deviation.

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

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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).

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).

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

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MICHAEL S. WRIGHT 452831 Digitally signed by MICHAEL S. WRIGHT 452831 Date: 2021.08.13 09:58:08 -04'00'

8. DOCUMENTING PERFORMANCE

a. The Government will 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 will inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO will 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 will review the contractor's corrective action plan to determine acceptability. The CO will 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 on the following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

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CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS

DISCREPANCY

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

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CONTRACTING

OFFICER

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