ATTH 1- QASP-rv word doc.docx

ATTACHMENT D. 1 36C25626Q0425

Quality Assurance Surveillance Plan PATHOLOGY AND LABORATORY MEDICINE SERVICES For: Pathology and Laboratory Medicine Services

Contract Number:

Contract Description: An agreement to provide Pathology and Laboratory Medicine Services.

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 nsibility to be objective, fair, and consistent in evaluating performance.

basis. However, the Government shall coordinate changes with the contractor. 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 performance.

b. - The COR is responsible for administration of the contract and shall assure proper Government surveillance of the . The COR is not empowered to make any contractual commitments or to authorize any contractual

Assigned COR: Darby Matthews Organization or Agency: New Orleans VA (NOLA VAMC)

3. CONTRACTOR REPRESENTATIVES

contract.

Program Manager

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Performance Requirements Summary Matrix of the contract includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

CONTRACT PERFORMANCE METRICS

PROFESSIONAL SERVICES

Quality Level Method Of Surveillance Incentive

Clinical Info Return

a.m. 4:30 p.m. M-F, exclusive of federal holidays)

100% Clinical Pathology Staff Anatomic Pathology Staff

consultations, including but not limited to, unexpected frozen section, blood bank, compatibility and blood bank transfusion reaction interpretations.

Response time of one-half hour

value report.

Past performance

for typical single frozen sections Initial frozen section is 20 minutes; 10 minutes for each additional 90% with notification documented on final report Review critical value report.

Past performance

PROFESSIONAL SERVICES

Quality Level Method Of Surveillance Incentive specimen - specimen receipt to physician notification

carcinoma)

squamous and basal cell carcinoma)

diagnoses

Minutes.

Past performance

Surgical Pathology report completion Routine within 3 working days of specimen receipt, complicated within 5 working days of specimen receipt.

100% Pathologist review of referral testing requested after technologist screening.

80% Attendance at monthly P&LMS Meeting Random sampling

Meeting Minutes Past performance

PROFESSIONAL SERVICES

Quality Level Method Of Surveillance Incentive

-Consults -Electronic consent form

Medical Records to alert COTR of any provider who is non-compliant with these requirements.

Past performance

TECHNICAL SERVICES

Quality Level Method Of Surveillance Incentive

received Past performance

5. INCENTIVES

The Government shall use Exercise of Option Period and past performance as an incentive. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE - CHANGE TO MATCH ACTUAL METHOD IN CONTRACT

a. Performance Measures Review: The COR shall use the surveillance methods listed below. See scale in paragraph 7 for rating/rating methodology.

(1) Sign-in Sheets/VISTA log-in

(2) Review critical value report.

(3) Review PLMS QA Management Minutes

(4) Review monthly report.

(5) Print TAT report monthly.

(6) Random sampling.

(7) Meeting minutes.

(8) Monitored by HIMS using reports from VistA. Medical Records to alert AO/COR of any provider who is non-compliant with these requirements.

(9) Documentation when slides are received.

b. Performance on Other Contract Requirements: The following items will also be monitored. See scale in paragraph 7 for rating/rating methodology. Ratings for these items will be achieved by random sampling, inspections, observation and customer complaints.

(1) Contractor conforms to contract requirements

(2) Contractor meets quality patient care standards

(3) Administrative matters handled appropriately (reports, credentialing, etc.)

7. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

SCALE FOR PERFORMANCE MEASURES REVIEW

standard were met

SCALE FOR PERFORMANCE ON OTHER CONTRACT REQUIREMENTS

8. DOCUMENTING PERFORMANCE. In conjunction with the quarterly performance measure reports prepared by the COR, this data will also be used for documentation for a request to renew/not to exercise option period or renew of a contract.

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action. In order for a contractor to scale above).

AND

Requirements items.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the contractor's program manager.

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 COR. The Government shall review the contractor's corrective action plan to determine acceptability.

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

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COR shall visit/correspond, at a minimum, with the contractor twice during the contract period: (1) middle of contract period and (2) end of contract period to assess performance and shall provide a written assessment. This written assessment will be and/or for a request to exercise option period, renewal of a contract or termination of a contract.

c. Semi-Annual Performance Measure Reports. COR will provide CO with semi-annual reports (due 45 days after the end of each performance period). CO will forward these reports to the Contractor. In turn, the Contractor will review the reports and acknowledge receipt of report by returning a signed copy, along with any comments, to the Contracting Officer within 30 days of receipt of the report.

Signature Contractor Program Manager

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