D 1 Quality Assurance Surveillance Plan.pdf

Quality Assurance Surveillance Plan (QASP) Dermatologist Services

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 Contracting Officer (CO): Troy Davis troy.davis@va.gov Organization or Agency: U.S. 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: James Aiken – Program Specialist – james.aikensjr@va.gov – 501-257-1015

Organization or Agency: CAVHS Medicine Service

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager:

James Aikens

Alternate Program Manager:

Stephen Pettit mailto:troy.davis@va.gov mailto:james.aikensjr@va.gov

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. 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: Conducted by Section or Service Chief.

a. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

Inspections scheduled and reported quarterly per COR delegation or as needed. In accordance with the process for Ongoing Professional Practive Evaluation (OPPE), six (6) randomly selected patient files will be reviewed per six (6) month inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards. The Professional Standards Committee will review the OPPE data every other year. The Chief of Cardiology is responsible for providing this information to the COR every 6 months.

b. VALIDATED USER/CUSTOMER COMPLAINTS. The Patient Advocate Tracking System (PATS) will be used for tracking patient complaints.

c. RANDOM SAMPLING. Ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

d. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR: Review PWS and if this method of surveillance is selected, define how documentation will be verified and how assessment will be conducted (For example, off-site contracts may require the contractor to provide information on services provided to patients)

6. QASP PERFORMANCE REPORT

Measures PWS

Reference

Performance

Requirement

Standard Acceptable Quality Level

Surveillance

Method

Met AQL/DID NOT MEET AQL-

CPARS RATING/ADD COMMENTS

Provider Quality Performance

4.6.4.1. All Contractor’s

physician(s) shall perform in accordance with clinical standards

100% of care provided within clinical standards of care

80% OPPE

Qualifications of Key Personnel

4.6.4.2. All Contractor’s

physician(s) shall be board certified/board eligible in accordance with AAD Standards for dermatology.

All (100%) Contractor’s physician(s) are board certified/board eligible.

100% Random sampling of qualification documents

Scope of Practice/Privileging 4.6.4.3 Contractor’s physician(s) perform within their individual scopes of practice/privileging

All (100%) Contractor’s physician(s) perform within their scope of practice/privilege s 100% of the time.

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

Random sampling of records.

Patient Access 4.6.4.4. The Contractor shall provide contractor’s physician(s) in accordance with the operating hours and VA Clinical schedule as

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

Contractor’s physician(s) are on-time and available to perform services 90% of the time

Periodic Inspection of Time and Attendance Sheets outlined in this

PWS.

Patient Safety 4.6.4.5. Patient safety incidents shall be reported using VA Patient Safety Reporting System.

All incidents reported immediately (within 24 hours.)

All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

80% of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

Random Sampling or Periodic Inspection

Maintains licensing, registration, and certification

4.6.4.6. 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 Contractor’s physician(s) shall be provided as they are renewed.

Licensing and registration information kept current.

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

Licensing and registration information kept current. No acceptable deviation.

Periodic Inspection or Random Sampling

Mandatory Training 4.6.4.7. Contractor shall complete all required training on time per facility policy

All (100%) of required training is complete on time by Contractor’s physician(s).

90% completions

Inspection or Random Sampling

Privacy, Confidentiality and

HIPAA

4.6.4.8. Contractor is aware

of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

All (100%) Contractor’s physician(s) comply with all laws, regulations, policies and

100% compliance

Inspection- Contractor shall provide evidence of annual

HIPAA and complies with all standards Zero breaches of privacy or confidentiality procedures relating to Privacy, Confidentiality and HIPAA training required by facility, reports violations per VA Directive 6500.6.

Employment Eligibility Verification

4.6.4.9. Reports shall be

completed and submitted IAW para 4.5.3.5

100% compliance 100% Quarterly and Periodic Reviews and spot checks

Service Contract Report 4.6.4.10 Reports shall be completed and submitted IAW para 4.5.3.6

100% compliance 100% Annually and Periodic Reviews and spot checks

7. 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/documents/CPARS-Guidance.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).

UNSATISFACTORY:

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/documents/CPARS-Guidance.pdf

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 REPORTING SYSTEM

(CPARS).

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 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 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 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