D.1 QASP.docx

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Q522--Interventional Radiology Services - E Orange VAMC | Phase I: Planning
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36C24223Q0017
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PERFORMANCE MEASURES

Measures
PWS

Reference Performance Requirement

Standard
Acceptable Quality Level
Surveillance

Method

Time and Attendance
4.1.1. and 4.5
Sign in and sign out for each visit using biometrics system
100% accurate documentation of time worked.
98% IR Radiologists time and attendance are compliant with required hours on duty 100% of the time, (excluding equipment malfunction)
Weekly print out (biometrics) indicates actual hours worked- Notify COR when equipment malfunctions occur immediately
Clinical competence confirmed and documented through Focused Professional Practice Reviews and Ongoing Professional Practice Reviews(note: this standard is monitored in conjunction with the OPPE reporting schedule to PSB.
4.4.8.5. and 4.5
Review of results of OPPEs/FPPEs to identify competency deficiencies.
100% Work product is of acceptable quality with correct procedures performed
100% No deficiencies found warranting Professional Standards action.
Quarterly report to PSB at VANJ by service chief
Rate of Response times < 75 minutes in person from time of notification – STAT on-call services and procedures completion within 24 hours for urgent procedures.
3.1.3.5. and 4.5
Contract IR Radiologist shall be available within 75 minutes for STAT and 24 hours for urgent procedures.
100% IR Radiologists available within 75 minutes for STAT and 24 hours for urgent procedures.
95% of IR procedures are completed within availability of timeliness stands and results are communicated to the Ordering VA Clinician.
Number of complaints received by the Chief of Service; # of procedures cancelled
Customer Service
2.10.3., 4.5, and 5.1.1.2.
Number of sustained patient complaints; number of sustained clinician complaints per Medical Center employees
100% Level of customer satisfaction meets VHA acceptable standards/guidelines
97% Care should be of quality and efficiency recognized as the standard within the professional area of expertise
Periodic sampling of EMR < 5 cases per quarter
Patient Safety
4.5 and 4.4.8.5.
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
Invoicing
4.5 and 6.2.
The correct number of hours invoiced based upon actual hours worked monitored by Biometrics electronic system
100% Invoices submitted for payment reflect actual hours worked with correct hourly rates included
97% compliance using electronic monitoring system
Weekly print out of actual hours worked and through COR and CO quarterly reporting
Maintains licensing, registration, and certification
1.4.2., 2 and 4.5
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 physician (s) shall be provided as they are renewed. Licensing and registration information kept current.
All (100%) licensing, registration(s) and certification(s) for contract physician (s) shall be provided as they are renewed. Licensing and registration information kept current. No acceptable deviation.
Periodic Sampling, Random Sampling, during vetting of new key personnel, through CO, and Credentialing.
Mandatory Training
B.5 Section 6.8.9., 2.1.4, 2.1.6., and 4.5
Contractor shall complete all required training per VAMC policy
All (100%) of required training is complete on time by contract physician (s).
95% completions,

Periodic Sampling, during vetting of new key personnel by CO, COR, and Credentialing.

Privacy, Confidentiality and HIPAA
4.4., 4.5., and 6.8.4.,
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%) contractor physician (s) 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 and during Option Year renewal by CO and COR.

Report Dictation Timeliness
4.5 and 4.4.7.1.
Reports must be dictated and finalized on the date of procedures.
95% within 48 hours and 100% within 72 hours
<1% deviation for extending circumstances
Administrative Officer or Chief Technologist to produce data reports on a monthly basis

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: Kathleen Sciortino Organization or Agency: Network Contracting Office 2

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: Gunal Bubay Organization or Agency: VA New Jersey Healthcare System

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 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

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.

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

c.VALIDATED USER/CUSTOMER COMPLAINTS. Review of Ongoing Provider Practice Evaluation Report andsurveillance of submitted patient complaints.

d.VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR.

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 thecontractual 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 orEnvironmental Deficiency Reports, or letters).

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.

File details come from the government source that posted it. Updated .