D.1 QASP.pdf

Quality Assurance Surveillance Plan (QASP)

Urgent Care Medical Officer of the Day (MOD) Physician Services

Contract Description: The contractor(s) to provide up to one GSA 621-001, Internal Medicine or Family Practice, Urgent Care Medical Officer of the Day, to include medical coverage for Community Living Center (CLC), Mental Health (MH), Substance Abuse Residential Recovery Treatment Program (SARRTP), Veterans Administration Northern Indiana Health Care System (VANIHCS) located at 1700 E. 38th Street, Marion, IN, 46953. The need is for Contract Internal Medicine or Family Practice Physicians to cover 6,896 hours or approximately 3.3 full-time equivalent (FTEE) positions from 4:30pm through 8:00am Monday through Friday; and 4:30pm Friday through 8:00am Monday; (entire weekend); and on Federal Holidays for twelve

(12) months.

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. 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: Karen Williams 2780 Airport Drive, Suite 340

Columbus OH, 43219

(614) 257-5220 Karen.Williams4@va.gov

Organization or Agency: Network 10 Contracting Office

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: Howard Pooler, HSS 2121 Lake Avenue Fort Wayne IN, 46805 (260)426-5431, ext. 71134 Howard.Pooler@va.gov

c. Other Key Government Personnel:

3. CONTRACTOR REPRESENTATIVES

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

Primary:_______________________________

Alternate: ______________________________

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 below, in the Performance Work Statement (PWS), includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

mailto:Karen.Williams4@va.gov mailto:Howard.Pooler@va.gov

QUALITY ASSURANCE SURVEILLANCE PLAN

Tasks PWS Indicator

Standard

Acceptable Quality Level

(AQL)

Method of surveillance

Availability of Contracted Staff

1.1 1.2 1.3 4.

Staff must be available between the hours of 4:30 p.m. through 8:00 a.m. Monday through Friday.

Also, from 4:30 p.m. on Friday through 8:00 a.m.

on Monday. As well as 24-hour coverage on all 10 Federal holidays.

Staff must be available between the hours of 4:30 p.m. through 8:00 a.m. Monday through Friday.

Also, from 4:30 p.m.

on Friday through 8:00 a.m. on Monday. As well as 24-hour coverage on all 10 Federal holidays.

100% Inspection and Periodic Sampling - Daily attendance logs

Medical/Clinic al Knowledge/ Timely Medical Record Documentation

2.1.4 2.1.7 2.1.8

Provide acceptable medical care and services and documents findings in the medical record.

Uses evidence-based guidelines and Demonstrates selection of the most effective and appropriate approaches.

Documentation of encounters and notes will be complete, signed, and checked-out.

95% Inspection and Periodic Sampling - Observation, Peer review and Ongoing Professional Performance Evaluation (OPPE / FPPE), periodic data analysis and confirmation by COR.

Medication Reconciliation

/ EDIS

Utilization and compliance

2.1.4 2.1.5 2.1.6

2.1.12

Admission Medical Record.

Performed

EDIS Compliance

Within 24 hrs. of admission.

Entries are complete and filled timely per VHA Directive

100% Inspection - Daily verification by Quality Management (QM) &

COR

Prescribing Medication

2.1.6 2.1.7 2.1.8

Responsible for prescribing medication as needed, shall be required to utilize VA formulary.

Utilizes VA formulary and prescribes appropriate medication per medical guidelines

100% Inspection and Periodic Sampling - Observation and mortality & morbidity reporting.

Feedback from QM.

Overall medication management and evidence-based practice.

Timely entry for medications and signed orders before end of daily tour

Reports of timely medication or missing medication orders from Medical Records Chief.

Certifications 3.1 Provide licensing As requested by using service line

100% Inspection and Periodic Sampling - Hard copy of each in credentialing and contracting folders;

credentialing and training must be up to date at all times.

3.1 Provide

accreditation

Before contract award

3.1 Provide BLS and

ACLS certification

Prior to scheduled on site work

3.3 Obtain

credentialing

As necessary and determined by using service line

Privacy & Security

10.3 Maintains privacy

and security of patient information

Maintains privacy and security of patient information before expiration and/or account disabling

100% Inspection and Periodic Sampling - Completes mandated annual education. Medical Records and information Security Officer (ISO) reporting

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. INSPECTION - COR evaluates outcomes through documentation/dictation and results as documented above.

b. PERIODIC SAMPLING - Sample is taken when a problem/deficiency is suspected. Sample results are applicable only for the specific work inspected.

6. 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.

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COR shall inform the contractor and the Contracting Officer. 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 Memorandum of Record, and present it to the contractor's program manager.

The contractor shall acknowledge receipt of the Memorandum of Record in writing. The Memorandum of Record 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 Memorandum of Record 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 Memorandum of Record may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

8. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement - The COR shall assess performance as specified above. During contract performance, the COR will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings - The COR and Contractor will meet upon request of either party to assess performance and provide a written assessment. The Contracting Officer may be invited to attend if there are serious issues to address.

Signature – Contracting Officer’s Representative

Signature – Contractor’s Signature