D.1 QASP.pdf

Quality Assurance Surveillance Plan (QASP)

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 will 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 CO: Veronica Baldwin Organization or Agency: VHA NCO2

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: Alex Shuyan Wong Organization or Agency: BRONX VAMC James J. Peters VAMC

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager:

Alternate Program Manager:

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: The COR will be on site and observe the operation of the program while the contractor are conducting the services.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. The COR will schedule a time to inspect ten (10) randomly selected patient files every quarter of the fiscal year and review. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Facility centralized patient complaint mechanism will be monitored. Patient complaints regarding Interventional Radiology Service will be retrieved and followed up to discern any opportunities for improvement. Service Chief of General Surgery Department will be notified, and will provide guidance on the solution of the complaints.

d. RANDOM SAMPLING. For every quarter of the fiscal year, the COR will follow from the requesting process to the point of completion one randomly selected requested procedure. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards. Adherence to the standard of operations, clinical and business compliance and patient experience will be evaluated.

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. Service Chief of the General Surgery Department or his/her designee, Quality Management Department will sample clinical documentation provided by the physician contractors every quarter. Adherence to the standard of operations, clinical and business compliance and patient experience will be evaluated. Survey report will be provided by the Service Chief of General Surgery Service to the Medical Executive Council and Surgery Workgroup committee.

6. SAMPLE QASP PERFORMANCE REPORT DATE: __________________

Measures PWS Reference

(Fill-in)

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT MEET

AQL-

CPARS RATING/ADD

COMMENTS

Provider Quality Performance

Interventional Radiology (IR)

STANDARD

OPERATING

PROCEDURES

All contractor’s physician(s) shall perform in accordance with clinical standards

100% of care provided within clinical standards of care

100% OPPE

Qualifications of Key Personnel

ACR Standards for Interventional Radiology.

All contractor’s physician(s) shall be board certified/board eligible in accordance with ACR Standards for Interventional Radiology.

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

100% Periodic Inspection or Random Sampling of qualification documents

Scope of Practice/Privileging

James J. Peters VAMC By-Laws

Contractor’s physician(s) perform within their individual scopes of practice/privilegi ng

All (100%) contractor’s physician(s) perform within their scope of practice/privileg es 100% of the time.

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

Periodic Inspection or Random Sampling of records.

Lawrence, Shawn A.

REVIEW MATRIX FOR ACCURACY

Lawrence, Shawn A.

ADD WHERE EACH BULLET IS REFERENCED IN THE PWS TO MATCH QASP

Patient Access PWS The Contractor shall provide Contractor’s physician(s) in accordance with the operating hours and VA clinical schedule outlined in this

PWS

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 100% of the time

Periodic Inspection or Random Sampling of Time and Attendance Sheets

Patient Safety James J. Peters VAMC By-Laws

Patient safety incidents shall to 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.

100% of patient safety incidents are reported using Patient Safety Report within 24 hours of incident.

No acceptable deviation.

Direct Observation

Maintains licensing, registration, and certification

James J. Peters VAMC By-Laws

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 James J. Peters

VAMC By-Laws Contractor shall complete all required training on time per facility policy

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

100% completions, no deviations.

Periodic Inspection or Random Sampling

Privacy, Confidentiality and

HIPAA

James J. Peters VAMC By-Laws

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;

Periodic Inspection;

Contractor shall provide evidence of annual training required by the facility, reports violations per VA Handbook 6500.6.

Favorable contactor performance evaluation.

Invoicing Human Resource Regulations;

Fiscal Department Regulations

The correct number of hours invoiced based upon actual hours worked monitored by Biometrics electronic system

Invoices submitted for payment reflect actual hours worked with correct hourly rates included

100 % compliance using electronic monitoring system

Weekly print out of actual hours worked

Customer Service Centralized Patient Complaint tracking Mechanism;

Patient Representative

Number of sustained patient complaints;

number of sustaniated

Level of customer satisfaction meets

VHA

acceptable

Care should be of quality and efficiency recognized as the standard within the

Periodic sampling of

EMR < 5

cases per quarter standards/guidel ines

Rate of Response times < 60 minutes from time of notification – on call services

Interventional Radiology (IR)

STANDARD

OPERATING

PROCEDURES

Contract IR Radiolgosit shall be available and in location as needed to properly perform tasks as specified

IR Radiologists are available as needed to perform stat or urgent IR procedures.

Timely completion of IR procedures, communicating results to VA clinicians

Number of complaints received by the Chief of Service; # of procedures cancelled

Clincial competence confirmed and documented thorugh Focused Professional Practice Reviews and Ongoing Professional Practice Reviews(note: this standard is monitored ub conjunction with the OPPE reporting schedule tp PSB.

FPPE process under the Chief of Staff office

Review of results of OPPEs/FPPEs to identify competency deficiencies.

Work product is of acceptable quality with correct procedures performed

No deficiencies found warranting Professional Standards action.

Quarterly report to PSB at VA by service chief

Time and Attendance Human Resource Regulations;

Fiscal Department Regulations

Sign in and sign out for each visit, communication with Surgery Administrative Team, Admin.

Officer and timekeepers

Accurate documentation of time worked

IR Radiologists time and attendance are compliant with required hours on duty 100% of the time, (excluding equipment malfunction)

Weekly print out indicates actual hours worked- Notify COR when equipment malfunctions occur immediately

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).

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 https://www.cpars.gov/documents/CPARS-Guidance.pdf https://www.cpars.gov/documents/CPARS-Guidance.pdf 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).

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 below.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER

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

CONTRACTING

OFFICER

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: Veronica Baldwin

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: Alex Shuyan Wong Organization or Agency: BRONX VAMC James J. Peters VAMC

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:

EXCEPTIONA

L:

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.

SATISFACTO

RY: 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).

UNSATISFAC

TORY: 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).

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.