D.1 QASP TELRADIOLOGY CONTRACTORS.docx

ATTACHMENT D.1 – QUALTIY ASSURANCE SURVEILLANCE PLAN

CONTRACT NUMBER: CONTRACTOR:

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 CS: Ramona Bonness Assigned CO: Carol Franklin Organization or Agency: Network Contracting Office 9 (NCO 9)

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.

Primary COR:

Debbie Thompson Alternate CORs (by station):

Debbie Thompson – Mountain Home Tiffany Cannon – Tennessee Valley (TVH) Rodney McKinney – Lexington Virgil Snashall – Louisville Reginald Penny – Memphis

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract. (List, include POC Names, Phone and Emails.)

CONTRACTOR’s Primary Program Manager:

Alternate Program Manager(s):

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: CORs and PACS Administrators will actively monitor Radiology PACS for completion of radiology exam reports and timeliness thereof.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. CORs and/or PACS Adminsitrators will run monthly reports to validate invoicing prior to payment. Reports from VistA to monitor accurate documentation of critical findings within the report, timeliness reports, and random sampling will be performed monthly, quarterly, annually, or on demand. Peer reviews will randomly be performed daily with escalation of any 2b findings or greater to peer subcommittee review.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints will be reported to Primary COR in real time, communicated to CO, and validation process completed. Contractor to be notified in writing.

d. RANDOM SAMPLING. Various reports and dashboards are configured to monitor Radiology processes throughout the VISN. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. Contractor will provide information, updated documents, and reports on demand. Contractor is required to update VISN of any changes that will impact contract performance.

6. ASP PERFORMANCE REPORT DATE: ___________________

Measures

Surveillance Met AQL/DID NOT MEET AQL-

CPARS RATING/ADD COMMENTS

4.5.1.2.5 4.5.1.2.7

Prompt delivery (timeliness) of interpretations and return for routine/ stat/immediate

Delivery 100% of the time.

2. Provider Quality Performance

Special Contract Requirements

And Para 4.6, 4.8.1, 4.8.1.2 All contract physician(s) shall perform in accordance with clinical standards provided by the VA for Ongoing Professional Performance Evaluation

Timeliness of peer review and exam summary quarterly and annual reports

All (100%) contract physician(s) shall perform in accordance with clinical standards

Required reports are received timely and complete for every credentialed provider for VISN 9.

2.1.5 2.1.3 1.5.12

PERIODIC INSPECTION OR RANDOM SAMPLING of qualification documents

4. Scope of Practice/Privileging

2.1.3 2.1.3.3 2.1.3.8 2.1.5 4.2.2

3.2 3.4.4 4.1

Para. 4.3 4.6

2.1.6

8. Privacy, Confidentiality and HIPAA

PWS para. 1.5.14 1.5.26 4.4.1 4.4.2 4.4.3.

4.7.3.

and Special Contract Requirements

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.

TELERADIOLOGY SERVICES 36C24926R0007

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:

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.

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.

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.

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 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

CONTRACT REPORT

5. DATES

a. CR PREPARED

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

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.)

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER