D.1 QUALITY ASSURANCE SURVEILLANCE PLAN.docx

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Patient Satisfaction Surveys

Solicitation Number: 36C25722Q0744

Contract Description: The overall purpose is to develop and acquire a health care consulting service that specializes in the creation, administration, and analysis of patient satisfaction surveys. The primary objective is to increase patient satisfaction at VA North Texas Healthcare System (VANTHC) and South Texas Veterans Healthcare System (STVHCS) inpatient units and outpatient clinics by providing frontline staff with real-time feedback on patient perceptions that will enable employees to improve their performance and deliver excellent care. The results will be used to gain insight on the opinions of Veterans who use our services. The information will include detailed, comprehensive assessment of patient satisfaction within VANTHC and STVHCS.

Contractor’s name:____________________

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: Frank Mendoza Network Contracting Office 17

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: Sherrie Walker

c. Other Key Government Personnel same agency:

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager _________________

b. Other Contractor Personnel - NA

4. PERFORMANCE STANDARDS

The Contractor shall be aware that in the absence of any contract requirement from the Service Summary (SS) does not detract from its enforceability nor limit the rights or remedies of the Government under any other provision of the contract. The Contractor shall ensure the following SS requirements are accomplished:

D.1 ATTACHMENT

Reference Performance Requirement

Method Incentive

All indicators of nursing care required by ANCC Magnet recognition program to include courtesy and respect from nurses, careful listening by nurses, response time, pain and education Front-line staff courtesy and helpfulness Scheduling ease and accuracy Speed of registration process and length of wait Nursing staff (LPN, RN) courtesy Provider courtesy, quality of explanations, amount of face-to-face time with patient Office operations (hours of operations, cleanliness, etc.)

Sensitivity to the patient’s needs (scheduling, privacy concerns, convenience of office hours) Ability to add custom questions to the survey tools for each location

5. INCENTIVES

The Government shall use recognition in the contractor’s Past Performance Record as incentives. Incentives shall be based on exceeding, meeting, or not meeting 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. (Can be performed periodically or through 100% surveillance)

· Patient safety incidents must be reported to the COR and/or Laboratory Manager.

b. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.)

· Key Personnel

· Timely Invoicing

c. PERDIOCALLY. At a minimum every quarter or as frequent as deemed necessary by the COR.

8. 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. The following ratings shall be used:

Exceeds: 2-5% above acceptable level in table above Meets: Reach acceptable level in table above Does Not Meet: 5% or more below acceptable level in table above

9. 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. 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 Contract Discrepancy Report (CDR), and present it to the contractor's program manager.

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 COR. The Government shall review the contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

10. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor every quarter to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative