D.1 Quality Assurance Surveillance Plan.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Teleradiology Physician Services – Dayton VA Medical Center

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 must coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions must be provided to the contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES

The following personnel must oversee and coordinate surveillance activities.

a. Contracting Officer (CO) – The CO must ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and must safeguard the interests of the United States in the contractual relationship. The CO must 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, 614-257-5220, Karen.Williams4@va.gov

Organization or Agency: Veterans Health Administration

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and must assure proper Government surveillance of the contractor’s performance. The COR must 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 Michael Galiardi, (937) 268-6511 ext. 1015, michael.galiardi@va.gov

Organization or Agency: Veterans Health Administration

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:

mailto:Karen.Williams4@va.gov mailto:michael.galiardi@va.gov

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 must 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 must use these standards to determine contractor performance and must 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 must use the surveillance methods listed below in the administration of this QASP.

5.1 DIRECT OBSERVATION. 100% surveillance: DVAMC will be able to monitor directly the cases being completed through referencing the case number and following the patient exam. Evaluation of the Contractor’s performance will be completed by assigning a representative to monitor performance to ensure services are received. The DVAMC may inspect each task as completed or increase the number of quality assurance inspections if deemed appropriate because of repeated failures or because of repeated customer complaints. Likewise, the Government may decrease the number of quality assurance inspections if performance dictates. DVAMC Quality Assurance Personnel will validate any complaints and report to the Government Contracting Officer who will then take necessary action to enforce Contract compliance.

5.2 PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. The Contractor will provide quarterly volume reports by radiologist. The peer review and volume information by contract radiologist will be displayed and available to the VAMC through an electronic web-based portal with appropriate security protections. The VAMC facility will be given access to the web portal to access the quality data and reports. The electronic web-based portal will be available for use by the VAMC on the first day of the contract. Reports will be available for the VAMC facility to print from the electronic web-based portal to utilize for Focus Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) for each privileged contract radiologist.

5.3 RANDOM SAMPLING. Fifty (50) randomly selected patient files will be reviewed annually according to contract start and end dates. If fifty (50) reports were not achieved by an individual contractor, then one hundred (100) percent of cases will be reviewed. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

6. Sample QASP PERFORMANCE REPORT DATE: ___________________

Measures PWS Reference

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT MEET

AQL-

CPARS RATING/ADD

COMMENTS

Timeliness of Reports

4.3.3

4.7.3.1

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

- Stroke protocol non-contrast CT exam turnaround time: Read and reported within fifteen

(15) minutes of image transmission.

- STAT exam turnaround time: Read and report within one (1) hour of image transmission.

- Urgent exams guarantee turnaround time: Read and report within two (2) hours of image transmission.

- Routine exams guarantee turnaround time: Read and reported within forty-eight (48) hours of image transmission. Situation may allow this time to be adjusted on a case-by-case basis.

Delivery 100% of the time. 95% meet timeliness standards.

Frequency: Quarterly

The Teleradiology vendor must provide detailed time log data for each case.

Data must include Radiology Case Number, Time/Date of Radiology Image receipt by vendor, Time/Date of Final Report sent to VA CPRS/VistA HIS, and Time between Image Receipt and Final Report Transmission to VAMC Dayton CPRS/VistA HIS. Data must also include the Time of the beginning of image transmission from DVAMC since this is when the Turnaround Time Data begins to document timeliness of vendor performance.

Provider Quality Performance

4.6.3

4.7.1

4.7.3.2

All contract physicians must perform in accordance with clinical standards.

OPPE

documentation for all (100%) staff providing services under the contract. All staff (100%) meet Standards.

Less than 5% of 3a and 3b per evaluation period.

All other criteria are

MET.

Frequency: At least annually, it may be performed at a shorter interval if the DVAMC deems necessary.

OPPE data pertinent to care performed for each provider working under this contract as described in 4.6.

Qualifications of Key Personnel

2.1.2

4.7.3.3

All Contractor’s physician(s) must be Board Certified/Board Eligible in accordance with ACR Standards.

All (100%) contract physician(s) are Board Certified/Board Eligible.

100% No deviations accepted.

Periodic Inspection of qualification documents.

When new certifications occur within a period of performance, the contractor is required to submit the new document to the COR within 1 week of issuance.

Frequency: Annually. It may be performed at a shorter interval if the DVAMC deems necessary.

Scope of Practice/Privileging

4.7.3.4 Contract physician(s)

perform within their individual scopes of practice/privileging

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

100% Contractor’s physicians perform within their scope of practice/ privileges 100% of the time.

Periodic Inspection or Random Sampling of records.

Frequency: Quarterly

Maintains licensing, registration, and certification

2.1.1

2.1.2

4.7.3.5

Updated Licensing, registration and certification must be provided as they are renewed. Licensing and registration information kept current.

All (100%) licensing, registration(s) and certification(s) for contract physician(s)

100% licensing, registration(s) and certification(s) for Contractor’s

Periodic Inspection or Random Sampling. When new certifications occur within a period of performance, the contractor is required to submit the must be provided as they are renewed.

Licensing and registration information kept current.

physician(s) must be provided as they are renewed.

Licensing and registration information kept current.

No acceptable deviation.

new document to the COR within 1 week of issuance.

Frequency: Annually. It may be performed at a shorter interval if the DVAMC deems necessary.

Mandatory Training 2.1.6

4.7.3.6

Contractors must complete all required training per Facility policy

All (100%) required training is completed on time by Contractor’s physicians.

100% completions

Periodic Inspection or Random Sampling

Privacy, Confidentiality and

HIPAA

4.4.2

4.7.3.7

Contractor is aware of all laws and regulations, policies and procedures relating to Privacy, Confidentially and HIPAA and complies with all standards. Zero breaches of privacy or confidentiality.

All (100%) Contractor’s physician(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA

100% compliance

Periodic Inspection:

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

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 must be used (Reference: CPARS User Manual https://www.cpars.gov/cparsweb/assets/documents/CPARS_User_Manual.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).

UNSATISFACTOR

Y: 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).

https://www.cpars.gov/cparsweb/assets/documents/CPARS_User_Manual.pdf

8. DOCUMENTING PERFORMANCE

a. The Government must 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 must inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO must document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR must prepare a Contract Deficiency 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 must 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 must 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 must review the contractor's corrective action plan to determine acceptability. The CO must 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 on the following page.

9. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT DEFICIENCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR 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