D.1 QUALITY ASSURANCE SURVEILLANCE PLAN.pdf

D.1 36C25722R0052

Quality Assurance Surveillance Plan

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 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: Dewana Raynor, Network Contracting Office 17, Health Care Resources Branch.

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: Anthony Brannon, Department of Veterans Affairs North Texas Health Care System (VANTHCS).

3. Contractor Representatives:

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

a. 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.

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 PM will use the following surveillance methods in the administration of this QASP:

a. Direct Observation: 100% surveillance: PM shall observe the activities of the contractor and/or receive reports of contact from other VA staff.

b. Periodic Sampling: Inspections scheduled and reported routinely per PM or as needed.

c. Random Inspection: Inspections scheduled and reported routinely per PM or as needed. Ten

(10) randomly selected patient charts will be reviewed per inspection per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security.

d. Verification and/or documentation provided by Contractor. The COR will review data monthly when invoices are received and certify all invoices for payment by checking workload reports and verifying documentation in patient records.

Performance Measures

Measure PWS Reference

Performance Requirement

Standard Acceptable Quality Level

(AQL)

Surveillance Method Met AQL/DID NOT

MEET AQL-

CPAR

RATING/ADD

COMMENTS

Provider Quality Performance

4.5.4.1. All Contractor’s

physician(s) shall provide quality patient care in accordance with clinical standards and standard of care outlined in the PWS.

OPPE documentation for all (100%) staff providing services under the contract.

100% OPPE

Qualifications of Key Personnel

4.5.4.2. All Contractor’s

physician(s) shall be Board Certified in accordance with ABPN Standards and PWS requirements.

All (100%) of Psychiatrist are board certified.

100% Periodic sampling of qualification documentation records submitted in accordance with contractor reporting requirements.

Scope of Practice/Privileging

4.5.4.3. Contract

physician(s) perform withing their individual scopes of practice/privilegi ng.

All (100%) Contractor’s physician(s) perform withing their individual scopes of practice/privileging.

100% Periodic sampling and inspection of records.

Patient Access 4.5.4.4. The contractor shall provide contractor’s physician(s) in accordance with the operating hours and VA clinical schedule outlined in the PWS.

All (100%) Contractor’s physician(s) are on time and available to perform services.

100% Period inspection of time and attendance sheets which are required to be completed timely, accurately, and legibly.

Patient Safety 4.5.4.5. Contractor shall ensure that patient safety incidents will be reported using Patient Safety Report. All incidents will be reported to the PM immediately (within 24 hours).

All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident.

100% Periodic Inspection

Maintains license, registration and certifications

4.5.4.6. Updated licensing, registration and certification shall be provided as they are renewed.

Licensing and registration information is kept current.

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

100% Periodic inspection and random sampling.

Mandatory Training

4.5.4.7 Contracted

complete all required training on time per VAMC policy.

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

inspection.

Privacy, Confidentiality and

HIPPA

4.5.4.8. 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 of confidentiality.

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

HIPAA.

inspection.

Timely Invoicing 4.5.4.9 Invoices are submitted timely in compliance with timeframe set forth in section 6.2 of

PWS.

Contractor complies with timeframe set forth in section 6.2 of PWS.

sampling.

6. Ratings Metrics and methods are designed to determine rating for a given standard and quality level. The following ratings shall be used:

EXCEPTIONAL: Performance meets contractual requirements (AQL) 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 (AQL) 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:

(Acceptable Quality Level)

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).

UNSATISFACTORY: 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).

7. 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 Contracting Performance Assessment Report (CPAR).

b. If contractor performance does not meet the AQL, 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 determine 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 the receipt the contractor has to present this corrective action plan to the CO. The Government shall review the contractor’s corrective action plan to the CO. 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.

8. Frequency of Measurement

a. Frequency of Measurement

The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting

The COR shall communicate with the Contractor and will provide written reports to the Contracting

Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

9. COR and Contractor Acknowledgement of QASP

Signed:

Anthony Brannon

CONTRACTOR NAME/TITLE DATE

CONTRACT

REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

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

5. DATES

a. CR PREPARED b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

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

CONNTRACTOR

NOTIFIED

COR

CONNTRACTING

OFFICER