D.1 QUALITY ASSURANCE SURVEILLANCE PLAN Medical Physicist 36C24226Q0905.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) – 36C24226Q0905

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 CO & CS:

Donna Richardson, Contracting Officer Department of Veterans Affairs, Bronx VA Medical Center 130 W Kingsbridge Rd.

Bronx, NY 10468 Phone: 917-951-1695

Email: Donna.Richardson4@va.gov

Meaghan Gallagher, Contract Specialist Department of Veterans Affairs, Buffalo VA Medical Center 4895 Bailey Ave.

Buffalo, NY 14215 Phone: 716-862-7461 Email: Meagahan.Gallagher@va.gov

Organization or Agency: Department of Veterans Affairs, Network Contracting Office NCO2 mailto:Meagahan.Gallagher@va.gov

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.

The COR for this contract is:

Melinda Bishop Department of Veterans Affairs, Bath VA Medical Center 76 Veterans Ave.

Bath, NY 13210 Phone: (607)664-4487

Email: Melinda.Bishop2@va.gov

Organization or Agency: Department of Veterans Affairs, Bath VA Medical Center

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:

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.

4. 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: Per the contract requirements, all patient safety incidents are to be reported within 24 hours to the Chief, Radiology. Compliance will be determined by his/her review of the incident. The Chief, Radiology, will report results to the COR.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.

c. VALIDATED USER/CUSTOMER COMPLAINTS. The COR will receive validated customer complaints through the VA NYHHS's Patient Representative's Office and follow up in conjunction with the Chief, Radiology, as necessary.

d. RANDOM SAMPLING. Quality monitoring is performed randomly on contract radiologists; for the radiologists reviewed, cases are randomly selected for overreads to evaluate the quality of interpretations. 98% of cases read have no major discordance with over reader’s interpretations. If >2% of cases are discordant (i.e., missed, or inaccurate diagnoses), a focused review of the practitioner is performed, and results reported to the Professional Standards and Credentialing Board for its consideration in continuing, limiting, or revoking privileges.

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. Any lapse in accreditation, licenses, board certifications, privileges, or any finding by the PSCB of less than satisfactory clinical competence is reported to the service chief and COR as well as to the Medical Staff Office and Chief of Staff.

5. Sample QASP PERFORMANCE REPORT DATE: ___________________

Measures PWS Referen ce

Performance Requirement

Standard Acceptable Quality Level

Surveillance Method

Met AQL/DID NOT MEET

AQL-

CPARS RATING/ADD

COMMENTS

Timeliness of Reports 4.7.3.3. Prompt delivery (timeliness) of interpretations and return for routine/stat/imme diate

Delivery 100% of the time

98% Periodic Inspection of reports available in VistA Radiology Program on a quarterly basis (at minimum).

Provider Quality Performance

4.7.3.4. All contract

physician(s) shall perform in accordance with clinical standards

OPPE

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

100% Periodic Inspection of

OPPE

documentation, every six months (at minimum).

Qualifications of Key Personnel

4.7.3.5. All Contractor’s

physician(s) shall be Board Certified or Board Eligible in accordance with ACR Standards.

All (100%) contract physician(s) are board certified or board eligible.

100% No deviations accepted.

Random Sampling of qualification documents upon submission of CV and on a quarterly basis (at minimum).

Scope of Practice/Privileging

4.7.3.6. Contract

physician(s) perform within

All (100%) contract physician(s)

100% Contractor’s physician(s)

Random Sampling of records on a their individual scopes of practice/privilegin g perform within their scope of practice/privileg es 100% of the time.

perform within their scope of practice/privileges 100% of the time.

quarterly basis (at minimum).

Patient Access 4.7.3.7. The Contractor shall provide Contractor’s physician(s) in accordance with the schedule outlined in this

PWS

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

Contract physician(s) are on-time and available to perform services 98 % of the time

Periodic Inspection of selected random cases for overreads to evaluate the quality of interpretations on a quarterly basis (at minimum).

Maintains licensing, registration, and certification

4.7.3.8. 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 contract 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 and Random Sampling, on a quarterly basis (at minimum)

Mandatory Training 4.7.3.9. Contractor shall complete all required training per Facility policy

All (100%) of required training is complete on time by

100% completions, no deviations

Periodic Inspection, on a quarterly basis (at minimum)

Contractor’s physician(s).

Privacy, Confidentiality and HIPAA

4.7.3.10. 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’s physician(s) comply with all laws, regulations, policies, and procedures relating to Privacy, Confidentiality and HIPAA

100% compliance, no deviations

Periodic Inspection annually;

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

6. 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).

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).

https://www.tungsten-network.com/ https://www.tungsten-network.com/

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 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.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME: DATE

TITLE:

SIGNED:

CONTRACTOR NAME: DATE

TITLE:

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