D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP).docx

36C24624R0024

D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

PET/CT SCAN SERVICES FOR ASHEVILLE, SALEM, AND HAMPTON VAMC

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 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 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: Mario L. Santiago Organization or Agency: Network Contracting Office (NCO) 6 Email: Mario.Santiago@va.gov Phone: 757-251-4254

Assigned CS: David E. Smith Organization or Agency: Network Contracting Office (NCO) 6 Email: David.Smith78@va.gov Phone: 757-728-7156

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.

Asheville VAMC Kenneth Thomas, CNMT Nuclear Medicine Supervisor U.S. Department of Veteran Affairs WNC VA Health Care System

(828) 298-7911 ext. 5238 kenneth.thomas22@va.gov

Hampton VAMC Erika Congress, B.B.A., R.T.(R)(CT)(ARRT) Administrative Officer U.S. Department of Veterans Affairs Hampton VA Medical Center

(757) 722-9961 ext. 3517 Erika.congress@va.gov

Salem VAMC Sara “Beth” Asbury Acting Administrative Officer U.S. Department of Veteran Affairs Salem VA Medical Center

(540) 982-2463 ext. 2271 Sara.asbury@va.gov

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract.

Primary: _________________________________

Alternate: ________________________________

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. INCENTIVES/DEDUCTS

The Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards (Inclusion of any monetary incentives requires approval through the Department’s Senior Procurement Executive (SPE).

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. 100% surveillance: Action required via daily reporting.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. 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. Customer complaint data will be obtained via Customer feedback and will be compiled weekly and reviewed by Service Chief. Any validated complaints against the Contractor which are not resolved within seven business days will be further investigated.

d. RANDOM SAMPLING. Patient treatment files will be quarterly randomly and or periodically selected for review. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

The table below is a sample that can be tailored – note that the table must identify where in the PWS the standards are found for monitoring performance. Check the MSO Customer Resource Center for approved mandatory QASPs.

7. PERFORMANCE MEASURES

Requirement

Method Met AQL/DID NOT MEET AQL-CPAR RATING/ADD COMMENTS

100%

Positive contractor performance evaluation.

Did Not Meet AQL:

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

100%

Positive contractor performance evaluation.

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

100%

Positive contractor performance evaluation.

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

100%

Positive contractor performance evaluation.

Did Not Meet AQL:

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

Positive contractor performance evaluation.

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

100%

Positive contractor performance evaluation.

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

98%

Positive contractor performance evaluation.

Did Not Meet AQL:

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

95%

Random inspection, complaints from Radiologists Meet AQL:

Positive contractor performance evaluation.

Did Not Meet AQL:

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

Radiation Safety

95%

Positive contractor performance evaluation.

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

Par 3&10 100%

Positive contractor performance evaluation.

1ST Offense = written notice to the contractor to correct the deficiency. Subsequent offenses = other than positive contractor evaluation

8. CPAR 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 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).

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).

9. 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

REPORT (CPAR).

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

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