D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP).docx
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- Solicitation number
- 36C24626Q0496
About this file
This is a Quality Assurance Surveillance Plan (QASP) for off-site tele-radiology services provided to the Asheville VA Medical Center under contract 36C24626Q0496. The QASP establishes systematic methods for evaluating contractor performance across six key performance standards: timeliness of reports, provider quality performance, qualifications of key personnel, scope of practice/privileging, maintenance of licensing and certifications, and privacy/confidentiality compliance. All contract physicians must be board-certified in radiology per American College of Radiology (ACR) standards, and 100% compliance is required across all metrics with no acceptable deviations for qualifications, licensing, and privileging requirements. Reports must be delivered with 98% timeliness compliance, clinical care must meet 100% of clinical standards, and zero breaches of privacy or HIPAA compliance are tolerated.
The surveillance plan identifies David E. Smith as the Contracting Officer and Kenneth L. Thomas as the Contracting Officer's Representative responsible for oversight and administration. The COR will conduct quarterly progress reports using multiple surveillance methods including direct observation, periodic inspections, random sampling, and validated user complaints. Performance will be rated using a five-tier CPAR (Contractor Performance Assessment Report) system ranging from Exceptional to Unsatisfactory. Non-compliance triggers a corrective action process beginning with written notice; first offenses result in written notice to correct deficiencies while subsequent offenses result in less than positive contractor evaluations. Any performance deficiencies require documented Contract Reports with contractor acknowledgment and corrective action plans subject to Government approval and closeout.
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SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS
D.1 QASP Off-Site Tele-Radiology
Quality Assurance Surveillance Plan (QASP)
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: David E. Smith | CS: Kathyann Chase-Moore
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: Kenneth L. Thomas / (828) 298-7911 Ext.15238 / kenneth.thomas22@va.gov Organization or Agency: Asheville VAMC
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. 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:
b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.
c. VALIDATED USER/CUSTOMER COMPLAINTS.
d. RANDOM SAMPLING.
e. Verification and/or documentation provided by Contractor.
36C24626Q0496
6. QASP PERFORMANCE REPORT DATE: ___________________
| Measures |
| PWS |
Ref
Performance Requirement
| Standard |
| Acceptable Quality Level |
| Surveillance |
Method Met AQL/DID NOT MEET AQL-
CPAR RATING/ADD COMMENTS
| Timeliness of Reports |
| 4.7.3.1 |
| Prompt delivery (timeliness) of interpretations and return for routine/stat/immediate |
| 100% of reports are delivered per the requirements of the PWS |
| 98% |
| Periodic Inspection |
| 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
| Provider Quality Performance |
| 4.7.3.2 |
| All contract physician(s) shall perform in accordance with clinical standards |
| 100% of care provided within clinical standards of care |
| 100% |
| OPPE |
| 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
| Qualifications of Key Personnel |
| 4.7.3.3 |
| All contract physician(s) shall have current board certified in accordance with ACR Standards for Radiology. |
| All (100%) contract physician(s) are board certified. |
| 100% No deviations accepted. |
| Periodic Inspection |
| 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
| 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/privileges 100% of the time. |
| All (100%) contract physician(s) perform within their scope of practice/privileges 100% of the time. No deviations accepted. |
| Periodic Inspection / Random Sampling of records. |
| 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
| Maintains licensing, registration, and certification |
| 4.7.3.5 |
| 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. |
| 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. No acceptable deviation. |
| Periodic Inspection |
| 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
| Privacy, Confidentiality and HIPAA |
| 4.7.3.6 |
| 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 physician(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA |
| 100% compliance; no deviations. |
| Periodic Inspection Contractor shall provide evidence of annual training required by VAMC, reports violations per VA Handbook 6500.6. |
| 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
7. 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:
| 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).
8. 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, Kenneth L. Thomas DATE
SIGNED:
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 |
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
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