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

D.1 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

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. In addition, the QASP should recognize that unforeseen and uncontrollable situations may occur.

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. Updates shall ensure that the QASP remains a valid, useful, and enforceable document. 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 Contract Specialist: Danelle Wassink Network Contracting Office 2 76 Veterans Avenue Bath, NY 14810-0810 Phone: 607-664-4783 Email: Danelle.Wassink@va.gov

• Assigned Contracting Officer: Jadwiga Kustra Network Contracting Office 2 130 W Kingsbridge Road Bronx, NY 10468 Phone: 718-584-9000 X5267 Email: Jadwiga.Kustra@va.gov mailto:Danelle.Wassink@va.gov mailto:Jadwiga.Kustra@va.gov

• Organization or Agency: U.S. Department of Veterans Affairs

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(s): Chari Mayer Administrative Officer, Surgical Service Syracuse VA Medical Center 800 Irving Avenue Syracuse, NY 13210 Phone: (315) 425-2640 Email: Chari.Mayer@va.gov

• Organization or Agency: U.S. Department of Veterans Affairs

3. CONTRACTOR REPRESENTATIVES

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

a. Primary –

b. 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.

To be paid the full rate in the price schedule, the Contractor must provide services as required in the entire contract and to meet or exceed the acceptable quality level outlined in this section/sub-sections. If any portion of the requirement is not met and/or the acceptable quality level in any of the elements in this section/subsection are not maintained, the Contractor will be notified by the contracting officer for response outlining the Contractor’s proposed remedy. The Government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming services per FAR 52.212-1.

Performance standards define desired services. The Government performs surveillance to determine the level of Contractor performance to these standards.

The performance measures 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 method listed below in the administration of this QASP.

• DIRECT OBSERVATION. 100% surveillance: VA Surgical Service staff will observe on an ongoing basis the contractor performance to ensure patient satisfaction and patient access standards are maintained. Deviations from performance requirements will be documented as they occur and reported to the COR for review.

• PERIODIC INSPECTION. Evaluates outcomes on a periodic basis. Inspections may be scheduled daily, weekly, monthly, quarterly, annually, or unscheduled, as required.

• VALIDATED USER/CUSTOMER COMPLAINTS. Relies on the patient to identify deficiencies. Complaints are then investigated and validated.

• RANDOM SAMPLING. Random sampling shall be done on a quarterly basis or more frequently as necessary if problems should be discovered. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.

6. PERFORMANCE MEASURES

Measure ID Performance Requirement Standard

Acceptable Quality Level

Surveillance Method

Met AQL/ Did Not Meet

AQL

Billing 1 Contractor shall submit invoices in a timely manner

Contractor shall submit invoices for review within two weeks of the end of the month for which services are being billed

95% Random Sampling of invoice submissions.

COR shall ensure that invoices are received timely.

Patient Access/ Timeliness

2 Contractor personnel shall be on time.

Contractor personnel will be present and prepared to start assigned shift on or before the scheduled start time.

98% Periodic Sampling of Time and Attendance Sheets; Direct observation by nursing management staff.

Patient Safety

3 Patient safety incidents shall be reported using Patient Safety Report. All incidents reported immediately (within 24 hours.)

All patient safety incidents are reported using Patient Safety Report within 24 hours of incident.

100% Direct Observation

Entry of Medical Data

4 Timely entry of all applicable medical record data

All applicable medical data entered into the VISTA and/or CPRS package

95% Periodic review of the timeliness of documentation will be monitored on a weekly basis

(i.e. progress notes, encounters, etc.)

Contractor shall have no unsigned / un-cosigned documents requiring signature that exceeds more than 3 days within 3 days or less of patients encounter by the designated person in the department in which the contractor works

Patient Satisfaction

5 Patient Complaints

Contractor personnel shall have no more than 1 substantiated patient complaint per quarter

100% Validated user/customer complaint

Mandatory Training

6 All Contractor personnel shall complete all mandatory training on time per VA policy.

All training is up to date at all times for all contractor personnel.

100% Periodic Sampling of training records.

7. RATING STANDARDS: Ratings shall be based on exceeding, meeting, or not meeting performance standards.

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 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. RATINGS: Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used:

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.

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.

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.

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.

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.

10. 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 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 receipt the Contractor must 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. A sample CDR is below:

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS

DISCREPANCY

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

5. DATES

a. CDR PREPARED b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (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, CORRECTIVE ACTION 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. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

7. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE