D.2 QASP.pdf

D.1 Quality Assurance Surveillance Plan (QASP)

RFP#: 36C25720R0099

Description: Registered Nursing Service Staffing Contract

The Contractor will be evaluated in accordance with the following 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. 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. 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: Diondra Coleman/ Diondra.coleman@va.com

b. Administrative Contracting Officer (ACO): An individual responsible for day-to-day contract management in accordance with FAR Part 42 for an assigned contract workload. Contract workload is defined as one or more contract(s) for management on a continuing basis.

Assigned Administrative Contracting Officer: Diondra Coleman/

Diondra.coleman@va.com

c. Contracting Officer’s Technical Representative (COTR) - The COTR is responsible for technical administration of the contract and shall assure proper Government surveillance of

The Contractor’s performance. The COTR shall keep a quality assurance file. The COTR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: Samuel Jones, Administrative Officer

3. CONTRACTOR REPRESENTATIVES

The following employees of The Contractor serve as The Contractor (Affiliate)’s program manager for this contract.

Program Manager – To be completed at award Other Contractor Personnel – To be completed at award; if any (name and title)

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if The Contractor exceeds, meets or does not meet 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 Acceptable Quality Level (AQL).

5. INCENTIVES

The Government shall use past performance as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COTR shall use the surveillance methods listed below in the administration of this QASP. See previous comments for penalties assessed if you intend to include a disincentive as well as an incentive

Measure PWS

Reference

Performance

Requirement

Standard Acceptable

Quality

Level

Surveillance

Method

Key Personnel B.1.10 Provide required medical service as specified in the requirements.

Qualified personnel are available and in location as needed to properly perform tasks as specified.

100% Random

Inspection, Time and

Attendance

Sheets, Quality

Assurance

Reports

Patient Safety B.1.8 Patient safety incidents must be reported using

All incidents reported immediately (within

24 hours.)

100% Direct

Observation

Patient Safety

Report.

Maintains licensing, registration, and certifications

B.1.11 Updated Licensing, registration and certifications will be provided as they are renewed.

Licensing and registration information kept current.

Contract

Provider records will be kept 100% up-to-date

Periodic

Sampling and

Random

Sampling

Mandatory Training B.1.14 Contractor completes all mandatory required training

Contractor will complete all required training per VAMC policy

100% Contractor to provide documented evidence

Privacy, Confidentiality and

HIPPA

B.1.15 Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPPA and complies with all standards

Zero breaches of privacy or confidentiality

100%

Contractor to provide evidence of annual training required by VAMC, reports violations per policy

Timely Invoicing B.1.18 Within 30 days of the end of each month services were provided, as described above, the vendor shall provide itemized invoicing

All itemized invoices provided within 30 days of end of each month services delivered

100% Inspection

Other performance evaluation factors will be monitored that are not quantified by numerical measurements which include: no inappropriate prescriptions; patient customer service comments; provider and Contractor relationship with hospital staff/government contracting personnel; compliance with hospital policy and procedures.

a. DIRECT OBSERVATION. 100% surveillance

b. PERIODIC INSPECTION. Inspections scheduled annually. 10 randomly selected patient files per 12-month contract period.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Customer complaint data is compiled quarterly and reviewed by Service Chief – any validated complaints against a

Contractor that are not resolved within the required seven-day period will be further investigated.

d. RANDOM SAMPLING. Patient treatment files to be reviewed will be randomly selected and cover the period of service.

e. Verification and/or documentation provided by Contractor (Affiliate).

7. 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 significantly exceeds contract requirements to the Government’s benefit.

Satisfactory: Performance meets contractual requirements.

Unsatisfactory: Performance does not meet contractual requirements.

8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

b. UNACCEPTABLE PERFORMANCE

When unacceptable performance occurs, the COTR shall inform The Contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case, the COTR shall document the discussion and place it in the COTR file.

When the COTR determines formal written communication is required, the COTR shall prepare a Contract Discrepancy Report (CDR) and present it to the Contractor's program manager.

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 has to present this corrective action plan to the COTR. The

Government shall review the Contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. Example of CDR to be used.

Contract Discrepancy Report (CDR)

1. Contract Number:

2. TO: (Contractor Task Manager or on-site representative)

3. FROM:

4. DATE AND TIME OBSERVED DISCREPANCY:

5. DISCREPANCY OR PROBLEM:

<Describe in detail. Identify any attachments.>

6. Corrective action plan:

A written corrective action plan is required. The written Corrective Action Plan will be provided to the undersigned not later than 3 days after receipt of this CDR.

Prepared by:

Signature – Contracting Officer’s Representative Date

Received by:

Signature - Contractor Task Manager or on-site representative Date

< The COR may initiate a CDR at any time, including whenever the number of monthly recorded defects for a performance standard exceeds the allowable number of defects;

anytime unacceptable performance is determined critical in nature and requires formal corrective action; and whenever an unfavorable trend is detected in Contractor performance.>

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement

During contract performance, the COTR will determine the necessary frequency of measurement and periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COTR shall meet contractor semi-annually to assess performance and shall provide a written assessment.

Quality factors that VA may consider when monitoring quality of care may include, but are not limited to: Timeliness of Service, Quality of Care, and Patient Safety.

QUALITY ASSURANCE MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD: _____________________________________________________

SURVEILLANCE METHOD (Check):

Direct Observation Periodic Inspection Validated User/Customer Complaints

Random Sampling

LEVEL OF SURVEILLANCE (Check):

Monthly Quarterly As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: ______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (Check): Acceptable Performance

Unacceptable Performance

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________

DATE: _________________