Dentist_QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

DENTIST

(PERSONAL SERVICES)

AT

42 MEDICAL GROUP

MAXWELL AFB, AL

MAY 2013

Note: This Quality Assurance Surveillance Plan may be made part of the solicitation, but shall not be part of the resulting contract.

1. PURPOSE.

This quality assurance surveillance plan (QASP) has been developed to provide an effective and systematic method to assess contractor services as required by the terms and conditions of the contract. This quality assurance surveillance plan implements the requirements of Federal Acquisition Regulation Subpart 37.6 and 46.4. , Performance Based Acquisitions and Government Quality Assurance, with respect to the Government’s quality assurance requirements. This QASP will be used by the Multi-functional team (MFT) and the Contracting Officer Representative (COR) to ensure contractor compliance and progress at meeting mission objectives on the Dentist Contract.

2. OBJECTIVE.

This QASP is designed to provide the MFT a vehicle to ensure delivery of the desired mission support services within cost and on schedule. The QASP will also provide the COR an effective systematic assessment method for each item listed in the Performance Work Statement (PWS), specifically on the Service Summary (SS). The premise of commercial contracting is for the Contractor to assume responsibility for the work they produce. The government will also rely on the Contractor’s submitted Quality Control Plan (if applicable) for ensuring contractual requirements are met.

3. RESULTS.

The results in managing this acquisition through this QASP, is to provide team Maxwell with the Dentist contract services that are acceptable and timely while protecting Government resources.

4. KEY MANAGEMENT DUTIES AND RESPONSIBILITIES.

4.1. Contracting Squadron Commander (CSC) and/or Director of Business Operations (DBO):

Serves as the Business Advisor to senior leadership; developing and implementing acquisition strategies for services acquisitions; providing oversight of the MFT in planning, assessing contractor performance, and managing the acquisition throughout the life of the requirement IAW the FAR, DFARS, and AFFARS.

4.2. Functional Commander/ Functional Director (FC/FD):

Review contractor performance documentation, prepared by the COR on a regular basis to ensure performance is compatible with contract and mission objectives. The FC/FD is also responsible for identifying mission essential services and developing the necessary documents IAW DoDI 3020.37, Continuation of Essential DoD Contractor Services During Crisis.

4.3. Multi-functional Team (MFT):

Has overall responsibility for developing the PWS and the QASP and ensuring they satisfy mission requirements, are performance-based, foster innovation, and define metrics.

5. MULTI-FUNCTIONAL TEAM ROLES & RESPONSIBILITIES.

5.1. Quality Assurance Program Coordinator (QAPC):

Develops, manages and implements the Maxwell AFB Quality Assurance Program; supports the MFT in development of the contract requirements, ensuring requirements are clearly stated and enforceable; aids in development of the SS and QASP and provides training to all COR supervisors, COR’s, and others that interact with this contract as needed.

5.2. Contracting Officer (CO):

Has overall responsibility for overseeing the contractor’s performance. The CO will also be responsible for the day-to-day monitoring of the contractors’ performance in the areas of contract compliance, contract administration, cost control, and property control; and resolving all differences between the COR version and the contractor’s version of events. The CO is the only person with the authority to direct the contractor in the performance of their duties under the contract and to make interpretations of and changes to the contract. The CO will facilitate MFT meetings. The CO determines if a COR; or multiple or alternate CORs are required to assist in technical monitoring and administration of a contract. The CO is also responsible for informing the contractor of the names, duties, and limitations of authority for all COR assigned to the contract. The CO also delegates’ authority for inspection and acceptance to the COR.

5.3. Contract Administrator (CA):

Is the focal point for issues regarding the contract; prepares and processes modifications to the contract, assists the CO in ensuring contractor performance meets contract standards; records and transcribes minutes for meetings.

5.4. Contracting Officer Representative (COR):

Responsible for monitoring, assessing, recording and reporting on contractor compliance with the terms and conditions of the contract. These individuals will have primary responsibility for completing quality assurance monitoring forms that will be used to document the inspection and evaluation of the contractor’s performance. The COR will maintain assessment documentation, notify the CO of any significant performance deficiencies and recommend improvements to the QASP and PWS throughout the life of the acquisition.

5.6. Contractor:

Becomes part of the MFT after contract award. Is the service provider and shall ensure that a government acceptable quality control system is provided and maintained. The contractor is required to provide all services identified in the PWS not just those identified in the SS. The contractor will also provide support to Senior Leadership as required (e.g., performance metrics, briefings).

6. COR APPOINTMENT AND TRAINING:

6.1. A primary and alternate COR shall be nominated and appointed for this contract. The COR Supervisor is the designating authority for the nomination of COR. The CO is the designating authority for appointment of COR.

6.2. Each COR will be available to accomplish the required training as designated by AFFARS Mandatory Practice (MP) 5301.602-2(d) based on the type of requirement as determined by the CO: (please see the above MP for specific training requirements)

6.2.1. The CO has determined that this requirement is a Type C: Unique requirements that necessitate a professional license, higher education, or specialized training.

6.3. Each COR will be available to receive Annual Refresher training provided by the QAPC.

7. PERFORMANCE OBJECTIVES.

Government assessment will be conducted by inspections of the CRITICAL performance objectives of the PWS.

COR documentation of contractor performance must be accomplished as the observation is completed, in accordance with the Services Summary (section 8), thus preventing loss of information. All documentation generated in the performance of this plan will be marked, “For Official Use Only”.

8. SERVICES SUMMARY (SS) WITH ASSESSMENT METHODS INCLUDED

Performance Objective PWS Para Performance

Threshold Method of Assessment

Work Requirement

4.1.1. thru

4.1.18.

90% Weekly Periodic Assessment/Inspection

Arrange for Replacement Staff 1.2.3. 95% Compliance Periodic Assessment/Inspection

Patient Sensitivity 4.1.9. 95% Compliance Customer Complaint/Feedback

Complete paper and electronic dental records within 72 hours of the patient encounter

4.1.17. 95% Compliance Periodic Assessment/Inspection

9. METHODS OF ASSESSMENT APPLICABLE TO THIS CONTRACT.

9.1 Periodic Assessment/Inspection

Periodic assessment/inspection is the type of assessment that is based upon selecting samples for evaluation on other than 100% inspection or on a statistically random basis. Selecting this tool to determine a contractor’s compliance to contract requirements can be quite effective and allows COR to establish confidence or lack of confidence in the contractor while not consuming a significant amount of time. An example of periodic assessment/inspection is weekly inspections when COR choose the location and time in other than a statistically random basis.

9.2 Random Sampling - N/A

9.3 Customer Complaint/Feedback

Customer complaints/feedback and comments can be a way to validate information obtained through other sources.

They may also provide a basis for an incentive payment to the contractor. However, customer complaints/feedbacks are likely to be subjective and may not always relate to actual requirements of the contract; therefore, they need to be fully validated. Customer complaints/feedback are useful in those areas that do not lend themselves to other types of assessment.

COR should furnish written instructions and customer training to each organization receiving the contractor’s service. Instructions and training should cover the format and content of the program and service to be surveyed; the action that may be expected from COR, contract administrator, and CO as a result of the complaints, and the limitations on the customers in dealing with contractor personnel. Instructions should also clearly explain what service/level of service the customers should expect from the contractor, based on what is in the contract.

COR are the point of contact and must collect all customer complaints/feedback. All complaints/feedbacks and any resulting resolution of such complaints/feedback must be documented. A locally developed form may be used for this purpose. Customer complaint forms/feedback becomes a permanent part of the COR assessment records.

Customer complaints/feedback may be used to assess performance in any area. Valid customer complaints/feedbacks may be used as the basis for adverse action against the contractor. In such cases, the Inspection of Services Clause becomes the basis for the CO’s actions. Again, the preferred method of correcting the defect is re-performance of the action or service at no additional cost.

10. ASSESSMENT PROCEDURES

10.1 Assessment Schedule.

10.1.1 The COR will develop an assessment schedule, based on the requirements of this QASP. A locally devised form may be used. The schedule shall be completed no later than seven (7) calendar days before the beginning of the period it covers. Copies of the assessment schedule shall be provided to the CO before the start of the assessment period. Assessment schedules, when completed, shall be marked “For Official Use Only”, and shall not be shown to the contractor.

10.1.2 Changes to the assessment schedule shall be posted promptly. Copies of the changed schedule shall be sent to the CO. The COR shall document the reason(s) for changes of the assessment schedule, and maintain the documentation in the COR files with the corresponding changed assessment schedule.

10.1.3 In addition, if anytime during the month a performance threshold is exceeded, the government representative shall immediately notify the contracting office in writing of the finding. The CO shall then take appropriate action in accordance with the Inspection/Acceptance clause.

10.2 Assessment of SS Items.

10.2.1 It is essential that the COR conduct assessments in accordance with projected assessment schedule for an effective quality assurance program. Mission requirements may require deviations from the assessment schedule;

however, assessments should be performed as close to the schedule as is practicable. COR shall document assessments as they are conducted.

10.2.2 The COR shall conduct assessment of the contractor’s performance by determining whether or not the performance meets the standards contained in the contract, the PWS and the SS items.

10.2.3 Assessment documentation shall include as a minimum, the date, time, and location the assessment was conducted, results of the assessment (acceptable or unacceptable), PWS paragraph number referencing the requirement, a short description of the requirement being surveyed, applicable remarks, signature of COR conducting the assessment. When COR determine that contractor performance is unacceptable, the specific reason for the unacceptable performance shall be recorded on the COR assessment documentation.

10.3 Assessment of non-SS Items. The Government has the right to inspect all services called for by the contract, to the extent practicable at all times and places during the term of the contract. Therefore, COR have the right to conduct assessment for SS items and non-SS items as well. When the COR identifies unacceptable performance on non-SS items, the COR shall follow the procedures in section 11. of this QASP, entitled Unacceptable Performance.

11. UNACCEPTABLE PERFORMANCE

11.1 Unacceptable Performance

11.1.1 When the contractor’s performance is deemed unacceptable, COR will determine the cause of the unacceptable performance. If any Government action, or lack of action, caused or contributed to the unacceptable performance, the unacceptable performance will not be counted against the contractor. The COR will take action to ensure Government action, or lack of action, does not interfere with the Contractor’s performance in the future. The COR will completely document the circumstances.

11.1.2 When the unacceptable performance is not the result of Government action, or lack of action, COR shall promptly notify the contractor and issues a Corrective Action Report (CAR) to the contractor to assure corrective action is taken. By initialing and dating the CAR, the contractor is acknowledging that she/he has been informed of the unacceptable performance and is not agreeing with the performance assessment. COR shall direct the contractor to re-perform the service, if possible, without additional cost to the Government. If the contractor challenges the validity of the COR unacceptable assessment finding, and the COR and contractor cannot come to an agreement, the matter shall be referred to the CO for resolution. The contractor shall be required to return all completed CAR’s to the COR no later than the suspense date indicated on the CAR.

11.1.3 Unacceptable performance re-performed by the service provider shall still count as unacceptable performance.

11.1.4 The COR shall maintain a CAR log of all CAR’s issued to the Contractor (a locally devised form may be used). The CAR log shall contain the CAR number, date issued, contractor, description of unacceptable performance, suspense date, and closeout date. All CAR’s and CAR logs shall be maintained by the COR for the life of the contract.

11.2 Contracting Officer (CO) Notification.

11.2.1 Major Finding. If at any time COR identify a condition as having a significant adverse effect on the quality of the activity, such as those stated below, COR will document their findings and notify the CO immediately in writing. E-mail is acceptable.

11.2.1.1 Contractor failure to meet a Performance Threshold.

11.2.1.2 Failure to provide adequate corrective action to preclude reoccurrence of Government identified findings.

11.2.1.3 Failure to provide corrective action to deficiencies identified by the contractor within a prescribed suspense period.

11.2.1.4 Any failure to adhere to security regulations that results in a security incident.

11.2.2 Minor Finding. A departure from established standards having little bearing on the service provided. When COR identify a minor finding, the COR shall document the findings, but is not required to notify the CO. However, if the same minor finding is repeatedly identified, it may be an indication that a major finding is occurring or has occurred because the Contractor has not taken proper steps to prevent recurrence. In this case, the COR shall notify the CO in writing.

11.3 Remedies for Unacceptable Performance.

11.3.1 In accordance with the contract Inspection of Services clause, if any of the services do not conform to contract requirements, the Government may require the Contractor to perform the services again in conformity, at no increase in contract amount. This includes but is not limited to termination of Contractor personnel and recruitment of substitute personnel that are equally qualified within established timeframes. When the defects in services cannot be corrected by re-performance, the Government may:

11.3.1.1 Require the Contractor to take necessary action to ensure that future performance conforms to contract requirements; and

11.3.1.2 Reduce the contract price to reflect the reduced value of the services performed. This may include a reduction in the number of paid hours to reflect the total non-performance period.

11.3.2 If the Contractor fails to promptly perform the services again or to take the necessary action to ensure future performance in conformity with contract requirements, the Government may:

11.3.2.1 By contract or otherwise, perform the services and charge to the Contractor any cost incurred by the Government that is directly related to the performance of such service; or

11.3.2.2 Decrement invoice as stated in the PWS related to performance; or

11.3.2.3 Terminate the contract.

12. CONTRACT MANAGER NOTIFICATION.

The COR will ensure that the contract manager/project manager is informed of contract performance status. The contract manager/project manager should also be informed of any contract discrepancies noted during COR assessment.

13. DISCREPANCY REPORTING.

The COR will notify the contract manager/project manager of any discrepancies noted during the COR inspections.

This notification is for discrepancy correction only and does not indicate concurrence of the discrepancy by the contractor. The COR will also notify the CA of all discrepancies noted during the assessment. The frequency and method of notification to the CA will be provided to the COR during CO led training.

14. CERTIFICATION OF SERVICES.

14.1 Certification of services is performed by COR via Wide Area Work Flow (WAWF) system. At the end of each billing period, service provider inputs invoice information in the WAWF system. WAWF automatically notifies appropriate COR via email of pending invoice. COR accesses WAWF and verifies accuracy of service provider’s data. If data is correct, COR certifies invoice and payment is conducted by Defense Finance Accounting System (DFAS). If COR encounters errors in service provider’s invoice, COR consults with on site manager to mutually rectify data. If service provider disagrees with COR, issue is forwarded to the CO for resolution.

14.2 COR are responsible for obtaining, scheduling, and completing WAWF training from the base Accounting and Finance Office.

15. CONTRACT MANAGEMENT.

15.1 The multi-functional team shall utilize the following approaches, methods, and tools to manage the contract upon award:

15.2 COR shall conduct, document, track, and analyze contractor performance via regularly scheduled assessments.

The assessment results shall be maintained as Past Performance Information and utilized to prepare and support annual Contractor Performance Assessment Report System (CPARS) reporting if applicable. Assessment results, along with the contractor’s submittals will be used to develop metrics to track Contractor’s overall compliance with contract terms and conditions.

15.3 The MFT team shall conduct periodic progress meetings, at least annually, to review the contractor’s performance. At these meetings the CO will apprise the contractor of how the Government views the contractor’s performance and the contractor will apprise the Government of problems, if any, being experienced. The contractor will also notify the CO, in writing, of any work being performed, if any, that the contractor considers over and above the requirements of the contract. Appropriate action shall be taken to resolve any outstanding issues.

16. CONTRACTOR RATING.

Contractor Performance Assessment Rating (CPAR) is applicable to all service contracts valued over $1,000,000 and medical contracts $150,000. Guidance on CPARS is available from the Department of the Air Force CPARS Guide and the 42 CONS CPARS focal points.

17. REVIEW & ACCEPTANCE.

The following Multi-Functional Team member signatures indicate their review and acceptance of the Quality Assurance Surveillance Plan (QASP) for Dentist service. These signatures indicate coordination on this QASP at the time of development. These team members are not the only individuals on the MFT but are the individuals that will have continual interface with this contract. No further Multi-Functional Team coordination is needed unless the intent of the QASP is changed.

Print Name: Print Name:

Contracting Officer Contract Administrator

Print Name: Print Name:

QAPC COR (Primary)

Print Name:

COR (Alternate)

ATTACHMENTS

CUSTOMER COMPLAINT RECORD

DATE/TIME OF COMPLAINT

SOURCE OF COMPLAINT

ORGANIZATION

BUILDING

NUMBER

INDIVIDUAL

PHONE NUMBER

NATURE OF COMPLAINT

CONTRACT REFERENCE

VALIDATION

DATE/TIME CONTRACTOR INFORMED OF COMPLAINT

ACTION TAKEN BY CONTRACTOR

RECEIVED/VALIDATED BY

Customer Complaint Record Template, Feb 05 (SAF/AQCP)

COMPLAINANT - 1

COR - 2

CONTRACTOR - 3

Customer Complaint Record Template, Feb 05 (SAF/AQCP) CONTRACT

ADMINISTRATOR - 4

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY MAJOR MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. CONTRACTING OFFICER REPRESENTATIVE (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. COR DETERMINATION

ACCEPTED REJECTED

12. CLOSE DATE

CORRECTIVE ACTION REPORT (CAR)

Continuation Sheet

(Number to correspond with applicable Item Number on reverse)

Corrective Action Report (CAR) Instructions

Block 1. Enter Contractor Name.

Block 2. Enter Contract Number.

Block 3. Enter Contract Name or Type of Services.

Block 4. Enter Functional Area of the Contract.

Block 5. Enter the assigned suspense date given the contractor to provide a response to the CAR. A date must be entered for a Major CAR. A date is optional at the discretion of the Contracting Officer Representative (COR) initiating the CAR if the finding is Minor.

Block 6. All CARs will be tracked with a Control Number. The functional commander/functional director is the Issuing Authority for his/her contract Quality Assurance Personnel (CORs) generating CARs. By providing the control number to the COR originating the CAR, the Issuing Authority demonstrates concurrence with the finding.

The control number will be made up of the first two letters of the name of the site or contract, the last two digits of the calendar year, and a three digit number starting with 001 and progressing upward throughout the calendar year (e.g., WP04-001).

Block 7.

1. Check the block that indicates whether the identified deficiency is assigned as a Major or Minor finding. See Quality Assurance Surveillance Plan (QASP), paragraph 11.2, for the definitions of Major and Minor findings and associated explanations.

2. Finding: Clearly state the details of the finding followed by a reference to the stated contractual requirement. The reference must state the portion of the contract, part, section, paragraph and subparagraph and must make a complete brief quotation of the contract reference.

3. State the impact that the finding has or could have on the accomplishment of the mission that the contract provides.

4. When determining how long to give the contractor to respond to the identified finding, the normal is 10 working days. The suspense date should reflect this unless the finding requires a greater amount of time to come to solution.

Major findings require a contractor response. Minor findings may require a contractor response at the discretion of the COR initiating the CAR and/or the Issuing Authority.

Blocks 8 and 9. Contract CORs initiating a CAR must sign in Block 8 and the Issuing Authority signs in Block 9.

Each annotates the date at the time of signature.

Block 10. Upon review of the contractor’s reply, the originator of the CAR will enter comments regarding acceptance or rejection of the contractor’s response. This block may also contain any comments regarding follow-on inspections conducted or needed at a later date to validate that the finding has not reoccurred.

Block 11. The COR selects Accept or Reject after reviewing the contractor’s response.

Block 12. The COR enters a close date after advising the Issuing Authority that the contractor’s response is acceptable and the Issuing Authority concurs. The Issuing Authority will then forward the closed CAR to the contractor and report accordingly in the monthly Certificate of Service (COS) or other applicable contracting officer services report. This routing remains the same if the contractor response is unacceptable and the CAR remains open until an acceptable response is received except that the Issuing Authority forwards the open CAR back to the contractor for additional information.

Continuation Sheet. The Continuation Sheet is to be used to expand on any information that will not fit in the applicable numbered block.

QUALITY CONTROL CHECKLIST

PAGE OF PAGES

TITLE: Pharmacist OPR CONTROL NO DATE

REQUIREMENTS YES NO REMARKS

SS-1. Work Requirement Reference paragraph 4.1.1. thru 4.1.18.

SS-2. Arrange for Replacement Staff Reference paragraph 1.2.3.

SS-3. Patient Sensitivity Reference paragraph 4.1.9.

SS-4. Complete paper and electronic dental records Within 72 hours of the patient encounter Reference paragraph 4.1.17.