3._QASP_-_Mobile_MRI.pdf

THIS DOCUMENT IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND

WILL NOT BE INCLUDED AS PART OF THE CONTRACT AWARD.

QUALITY ASSURANCE

SURVEILLANCE PLAN (QASP)

FOR

MOBILE MAGNETIC RESONANCE IMAGING SERVICES

REVIEWED BY _______________________________________________________________

1LT. SARAH F. MANHERTZ, Functional Commander

MARTY W. HAMMONDS, GS-11, Quality Assurance Program Coordinator

CARRIE E. MARTIN, GS-12, Contracting Officer

QUALITY ASSURANCE SURVIELLANCE PLAN

TABLE OF CONTENTS

Section Title Page

A Purpose 3

B Roles and Responsibilities of the Multi-Functional Team 4

C Services Summary Table 7

D Surveillance Procedures 9

E Surveillance of Non-Services Summary Items 11

F Unacceptable Performance 12

G Certification/Acceptance of Services 14

H Contract Management 15

I Sample FRED Surveillance Form 16

SECTION A

PURPOSE

This Quality Assurance Surveillance Plan (QASP) has been developed to provide Contracting Officer (CO), Contracting Officer’s Representative (COR), and Functional Requirements Evaluator Designee (FRED) with an effective and systematic method of evaluating contractor-provided services as required by the terms and conditions of the contract. This surveillance plan was developed in accordance with (IAW) Air Force Acquisition Circular (AFAC) 2011-0421 and implements the requirements of AFI 41- 209, Medical Logistics Support.

1. This QASP prescribes how the Government will assess contractor performance and manage the contract. The contractor, not the Government, is responsible for contract management and quality control. The Government’s objective in having the service provided is to support the military health care system by providing quality health care workers to treat patients within the realm of MRI Services. The result the Multi-Functional Team (MFT) is striving to achieve in managing the acquisition is to assure personnel are adequately recruited, qualified to work, and are available to provide services according to Air Force needs. A contract to provide the service is the best means of achieving that objective and result.

2. This QASP describes the method(s) used to evaluate contractor-provided services rather than the details of how the contractor accomplishes the work. The COR/ FRED shall use monthly surveillance as a means to evaluate contractor’s performance. The surveillance procedures identified in this surveillance plan, in concert with the contractor’s quality control procedures, will assure the Government of acceptable contractor performance.

3. The role of Government quality assurance is to ensure contract standards are achieved. In conducting surveillance, COR/ FRED are to be objective, fair, and consistent in evaluating contractor performance against the performance standards.

4. This QASP is a living document and shall be revised or modified by members of the Multi-Functional

Team as circumstances warrant throughout the life of the contract to ensure adequate oversight of contractor performance is maintained.

SECTION B

ROLES AND RESPONSIBILITIES OF THE MULTI-FUNCTIONAL TEAM

1. Contracting Squadron Commander shall:

a. Ensure a Quality Assurance Program Coordinator (QAPC) is appointed to integrate the quality contract requirements into the quality assurance program; act as the liaison between the contracting and functional organizations; and provide training and record keeping in accordance with (IAW) MP5301.602-2(d).

b. Provide oversight for requirements in planning and assessing contractor performance.

c. Ensure personnel on the MFT receive the appropriate level of training to meet local needs.

2. Contracting Officer (CO)/Contract Administrator (CA) shall:

a. Ensure open communication is maintained between all parties, pre- and post-award.

b. Appoint COR via the COR Designation Memorandum and forward a copy of the fully executed

COR Designation Memorandum to the COR, COR Supervisor, and QAPC.

c. Delegate authority for inspection and/or acceptance in accordance with the terms and conditions of the contract.

d. Provide oversight for COR training programs. Ensure contract-specific training is scheduled and provided to the prospective COR.

e. Provide an assessment on COR performance to the COR supervisor as requested and advise the

QAPC of any problems.

f. In cases where COR performance is poor, the CO shall terminate the COR duties and request a COR replacement. The requiring activity must provide a COR replacement to ensure continuous contract monitoring by a qualified individual.

g. Forward a copy of the fully executed Termination of COR Designation Memorandum to the COR, COR Supervisor, and QAPC.

h. Manage contractor performance assessment data, including submitting Contractor Performance

Assessment Reporting System (CPARS) reports.

i. Take appropriate action should unacceptable contract performance occur.

3. Quality Assurance Program Coordinator (QAPC) shall:

a. Train CORs and COR management (e.g. COR Supervisor, Functional Commander) on the contracting requirements associated with the quality assurance program IAW Mandatory Procedures.

b. Support the MFT in the development of contract quality assurance requirements specifically ensuring that requirements are clearly stated and enforceable.

c. Assist the MFT during market research efforts in determining commercial quality assurance practices.

d. Review and coordinate all PWS and QASP.

4. COR Supervisor (e.g., Functional Commander (FC)) shall:

a. Ensure requirements documents developed by the medical treatment facility (MTF) satisfy mission requirements, are performance-based, foster innovations, and define metrics. Assist in preparation of PWS and QASP and obtain CO coordination on the final product.

b. Nominate qualified individuals as Contracting Officer’s Representatives (COR) and have each

Squadron Commander appoint the FREDs for MRI Services to oversee the MTF’s contract service section.

c. Ensure CORs maintain proficiency and evaluate COR’s job performance not less than annually throughout the period of the contract.

d. Ensure all personnel within the functional area who may have contact with contractor employees are aware of the contractual working relationship and the necessity to avoid any conduct that may constitute a real or perceived conflict of interest.

5. Chief COR shall:

a. Be responsible for overseeing the MTF’s contract services section (IAW section 4.38.3.1 of AFI 41-209).

b. Provide information necessary to assess actual or potential personal conflicts of interest and immediately notify the CO if subsequent situations arise.

c. Serve as the MTF’s primary POC to oversee documenting for contractor’s performance information obtained from FRED.

d. Develop technical requirements and the Independent Government Cost Estimate (IGCE) for contract services.

e. Participate, as requested, in requirements definition/pre-award activities.

f. Remain abreast of changes to terms and conditions of the contract resulting from contract modifications.

g. Perform only those duties/responsibilities delegated by the CO in the CO’s Designation Letter.

h. Provide reports on contract performance to the CO. If advised by the CO that reports are inadequate, ensure follow-on reports address issues expected by CO.

i. When advised by the CO or COR management that COR designation will be terminated, ensure reports/records are made available to the CO, COR management, and a successor COR, if one is designated by the CO.

j. Review invoices loaded into Wide Area Workflow (WAWF) for services received, verify that requested payment is correct, and certify acceptance of invoices for payment.

6. Functional Requirements Evaluator Designee (FRED) shall:

a. Develop technical requirements and provides technical assistance to the COR and CO.

b. Evaluate and document the contractor’s performance.

c. Notify the COR of any significant performance deficiencies.

d. Obtain proficiency in surveillance procedures and maintain surveillance documentation.

e. Provide a copy of the surveillance documentation to the COR in the Medical Logistics Office.

f. Recommend improvements to the PWS and QASP throughout the life of the contract.

g. Recommend any changes necessary to the contract, specifications, instructions, or other requirements that will provide more effective operations or eliminate unnecessary costs.

h. Maintain technical competency in the functional area surveyed.

7. Contractor shall:

a. Comply fully with the terms and conditions of the contract such as meeting standards of care, timely responsiveness, and resolving patient complaints.

b. Ensure that non-conformance of contract requirements are identified and corrected to prevent reoccurrence.

c. Tender to the Government for acceptance only of those services that conform to contract requirements.

d. Recommend any changes to the contract that will provide more effective operations or eliminate unnecessary costs.

SECTION C

SERVICES SUMMARY TABLE

SS

PERFORMANCE

OBJECTIVE PWS REF

PERFORMANCE

THRESHOLD

SURVEILLANCE

METHOD

1 Quality of Service.

The contractor will provide qualified

MRI

personnel/services that fulfill the requirement of the PWS enabling the MTF to provide services at a high quality level.

1.2.1, 1.2.2, 1.4, 1.4.1, 1.4.2, 1.4.3, 1.4.4

100% of the time FRED will review all MRI technicians’ credentials to ensure they meet the minimum qualifications per the contract.

2 Promptness of Service. The contractor will contact patient within 24-48 hrs to schedule appointment.

Patient wait time for scheduled appointment should not exceed 30 mins.

1.2.2 No more than two

“not met” in a one year period

Periodic review of scheduling and patient wait times.

3 Standard of Care.

MRI Technician shall perform all exams IAW established protocols and ensure diagnostic quality and ensure complete and accurate documentation in patient records.

1.2.1, 1.2.2, 1.3.1

No more than one “not met” in a six month period

FRED will do periodic inspection of examination as they are performed and keep a log of all examinations which did not meet the standard of care. The Radiologist will review the each examination and keep a log of all examination that did not meet diagnostic quality.

4 Staff/Customer Complaints. The contractor shall meet the standard of care and the

1.2.1, 1.2.2, 1.3, 1.3.1, 1.3.1.1, 1.3.1.2, 1.3.1.3, 1.3.1.4, 3.3, 3.4, No more than two valid complaints within a six month period

FRED will validate all staff/customer complaints and track number of valid complaints per month.

requirements of the

PWS.

3.4.1, 3.5, 3.9, 3.9.1

SECTION D

SURVEILLANCE PROCEDURES

1. Surveillance.

The FRED monitors performance through daily surveillance/observation and is a Government person who often times possesses the same level of training/certification as required for the contractor providing the service. The FRED conducts surveillance of the contracted contractor’s performance by determining whether or not the performance meets the standards contained in the contract, and reports that performance information to the Service Contract Manager for documentation. The Service Contract Manager is a trained COR who is normally located in the Medical Logistics Office.

1.1 FRED Surveillance.

On a daily basis, the FRED monitors the performance of contractor and, on a monthly basis, provides the performance information to the COR. To be effective, the FRED must follow a systematic approach to ensure all pertinent surveillance documentation is provided to the COR as outlined in section 4.38.10.3 of AFI 41-209. This documentation of contractor performance is to be provided using the sample surveillance form available in Section I of this QASP. When complete, the FRED should provide a copy to the COR.

1.1.1 The FRED must survey contractor performance on a monthly basis, at a minimum, and forward the information to the COR no later than 10 calendar days following the month in which the surveillance occurred.

1.1.2 Performance issues can be documented as they occur. Any time a performance issue has a significant adverse effect on the quality of health care, the FRED must immediately inform the COR. The COR will forward all documentation to the Contracting Officer.

1.2 COR Documentation.

The COR is located in the Medical Logistics Office and is the critical link between the FRED, the MTF, and the Contracting Officer to ensure contractor adherence to the terms and conditions of the contract. The COR shall validate and maintain copies of surveillance documentation from the FRED.

Since the COR does not have the training or certification to determine if the contractor’s performance meets the standards in the contract, he or she relies on the surveillance form from the FRED. The surveillance form includes the date and location the surveillance was conducted, results of the surveillance (Satisfactory or Unsatisfactory), contract number, applicable remarks, and signature of FRED conducting the surveillance (see Section I). When the COR determines that contractor performance is unacceptable (i.e., major or minor finding), the specific reason for the unacceptable performance must be forwarded to the Contracting Officer (see paragraph 2, Patient/MTF Complaints, below).

2. Patient/Medical Treatment Facility (MTF) Complaints.

Any patient or MTF personnel that observes unacceptable services (i.e., incomplete, not performed, or performed improperly) should immediately contact the FRED or fill out Feedback forms, which are forwarded to the patient advocacy office or the MTF commander. The patient advocate or commander shall forward substantiated complaints to the COR. The FRED shall ensure MTF complaint procedures and forms are made available to all customers/patients. The FRED shall receive, document, and substantiate all MTF complaints. If the complaint is not substantiated, the FRED shall contact the MTF personnel and explain why the complaint was invalid. The FRED shall forward all substantiated Patient/MTF complaints to the COR. The COR will notify the Contracting Officer. The Contracting Officer will forward all complaints to the contractor for corrective action on all substantiated Patient/MTF complaints. When the complaint is resolved, the COR shall notify the FRED. If the contractor challenges whether the patient/MTF complaint is a substantiated complaint, and the COR and contractor cannot come to an agreement, the COR shall forward the patient/ MTF complaint to the Contracting Officer for a final resolution.

SECTION E

SURVEILLANCE OF NON-SERVICES SUMMARY ITEMS

1. The Government has the right to inspect and test all services called for by the contract to the extent practicable at all times and places during the term of the contract. Therefore; FREDs have the right to conduct surveillance for SS items and non-SS items. When the FRED identifies unacceptable performance on non-SS items, the FRED shall follow the procedures in section F of this QASP, entitled Unacceptable Performance.

2. COMBATING TRAFFICKING IN PERSONS: The COR will verify and monitor that the Contractor has policies and procedures in place to prohibit any activities on the part of contractor employees that support or promote trafficking in persons as part of ongoing surveillance of performance of contract services. The Contractor or the COR shall immediately bring to the attention of the CO any non-compliance with contract clause FAR 52.222-50, Combating Trafficking in Persons. Additional information on DoD efforts to combat trafficking in persons can be found at the DoD Federal Acquisition Supplement (DFARS) Procedures, Guidance and Information (PGI) 222.17.

SECTION F

UNACCEPTABLE PERFORMANCE

1. Unacceptable Performance.

When the contractor’s performance is deemed unacceptable, the FRED shall attempt to determine the cause of the unacceptable performance. If any Government action, or lack of action, caused the unacceptable performance, the unacceptable performance shall not be counted against the contractor. The FRED shall take action to ensure Government action, or lack of action, does not interfere with the contractor’s performance in the future. When the unacceptable performance is not the result of Government action, or lack of action, the FRED shall document the specific reason for the unacceptable performance on the surveillance form (see Section I) and forward it to the COR. The COR will then notify the Contracting Officer.

Unacceptable performance should be addressed early on in a timely manner through the CO in order for the Government to give the contractor an opportunity to resolve any on-going issues.

If the contractor challenges the validity of the FRED’s unacceptable surveillance findings, and the COR and contractor cannot come to an agreement, the COR shall refer the surveillance dispute to the CO for resolution.

2. Contracting Officer Notification.

a. Major Finding. A major finding is any performance (or lack of performance) that has a significant adverse effect on the quality of service. Anytime the FRED identifies a major finding, he or she shall document the finding on a surveillance form and immediately notify the COR.

The COR will notify the Contracting Officer in writing. Major findings include the following:

• A significant morbidity or mortality involving contractor personnel.

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

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

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

• Contractor failure to meet a Performance Threshold.

b. Minor Finding. A minor finding is a departure from established standards having little bearing on the service provided. When the FRED identifies a minor finding, he or she shall document the finding on the surveillance form. If a 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 FRED shall follow the process under the major finding section.

3. REMEDIES FOR UNACCEPTABLE PERFORMANCE (Commercial Items). In accordance with the FAR clause 52.212-4 -- Contract Terms and Conditions – Commercial Items, the Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance. The Government may require repair or replacement of nonconforming supplies or reperformance of nonconforming services at no increase in contract price. If repair/replacement or reperformance will not correct the defects or is not possible, the government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services.

The Government must exercise its post-acceptance rights --

(1) Within a reasonable time after the defect was discovered or should have been discovered; and

(2) Before any substantial change occurs in the condition of the item, unless the change is due to the defect in the item.

SECTION G

CERTIFICATION/ACCEPTANCE OF SERVICES

The FRED shall confirm/verify that MRI Services have been received by comparing a monthly scan report provided the contractor to actual MRI scans documented by the clinic. The COR shall certify that services were received in accordance with the terms and conditions of the contract. The COR shall match verified report to the contractor invoice via the WAWF website. If correct, the COR shall certify receipt of contract services. Certification of services shall be accomplished on the first workday following the completion of the contract payment period, to avoid payment of interest penalties. If the hours exceed the performance threshold in the services summary, the COR will follow the major finding procedures in section F of this surveillance plan. CORs must schedule and complete WAWF training from the base Accounting and Finance Office to certify services.

SECTION H

CONTRACT MANAGEMENT

The MFT shall utilize the following approaches, methods, and tools to manage the contract upon award:

1. The FRED shall conduct, document, track, and analyze contractor performance on a monthly basis.

The surveillance results shall be submitted to the COR for documentation. Surveillance results will be used to develop metrics to track contractor’s overall compliance with contract terms and conditions. This information will be used in the completion of the annual Contractor Performance Assessment Reporting System (CPARS) report, which is due at the completion of each performance period.

2. Performance Ratings Definitions. In evaluating the quality of contractor’s performance, the following performance ratings may be used.

Performance

Rating Criteria

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.

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 contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

3. Initial Contract Performance Review

3.1 The initial evaluation of contractor performance is a joint determination by the Multi-Functional Team that the contractor has successfully started performance, completed transition, is fully operational, and is within the estimated cost, schedule, and performance parameters of the contract. The Services Designated Official (SDO) may waive the initial evaluation for contractors that have continued performance under a successor contract award (prior incumbent), or for contractors which have otherwise demonstrated full compliance with contract start-up.

3.2 Scheduling: The initial performance review criteria shall be included in the QASP and the review shall take place within 30 days after the contractor assumes full performance responsibilities (i.e. after completion of transition/mobilization).

4. The contract administrator will review the CORs surveillance files no less than semi-annually to ensure surveillance is properly conducted and documented, and contractor performance is within acceptable levels. This review will be documented and acknowledged by the CO and FC.

5. The MFT reserves the right to conduct progress meetings with contractors to review performance. At these meetings, the CO may 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 applicable, that the contractor considers over and above the requirements of the contract. Appropriate action shall be taken to resolve any outstanding issues.

6. Contracting Officer Representative Tracking Tool (CORTT).

The DoD CORT Tool (CORTT) is used to nominate, appoint, track, terminate and revoke an individual as a COR against a DoD contract or order; or a contract or order issued against on behalf of a DoD assisting agency. This Tool allows a prospective COR to create a profile and process a nomination package for one or multiple contracts and/or orders. It provides contracting personnel a web based portal for all relevant COR actions. The COR, COR Supervisor, CO and CA must comply with the DoD requirements for participation in the CORTT. CORTT is now located on the Wide Area Workflow website and requires that users first be registered in WAWF in order to access the Tool. WAWF is located at https://wawf.eb.mil/

GOVERNMENT SUPERVISOR MONTHLY SURVEILLANCE REPORT

*(Note: A monthly surveillance report shall be submitted, with the contracted HCW’s monthly time sheet, by the 10th duty day of the month to the COR).

Name:

Company Name:

Month/YR

Contract & Task Order Number

Please mark appropriate box for each DESCRIPTION N/A Unsatisfactory Marginal Satisfactory Very Good Exceptional

Overall Performance

Maintains Qualifications

Performs IAW work schedule

Patient Satisfaction

Customer Satisfaction

Assessment Definitions N/A

Performance cannot be resolved in a timely manner even with discrepancy notice (Major)

Minor Performance issue (needs discrepancy notice to resolve)

Meets performance standards

Performance adds some value to MTF

Performance adds much value to MTF

NA Duty Hours Worked*

Overage Hours Worked

On-Call Hours Worked

Approved Leave Hours**

Monthly Hours n/a n/a

* Duty hours are actual hours worked at the place of performance including hours from directed training, unplanned closures, or administrative duties ** Leave hours are hours the Government supervisor scheduled, and HCW took, as leave during the month.

The Government supervisor will assess Contractor Performance IAW the terms and conditions of the contract.

Other-than-satisfactory assessments (i.e., Exceptional, Very Good, Marginal, and Unsatisfactory) must include comments to explain the assessment.

Comments:

Print Name of Government Supervisor

Signature Government Supervisor: Date:

Print Name of COR Reviewer:

Signature of COR: Date: