CLR_QASP_3_Dec_13.pdf

Attachment 2 To Solicitation No. FA5209-14-T-0009

QUALITY ASSURANCE SURVEILLANCE PLAN

FOR

REFERRAL MANAGEMENT CENTER

CLEAR AND LEGIBLE RESULTS TECHNICIAN

MEDICAL GROUP, YOKOTA AIR BASE, JAPAN

Date: 3 Dec 2013

NOTE: THIS QUALITY ASSURANCE SURVEILLANCE PLAN (QASP) IS PROVIDED AS

AN ATTACHMENT TO THE SOLICITATION FOR INFORMATION PURPOSE ONLY. IT

WILL NOT BECOME PART OF THE CONTRACT.

This Quality Assurance Surveillance Plan (QASP) has been developed as identified in Air Force Instruction (AFI) 63-138. The QASP has been developed to evaluate contractor actions while implementing the Performance-based Work Statement (PWS). This plan will be used by the Contracting Officer Representative (COR) to ensure contractor compliance on the Referral Management Center (RMC) Clear and Legible Results Technician contract. This plan prescribes the objective in having the services, the goals of the multi-functional team (MFT), team members and their roles and responsibilities, and how the MFT will assess contractor performance and manage the contract to obtain efficiencies, improved performance, and cost savings throughout its life cycle.

1. OBJECTIVE.

The objective is to provide all labor, materials, tools, equipments, parts, transportation, and other items and services necessary for RMC Clear and Legible Results Technician in accordance with the attached PWS. In addition to the services described in the PWS, the contractor is expected to be a partner with the base community in continuously improving the quality of programs and services offered to customers. This QASP is designed to provide the COR with an effective and systematic method of monitoring contractor performance for each listed objective on the Service Summary (SS) in the PWS. This QASP provides a systematic method to evaluate the services the contractor is required to furnish and not the details of how the contractor accomplishes the work. This QASP is based on the premise that the contractor, and not the Government, is responsible for management and quality control actions to meet the terms of the contract. The role of the Government is quality assurance to ensure contract standards are achieved. The Government will also rely on the contractor's submitted Quality Control System for ensuring contractual requirements are met. The contractor is required to develop and implement a comprehensive program of inspections and monitoring actions. The COR is to be objective, fair, and consistent in evaluating the contractor’s performance against the standards contained in the

PWS.

2. GOALS OF THE MFT.

The Government officials listed in paragraph 3 below will participate in performance management of the contractor. The goals of this team are to manage this contract and to provide an avenue to collectively work together to create a strong working relationship between the using agency, contracting and the contractor and to provide the highest level of contract performance and customer service. Working together will reduce costs and improve contract performance.

Contractor input shall be encouraged throughout the contract.

3. MFT ROLES AND RESPONSIBILITIES.

The following government officials will participate in performance management of the contractor. Their roles and responsibilities are described as follows:

3.1. Contracting Officer’s Representative (COR):

3.1.1. Responsible for monitoring, assessing, recording and reporting on contractor compliance with the terms and conditions of the contract. A primary and alternate COR will be appointed for this contract. The COR Supervisor is the designating authority. COR 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 surveillance documentation, notify the Contracting Officer of any significant performance deficiencies and recommend improvements to the QASP and PWS throughout the life of the acquisition.

3.1.1.1. Assessment Schedule: The COR will develop a monthly surveillance schedule either computer generated or locally revised forms may be used based on the surveillance plan’s requirements. This schedule should indicate contract number, SS number (inspection items) and paragraph numbers of the PWS, and dates and times of inspections. The monthly schedule must be completed before the first day of the surveillance period that it covers, and will be sent to the Contracting Officer. The schedule shall be marked “FOR OFFICIAL USE ONLY” and shall not be shown to the contractor. Either the COR’s supervisor or COR Supervisor will sign the schedule.

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

3.1.1.3. Surveillance: The COR will conduct inspections of all SS items. The COR may also receive feedback from customers and other government employees and pass them on to the contractor’s QCI for correction. Completion of the surveillance for the month will be signed by the COR. If discrepancies are found during surveillances, the COR Supervisor must sign surveillance documentation.

3.1.1.4. Invoices: An original invoice shall be submitted to the COR on a monthly basis. The COR will then certify and forward the invoice to DFAS for payment and cc 374 CONS/LGCBB.

Invoices shall contain the information required by FAR 52.212-4(g).

3.2. The Contracting Officer (KO):

Has overall responsibility for overseeing the contractor’s performance. The KO will be responsible for monitoring of the contractor’s performance in the areas of contract compliance, contract administration, cost control, and property control; reviewing the COR’s assessment of the contractor’s performance; and resolving all differences between the COR and the contractor’s disagreements. The KO is the only person with the authority to direct the contractor in the performance of his duties under the contract and to make interpretations of and/or changes to the contract. The KO will facilitate MFT meetings.

3.3. The COR Supervisor:

Has overall responsibility for developing the PWS and the QASP to ensure mission requirements, are performance-based, foster innovation, and define metrics. Conduct Post-award Annual Execution Review, briefing top 5 contracts in the aggregated amount to the Service Advocate (SA) thru the Service Designated Official (SDO), and annually report the Health of Service Assessment to SA thru SDO. The COR Supervisor is responsible for identifying mission essential services and developing the necessary documents IAW DoDI 3020.37, Continuation of Essential DoD Contractor Services During Crisis. The COR Supervisor is responsible for reviewing contractor’s performance documentation prepared by the COR ensuring contract compliance.

3.4. The Contracting Squadron Commander:

Serves as the business advisor to senior leadership i.e. wing commander and group commanders.

Annually brief Senior Leadership on the health of Quality Assurance Program. Ensures that the MTF exercises acquisition authorities and responsibilities in accordance with the Federal Acquisition Regulation (FAR), Defense Federal Acquisition Regulation Supplement (DFARS), Air Force Federal Acquisition Regulation Supplement (AFFARS) and Air Force instructions.

Responsible for 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; and ensuring personnel on the MFT receive the appropriate level of training to meet local needs.

3.5. The Quality Assurance Program Coordinator (QAPC):

Develops, manages and implements the base Quality Assurance Program; supports the MFT in the development of contract requirements, ensuring requirements are clearly stated and enforceable; aids in development of the Services Summary (SS) and QASP and provides training to all COR Supervisor, COR and others that interact with this contract as needed.

3.6. The Contract Administrator (CA):

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

3.7. Others as needed: The MFT may include other organizations as deemed necessary.

4. PERFORMANCE ASSESSMENT.

4.1. The following Services Summary Guides reflect the performance evaluation required by the

PWS.

SERVICES SUMMARY (SS) AND METHOD OF ASSESSMENT

SS Number and Performance Objectives

PWS

Para

Performance Threshold Method of Assessment

SS#1: Responsible for tracking and receiving CLRs of referrals deferred to network within 60 calendar days for review by applicable healthcare provider and tracking open referrals on a daily basis to ensure Access-to Care (ATC) standards are maintained and notify patient and healthcare provider as applicable.

1.2.3.1.

98 % complete performance of the requirements under the PWS.

Periodic Inspection

SS#2: Responsible for scanning CLRs into Armed Forces Heath Longitudinal Technology Application (AHLTA) IAW

1.2.3.2.

98 % complete performance of the requirements under the local/Air Force Instruction (AFI) 44-176, Chapter 14 guidance and closure of the referral in Composite Health Care System (CHCS) within 60 calendar days and will prepare a wide variety of recurring and some nonrecurring correspondence, reports and other documents IAW

MDGI 41-111..

SS#3: Proofreads/edits documents.

Ensures coordination procedures are followed and prepare patient briefing packets, routing/delivery of correspondences (referrals, CDs, reports, etc.) from RMC staff throughout the Medical Treatment Facility (MTF).

1.2.3.3.

98 % complete performance of the

SS#4: Covers front desk. Answers telephone calls, greets visitors, and receives/relays messages for RMC staff members. Demonstrates telephone etiquette and communication skills and will schedule of patient referral appointments (internal/external appointments) and documenting/tracking of the referral in the Referral Management System (RMS) Tracking Database and within CHCS.

1.2.3.4.

98 % complete performance of the

SS#5: Verifies patients are registered In CHCS and Defense Enrollment Eligibility Reporting System (DEERS); updates demographic information as needed. Obtain current, accurate contact information (i.e. cell/home phone number).

1.2.3.5.

98 % complete performance of the

SS#6: Schedules of specialty referral appointments to MTF or Network providers using correct CHCS booking procedures, ATC standards and established clinic capability/booking protocols.

Performs/assists with appointing network specialty care referrals as allowed by the Managed Care

1.2.3.6.

performance of the

Support Contractor (MCSC), IAW

MDGI 41-111.

SS#7: Informs patients of the provider, location, time and day of referral appointments. Requests the patient to call back for appointment information if not provided appointment prior to leaving MTF for MTF and network provider initial specialty care appointments and will provide pre-appointment instructions to patients as indicated by the MTF IAW

MDGI 41-111.

1.2.3.7 performance of the

SS#8: Submits referrals to the appropriate reviewer when required for medical necessity and appropriateness review and will document patient appointments in CHCS and/or RMS Tracking Database.

1.2.3.8.

98 % complete performance of the

SS#9: Creates referrals into standard format for submission to request appointments on DD Form 2161, Referral for Civilian Medical Care and will coordinate of referral authorizations from International SOS (ISOS).

1.2.3.9.

98 % complete performance of the

SS#10: Copies medical records for Release of Information as required. 1.2.3.10.

98 % complete performance of the

SS#11: Coordinates translation services for beneficiaries with translation contact services and will communicate to host nation hospital/healthcare providers to facilitate beneficiary referral requirements as needed..

1.2.3.11.

performance of the

SS#12: Trained on the following systems to assist as needed.

AHLTA

CHCS

Referral Manage System (RMS) Carepoint

Juniper

1.2.3.12.

98 % complete performance of the

4.2. Assessment of SS Items. The COR will perform inspections to ensure contractor compliance with the appropriate paragraphs of the PWS and will record the results of inspection, noting the date of inspection.

4.3. 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 the COR determine that contractor performance is unacceptable, the specific reason for the unacceptable performance shall be recorded on the COR’s assessment documentation. The methods of inspection are listed below.

4.4. Methods of Inspection.

4.4.1. Periodic Inspection

4.4.1.1. Standard: Deficiencies shall not exceed the performance thresholds cited in the SS for each performance objective. The COR shall notify the KO for appropriate action in accordance with FAR 52.212-4, Contract Terms and Conditions-Commercial Items or the appropriate Inspection of Services clause, if any of the above service areas exceed the performance thresholds.

4.4.1.2. Procedures: The COR shall inspect the performance objectives indicated in SS at monthly basis and indicate performance as acceptable or unacceptable. The surveillance documentation should outline the same items indicated on the COR’s monthly schedule. If during an inspection the COR finds unacceptable service they will document the findings and conduct an investigation to ascertain the validity and cause of the unacceptable service and notify the contractor’s contract manager of the findings. Based on the findings, the contract manager may be asked to re-perform. If the contract manager disagrees with the complaint and challenges the validity, the COR will contact the KO. The unacceptable condition will be recorded.

Recurring deficiencies in excess of the performance thresholds listed in the SS are not permitted for any of the performance objectives listed in the SS. If a repeated unacceptable service is received indicating the same deficiency during the same service period (month, quarter, etc.), the COR should contact the KO for appropriate action.

4.4.1.3. Assessment of Non-SS Items. All other tasks required under the PWS may be inspected on a random basis at a frequency determined by the COR Supervisor and the KO.

4.4.1.4. Remedies for Non-Conformance. If inspections indicate unacceptable performance, the COR will notify the contractor’s project manager of the deficiencies for correction. The contractor shall be given an appropriate time frame (depending on the discrepancy identified) after notification to correct the unacceptable performance. If deficiencies are not corrected within the required time frame, the COR should notify the KO for action. If the contractor disagrees with the noted discrepancy and an agreement cannot be reached, the KO shall be notified for a final decision. When re-accomplish of performance is not possible, contract price may be reduced to reflect the reduced value of the services performed.

4.4.2. Customer Complaints:

The key to the success of a customer feedback system is customer education. If customers are aware of the services they are entitled to receive and the contract standards for those services, the result is an effective customer feedback system. The COR will establish a customer education program and familiarize their customers with applicable contract requirements and this information shall be maintained in the COR surveillance file. The information provided may consist of brochures, newspaper articles, emails, or anything that provides the customer with status on the service, the COR, and the complaint process. Customer feedbacks are not considered valid upon receipt, the COR must validate and process for action, as applicable.

4.4.3.1. Standard: Deficiencies shall not exceed the performance thresholds cited in the SS for each performance objective. The COR shall notify the KO for appropriate action in accordance with FAR 52.212-4, Contract Terms and Conditions-Commercial Items clause, if any of the above service areas exceed the performance thresholds.

4.4.3.2. Procedures: Customer complaints may be received from customers through any method that contains adequate information for the COR to validate the complaint (i.e. date/time of complaint, organization, name, phone no., bldg. no., contract title or number, detailed description of the complaint). A sample of the Customer Complaint Record is found in Appendix A. The Customer may verbally express his/her complaint by a telephone call or in person. The COR may also accept customer complaints by e-mail or fax. When a customer complaint is received, the COR will conduct an investigation to determine the validity of the complaint. When the COR validates the complaint, the COR should inform the contractor’s contract manager/quality control personnel of the approximate time the defect(s) will be corrected. Customer complaints will be maintained in a customer complaint log (Appendix B). The COR will also inform the KO of the matter. The contract manager/quality control personnel shall return the written customer complaint document, properly completed with actions taken, to the COR, who will file the complaint for monitoring future recurring performance.

4.4.3.3. After investigation and validation of the services, a completed copy of Customer Complaint Record Form will be distributed to the complainant, the Contractor and KO respectively and the original will be filed in COR folder. Customer complaint forms become a permanent part of the COR surveillance records.

4.4.3.4. If the contract manager/quality control personnel disputes the complaint and challenges the validity of the complaint, and the dispute cannot be resolved between the contract manager and the COR, the COR will refer the matter to the Contracting Officer for a final decision. If the COR determines the complaint as invalid, he/she will document the findings, and file the annotated complaint form for file. All surveillance documentation will be forwarded to the KO at contract completion except deficiency that will immediately be forwarded to the KO.

5. PERFORMANCE MANAGEMENT.

5.1. Market Research. Market research will be used as a tool throughout the life of the contract to remain current with the most efficient and effective assessment methods and techniques of the commercial marketplace. As a minimum, market research will be conducted annually prior to exercising the option periods.

5.2. MFT Meetings. The MFT will manage the contract for the life of the contract. This team will form a partnership between the Government and the contractor upon award of the contract to ensure the best possible service if provided for the life of the contract. This team will meet on an as needed basis.

5.2.1. All performance assessment documentation will be reviewed at these meetings. If performance improvement is necessary a plan of action will be created. The MFT will continually review documentation and procedures to improve efficiency. If the MFT is required more often than annually it will be scheduled by the KO.

5.3. Monthly COR Performance Assessment: Contract Administrator will perform at a minimum quarterly surveillances to ensure contract compliance and proper documentations of COR files.

5.4. Contract Performance Assessment Reporting System (CPARS). The 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 Performance Assessment Report System (CPARS) reporting. CPARS will be updated at least annually documenting contractor performance for this specific contract.

More frequent updates may be made as required to document a significant improvement or degradation of the level of contract performance. The Assessing Official (AO) or Assessing Official Representative (AO Rep) will be the COR Supervisor, supervisor, or COR and COR respectively, who will also prepare the CPAR document. The AO will obtain approval from the KO prior to releasing the CPAR to the contractor. The contractor will select personnel to serve as Contractor Representatives (CR) to review and comment on the CPAR. The CPAR will be sent to the Reviewing Official (RO) if there is significant disagreement on the CPAR's ratings between the AO and the CR or if the AO chooses to revise the assessment as a result of the CR's comments. The RO is will be the KO.

6. REVISIONS TO THIS QUALITY ASSURANCE SURVEILLANCE PLAN.

Revisions to this QASP will be authorized by the KO. The COR will review the PWS and QASP prior to the determination of exercising an option and will provide proposed changes through the COR Supervisor to the MFT for review. This is a living document that can be changed at any time if the overall scope of the contract does not change.

Appendix A Sample Customer Complaint Record

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

Appendix B Sample Customer Complaint Log

Date Customer Name ORGN/Phone

Number Complaint

Section Referred to & Date

Complaint: