Performance Plan - Anesthesia.doc

PERFORMANCE PLAN

FOR

ANESTHESIOLOGIST

INCIRLIK AB, TURKEY

31MAR2011

REVISION CONTROL

REVIEW & ACCEPTANCE

Multi-Functional Team (MFT) member signatures indicate their review and acceptance of the Performance Plan for Anesthesiologist. These signatures indicate coordination on this plan at the time of development and will remain in effect until the plan is changed.

Coordination:

Signature Date Quality Assurance Personnel (QAP):

ROBERT CHAPLIN, Maj, USAF

Functional Commanders (FCs):

JAMIE BING, Capt, USAF

Quality Assurance Program Coordinator (QAPC):

WILLIAM ANDERSON, Civ, USAF

Contracting Officer (CO):

SHELLIE A. MURPHY, MSgt, USAF

PERFORMANCE PLAN SECTION A

PURPOSE

1. This performance plan has been developed to provide Quality Assurance Personnel

(QAP) and Service Contract Managers with an effective and systematic method of evaluating contractor provided services as required by the terms and conditions of the Anesthesiologist service contract. This performance plan implements the requirements of AFI 41-209, Medical Logistics Support and AFI 63-124, Performance Based Service Acquisitions (PBSA), with respect to the Government’s quality assurance requirements.

2. This performance plan 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 Incirlik Air Force Base (IAFB) by providing quality health care workers to treat patients within the medical treatment facilities (MTFs). The results the multi-functional team 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 results.

3. This performance plan describes the method(s) used to evaluate contractor provided services rather than the details of how the contractor accomplishes the work. QAP’s are to be objective, fair, and consistent in evaluating contractor performance against the performance standards. The QAPs shall use monthly surveillance as a means to evaluate contracted health care worker’s performance. Documentation is required to record, evaluate, and report contractor’s performance. QAP are required to maintain records of the contractor’s performance and keep the CO informed. The surveillance procedures identified in this performance plan, in concert with the contractor’s submitted quality control procedures, will assure the Government of acceptable contractor performance.

4. Authority for issuance of this Plan is provided in accordance with FAR Part 52.246-4 -- Inspection of Services -- Fixed-Price and under Contract Section E, Inspection and Acceptance, which provides for inspections and acceptance of the articles, services, and documentation called for in this contract.

5. This performance plan 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.

PERFORMANCE PLAN SECTION B

ROLES AND RESPONSIBILITIES OF THE MULTI-FUNCTIONAL TEAM

1. Base-Level Contracting Squadron Commander (39 CONS/CC)

a. Serves as the Business Advisor to the Base Commanders and Group Commanders.

b. Developing and implementing acquisition strategies for services acquisitions

c. Provides oversight for multi-functional team (MFT) requirements in planning, assessing contractor performance, and managing the acquisition throughout the life of the requirement.

d. Ensures personnel on the MFT receive the appropriate level of training to meet local needs.

2. Quality Assurance Program Coordinator (QAPC):

a. Develops, manages and implements the base Quality Assurance Program

b. Provides training for the Functional Director/Functional Commander (FD/FC).

c. Provides Phase I training for Quality Assurance Personnel.

e. Reviews and coordinates all PWS and performance plans.

f. Reviews and coordinates on all changes to the PWS and performance plan.

g. Conduct Annual Refresher training to the QAP

3. Cognizant Base-Level CO

a. Has overall responsibility for overseeing the contractor’s performance.

b. Delegates responsibilities to QAP.

c. Provides oversight for QAP phase 1 and phase 2 training programs.

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

e. Informs the contractor of the names, duties, and limitations of authority for all quality assurance personnel.

f. Periodically assesses the QAPs performance, not less than quarterly, and advises the

MFT Functional Director/Functional Commander (FD/FC) of any problems.

g. Assesses/manages contractor performance assessment data, including submitting input to the Program Management Office in the development of the annual Contractor Performance Assessment Reporting System (CPARS) reports.

h. Resolving all differences between the QAP version and the contractor’s version of events.

i. Issues modifications as necessary.

j. Takes formal action against the contractor for unacceptable performance, when appropriate.

k. The CO 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 changes to the contract.

l. Facilitate MFT meetings.

4. Contract Administrator (CA)

a. Provides Phase II training for Quality Assurance Personnel.

b. Focal point for issues regarding the contract;

c. Prepares and processes modifications to the contract;

d. Assists the CO in ensuring contractor performance meets contract standards;

e. Records and transcribes minutes for meetings.

5. MTF Functional Director/Functional Commander (FD/FC)

a. Ensures requirements documents developed by the MTF multi-functional team satisfy mission requirements, are performance-based, and foster innovation.

b. Assign competent and capable functional experts to the MFT who will be available full time or as warranted by the procurement cycle.

b. Nominates as a minimum, a primary and an alternate QAP that is qualified to oversee and notify the CO of any changes to this designation and any significant contractor deficiencies related to the performance of the contract.

c. Ensures QAPs maintain proficiency and evaluates QAP job performance not less than annually.

d. Ensures 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.

e. The FC/FD is responsible for identifying mission essential services and developing the necessary documents IAW DoDI 3020.37, Continuation of Essential DoD Contractor Services During Crisis.

6. Service Contract Manager

a. Responsible for overseeing the MTF’s contract services section (see section 4.38.3.1 of

AFI 41-209).

b. Trained as a QAP.

c. Serves as the MTF’s primary POC to document contract health care worker performance information obtained from QAP in a surveillance contract file.

7. Quality Assurance Personnel

a. Is responsible for monitoring, assessing, recording and reporting on contractor compliance with the terms and conditions of the contract.

b. Develops technical requirements and the Independent Government Cost Estimate (IGCE) for contract services.

c. Conducts Government contract quality assurance by or under the direction of the QAPC & CO.

d. Evaluates and documents the contractor’s performance in accordance with the procedures set forth in this performance plan.

e. Notifies the CO of any significant performance deficiencies.

f. Maintains surveillance documentation.

g. Provides a copy of the surveillance documentation and time card to the Service Contract Manager in the Medical Logistics Office.

h. Recommends improvements to the performance plan, PWS and the position descriptions, throughout the life of the contract.

i. Maintains technical competency in the functional area surveyed.

j. Obtains proficiency in surveillance procedures.

k. Certifies acceptance of services.

l. Identifies opportunities to improve performance throughout the life of the contract.

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

8. Contract Manager (CM)

a. The contract manager shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract.

b. The CM shall be available during normal duty hours within one (1) hour to meet on the installation with government personnel designated by the CO to discuss problem areas.

c. The contract manager shall be on-site during normal duty hours and contingencies requiring work beyond normal duty hours.

d. The CM ensures that Self-Inspections are conducted semi-annually throughout the contract and copies are provided to the FC.

9. Contractor

a. Complies fully with the terms and conditions of the contract such as filling positions on time, minimizing turnover ratio, and resolving patient complaints.

b. Maintains and implements a quality control plan that is acceptable to the Government.

c. Ensures that non-conformance of contract requirements are identified, corrected, and prevents recurrence.

d. Tenders to the Government for acceptance only those services that conform to contract requirements.

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

PERFORMANCE PLAN SECTION C

SERVICE DELIVERY SUMMARY AND METHOD OF SURVEILLANCE

As a minimum, QAPs will monitor, review, and report on the contractor’s performance and compliance with all Service Delivery Summary (SDS) items shown below (from Section 2 of the PWS). The service requirements summarized below are performance objectives that relate directly to mission essential items. The performance thresholds referenced in the table briefly describes the minimum acceptable levels of service required for each service requirement. The performance thresholds established for each of the performance objectives are the number of defects permitted before the QA notifies the CO in accordance with FAR 52.212.4, Contract Terms and Conditions-Commercial Items, or FAR 52.246-4, Inspection of Services - Fixed Price.

PERFORMANCE PLAN SECTION D

SURVEILLANCE PROCEDURES

1. Surveillance The QAP normally oversees the performance of the contracted health care worker. The QAP monitors performance and is a Government person who oftentimes possesses the same level of training/certification as required for the contracted health care worker. The QAP conducts surveillance of the contracted health care worker’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 in the contract file. The Service Contract Manager is a trained QAP who is normally located in the Medical Logistics Office.

2. Methods of Inspection Applicable to This Contract 2.1.. One-hundred percent inspection. The QAP will inspect and evaluate the contractor’s performance each time it is performed. The results of the contractor’s overall performance is then evaluated to determine acceptability of the service provided.

2.2. Periodic inspection. These items are inspected using periodic surveillance (daily, weekly, monthly, quarterly, etc.) as determined by the QAP. The results of the periodic surveillance inspections may be used as the basis for actions (other than payment deductions) toward the contractor. In such cases the Inspection of Services clause becomes the basis for the CO’s actions.

3. Medical Quality Improvement/Risk Management (QI/RM) The contract provider(s) shall participate in QI/RM activities to the extent required by Section 2C, AFI 44-119 and the individual MTF QI/RM plan or regulation.

The Government will evaluate the providers’ professional, as differentiated from administrative, performance under this contract using Quality Improvement standards specified in paragraphs 2.12 and 2.13, AFI 44-119. Nothing in this paragraph precludes the Government from also conducting inspections under the Inspection/Acceptance requirement of FAR clause 52.212-4

4. QAP Surveillance On a daily basis, the QAP monitors the performance of the contracted health care worker and, on a monthly basis, provides the performance information to the Service Contract Manager no later than 7 days of the following month. Surveillance Assessment Report (SAR) when completed shall be marked “For Official Use Only” and shall not be shown to the contracted health care worker. See section J for more information on SAR. When complete, the QAP should file this form in their 6-part folder as outlined in section 4.38.10.1 of AFI 41-209. Performance issues can be documented as they occur. Any time a performance issue has a significant adverse affect on the quality of health care, the QAP must inform the Service Contract Manager. The Service Contract Manager will document all findings on a Corrective Action Report (CAR) available also in section J of this performance plan, and reported to the Contracting Office.

5. Assessment Procedures

5.1. Monthly Surveillance Schedule. The QAP shall develop a monthly surveillance schedule, based on this Plan, see section J for more document setup. The schedule shall be submitted to the contract administrator no later than the five duty days before the beginning of the period it covers. The FD/ FC must review and sign prior to submission to 39 CONS. The QAP must ensure a copy of the signed schedule is provided to the CA before the start of the surveillance period. The schedule shall be marked “FOR OFFICIAL USE ONLY” and shall not be shown to the contractor.

5.2. Changes to the schedule shall be posted promptly. Copies of the changed schedule shall be sent to the FD/FC and the CA. The QAP shall document the reason(s) for changes of the assessment schedule, and maintain the documentation in the QAP files with the corresponding changed assessment schedule. Any changes to the schedule will be submitted to the CA when the change occurs.

5.3. 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, QAP have the right to conduct assessment for SDS items and non-SDS items as well. When the QAP identifies unacceptable performance on non-SDS items, the QAP shall follow the procedures in Section F of this Performance Plan, entitled Unacceptable Performance.

6. Service Contract Manager Documentation The Service Contract Manager is normally located in the Medical Logistics Office and is the critical link between the QAP, the MTF, and the base CO to ensure contractor adherence to the terms and conditions of the contract. The Service Contract Manager shall record (log) surveillance results from the QAP, validate surveillance documentation, and manage contract health care worker changes. When the Service Contract Manager determines that contractor performance is unacceptable (i.e., major or minor finding), the specific reason for the unacceptable performance must be recorded on a CAR report and submitted to the CA. All major findings must also be reported to the base CO for the issuance of a discrepancy letter (see section 7, MTF Complaints and section 8, Patient Complaints below).

6.1. Surveillance Activity Log: The Service Contract Manager may use the Surveillance Activity Log provide, (see Section J for more information) or a locally devised form may also be used. When the Service Contract Manager obtains the SAR from each of the QAP, they will document those items that are “other than satisfactory” in the Surveillance Activity Log. The Surveillance Activity Log lists all SDS as “satisfactory” and only requires the Service Contract Manager to document those items/issues that are other than satisfactory (i.e., exceptional, very good, marginal, or unsatisfactory). Since all SDS’s are already listed as satisfactory, the Service Contract Manager will only have to “validate” surveillance (see section 1.2.2 below) in the Surveillance Activity Log when the SAR lists the performance as satisfactory; there would be no need to log surveillance in this case. In most cases, documentation in the Surveillance Activity Log will occur at the beginning of each month for performance from the previous month. On those occasions where a major performance finding is identified (i.e., quality of care issue), the Service Contract Manager must document the issue in the Surveillance Activity Log and notify the base CO. As with the QAP, the Service Contract Manager should also maintain a copy of the completed QAP SAR in their 6-part folder IAW AFI 41-209.

6.2. Validating Monthly Performance: The Service Contract Manager must validate monthly performance on the Surveillance Activity Log no later than the 15th of the following month. Validation must be accomplished whether or not the Service Contract Manager logged any surveillance comments. Validation of the monthly performance on the Surveillance Activity Log must be accomplished by printing and signing the Surveillance Activity Log before submitting to the contracting office.

7. Medical Treatment Facility (MTF) Complaints Any MTF personnel that observe unacceptable services (i.e., incomplete, not performed, or performed improperly) should immediately contact the QAP. The QAP shall ensure MTF complaint procedures and Customer Complaint forms, see section J for more information, are available to all customers. The QAP shall receive, document, and substantiate all MTF complaints. If the complaint is not substantiated, the QAP shall contact the MTF personnel and explain why the complaint was invalid. The QAP shall forward all substantiated MTF complaints to the Service Contract Manager. The Service Contract Manager will document the substantiated complaint on CAR report and the Surveillance Activity Log AND notify the base CO. The CO will issue a discrepancy letter to the contractor for corrective action on all substantiated MTF complaints. When the complaint is resolved, the Service Contract Manager shall notify the QAP and document the resolution on the Surveillance Activity Log. If the contractor challenges whether the MTF complaint is a substantial complaint, and the QAP and contractor cannot come to an agreement, the Service Contract Manager shall forward the MTF complaint to the CO (CO) for a final resolution. MTF complaints will be tracked on the Surveillance Activity Log.

8. Patient Complaints

Any patient that observes unacceptable services (i.e., incomplete, not performed, or performed improperly) should immediately contact the patient advocacy office or the MTF commander. The patient advocate or commander shall forward substantiated complaints to the QAP. The QAP shall forward all substantiated patient complaints to the Service Contract Manager. The Service Contract Manager will document the substantiated complaint on CAR report and the Surveillance Activity Log AND notify the base CO (CO). The CO will issue a discrepancy letter to the contractor for corrective action on all substantiated patient complaints. When the complaint is resolved, the Service Contract Manager shall notify the QAP and document the resolution on the Surveillance Activity Log. If the contractor challenges whether the patient complaints is a substantial complaint, and the QAP and contractor cannot come to an agreement, the Service Contract Manager shall forward the patient complaints to the CO for a final resolution. Patient complaints will be tracked on the Surveillance Activity Log.

9. Customer Training

QAP 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 QAP, 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.

PERFORMANCE PLAN SECTION E

SURVEILLANCE OF NON-SERVICE DELIVERY SUMMARY ITEMS

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, QAP/Supervisors have the right to conduct surveillance for SDS items and non-SDS items. When the QAP/Supervisor identifies unacceptable performance on non-SDS items, the QAP/Supervisor shall follow the procedures in section F of this performance plan, entitled Unacceptable Performance.

PERFORMANCE PLAN SECTION F

UNACCEPTABLE PERFORMANCE

1. Unacceptable Performance

When the contractor’s performance is deemed unacceptable, QAP 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 QAP 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 QAP shall document the specific reason for the unacceptable performance on the CAR and forward it to the Service Contract Manager and the contractor to assure corrective action is taken. By initialing and dating the CAR, the contractor is acknowledging that s/he has been informed of the unacceptable performance and is not agreeing with the performance assessment. QAP shall direct the contractor to re-perform the service, if possible, without additional cost to the Government.

The Service Contract Manager documents the unacceptable performance in the Surveillance Activity Log and notifies the CO. Unacceptable performance should be addressed early on through the base CO in order for the Government to give the contractor an opportunity to resolve any on-going issues. Documenting this information in the Surveillance Activity Log is critical since the data in the Surveillance Activity Log is used to generate the annual contract performance assessment report (CPAR) on each contractor.

If the contractor challenges the validity of the QAP unacceptable surveillance findings, and the QAP and contractor cannot come to an agreement, the Service Contract Manager shall refer the surveillance dispute to the CO for resolution. The contractor shall be required to return all completed CAR to the QAP no later than the suspense date indicated on the CAR. Both the QAP and the Service Contract Manager shall maintain a copy of the CAR in their 6-part folders as outlined in section 4.38.10.1 of AFI 41-209.

2. CO Notification

2.1. Major Finding. A major finding is any performance (or lack of performance) that has a significant adverse affect on the quality of service. Anytime the QAP identifies a major finding, he or she shall document the findings on a surveillance form and immediately notify the Service Contract Manager. The Service Contract Manager will notify the CO, in writing, and document the issue in the electronic surveillance system. Major findings are the following:

· Contractor failure to meet a Performance Threshold.

· Significant mission degradation in any contractor operated function.

· 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.

· A situation that is likely to result in a hazardous or unsafe condition for individuals or other government resource.

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

2.2. Minor Finding. A minor finding is a departure from established standards having little bearing on the service provided. When the QAP identifies a minor finding, he or she shall document the finding on the surveillance form. Unless it is a major finding, the QAP does not have to notify the Service Contract Manager. The Service Contract Manager will document the minor finding when the QAP submits the monthly SAR. 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 QAP shall follow the process under the major finding section.

3. Remedies for Unacceptable Performance

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 with contract requirements--at no increase in contract amount. This includes but is not limited to termination of health care workers and recruitment of substitute health care workers that are equally qualified within established timeframes. When the defects in services cannot be corrected by re-performance, the Government may:

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

3.1.2. Reduce the contract price to reflect the reduced value of the services performed.

3.1.3. This may include a reduction in the number of paid hours to reflect the total nonperformance period.

3.1.4. Revocation of clinical privileges.

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:

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

3.2.2. Terminate the contract for default.

PERFORMANCE PLAN SECTION G

CERTIFICATION/ACCEPTANCE OF SERVICES

The QAP shall confirm that the number of hours on the contracted health care worker timecard was actually worked and forward the timecard to the Service Contract Manager with the monthly SAR. The Service Contract Manager shall certify that services were received in accordance with the terms and conditions of the contract. The Service Contract Manager shall match the hours on the timecard to the contractor invoice via the Wide Area Workflow (WAWF) website. If correct, the Service Contract Manager 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 acceptable quality level (AQL) in the service delivery summary, the Service Contract Manager will follow the major finding procedures in section F of this performance plan. Service Contract Managers must schedule and complete WAWF training from the base Accounting and Finance Office to certify services.

Contractor Inspection Records.

Records of inspections shall be kept and made available to the Government throughout the contract performance period and for the period after contract completion until final settlement of any claims under this contract.

PERFORMANCE PLAN SECTION H

CONTRACTOR’S QUALITY CONTROL PLAN

1. In accordance with the PWS, the contractor shall establish and maintain a Quality Control Plan to ensure the requirements of the contract are provided as specified. The contractor shall provide a Quality Control Plan describing the inspection system for the requested services listed in the PWS. The Contractor shall develop and implement procedures to identify, prevent and ensure non-recurrence of unacceptable services. The contractor shall update the plan as changes occur and changes shall be submitted for review and acceptance by the CO. The contractor’s quality control plan shall contain, as a minimum, the following items:

1.1. A description of the inspection system to cover all services. Description shall include specifics as to the areas to be inspected on a scheduled and unscheduled basis, frequency of inspections, and the title and organizational placement of the inspector(s).

1.2. A description of the methods to be used for identifying and preventing defects in the quality of service performed.

1.3. A description of how the records will be kept. Records must document all inspections and corrective or preventive actions taken.

2. Contractor Inspection Records. Records of inspections shall be kept and made available to the Government throughout the contract performance period and for the period after contract completion until final settlement of any claims under this contract.

PERFORMANCE PLAN SECTION I

CONTRACT MANAGEMENT

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

1. The QAP shall conduct, document, track, and analyze contractor performance on a monthly basis. The surveillance results shall be maintained in a 6-part folder and submitted to the Service Contract Manager for documentation in the Surveillance Activity Log. The surveillance information that is documented is used in the completion of the annual Contractor Performance Assessment Reporting System (CPARS) report. Surveillance results, along with the contractor’s submittals, and overall fill rates will be used to develop metrics to track contractor’s overall compliance with contract terms and conditions.

2. The contractor shall maintain and implement a quality control plan to ensure the contract services conform to the requirements of the performance work statement. The QAP shall monitor contractor’s performance against this the requirements in the contract as outlined in this performance plan.

3. The multi-functional team reserves the right to conduct progress meetings, not less than semi-annually, with contractors to review performance. At these meetings, the Service Contract Manager and 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.

4. QAP shall complete a Quarterly Assessment Survey no later than the first week of January, April, July, and October. The report shall identify the number of assessments scheduled and conducted, the number of unacceptable performances observed, the number of CARs issued, number of valid complaints, any significant contractor performance discrepancies, and a rating of the Contractor’s overall performance. The QAP will complete a narrative summary of contractor performance and forward it to the Contractor, QAPC, FC/FD and CO that includes the following assessment elements. This information is strictly a tool to provide the contractor a snapshot view of their performance.

4.1. Performance Ratings. Contractor ratings and criteria are described below:

Performance

Rating Criteria

PERFORMANCE PLAN SECTION J

DOCUMENTATION REQUIREMENTS

1. GENERAL

All documentation of this surveillance plan will be marked, "FOR OFFICIAL USE ONLY."

1.1 General. All insight activity in support of the PERFORMANCE PLAN must be documented to provide the required objective evidence to justify Government acceptance. Thorough documentation of unperformed or poorly performed work is essential for tracking contractor performance throughout the period of performance. This documentation provides the CO with contractor status as it applies to the performance criteria and award fee data (if applicable). The QAPs, as trained inspectors, will document deficient work by compiling facts describing the inspection methods and results. The QAPs will develop documentation to substantiate nonconformance with the Contract. The documentation, together with any recommendations, will be forwarded to the contract administrator, who will decide whether to elevate the problem to the CO for corrective action.

1.2. The QAP is delegated by the CO via a QAP Duties and Responsibilities letter. The QAP's are required to maintain accurate records of the contractor's performance and keep the FC informed of all data pertaining to contractor status.

1.3. The QAP shall maintain the following documentation:

1.3.1. QAP Surveillance Folder. A surveillance folder must be developed and maintained by each QAP who is assigned to accomplish quality assurance for a performance requirement. The folder is typically contained in a hardcopy, but may be maintained in a computer database provided there is adequate back up of the data to preclude accidental loss. The folder may contain any other sections or information that the QAP finds useful. A template will be provided by contracting upon request.

1.3.2. Monthly Surveillance Schedule. A schedule that the QAP will develop that will list all of the monthly inspections scheduled for that potential month. Do not allow the contractor to see the schedule. QAP must complete the monthly schedule prior to the month to be surveyed and provide a copy to the CO no later than the fifth calendar day before the beginning of the period it covers. The functional director/functional commander (FD/ FC) must review and coordinate on it prior to submission to 39 CONS. A template will be provided by contracting upon request.

1.3.3. Surveillance Activity Log. A chronological log used by the Service Contract Manager to supplement the inspection records and provide a brief synopsis of contract assessment activities regarding contract performance. A template will be provided by contracting upon request.

1.3.4. Surveillance Assessment Report (SAR). A document used by the QAP to record surveillance activities listed under the Performance Objectives as it is accomplished. Any items inspected by QAP that are not identified in this plan must be documented and forwarded to the Contracting Office to make the appropriate modifications to the Plan. A template will be provided by contracting upon request.

1.3.5. Corrective Action Log. A chronological log used by the Service Contract Manager to record all CAR’s including date issued and any suspense’s. A template will be provided by contracting upon request.

1.3.6. Corrective Action Report (CAR). A CAR is used to document contract requirement findings and subsequent corrective actions taken whenever the contractor is not meeting contract quality requirements. A template will be provided by contracting upon request.

1.3.7. Customer Complaint Forms. Any MTF or Patient personnel that observe unacceptable services should complete Customer Complaint form. A template will be provided by contracting upon request.

1.3.8. Quarterly Assessment Survey. QAP shall complete a Quarterly Assessment Survey no later than the first week of January, April, July, and October. A template will be provided by contracting upon request.

1.4. Disposition of Documents. Documenting and maintaining records of all surveillance activities is required, and becomes a permanent part of the contract file. The QAP and/or FC must maintain contract surveillance files during the entire term of the contract and, at closeout of the contract, these files and records are to be provided to the CO for inclusion in the official contract file or for disposition as directed by the CO. At the completion of the contract, the FC will contact the CO for disposition instructions. This will include monthly-detailed records to substantiate that services were received or not received.

1.5. Unacceptable Performance Documentation. A section used for filing all documentation associated with contract quality assurance, e.g., CARs (both active and resolved), correspondence, the CO’s inputs/determinations, Cure Notices, Show Cause, and all supporting documentation.

2. CALCULATING CONTRACTOR COMPLIANCE

2.1. 100% INSPECTION

The following formula will be used to calculate contractor compliance when the aforementioned inspection methods are used.

2.1.1. QAE performed 100 observations in a given timeframe (normally measured monthly)

2.1.2. QAE noted 10 contractor non-compliances

2.1.3. # of defects (10) is divided by the # of observations performed (100)

2.1.4. Contractor is found to be 10% defective

2.1.5. This number is then subtracted from 100% to give you the percentage compliant

2.1.6. This number is then compared to the performance threshold to see if the performance objective is met.

Number of Defects Found

= % defective

Number of Observations Performed

2.2. CUSTOMER COMPLAINT

The following formula will be used to calculate contractor compliance when customer complaint is the method used to ensure contractor compliance.

2.2.1. Lot size – Number of times the Contractor performed a specific service in a given timeframe (normally measured monthly), e.g., 100 times

2.2.2. 10 customer complaints were submitted and validated

2.2.3. # of valid customer complaints (10) is divided by the lot size (100)

2.2.4. Contractor is found to be 10% defective

2.2.5. This number is then subtracted from 100% to give you the percentage compliant

2.2.6. This number is then compared to the performance threshold to see if the performance objective is met.

Number of Customer Complaints Submitted = % defective

Lot Size

Lot Size = Total number of service outputs in a surveillance period (normally a month).

(NOTE: The SDS, is the biggest influence on what is to be surveilled by the QA. If, for example, the SDS states that the contractor will be performing custodial services by square feet, then the QAE’s surveillance should parallel that objective.)

Defect = A service output that does not meet the terms and conditions of the contract.

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