Gen_Surg_QASP_(17_July_2014).pdf

For information only. Tailor to your requirement and agency policy

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

GENERAL

SURGEON SERVICES

(NON-PERSONAL SERVICE)

17 July 2014

TABLE OF CONTENTS

1 INTRODUCTION

1.1 Purpose

1.2 Performance Management Approach

1.3 Performance Management Strategy

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer

2.2 The Contracting Officer’s Technical Representative

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

4.2 Customer Feedback

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

5.2 Monitoring Forms

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.2 Reporting

6.3 Reviews and Resolution

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM…………………

QUALITY ASSURANCE SURVEILLANCE PLAN

(QASP)

1 INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled General Surgeon Services. This plan sets forth the procedures and guidelines 39MDG will use in ensuring the required performance standards or services levels are achieved by the contractor.

1.1 Purpose

1.1.1 The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the PWS and the contractor’s quality control plan (QCP), and to ensure that the government pays only for the level of services received.

1.1.2 This QASP defines the roles and responsibilities of all members of the integrated project team (IPT), identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

1.2 Performance Management Approach

1.2.1 The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results, not compliance). This QASP will define the performance management approach taken by 39MDG to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

1.2.2 Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

1.3 Performance Management Strategy

1.3.1 The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the government to take advantage of the contractor’s QC program.

1.3.2 The government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The government will make determination regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer

The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the “contracting officer's representative (COR)," "contracting officer's technical representative (COTR)" and the contractor. The CO will designate one full-time COR / COTR as the government authority for performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the CO.

2.2 The Contracting Officer’s Technical Representative

The contracting officer’s technical representative (COTR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COTR limitations are contained in the written appointment letter. The COTR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COTR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf.

Any changes that the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COTR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY

LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary.” If the contractor meets the required service or performance level, it will be paid the monthly amount agreed on in the contract. Failure to meet the required service or performance level will result in a deduction from the monthly amount.

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are as follows:

Random monitoring, which shall be performed by the COTR/COR designated inspector.

100% Inspection – Each month, the COTR/COR, shall review the generated documentation and enter summary results into the Surveillance Activity Checklist.

Periodic Inspection – COTR/COR typically performs the periodic inspection on a monthly basis.

4.2 Customer Feedback

The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems but the customer always has the option to communicate complaints to the 39MDG, as opposed to the contractor.

Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COTR/COR. The COTR/COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form – Customer Complaint Investigation, identified in Attachment 3.

Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes.

Performance standards are expressed in the PWS and are assessed using the performance monitoring techniques shown in Attachment 1.

5.2 Monitoring Forms

The government’s QA surveillance, accomplished by COR, or COTR, will be reported using the monitoring forms in Attachments 2 and 3. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results are being achieved.

5.2.1 The COR, COTR, CO, will retain a copy of all completed QA surveillance forms.

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.1.1 Government shall use the monitoring methods cited to determine whether the performance standards/service levels have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

6.2 Reporting

6.2.1 At the end of each month, the COR, will prepare a written report for the CO summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the contractor’s submitted monthly report and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

6.3 Reviews and Resolution

6.3.1 The CO may require the contractor’s project manager, or a designated alternate, to meet with the CO, COR, COTR, and other government personnel as deemed necessary to discuss performance evaluation. The CO, will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the COR, COTR, CO, as often as required or per the contractor’s request. The agenda of the reviews may include:

Monthly performance assessment data and trend analysis

Issues and concerns of both parties

Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

Recommendations for improved efficiency and/or effectiveness

6.3.2 The CO and contractor should jointly formulate tactical and long-term courses of action.

Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented.

Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the CO.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

7. SERVICE DELIVERY SUMMARY.

SDS Performance Objective

PWS

Para.

Performance Measure Surveillance Method

Frequency

1 Regular Clinical Services

Appendix B.2.

General surgeon available for duty, Ensure maximum compliance with contract hours for clinic and surgery cases performed monthly

95% Inspection

Monthly

2 Completes CHCS, AAAHC, or job specific data training as required.

1.6.5. Mandatory to initial or

maintaining job performance

Random As Needed

3 On-Call/After Duty Response Time

Appendix B.3

Within 60 minutes of notification for routine on-call consultation and 30 minutes for emergency requirement

95% inspection

Monthly

4 Documentation Accuracy/Timeliness

1.3.10. General surgeon shall

follow DoD, Air Force and MTF regulations and policies when documenting pharmacy interventions when required

95% inspection

Monthly

5 Patient Sensitivity 1.7.5. General surgeon shall respect the basic rights of patients, demonstrating concern for personal dignity

95% inspection

Monthly

6 Referrals and Consults

1.3.12. General surgeon shall

follow DoD, Air Force and MTF regulations and policies when arranging for a referral or consult

95% Inspection

Monthly

7 Medical Coding of Procedures/Office Visits

1.3.11. General surgeon must

accurately and timely code medical encounters

95% inspection

Monthly

8 Maintains patient privacy/ HIPAA compliance

6.4. General surgeon will have

zero breaches of privacy

100% Inspection

Monthly

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE

MONITORING FORM

Surveillance Assessment Report Contract Employee’s Name’s

Contract

Periods of Observation

Location (bldg, area, etc.)

Bldg 865, Contractor

The government will perform periodic surveillance to verify Contractor compliance with the following performance objectives. Surveillance Assessment Report will be completed on a monthly basis or as required.

Monthly SDS 1,Regular Clinical Services Rating

95% Inspection- General surgeon available for duty, Ensure maximum compliance with contract hours for clinic and surgery cases performed monthly

REMARKS:

Monthly SDS 2, Completes CHCS, AHLTA, or job specific data training as required by the 39 MDG, as necessary. Rating

Random Inspection- Mandatory to initial or maintaining job performance

Monthly SDS 3, On-Call/After Duty Response Time Rating

95%Inspection - Within 60 minutes of notification for routine on-call consultation and 30 minutes for emergency requirement

Monthly SDS 4, Documentation Accuracy/Timeliness Rating

95% Inspection - General surgeon shall follow DoD, Air Force and MTF regulations and policies when documenting pharmacy interventions when required

Monthly SDS 5, Patient Sensitivity Rating

95% Inspection - General surgeon shall respect the basic rights of patients, demonstrating concern for personal dignity

Monthly SDS 6, Referrals and Consults Rating

95 % Inspection - General surgeon shall follow DoD, Air Force and MTF regulations and policies when arranging for a referral or consult

Monthly SDS 7, Medical Coding of Procedures/Office Visits Rating

95% Inspection - General surgeon must accurately and timely code medical encounters

Monthly SDS 8, Maintains patient privacy / HIPPA compliance Rating

100% Inspection – General Surgeon will have zero breaches of privacy

//SIGNED//

Contracting Officer Representative