Otorhinolarynologist_Services_QASP_(11_Oct_16).pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

OTORHINOLARYNGOLOGIST SERVICES

INCIRLIK AB, TURKEY

ISSUED 11 OCTOBER 2016

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 Representative

3. IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

4. METHODOLOGIES TO MONITOR PERFORMANCE

4.1. Surveillance Techniques

4.2. Customer Feedback

4.3. Acceptable Quality Levels

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

7. ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

8. ATTACHMENT 2: 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 ENT Surgeon. This plan sets forth the procedures and guidelines 39 MDG 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 39 MDG 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) and the contractor. The CO will designate one full-time COR 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 Representative

The contracting officer’s representative (COR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR 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 COR 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 (include those that apply)

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

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

Periodic Inspection – COR typically performs the periodic inspection on an initial, monthly, or annual 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 COR and CO, 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 COR.

The COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form – Customer Complaint Investigation, identified in Attachment 2.

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

4.3. Acceptable Quality Levels

The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. For certain critical activities such as those listed below, the desired performance level is established at 100 percent. Other levels of performance are keyed to the relative importance of the task to the overall mission performance at 39

MDG.

− Routine Availability − On-Call/After Duty Response Time

− Documentation Accuracy/Timeliness − Possess CHCS and AHLTA Training − Medical Coding of Procedures/Office Visits − Referrals and Consults − Patient Sensitivity − Personal Reliability Program (PRP)

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 the COR, will be reported using the monitoring form in Attachment 2. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results for medical services are being achieved.

5.2.1. The COR 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/AQLs 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 COR may require the contractor’s project manager, or a designated alternate, to meet with the CO and other government IPT personnel as deemed necessary to discuss performance evaluation. The COR 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 and/or 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

Issues arising from the performance monitoring processes

6.3.2. The COR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

6.3.3. The COR 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.

7. ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

SDS Performance Objective

PWS

Para.

Performance Threshold

Surveillance Method Frequency

1 Routine Availability 1.2.2 Zero (0) tolerance, must be in compliance at all times.

100% Inspection Daily

2 On-Call/After Duty Response Time 1.2.2.1.

Zero (0) tolerance, must be in compliance at all times.

100% Inspection Daily

3 Language Requirements 1.3.1

Zero (0) tolerance, must be in compliance at all times.

90% Inspection Daily

4 License/Registration 1.5.1 Zero (0) tolerance, must be in compliance at all times.

Annual Inspection Annual

5 Board Certification 1.5.2 Zero (0) tolerance, must be in compliance at all times.

Annual Inspection Annual

6 Other Certifications 1.5.3 Zero (0) tolerance, must be in compliance at all times.

Annual Inspection Annual

7 Government Orientation 1.6 Zero (0) tolerance, must be in compliance at all times.

Initial Inspection Initial

8 Continuing Medical Education (CME) 1.6.3

Zero (0) tolerance, must be in compliance at all times.

Annual Inspection Annual

9 Annual Medical Evaluation 1.7.2

Zero (0) tolerance, must be in compliance at all times.

Annual Inspection Annual

10 Documentation Accuracy/Timeliness 1.10.7.

Zero (0) tolerance, must be in compliance at all times.

100% Inspection Daily

SDS Performance Objective

PWS

Para.

Performance Threshold

Surveillance Method Frequency

11 Possess CHCS and AHLTA Training 1.10.7.6

Zero (0) tolerance, must be in compliance at all times.

100% Inspection Annual

12 Medical Coding of Procedures/Office Visits 1.10.8.

Zero (0) tolerance, must be in compliance at all times.

100% Inspection Daily

13 Referrals and Consults 1.10.9.

Zero (0) tolerance, must be in compliance at all times.

100% Inspection Daily

14 Attendance at Meetings 1.10.11.

No more than 2 unplanned absences per quarter

95% Inspection Daily

15 Patient Sensitivity 1.10.15.

Zero (0) tolerance, must be in compliance at all times.

100% Inspection Daily

Health Insurance

Portability Accountability Act (HIPAA)

1.10.16 Zero (0) tolerance, must be in compliance at all

times.

Annual Inspection Annual

17 Personal Reliability Program (PRP) 1.10.19

Zero (0) tolerance, must be in compliance at all times.

100% Inspection Daily

8. ATTACHMENT 2: QUALITY ASSURANCE MONITORING FORM

Surveillance Assessment Report TO: Service Contract Manager, Medical Logistics Office FROM:

Contract Employee’s Name’s

Contract

Periods of Observation Location (bldg, area, etc.)

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.

SDS 1 Rating

Routine Availability

REMARKS:

SDS 2 Rating

On-Call/After Duty Response Time

SDS 3 Rating

Language Requirements

SDS 4 Rating

License/Registration

SDS 5 Rating

Board Certification

SDS 6 Rating

Other Certifications

SDS 7 Rating

Government Orientation

SDS 8 Rating

Continuing Medical Education (CME)

SDS 9 Rating

Annual Medical Evaluation

SDS 10 Rating

Documentation Accuracy/Timeliness

SDS 11 Rating

Possess CHCS and AHLTA Training

SDS 12 Rating

Medical Coding of Procedures/Office Visits

SDS 13 Rating

Referrals and Consults

SDS 14 Rating

Attendance at Meetings

SDS 15 Rating

Patient Sensitivity

SDS 16 Rating

Health Insurance Portability Accountability Act (HIPAA)

SDS 17 Rating

Personal Reliability Program (PRP)

//SIGNED//

Functional Representative Evaluator Designee

//SIGNED//

Contracting Officer Representative