A1g_PP_Ambulatory_Accred_Surveys_4-9-10.pdf

AIR FORCE MEDICAL OPERATIONS AGENCY

PERFORMANCE PLAN

FOR

Accreditation Surveys for Ambulatory Medical Treatment Facilities

30 March 2010

SECTION 1.0

1.1 Purpose: This Performance Plan (PP) has been developed and will be implemented in accordance with AFI 63-124, Performance-Based Services Acquisition (PBSA) guidelines. This plan will be used to support the Air Force Medical Operations Agency (AFMOA) with Accreditation Surveys for Ambulatory Medical Treatment Facilities.

1.2 Objective: This PP is based on the premise that the Contractor is responsible for contract management and quality control, not the Government. The Government’s objective is to obtain “Accreditation” for all AFMOA Ambulatory Medical Treatment Facilities by a nationally recognized Center for Medicare and Medicaid Deemed accrediting organization in accordance with the DoD and contractor standards, policies and procedures.

1.3 Results: The results in managing this acquisition through this PP are to provide AFMOA with a support contractor with the ability to conduct the required surveys and provide accreditation to all AFMOA Ambulatory Medical Treatment Facilities. Success for this contract is defined as achieving these outcomes as stipulated in the Performance Work Statement (PWS) and that the government receives the services it is paying for.

1.4 Incentive Plan: Positive incentives as a result of performance that continually exceeds the performance objectives as outlined in the PWS may result in reduced surveillance and favorable Contractor Performance Assessment Reports (CPAR). Negative performance incentives include re-performance of the defective service in accordance with the Inspection of Services clause, reduction of fee/price, negative CPAR reporting and/or increased surveillance.

1.5 Multi-Functional Team Roles & Responsibilities. The purpose of the multi-functional team is to create an environment that shapes and effectively executes acquisitions within their purview. The emphasis is on teamwork, trust, common sense and agility. These stakeholders are responsible for the acquisition throughout the life of the requirement, instituted under the authority of the senior leadership; every representative within the multi-functional team brings to the team their unique level of expertise. The following members will participate in the performance management of this specific contract. Their roles and responsibilities are described as follows:

1.5.1 The Functional Commander/Functional Director (FC/FD): Has overall responsibility for identifying mission essential services and developing the necessary documents in accordance with DoDI 3020.37, Continuation of Essential DoD Contractor Services During Crisis, assigning primary and alternate Quality Assurance Personnel

(QAP) who will be available full time or as warranted by the procurement cycle, and reviewing contractor performance documentation on a regular basis to ensure performance is compatible with contract and mission objectives while supporting a higher level of contractor performance, and fostering synergistic partnerships.

1.5.2 The Program Manager (PM): Has the overall responsibility for initiating, managing and tracking the various programs/projects that support the contract. The PM is the primary liaison of the contractor employees’ performance and the Contracting Officer (CO) and the Quality Assurance Person (QAP). The PM is responsible for assisting in the preparation of requirements documents providing customers with a single contact point, monitoring the contractor’s overall performance of all assigned contracts, task orders and initiating contract changes and other supporting documentation.

1.5.3 The Contracting Officer (CO): Has overall responsibility for overseeing the contractor’s performance. The CO, through assigned QAP monitors contractor performance in the areas of contract compliance, contract administration and cost control. The CO resolves all differences between the QAP version and the contractor’s version of events by reviewing the QAP’s assessment of the contractor’s performance.

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. The CO and PM share joint responsibility in facilitating the multi-functional team meetings.

1.5.4 The Quality Assurance Person (QAP): Has the responsibility for the contractual/ technical monitoring of the contractor’s performance and assessing, recording, and reporting on the contractor’s compliance with the terms and conditions of the contract.

The QAP is the primary liaison between the CO and the PM. The QAP will insure availability to receive Phase 1 & Phase 2 training prior to performing contractor surveillance. The QAP will ensure that contract surveillance documentation is accomplished, and notify the Functional Commander/Functional Director (FC/FD), through the PM and CO, of any significant performance deficiencies, and recommend improvements to the PP and PWS throughout the life of the contract.

1.5.5 The Contractor: Is responsible for complying fully with the terms and conditions of the contract, participating as a member of the multi-functional team in the post-award management phase, maintaining and implements a Quality Control Plan (QCP) that compliments the performance plan, insuring that non-conforming contract services are identified, and corrected. When necessary, revising the QCP to prevent recurrence.

Responsible for tendering to the Government for acceptance only those services that conform to contract requirements and recommending any changes to the contract that will provide more effective operations or eliminate unnecessary costs.

SECTION 2.0

2.1 Methods of Inspection Applicable To This Contract. This is a Firm Fixed-Price contract for acquiring the described services.

2.1.1 Periodic/Random Inspection: These items are inspected using periodic surveillance

(daily, weekly, monthly, quarterly, etc.) as determined by the QAP. The results of the periodic/random surveillance inspections may be used as the basis for actions towards the contractor. In such cases, the Inspection of Services clause becomes the basis for the contracting officer’s actions. Periodic/random inspections may be conducted via site visit to verify progress on site or telephone calls with on site representatives, review of contractor reports and other deliverable documents. The QAP will have access to all surveillance monitoring, meetings, and evaluation discussions conducted by the surveyors to include full access to the surveyor on site work area.

2.1.2 100% Inspection: These items are inspected on every instance they are performed.

The QAP will determine acceptability and compliance with the performance threshold by monitoring and tracking each deliverable document. Technical documents and other deliverable documents will be reviewed for technical accuracy and compliance with technical directives. The results of this inspection may be used as the basis for actions (other than payment deductions) towards the contractor. In such cases, the Inspection of Services clause becomes the basis for the contracting officer’s actions.

2.1.3 Customer Feedback: The QAP is the primary point of contact for collection of all customer feedbacks. The Customer Feedback Form (Appendix D to the PWS) or a contractor furnished form approved by the Government may be used for this purpose.

All feedbacks and any resulting resolution of such complaints must be documented.

Customer feedback forms and supporting documentation become a permanent part of the QAP surveillance records. The QAP will contact each customer involved with this contract periodically to assure there is an understanding of the contract requirement by all appropriate personnel and that they have a sufficient number of customer feed back forms. Positive feedback will also be maintained for inclusion in the final CPARs for this contract.

2.1.4. Contract Services Summary with Inspection Methods.

Performance Objectives PWS Paragraph

Performance Threshold Surveillance Method

Scheduling of accreditation surveys of Air Force MTFs

2.1.3 100% No later than (6) six months prior to the beginning of the first survey for the year

100% Inspection QAP reviews invoices

Notice of any survey not previously coordinated with

AFIA/SG, QAP

2.1.6 100% notification with AFIA/SG and QAP 10 working days prior to the survey

100% Inspection QAP reviews delivery of annual schedule from AFIA

Survey application from the MTF only during the required survey year

2.1.7. 100% applications only during scheduled survey year

Periodic Surveillance Quarterly

Notify the MTF and AFMOA/SGHQ Quality Assurance Person (QAP) in writing and electronically, prior to the date of the survey

2.1.8 100% notification with AFIA/SG and QAP 7 business days prior to survey

100% Inspection QAP reviews delivery of annual schedule from AFIA

Notify the (QAP), in the event MTFs are not updating their application information in accordance with contractor application requirements

2.1.9 100% notification to the

QAP

100% Inspection QAP reviews delivery of annual schedule from AFIA

Participate in daily discussion with AFIA HSI team and incorporate findings in final report

2.1.16 Provide evidence of

Crosstalk in the final report 90% of the time

Customer Feedback

Contractor Program Manager to provide assistance to MTFs, MAJCOMs, AFIA, AFMOA/SGHQ before, during and after application process and inspections.

2.2.7. Responds to telephone calls

and email inquiries within 24 hours or receipt during normal contractor business hours

Customer Feedback

2.2 Performance Status Notification: The QAP will ensure that the CO is continually informed of contract performance status. The CO should also be informed of any contract discrepancies noted during QAP surveillance.

2.3 Discrepancy Reporting: The QAP will notify the CO of any discrepancies noted during inspections. This notification is for discrepancy correction only and does not indicate concurrence to the discrepancy. The QAP will also notify the PM and the CO of all discrepancies noted during the surveillance. The frequency and method of notification to the CO will be provided to the QAP/QAE during Phase 2 training.

2.4 Remedies for Unacceptable Performance: 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 Contractor personnel and recruitment of substitute personnel that are equally qualified within established timeframes. When the defects in services cannot be corrected by re-performance, the Government may:

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

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

2.4.3 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

2.4.3.1 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

2.4.3.2 Decrement invoice as stated in the PWS related to performance; or terminate the contract.

2.5 Non-SS (Non-Service Summary) Items: Quality performance is expected on all contract requirements (Non SS) items by the contractor. All Non-SS items may be inspected by the QAP to include on site locations.

2.6 Certification of Services: Certification of services is performed by the QAP and or the PM via Wide Area Work Flow (WAWF) system. At the end of each billing period the contractor inputs invoice information in the WAWF system. The WAWF automatically notifies the appropriate QAP via email of pending invoice. The QAP accesses WAWF and verifies accuracy of the contractor’s data. If data is correct the QAP certifies invoice and payment is affected by the Defense Finance Accounting System. If the QAP encounters errors in the contractor’s invoice, the QAP will resolve with the CO. If the contractor disagrees with the QAP the issue is forwarded to the CO for resolution.

SECTION 3.0

CONTRACT MANAGEMENT

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

3.1.1 QAP 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. Assessment results will be used to develop metrics to track Contractor’s overall compliance with contract terms and conditions.

3.1.1.1 QAP FILE. A contract file must be established and maintained by the QAP assigned to the contract. The file is typically contained in hard-copy, but may be maintained in a computer data base provided there is adequate back up of the data to preclude accidental loss. Any computer maintained documents must be readily available for inspection by the contracting office and possible audits. All contract documents must be maintained for the life of the contract and turned in to the contracting office upon contract expiration, including all computer maintained documents. The contract file must contain as a minimum, the following documents and be set up utilizing an index:

a. Appointments. QAP assignment letters by the FC, the CO’s Letter of Delegation to the QAP, CO notification to the contactor of QAP assignment, Phase I & II training certificates.

b. Contract Documents. The Contract with all modifications (modifications to be posted to the contract), directive document references, maps, pertinent terms defined by the contract, equipment listings, Quality Assurance Surveillance Plan (QASP).

c. Surveillance Documentation. All surveillance inspections performed must be documented by the QAP and maintained in this section. Any customer complaint training and all customer complaints and resolution thereof will be maintained in this section. Other information that may be included are details of inspections or data gathering, conversations or meetings with the contractor, notes and comments that support the inspection paperwork.

d. Meeting Minutes: Copies of all MFT minutes (minimum annual) and Periodic Progress Meeting minutes (frequency to be determined at contract start and may be adjusted accordingly).

e. Unacceptable Performance. Documentation. A section used for filing all documentation associated with contract quality assurance correspondence, the COs inputs/determinations, Cure notices, Show Cause with all supporting documentation.

f. Acceptance and Funding Issues. A copy of the Service Contractor Monthly Satisfaction Survey will be maintained in this section. This is also the location to maintain AF9s, delivery orders, funding issues etc.

g. Reports/Submittals. Contractor reports/submittals as directed by the PWS.

h. Correspondence. Any other documentation that does not fall into sections listed above.

i. Lessons Learned. Document here any areas that you determine need to be changed/amended in future contracts. I.e. accountability issues, better description of work hours, cost and performance constraints.

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

3.2 Periodic Progress Meetings (PPM): The multi-functional team shall conduct periodic progress meetings, not less than quarterly/Annually/Semi Annually, to review the contractor’s performance. At these meetings the Contracting Officer will 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 Contracting Officer, in writing, of any work being performed, if any, that the contractor considers over and above the requirements of the contract. Appropriate action shall be taken to resolve any outstanding issues.

3.3 Contract Administrator Responsibilities: These responsibilities shall be in accordance with Federal Acquisition Regulation 42.201—Contract Administration Responsibilities.

SECTION 4.0

ASSESSMENT PROCEDURES

4.1 Assessment Schedule.

4.1.2 The QAP will develop an assessment schedule, based on this performance plan’s requirements. A locally devised form may be used. An annual surveillance schedule may be used. The schedule will be completed no later than 7 calendar days before the beginning of the period it covers. Copies of the assessment schedule shall be provided to the FD/FC and the Contracting Office before the start of the assessment period. Assessment schedules, when completed, shall be marked “For Official Use Only” and shall not be shown to the contractor.

4.1.3 Changes to the assessment schedule shall be posted promptly. Copies of the changed schedule shall be sent to the FD/FC and the Contracting Officer. 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.

4.2 Assessment of SS Items.

4.2.1 It is essential that the QAP conduct assessments in accordance with projected assessment schedule for an effective quality assurance program. Mission requirements may require deviations from the assessment schedule. Assessment should be performed as close to the schedule as is practicable. QAP shall document assessment as it is conducted.

4.2.2 The QAP shall conduct assessment of the contractor’s performance by determining whether or not the performance meets the standards contained in the contract, the PWS and the SS items.

4.2.3 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 QAP conducting the assessment. When QAP determine that contractor performance is unacceptable, the specific reason for the unacceptable performance shall be recorded on the QAP’s assessment documentation.

4.3 Assessment of non-SS Items. 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, the QAP has the right to conduct assessment for SS items and non-SS items to include on site locations. When the QAP identifies unacceptable performance on non-SS items, the QAP shall follow the procedures in section 2.4 of this performance plan, entitled Remedies for Unacceptable Performance.

4.4 Customer Complaints. QAP shall ensure complaint procedures and forms are made available to all customers. The requirement to inform the customers may belong to the Contractor or the QAP depending how the PWS is written. Any personnel that observe questionable services, incomplete, not performed, or performed improperly, should immediately contact the QAP. QAP shall receive, document, and validate or invalidate all complaints. If the complaint is invalid, the QAP shall contact the complainant and explain why the complaint was invalid. QAP shall fully document the resolution for each complaint on the Customer Complaint Record. QAP shall complete and issue the contractor a Corrective Action Report (CAR) for all valid complaints. If the Contractor challenges the validity of any complaint, and the QAP and contractor cannot come to agreement, the complaint in question shall be forwarded to the Contracting Officer for resolution. Complaints will be tracked and if the performance threshold is exceeded, the QAP shall notify the Contracting Officer in writing. The Contracting Officer will notify the contractor and appropriate action can be taken.

Courtesy copy will be provided, contractor, QAP, Contracting officer, and the complainants.

4.5 QAP Monthly Report. QAP shall submit a monthly summary assessment report to the CO and FC/FD no later than the first week (5 business days) of the month following the assessed month. The report shall identify the number of assessments scheduled and conducted, the number of unacceptable performances observed, the number of Corrective Action Reports issued, number of valid complaints, any significant contractor performance discrepancies, and a rating of the Contractor’s overall performance. The report shall be signed and dated by the QAP and FC/FD and a copy provided to the CO.

4.6 Service Contract Monthly Satisfaction Survey. (SCMSS) (Appendix 1). Monthly, the QAP is required to complete a SCMSS rating contractor performance for the past month. The QAP should look back at the monthly inspection results to rate the contractor. Elements included in the SCMSS are:

(1) Promptness of Service. Assess the timeliness of the contractor’s performance against contract requirements.

(2) Quality of Service. Assess the contractor’s conformance to contract requirements and standards of good workmanship (i.e. commonly accepted technical, professional, environmental or safety standards).

3) Courtesy/Cooperation by Contractor Personnel. Are open lines of communication maintained? Are contractor personnel courteous in dealing with customers and government representatives? Are problems resolved at the lowest level when possible?

4) Response to Defective Notices and Customer Complaints. Does contractor respond timely to customer complaints and provide satisfactory resolution? Are QAP directed re-performances accomplished within the allowed time frames?

5) Overall Satisfaction with the Service Received. Provide your rating as to the contractor’s ability to meet overall contract performance for the month.

6) Candid Comments. Provide comments to support lower ratings, comments to support exceptional ratings, etc.

Performance Ratings. The ratings used for the SCMSS are described by one of the following five adjectives: 5 = Exceptional, 4= Very Good, 3= Satisfactory, 2= Marginal and 1=Unsatisfactory. These terms are subjective and are not derived through use of any mathematical computations or formulas. The QAP will rate each one of the above assessment elements explained in paragraph b above, using one of the following ratings in their narrative summary. The criteria for each rating are reflected below:

RATING #

(5) Exceptional. Performance meets contractual requirements and *exceeds many to the governments benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

(4) Very Good. Performance meets contractual requirements and *exceeds some to the governments benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were highly effective.

(3) Satisfactory. Performance *meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

(2) Marginal. Performance *does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

(1) Unsatisfactory. Performance *does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

*Key Guidance to Ratings

Appendix 1, dated __________

SERVICE CONTRACT MONTHLY SATISFACTION SURVEY

SUBJECT: SERVICE CONTRACT MONTHLY SATISFACTION SURVEY

CONTRACT #: XXXXXX_XX_XXXXXX SERVICE:_______________________

MONTH/YEAR:____________________

Objective

Threshold

Performance Level

Valid Customer Complaints / Reperformance

General Contractor Satisfaction Promptness of the Service 5 4 3 2 1 Quality of the Service 5 4 3 2 1 Courtesy/Cooperation by Contractor Personnel 5 4 3 2 1 Response to Defective Notices and Customer Complaints

5 4 3 2 1

Overall Satisfaction with the Service Received 5 4 3 2 1

NOTE: 5=Exceptional, 4=Very Good, 3=Satisfactory, 2=Marginal, 1=Unsatisfactory

YOUR CANDID COMMENTS:

Quality Assurance Personnel Functional Commander

Contracting Officer