TeleRadiology_Attachment_6_Quality_Assurance_Surveillance_Draft_TO.pdf

Quality Assurance Surveillance Plan (QASP) For the

TELERADIOLOGY SERVICES

Note: This is a draft QASP and the Government reserves the right to revise or change the QASP as determined by the Government to ensure quality service and deliverables over the course of the IDIQ contracts and/or task orders.

1. PURPOSE.

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to evaluate performance for the stated contract. This QASP explains the following:

What will be monitored?

How monitoring will take place.

Who will conduct the monitoring?

How monitoring efforts and results will be documented.

This QASP does not detail how the Contractor accomplishes the work. Rather, the QASP is created with the premise that the Contractor is responsible for management and quality control actions to meet the terms of the contract. It is the Government’s responsibility to be objective, fair, and consistent in evaluating performance. In addition, the QASP should recognize that unforeseen and uncontrollable situations may occur.

This QASP is a “living document” and the Government may review and revise it on a regular basis. However, the Government shall coordinate changes with the Contractor. Updates shall ensure that the QASP remains a valid, useful, and enforceable document. Copies of the original QASP and revisions shall be provided to the Contractor and Government officials implementing surveillance activities.

2. GOVERNMENT ROLES AND RESPONSIBILITIES.

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (CO) - The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also assure that the Contractor receives impartial, fair, and equitable treatment under this contract. The CO is ultimately responsible for the final determination of the adequacy of the Contractor’s performance.

b. Contracting Officer’s Representative (COR) - The COR is responsible for technical administration of the contract and shall assure proper Government surveillance of the Contractor’s performance. The COR shall keep a quality assurance file. At the conclusion of the contract or when requested by the CO, the COR shall provide documentation to the CO. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf. The Contractor shall refer any changes they deem may affect contract price, terms, or conditions to the CO for action.

c. Other Key Government Personnel - Facilities Health Services Administrators, Immigration and Customs Enforcement (ICE) Health Service Corps (IHSC) Headquarters Staff or Federal employees as designated by the COR and/or CO.

All Point of Contact’s information will be released upon award.

3. PERFORMANCE STANDARDS.

Performance standards define desired services. The Contractor is responsible for performance of ALL terms and conditions of the contract. CORs will provide contract progress reports quarterly to the CO reflecting performance on this plan and all other aspects of the resultant contract. The performance standards outlined in this QASP shall be used to determine the level of Contractor performance in the elements defined.

The Government performs surveillance to determine the level of Contractor performance to these standards.

The Performance Requirements are listed below. The Government will use these standards to determine Contractor performance and shall compare Contractor performance to the standard and assign a rating. At the end of the performance period, these ratings will be used, in part, to establish the past performance of the Contractor on the contract.

The Government will use these standards to determine Contractor performance and compare Contractor performance to the Acceptable Quality Level (AQL).

Table 1: Performance Requirements Summary (PRS)

Metric Unit of Measure Minimum AQL

Radiology Equipment Uptime – Unit of measure 100% > 99.0

Operating Schedule 24/7/365

Scheduled downtime </= 4 hours per month

Meantime between failure (MTBF) 25,000 operating hours

Overall Support Service Support availability 24/7/365

Radiology Reports of Finding

Radiographic reports of all radiographic images response time

</= 2 hours of acquisition of images at patient site

4. METHODS OF QUALITY ASSURANCE (QA) SURVEILLANCE

Regardless of the surveillance method, the COR shall always contact the Contractor's task manager or on-site representative when a defect is identified and inform the manager of the specifics of the problem. The COR, with assistance from the CO, shall be responsible for monitoring the Contractor’s performance in meeting a specific performance standard/AQL.

Various methods exist to monitor performance. The COR will use the surveillance methods listed below in the administration of this QASP.

a. PERIODIC INSPECTION.

Scheduled annually inspection of equipment or as required

Review of Contractor’s Monthly Operational and Technical Report of discrepancies with equipment performance and network connectivity status.

b. VALIDATED USER/CUSTOMER COMPLAINTS.

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 dives 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 of communicate complaints to the COR, as opposed to the Contractor.

Customer complaints, to be considered valid, must be set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR.

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

Review of identified deficiencies and or complaints made by users of the services

Investigate and validate

Review of notification of report discrepancies

c. 100% INSPECTION.

Contractor Radiologist Credentialing review annually

Contractor General Liability and Malpractice Insurance review annually

Review of Contractor’s Daily Images/Volume report by facility

Review of Contractor’s Monthly consolidated reports

Review of Radiology Equipment uptime

Review of Radiology Operational Schedule

Review of Scheduled Downtime

Review Meantime Between Failure (MTBF)

Review Overall Support Service Availability

d. Analysis of Contractor’s progress report. The Contractor is required to provide a weekly progress report that will be used to communicate the Contractor’s status in the Transition phase.

e. Performance reporting.

Performance

Requirement Performance Standard

Performance

Indicator

Performance

Level

Surveillance

Method

Credentials/privileging packets completed.

Para 4.1.3.

100% complete prior to being granted privileges.

Completed

Credentialing

Packets.

Meets - 100 %. Monitoring by

Contracting

Officer

Representative

(COR and Facility

POC

Read diagnostic studies within 4 hours of transmission from

IHSC/Non-IHSC;

interpreting radiologist immediately available to discuss findings with IHSC/Non-IHSC personnel. Para 4.1.3.

100% of studies must be completed within 4 hours of transmission. Due to critical nature of studies as they relate to direct patient care; requirement is absolute and allows for no deviation, unless due to acts of God.

Studies completed 4 hours.

Meets - 100 %. Monitoring by

Contracting

Officer

Representative

(COR and Facility

POC

Interpret and transcribe all reports in electronic

Health Record System

(eHR-S) within 4 hours after transmission from

IHSC/Non-IHSC.

All records must be kept

100% of time, and be made available within 4 hours upon request. All records must be kept

100% of time, and be made available within 4 hours upon request.

Report submitted within 4 hours.

Meets - 100 %. Monitoring by

Contracting

Officer

Representative

(COR and Facility

POC

Availability of after hour response

100% Meets - 100 %. Monitoring by

Contracting

Officer

Representative

(COR and Facility

POC

Surveillance results will be used as the basis for actions against the Contractor Past Performance Report. In such cases, the Inspection of Services clause in the Contract becomes the basis for the CO’s actions.

5. DOCUMENTING PERFORMANCE.

Documentation must be accurate and thorough. Completeness, currency, and accuracy support both satisfactory and unsatisfactory performance

a. ACCEPTABLE PERFORMANCE.

The Government shall document positive performance. A Quality Assurance Monitoring Form is attached. This report may become a part of the supporting documentation for fixed fee payments, award fee payments, or other actions.

b. UNACCEPTABLE PERFORMANCE.

When unacceptable performance occurs, the COR shall inform the Contractor. This will be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the Contractor's representative. A CDR template is attached to this QASP.

The Contractor will acknowledge receipt of the CDR in writing. The CDR will specify if the Contractor is required to prepare a corrective action plan to document how the Contractor shall correct the unacceptable performance and avoid a recurrence. The CDR will also state how long after receipt the Contractor has to present this corrective action plan to the COR. The Government shall review the Contractor's corrective action plan to determine acceptability.

Any CDRs will become a part of the supporting documentation for Past Performance.

6. FREQUENCY OF MEASUREMENT.

While the Contractor is fully expected to comply with all requirements in the PWS, the Government’s assessment of Contractor performance will focus mainly on the objectives listed in the AQL column of the Performance Standards Summary Matrix. The COR will monitor the Contractor’s performance to ensure it meets the standards of the contract. Unacceptable performance may result in the Contracting Officer taking any of the following actions: Require the Contractor to take necessary action to ensure that future performance conforms to contract requirements, reduce the contract price to reflect the reduced value of the services, issue a Contract Discrepancy Report, or require the Contractor to re-perform the service. In addition, the Contractor’s performance will be recorded annually in the Contractor Performance Assessment Report (CPAR).

Signature – Contracting Officer’s Representative

Signature – Contracting Officer

QASP QUALITY ASSURANCE MONITORING FORM

REQUIRED TASKS/SERVICES:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint

LEVEL OF SURVEILLANCE (Check):

Monthly Quarterly As needed

ANALYSIS OF RESULTS:

Documented Performance Measurement Rate (# of errors): ______ (AQL = 5 or fewer errors)

Reviewer’s Performance Assessment (Check): Meets Standards Does Not Meet Standards

Narrative of Performance during Survey Period:

PREPARED BY: __________________________________________ DATE: _________________

Contract Discrepancy Report

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER

Report Number: Date:

2. TO: (Contractor and Manager Name)

3. FROM: (Name of COR)

DATES

CONTRACTOR NOTIFICATION

CONTRACTOR RESPONSE DUE

BY

RETURNED BY CONTRACTOR ACTION COMPLETE

4. DISCREPANCY OR PROBLEM (Describe in Detail: Include reference in PWS / Directive: Attach continuation sheet if necessary.)

5. SIGNATURE OF CONTRACTING OFFICER’S REPRESENTATIVE (COR)

6. TO: (COR)

7. FROM: (Contractor)

8. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT RECURRENCE. ATTACH

CONTINUATION SHEET IF NECESSARY. (Cite applicable Q.A. program procedures or new A.W. procedures.)

9. SIGNATURE OF CONTRACTOR REPRESENTATIVE

10. DATE

11. GOVERNMENT EVALUATION OF CONTRACTOR RESPONSE/RESOLUTION PLAN: (Acceptable response/plan, partial acceptance of response/plan, rejection: attach continuation sheet if necessary)

12. GOVERNMENT ACTIONS (Payment withholding, cure notice, show cause, other.)

CLOSE OUT

NAME AND TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER