HT0011-20-R-0043 HFAS PWS Attachment 8 - Quality Assurance Surveillance Plan (QASP).pdf

HT0011-20-R-0043

Attachment 8 – Quality Assurance Surveillance Plan

Quality Assurance Surveillance Plan (QASP)

Military Medical Treatment Facility Accreditation

Defense Health Agency Medical Affairs Directorate

Clinical Support Division, Clinical Quality Management Branch Accreditation and Compliance Program

1. Purpose.

This Quality Assurance Surveillance Plan (QASP) is a government developed document used to outline the standard for surveillance of the accreditation services provided to the Defense Health Agency (DHA) military medical treatment facilities (MTF), Markets, Regions, and Headquarters through the Medical Treatment Facility Accreditation Services Contract. The QASP provides the approach the government will use to conduct surveillance of the contractor’s performance on the requirements in the contract. The intent is to ensure that the contractor performs in accordance with the performance metrics set forth in the contract documents; the Government receives quality services for the tasks in the contract; and the Government only pays for services provided at an acceptable level of performance.

2. Scope.

The QASP is implemented to provide government surveillance of the contractor’s performance and quality control efforts to assure timely, and effective services that result in compliance with the requrements of the contract. The QASP is not intended to duplicate the contractor’s internal quality management efforts.

3. Govnment Roles and Responsibilities.

3.1 The following personnel shall oversee and coordinate surveillance activities.

3.1.1. Contracting Officer (CO): The 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 a COR in writing as the government representative for performance management. The number of additional government representatives serving as 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.

3.1.2. COR: The COR is designated in writing by the CO to act as his or her authorized representative. The COR will assist the CO with the technical administration of the contract to ensure proper government surveillance of the contractor’s performance. Any COR limitations will be identified with the designation letter. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf.

Any changes the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COR is responsible for quality assurance (QA) monitoring and completion of forms/reports used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the terms and conditions of the contract.

3.1.3. Other Key Government Personnel. Upon award, the government may enter performance monitors, clinical quality experts, etc., who may provide input to the COR for reporting purposes.

3.1.4. The following contract service provider will serve as the contractor’s representative for this contract: (Upon award, government will enter name(s)).

4. Inspection Instructions.

4.1. The contractor shall provide and maintain a quality control system acceptable to the government covering the services under this contract. Complete records of quality control work performed for the contract by the contractor will be maintained and made available to the Government during contract performance.

4.2. 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 additional cost to the government. When the defects in services cannot be corrected by re-performance, the Government may require the contractor to take necessary action to ensure that future performance conforms to contract requirements and reduce the contract price to reflect the reduced value of the services performed.

4.3 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. The government shall perform inspections and tests in a manner that will not unduly delay the work.

4.4 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, 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 terminate the contract for default.

4.5. If the government performs inspections or tests on the premises of the contractor or a subcontractor, the contractor shall furnish, and shall require subcontractors to furnish, at no increase in contract price, all reasonable facilities and assistance for the safe and convenient performance of these duties.

5. Methods of Inspection

5.1. The method of inspection and the level of surveillance used will be reflected in the PRS under the “Method of Inspection” column and must match what is selected on the QASP Checklist.

5.2. The below listed methods of surveillance may be used in the administration of this QASP.

5.2 1 100% Inspection. The COR may conduct 100% inspections of the work defined in the performance work statement (PWS). The COR will also review information submitted in the required reports defined in the PWS (if applicable).

5.1.2 Periodic Inspection. The government may conduct periodic inspections monthly, quarterly, or on an as-needed basis. The periodic inspection shall be conducted by the COR.

5.2.3 Random Inspection. The government may conduct random monitoring by reviewing information/reports required and submitted in accordance with the contract. The random monitoring shall be performed by the COR.

5.2.4 Performance Evaluation Meetings. The contractor and the COR will meet as often as necessary to review the contractor’s performance and address any contract discrepancy reports (CDRs) issued during the period. A mutual effort will be made to resolve identified issues.

5.2.5 Customer Feedback – The COR may provide and collect customer surveys or complaints regarding performance. A mutual effort will be made to resolve any problems/issues identified.

5. 3. Level of surveillance may be conducted on a monthly, quarterly or as-needed basis and an analysis of the results will determine if the contractor met the standards or did not meet the standards identified in the PWS/contract.

6. Performance Requirements Summary (PRS).

Performance Objective

PWS Reference Acceptable Quality Level (AQL)

Method of Surveillance

PRS # 1

CM and AM identified with three days after contract award and available between 9:00 a.m. to 5:00 p.m. Eastern Standard Time Monday thru Friday other than Federal Holidays or Government closure to respond to inquiries within two business days

1.12 95% compliance in CM and AM or alternate availability and response time

Periodic surveillance conducted monthly

Performance above or below the standard will be documented in the monthly contract report and documented in the CPARS

PRS # 2

Provided team of subject matter experts to serve as surveyors for onsite surveys based MTF size and the healthcare services offered.

5.1 and 5.4.2 Zero deviation allowed;

100% compliance required with the correct surveyor volume and subject matter expertise for accreditation survey according to AO policy and MTF size and services

100% inspection of assigned survey team on accreditation survey schedule

Performance above or below the standard will be documented in the monthly contract report and documented in the CPARS

PRS # 3

Schedule and conduct onsite routine unannounced accreditation compliance surveys based on MTF triennial survey date

5.1 and 5.4.3 Zero deviation allowed;

100% compliance required with timing of survey to ensure MTF is surveyed at least every 36 months to maintains accreditation

100% inspection of accreditation survey schedule

Performance above or below the standard will be documented in the monthly contract report and documented in the CPARS

PRS # 4

Schedule and conduct onsite Patient Centered Medical Home certification based on recognized medical home model standards on a triennial basis

5.1 and 5.3 Zero deviation allowed;

100% compliance required with timing of onsite certification to ensure MTF maintains PCMH certification

100% inspection of certification site visit schedule

Performance above or below the standard will be documented in the monthly contract report and documented in the CPARS

PRS # 5

Notifications to the DHA Accreditation Services COR on timing of surveys CONUS - at least 7 business days prior to the start of a routine unannounced survey OCONUS - 30 business days prior to the start of a routine unannounced survey

5.4.3.2.2 95% compliance with Notification +/- 2 days of the required time CONUS - at least 7 business days OCONUS - 30 business days

100% inspection of receipt of notification tracked on a monthly basis

Performance above or below the standard will be documented in the monthly contract report and documented in CPARs

PRS # 6

Notifications to the DHA Accreditation Services COR of Schedule to conduct unannounced special interest surveys prompted by substantiated complaints, whistleblower reports, news media coverage or the identification of a significant event affecting quality and/or safety of health care delivered at a DHA MTF.

5.4.3.3.1 Zero deviation allowed;

100% compliance with Notification of the COR NLT 24 hours prior to the start of the special interest survey

100% inspection of receipt of notification tracked on a monthly basis

Performance above or below the standard will be documented in the monthly contract report and documented in the CPARS

PRS # 7

Develop and provide DHA MTF and COR a comprehensive post survey report on all completed surveys within 10 business days

5.4.4 95% compliance with provision of comprehensive survey report for each completed survey in +/- 2 days of the required timeframe.

100% inspection of receipt of comprehensive report by the MTF and COR tracked on a monthly basis.

Performance above or below the standard will be documented in the monthly contract report and documented in the CPARS.

PRS # 8

Provide online access to Self-assessment tools to include annual standards self-assessment; Continual Compliance Tracer Tool and Assist Visit Support Tool

5.5.1; 5.5.2 and 5.5.3 90% compliance with access to the tools 24 hours / 7 days except during schedules maintenance and access to the self-assessment tool within 20 days of contract award

Random sampling of self-assessment tools availability and usability tracked monthly

Performance above or below the standard will be documented and reported in the monthly contract report and documented in the

CPARS

PRS # 9

Provide initial and ongoing training for the use of the online self-assessment tools

5.5.2.5 95% compliance with initial custom training with 60 days of award and ongoing training support coordinated with the COR

100% inspection for the initial training

Random sampling of ongoing training.

Performance above or below the standard will be documented and reported in the monthly contract report and documented in the

CPARS

PRS # 10

Provide online access to program-specific newsletters and periodic web or audio programs

5.9.4 100 % access required program-specific newsletters and periodic web or audio programs

100% inspection of access to program-specific newsletters and periodic web or audio programs tracked monthly by the COR.

Performance above or below the standard will be documented and reported in the monthly contract report and documented in the

CPARS

PRS # 11

Provide Comprehensive Systematic Analysis (CSA) review to MTF within 30 calendar days of submission to the Accrediting Organization

5.9.5.2 95% compliance with Comprehensive Systematic Analysis (CSA) review conducted +/- 2 calendar days of the required timeframe.

100% inspection of completion time for CSA tracked by the submitting MTF and reported to the COR.

Performance above or below the standard will be documented and reported in the monthly contract report and documented in the

CPARS

PRS # 12

Design and present required webinar series and custom training of DHA personnel through planning and coordination with the COR.

5.10 Zero deviation allowed;

100% compliance with content, timing and presentation of knowledge development webinars and custom training as required in the contract, 100% inspection of knowledge development webinars and custom training content, timing and presentation

Performance above or below the standard will be documented in the monthly

PRS # 13

Maintain confidentiality medical quality assurance and patient data per 1102 and HIPPA requirements, Privacy Act and HIPAA rules

6.3.1 No deviation allowed;

100% compliance required.

No unauthorized disclosure of information protected by the Privacy Act and HIPAA.

Performance above or below the standard will be documented in the monthly

A. 100 % Inspection: One Hundred Percent Inspection is exactly what the title implies – inspecting a requirement every time it occurs.

B. Customer Complaint: A customer complaint is a valid complaint when the Quality Assurance Plan (QAP), after a thorough investigation, determines that 100% of Medical Standards of Care have not been met.

C. Other Primary Surveillance Methods – Random sampling, customer complaints, 100% surveillance, inspections, reports, etc.

7. Successful Performance.

7.1. Successful performance can be incentivized with favorable past performance ratings and award of follow-on opportunities.

7.2. Acceptable services for performance is demonstrated by an accepted and executed certified invoice and receiving report, as applicable.

7.3. The acceptable quality level (AQL) consists of the performance standards established for the services required by the government to meet contract requirements. The AQL will be measurable and structured to permit an assessment of the contractor’s performance.

8. Documentation of Surveillance.

8.1. Effective contract surveillance relies on the COR identifying and documenting discrepancies during performance of routine daily services, or through the contractor’s quality control program. The COR will report discrepancies to the contractor for timely resolution. Survelliance may consist of periodic reports, and customer feedback and timeliness of contract deliverables/reports.

8.2. The COR will maintain a complete QA file which will be retained by the COR for the life of the contract.

Information in the QA file will be considered when completing the annual CPARS report.

8.3. Documented surveillance will consist of inspections performed by the COR. Examples of documentation that supports contract surveillance consist of details of inspections or data gathering, conversations or meetings with the contractor, notes and comments that support inspection paperwork, to include quality assurance surveillance reports.

If performance is deemed unacceptable, the COR will inform the contractor about possible reperformance soultions.

Disagreements or disputes will be referred to the KO for review.

8.4. All documentation resulting from surveillance will be made a part of the contract file. The COR must keep the QA files during the surveillance period, but at the conclusion of the contract, and as directed by the KO, the COR must give the files to the KO for inclusion in the official contract file.

9. Corrective Actions.

9.1. The contractor will be provided the opportunity to submit proposed corrective action to resolve the discrepancy.

The COR will review proposed corrective action and determine whether or not it is acceptable and whether or not the discrepancy has been corrected. If the discrepancy has been resolved, the COR will notify the contractor and document the quality assurance surveillance checklist.

9.2. The COR will notify the CO of unacceptable performance if any services do not conform to contract requirements. The contracting officer may require the contractor to re-perform the services to conform with contract requirements at no additional cost to the Government.

9.3. When unacceptable performance cannot be corrected by re-performance, the Government may require the contractor to take action necessary to ensure future performance conforms with contract requirements.

9.4. The Government may, by separate contract or otherwise, perform the services and charge the contractor any cost incurred that is directly related to the performance of such service, or issue:

9.4.1. Cure Notice

9.4.2. Show Cause

9.4.3. Terminate the contract for convenience of the government

9.4.4. Terminate the contract for cause

10. Certification of Services. Certification of services is performed by the COR via Wide Area Work Flow (WAWF) system. At the end of each billing period, the contractor inputs invoice information into WAWF system. WAWF automatically notifies the appropriate COR via email of pending invoice. COR accesses WAWF and verifies the accuracy of services provided by the contractor. The COR will certifiy the invoice and payment is conducted by the Defense Finance Accounting System (DFAS). If the COR encounters errors in the contractor’s invoice, the COR will reject the invoice, state the reason for rejection and WAWF will send the invoice back to the contractor. If the contractor disagrees with the COR, the issue will be forwarded to the CO for resolution.

11. QASP Checklist, Enclosure 1 to QASP

12. Contract Discrepancy Report (CDR), Enclosure 2 to QASP (Optional)

Enclosure 1 to QASP QASP Checklist

Service or Standard:

Survey Period: ___________________________________________________________

Surveillance Method: (Check) (The method of inspection and the level of surveillance selected must match what is reflected in the PRS under the “Method of Inspection” column.)

_____ 100% Inspection

_____ Periodic Inspection

_____ Random Monitoring (reports)

_____ Performance Evaluation Meetings

_____Customer Feedback

Level of Surveillance: (Check): ______Monthly

______Quarterly

______As needed

Analysis of Results:

Contract Service Provider’s Performance (Check): _____ Meets Standards

_____ Does Not Meet Standards

Narrative of Performance During Survey Period:

Prepared by____________________________________________ Date_____________________