QASP_MR_Draft.docx
DOCX document 43 KB Posted
- Solicitation number
- IHS1532109
About this file
This is a Draft Quality Assurance Surveillance Plan (QASP) for Certified Registered Nurse Anesthetist (CRNA) services at Quentin N. Burdick Memorial Health Care Facility in Belcourt, North Dakota. The QASP outlines the Government's proposed monitoring approach for monthly firm-fixed-price CRNA clinical services and is provided for industry feedback during the market research phase; final measures will be aligned with the Performance Work Statement and subsequent solicitation. The document establishes surveillance methods across six key performance areas: qualifications and privileges (requiring 100% compliance with current licenses, certifications, and clinical privileges before patient care); monthly coverage and availability (verifying full contract-required coverage with missed assignment documentation); arrival and call timeliness (proposing 98% on-time compliance for both scheduled arrivals and call responses); clinical documentation (proposing 95% compliance for complete and accurate pre-anesthesia assessments, anesthesia plans, and post-anesthesia evaluations based on monthly random sampling of 10-20 records per CRNA); safety reporting and follow-up (requiring escalation and documentation of all safety concerns under facility policy); professional conduct (proposing no more than one substantiated staff complaint per quarter); and reports and deliverables (requiring submission of Quality Control Plans, coverage records, monthly progress reports, and invoices).
The QASP defines roles and responsibilities for the Contracting Officer (CO), Contracting Officer's Representative (COR), clinical reviewers, credentialing officials, and the contractor; establishes deficiency management procedures including urgent safety escalation and routine corrective action timelines of five business days (subject to feedback); and clarifies that surveillance findings are reconciled monthly for service acceptance under firm-fixed-price terms, with any price reductions, reproration, or other remedies determined by the CO under applicable contract terms. The document requests industry feedback on practical surveillance methods for fourteen-day assignments, whether staffing covers assigned blocks only or continuous coverage through successive rotations, proposed chart sampling methodology, administrative quality levels, measurement definitions, reporting burden, the corrective-action deadline, and consistency with the draft PWS.
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| File | Type | Posted |
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| PWS.docx | DOCX document | |
| SSN_TMSU.docx | DOCX document | |
| IEE Representation Form.pdf |
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IHS1532109 | CRNA SERVICES | DRAFT QASP
Quality Assurance Surveillance Plan Certified Registered Nurse Anesthetist Services Quentin N. Burdick Memorial Health Care Facility
DRAFT FOR MARKET RESEARCH FEEDBACK
Sources Sought Notice IHS1532109. Read with the draft CRNA Performance Work Statement (PWS), including its addendum, posted with this notice. This draft describes proposed Government surveillance for monthly firm-fixed-price services. It is provided for industry feedback and does not establish final contract requirements, approved performance thresholds, a coverage quantity, a deduction formula, or facility clinical policy. Final measures will be aligned with the PWS and any subsequent solicitation.
1 Purpose and scope This draft QASP describes how the Government proposes to monitor CRNA clinical services, qualifications, staffing and coverage, documentation, reporting, professional conduct, and patient-safety processes under the PWS. It supports verification of performance and monthly service acceptance. The Contractor remains responsible for its own Quality Control Plan (QCP) and for meeting all resulting contract requirements.
Surveillance shall assess the services required by the contract. Any proposed new requirement or change in scope, price, schedule, or acceptance criteria shall be referred to the Contracting Officer (CO) for appropriate action. Sampling and acceptable quality levels do not waive required clinical standards or authorize patient care without current credentials and privileges.
2 Roles and responsibilities CO: Determines contractual remedies, authorizes contract changes, and takes payment-related action under the applicable contract terms. The CO designates the Contracting Officer’s Representative (COR) and the limits of delegated authority.
COR: Coordinates surveillance, reviews coverage and deliverables, documents findings, communicates deficiencies within delegated authority, and provides performance and acceptance recommendations to the CO. The COR does not independently change the contract or impose a new deduction formula.
Clinical Director or designated qualified clinical reviewer: Conducts or arranges clinical observations and chart reviews, evaluates clinical findings, and refers safety or privileging concerns through facility procedures. Reviewer assignments and protected peer-review processes will follow approved facility requirements.
Credentialing and Employee Health officials: Verify applicable provider clearance, credentials, privileges, and onboarding requirements within their assigned responsibilities. Clinical details remain in authorized facility systems.
Contractor or staffing agency: Maintains the QCP and provider compliance; supplies required coverage and records; investigates deficiencies; submits corrective actions; and provides qualified replacements when required by the contract.
3 Surveillance methods Complete verification: Verify required qualifications, clearance, and privileges before patient care and monitor expiration or status changes during performance. Monthly status review is proposed; the timing of renewed primary-source verification will be established under applicable credentialing procedures.
Coverage verification: Compare approved schedules with attendance or coverage records, OR logs, call records, and documented substitutions. Reconcile scheduled, delivered, and missed coverage for each invoice month. Time records verify performance under monthly pricing.
Clinical sampling: A monthly random review using an approved checklist and qualified reviewers is proposed. The proposed sample is 10–20 records per CRNA per month; the final sample size and checklist remain subject to refinement. Review all eligible records if fewer than the approved sample size are available. Record eligible population, selection method, records reviewed, findings, and follow-up. Targeted safety reviews are documented separately from the random sample.
Feedback and incidents: Review validated feedback from surgeons, nursing staff, patients, and other authorized sources, together with incident reports. Use the facility-approved reporting system. Protect confidentiality and peer-review material.
4 Proposed performance matrix The matrix presents proposed surveillance methods and, where expressly identified, proposed administrative quality levels for industry feedback. Final measures, definitions, reporting periods, and thresholds remain subject to approval and alignment with the PWS. Proposed percentages do not relax mandatory contract or clinical requirements. Critical clinical findings require prompt review regardless of aggregate percentages.
| Performance element and PWS reference |
| Standard and proposed quality level |
| Surveillance and frequency |
Qualifications and privileges
PWS 3.1–3.4
| All required licenses, certification, approvals, and clinical privileges current before patient care and throughout performance. 100% compliance; no lapses permitted. Include BLS, ACLS, PALS, NRP and DEA registration only as applicable to the finalized PWS. |
| Verify before initial placement and replacement; monthly status review and review upon a reported change or approaching expiration. Credentialing officials determine primary-source verification requirements. |
Monthly coverage and availability PWS 1.4 and 6.1
| Provide the full coverage required by the resulting contract schedule. Coverage days, assignment frequency, coverage between fourteen-day blocks, call-response time, backup, and closure treatment remain under development. Record each missed assignment or response failure. |
| Review each scheduled coverage assignment and applicable call event. COR reconciles coverage monthly with approved schedule, logs, and contractor records; clinical reviewer evaluates safety implications. |
Arrival and call timeliness
PWS 1.4
| Proposed for feedback: 98% on-time compliance. Separate measures for scheduled arrival and call response, including start point, deadline, exclusions, and reporting period, remain under development. This proposal does not authorize uncovered assignments or delayed emergency care. |
| Monthly review of attendance records, OR logs, call logs, and documented delay or incident reports. Record counts of eligible events and failures separately for each measure. |
Clinical documentation PWS 4.1 and 4.4
| Complete, accurate pre-anesthesia assessment, anesthesia plan, and post-anesthesia evaluation under approved facility requirements. Proposed for feedback: 95% compliant sampled records. Definitions of noncritical documentation defects and critical safety findings remain under development. Any final threshold must align with the PWS and does not waive mandatory documentation or clinical requirements. |
| Monthly random chart sample under section 3. Use an approved checklist, identify records meeting all measured requirements, and document each defect. Review critical findings through the facility’s clinical safety process. |
Safety reporting and follow-up
PWS 4.1–4.2
| All identified safety concerns and reportable events escalated, documented, and reviewed under facility policy. Applicable deadlines will follow approved facility requirements. Event occurrence alone does not establish negligence; authorized clinical review evaluates preventability, attribution, and corrective action. |
| Review reported incidents and follow-up through designated clinical and quality officials. Urgent concerns are escalated immediately. Monitor investigation progress under policy; document unresolved cases and responsible owners. |
Professional conduct
PWS 4.2
| Comply with facility conduct and communication requirements. Proposed for feedback: no more than one substantiated staff complaint per quarter. This proposed measure is not finalized; its reporting period, validation, attribution, and severity definitions must align with the PWS complaint measure. Serious misconduct requires immediate review. |
| Ongoing feedback review with quarterly summary. Record allegations separately from substantiated findings, avoid duplicate counting, and document disposition through authorized processes. |
Reports and deliverables PWS 1.6, 4.4 and 6; Exhibit 2
| Submit required QCP, coverage records, monthly progress reports, and invoices using the methods and deadlines established in the resulting contract. Monthly invoices cover accepted services under MO pricing. Final submission instructions will be provided with the solicitation or contract. |
| COR reviews each deliverable against the final schedule and records submission, deficiencies, corrections, and acceptance recommendations; CO handles contractual payment action. |
Measurement rules: Define the reporting period and eligible population for every rate. Document the number of compliant items, total items reviewed, exclusions and reasons, and any duplicate findings. Report “not assessed” when there are no eligible events; do not record an unmeasured item as compliant. These administrative surveillance measures do not replace clinical judgment or facility safety review.
5 Deficiencies and corrective action The COR or clinical reviewer shall document the requirement, objective evidence, date, severity, and operational or clinical effect of a deficiency. Clinical concerns shall be evaluated by qualified facility personnel. Contract performance findings and clinical peer review shall follow their respective authorized processes.
Urgent safety or credentialing concern: Immediately notify the Clinical Director or designated clinical authority and COR. The clinical authority initiates patient-protection, coverage, and privileging action under facility policy. Notify the CO promptly regarding contractual effects. Routine corrective-action timelines shall not delay necessary patient protection or emergency response.
Routine deficiency: The COR documents the finding and provides written notice within delegated authority, using a Contract Discrepancy Report (CDR) when appropriate. Refer unresolved or material deficiencies to the CO.
Corrective Action Plan (CAP): A deadline of five business days after receipt of written notice is proposed for routine deficiencies and is open for industry feedback. The final deadline will be established in the applicable contract requirements. The CAP should identify the cause, actions, accountable personnel, completion dates, replacement or training needs, and evidence of effectiveness. Routine timelines do not delay urgent safety action.
Verification and closure: The COR and qualified clinical reviewer, as appropriate, verify completed actions, reassess affected performance, document residual risks, and record closure or further action. The CO determines contractual remedies when deficiencies persist.
6 Monthly acceptance and remedies For each service month, the COR shall reconcile the approved coverage schedule, verified services, deficiencies, outstanding corrective actions, and required deliverables. The COR provides an acceptance recommendation or verification within delegated authority. Payment shall follow the contract’s monthly firm-fixed-price terms.
Any price reduction, proration, reperformance requirement, other remedy, or performance-evaluation action shall be determined under the applicable contract terms and authorized procedures. This QASP establishes no independent penalty, automatic percentage deduction, or new hourly payment basis. The CO shall establish any agreed adjustment method for partial months, missed coverage, or closures in the contract before applying it. Considerations affecting CPARS shall follow applicable evaluation procedures and documented facts.
7 Records reviews and improvement The COR shall retain a surveillance log showing the PWS requirement, review period, method and sample, objective findings, notices, contractor responses, follow-up, and disposition. Store patient information, credentialing material, incident reports, and protected peer-review information only in authorized systems with appropriate access restrictions. Use the minimum clinical information necessary for contract surveillance summaries.
Monthly surveillance and service reconciliation, quarterly trend reviews, and an annual review when the performance period permits are proposed. Meetings and reporting will be coordinated with the PWS to avoid duplicate deliverables. Contractor participation in quality improvement and training activities will follow the resulting contract. Changes to surveillance must remain consistent with the contract; changes affecting contractual requirements must be referred to the CO.
8 Requested Industry Feedback Recommend practical surveillance methods for fourteen-day assignments and identify whether the proposed staffing approach covers assigned blocks only or continuous coverage through successive rotations.
Comment on the proposed chart sample, administrative quality levels, measurement definitions, reporting burden, and treatment of low-volume months. Suggest alternatives with supporting rationale.
Comment on the proposed five-business-day corrective-action deadline for routine deficiencies and identify operational concerns.
Identify inconsistencies with the draft PWS and recommend changes that make performance expectations and monthly acceptance clearer. Submit comments with the capability response under the instructions and deadline in Sources Sought Notice IHS1532109.
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