PWS ATTACHMENT A - QUALITY ASSURANCE SURVEILLANCE PLAN - 07.16.2021.docx

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

DEPARTMENT OF VETERANS AFFAIRS

Office of Community Care

Credentialing Verification Organization (CVO)

Date: July 16, 2021 QASP Version Number: 1.0

For: Knowledge of provider/ facility demographic information and credentialing verification services.

Contract/Order Number: Blank until contract/order award

Contract/Order Description: The U.S. Department of Veterans Affairs (VA), Veterans Health Administration (VHA), Office of Community Care (OCC), requires services to support and implement certain functions related to VA credentialing and/or monitoring non-VA health care providers that furnish hospital care, medical services, or extended care services to Veterans under VA’s community care program.

The desired outcomes of this contract are to: 1) obtain the information needed to properly assess whether non-CCN providers should be credentialed by VA for purposes of furnishing care to Veterans under VA’s community care program, including whether they are medically qualified, licensed, and competent to provide care to Veterans; 2) establish and operate a credentialing review board that will conduct enhanced reviews of credentialing information, including marginal findings of the credentialing verification process and information asserted and provided in support of provider appeals of VA credentialing determinations, and provide assessments and recommendations to VA’s Credentialing Committee; and 3) monitor CCN and non-CCN providers to ensure they maintain appropriate qualifications, licenses, competence, and status throughout the time they are providing care to Veterans under VA’s community care program.

Contractor’s Name: Blank until contract/order award

1.0 PURPOSE

This Quality Assurance Surveillance Plan (QASP) provides a systematic method to monitor Contractor performance. This QASP describes:

· What will be monitored

· How monitoring will take place

· Who will conduct the monitoring

· How monitoring efforts and results will be documented

Copies of the original QASP and revisions shall be provided to the Contractor and Government officials responsible for surveillance activities. The Government can change the method of surveillance at any time without the approval of the contractor.

1.1 PERFORMANCE MANAGEMENT APPROACH

The PWS sets forth “what” service is required as well as the performance standards associated with that task, 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 the Office of Community Care (OCC) to monitor the Contractor’s

QUALITY ASSURANCE SURVEILLANCE PLAN

performance to ensure the expected outcomes or performance standards 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 to what extent the expected outcomes for the project are being achieved by the Contractor.

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. Required processes are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus by the Government provides the Contractor flexibility to continuously improve and innovate over the course of the contract/order as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

1.2 PERFORMANCE MANAGEMENT STRATEGY

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/order regardless of whether the work is performed by Contractor employees or by Subcontractors. The Contractor’s QC program will set forth the procedures for self- inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The Contractor will implement a performance management system with processes to assess and report its performance to the designated government representative.

The government representative(s) will monitor performance by the Contractor to determine how the Contractor is performing against performance standards. The Contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively. The Contractor will be monitored and assessed throughout the period of performance of the contract/order as to either meeting or not meeting the performance thresholds stated in the Performance Monitoring Section of the Performance Work Statement (PWS). The Contracting Officer’s Representative (COR) will perform monthly assessments. The Performance Based Service Assessment, or other method, may be used to document this assessment. A Performance Based Service Assessment is provided at the end of this document. When Contractor performance is unacceptable, the COR will notify the Contractor Program Manager (CPM) and the Contracting Officer (CO). Unacceptable performance is defined as; “the contractor is not meeting the Acceptable Levels of Performance (ALPs) as defined in the PWS or is in violation of any contract clause or terms and conditions. Notification of unacceptable performance issues shall be immediately provided to the CPM and shall not remain un-addressed until the end of an assessment period. In order to remediate performance issues in a timely manner, the COR should work collaboratively with the CPM. The COR/CO will engage the CPM to resolve the discrepancy.

1.3 PERFORMANCE FEEDBACK

For instances where immediate notification of performance issues is not required, the COR should review the assessment in accordance with the quarterly reviews with the CPM and provide the assessment to CO. The COR/CO will notify the Contractor of the results for a rating of 3 or less, no later than 15 working days after the end of the assessment period.

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 agreement 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 agreement. The CO is ultimately responsible for the final determination of the adequacy of the Contractor’s performance.

Assigned CO: Lindi Sylvester Organization or Agency: Strategic Acquisition Center – Frederick

b. Contracting Officer’s Representative (COR) - The COR is responsible for technical administration of the agreement and shall assure proper Government surveillance of the contractor’s performance. The COR shall keep a quality assurance file. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf.

Assigned COR: To be completed at award Organization or Agency: Office of Community Care (OCC)

c. Other Key Government Personnel: To be completed at award

3. CONTRACTOR REPRESENTATIVES

Program Manager – To be completed at award

Other Contractor Personnel – To be completed at award; if any (name and title)

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the Contractor exceeds, meets or does not meet these standards.

The Performance Requirements Summary Matrix, paragraph as provided below includes performance standards. The Government shall use these standards to determine Contractor performance and shall compare Contractor performance to the Acceptable Quality Level (AQL).

Incentive

(CPARS).

On-line database/ system access (Task 1/Section 7.1.1)

Any outages will be rectified within 24 hours of occurrence

Within 24 hours; 100% of the time

Access by users; reports of outages to COR Same as above.

Credentials verification services for new providers (Task 2/Section 7.2.2) Contractor shall initiate credentials verification process, including attempting to contact provider, a maximum 5 contact attempts, within seven days of receiving credentialing request from VA

90% of the time

Random sample review of contractor monthly report by COR

Same as above.

Accurate credentials verification information, specifically the documents required in the PWS: for new credentialing and for re-credentialing (Task 2/Section

7.2.2 and 7.2.3)

Contractor’s credentials verification information shall be accurate and complete

98% of the time Periodic audits of selected provider elements/ credentialing criteria by VA OCC/ Provider Relations Services (PRS)/ Network Management Office (NMO): Will be reported to the

COR

Incentive

Credentialing Review Board (Task 3/Section 7.3.1) Review board’s assessment and recommendations submitted to Credentialing Committee within 5 business days after assignment

98% of the time

Status report to be submitted to the COR in the monthly report.

Monthly Credentialing Committee Report (Task 3/ Section 7.3.2b)

15th day of each month/ 100% of the time

Same as above.

Monitor all providers assigned (Task 4/Section 7.4.1)

1. Contractor shall monitor all providers assigned by VA, on a monthly basis, for all required information, from all required sources; and

2. Notify VA within three business days of verifying a sanction and/or disciplinary action for any provider

1. 100% of the time; and

2. 100% of the time

Random sample review of contractor monthly report by COR

5. INCENTIVES

The Government shall use “Favorable review of Contract, reported to the Contractor Performance Assessment Reporting System (CPARS)” as an incentive. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance. The COR shall use the surveillance methods listed above in table in the administration of this QASP.

7. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following rating definitions can be used as a guide when completing the Performance Based Service Assessment:

contractor, and the corrective actions were highly effective.

highly effective.

or were satisfactory.

appear only marginally effective or were not fully implemented.

the contractor’s corrective actions appear or were ineffective.

8. DOCUMENTING PERFORMANCE

The COR shall maintain the Performance Based Service Assessment Worksheets in contract file and submit at end of each contract period of performance to the Contracting Officer. Poor performance may result in issuance of a Contractor Discrepancy Report (CDR) by the COR or Contracting Officer. A blank CDR is provided at the end of this document.

The contractor’s performance will be reported to the Contractor Performance Assessment Reporting System (CPARS) on an annual basis. The CO and COR will make use of information from the Quality Assurance Worksheets, any CDRs, as well as any additional knowledge and information available to them with respect to the contractor’s performance, to complete the CPARS.

9. FREQUENCY OF MEASUREMENT

a. FREQUENCY OF MEASUREMENT.

During contract/order performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed, and at a minimum shall be twice a year.

b. FREQUENCY OF PERFORMANCE ASSESSMENT MEETINGS.

The COR shall meet with the Contractor quarterly to assess performance and shall provide a written assessment to the CO.

Quality of submission should also be considered. See examples below. Error rates or resubmits for content flaws would be the measures associated with these standards.

· Accuracy - Work Products shall be accurate in presentation, technical content, and adhere to accepted elements of style.

· Clarity - Work Products shall be clear and concise. Any/All diagrams shall be easy to understand and be relevant to the supporting narrative.

· Consistency to Requirements - All work products must satisfy the requirements of this PWS.

· File Editing - All text and diagrammatic files shall be editable by the VA in Windows-based or Adobe environments/platforms.

· Format - Follow specified VA Directives or Manuals and/or best business practices.

· Presentations - Presentations shall be clear, concise, executive-focused, and written in plain, clear English with minimal jargon, understandable by lay persons. The quality of deliverables directly contributes to organizational communications.

· Project Plan - Project Plan shall be comprehensive; recognize and address authority, perceptions, and concerns of stakeholders; incorporate scope of requisite requirements across the organization and/or agency.

· Reports - There shall be no omissions in the reports, documents or functional requirements.

· Publications and other documents - Deliverables shall be in formats appropriate to target audiences; user friendly, clear, thorough and comprehensive.

· Meeting support - Pre-meeting preparations and logistics; smooth meeting operations; comprehensive post-meeting summaries to include but not limited to: Minutes, Action Items, Attendees, Program Objectives and Milestones and major decision points.

· Analyses and Assessments - Analyses and assessments are performed with accuracy, completeness and adherence to industry best practices.

· Obtain stakeholder input. Deliverables shall consist of the timely implementation of input mechanisms, and shall consist of an accurate and comprehensive synthesis of results and recommendations. Integration of relevant stakeholder input documented for deliverable.

PERFORMANCE BASED SERVICE ASSESSMENT

CONTRACT/ORDER NUMBER/TITLE:

PERIOD COVERED:

Excellent Very

Satisfactory

Good

A. MEETING TECHNICAL NEEDS:

1. What level of understanding does the contractor have of my technical needs and my mission requirements?

2. What level of efficiency and effectiveness does the contractor demonstrate in meeting my requirements?

3. Overall, how well does the contractor meet my technical needs and mission requirements?

4. Overall, the quality of the products/services provided are

B. PROJECT MILESTONES AND SCHEDULE:

1. How well does the contractor meet my established milestones and project dates?

2. How timely are products, reports, and invoices completed, reviewed, and delivered?

3. How would you assess the reasonableness of cost of the services being provided and the accuracy of submitted invoice?

4. How well does the contractor notify me in advance about potential milestones and scheduling problems so that I have enough time to correct them?

C. PROJECT STAFFING

1. How current is the expertise of those contractors performing requested tasks?

2. Do contractor personnel possess the necessary knowledge, skills and ability to accomplish assigned tasks?

3. Are the staffing levels assigned by contractor appropriate for accomplishing the mission?

D. VALUE OF THE CONTRACTOR:

1. How would you assess the value of the services provided by the contractor?

2. How do you rate the quality of the products delivered by the contractor?

3. What overall rating would you give to the contractor's performance?

***Poor and Below Satisfactory ratings must be explained in Section II (Narrative Clarification) below. Must be supportive and objective.

SECTION II. NARRATIVE CLARIFICATION (USE ADDITIONAL SPACE AS REQUIRED):

Typed Name and Title of Government Project Lead/COR:

Signed Name of Government Project Lead/COR:

CONTRACT DISCREPANCY REPORT

CO/COR Findings:

CO/COR (sign and date):

Contractor Response:

Contractor Project Manager (sign and date):

CO/COR Determination/Recommendation:

CO/COR (sign and date):

Contracting Officer Acknowledgement and Recommendation (if not original author of CDR):

Contracting Officer (sign and date):

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