QASP.doc

Quality Assurance Surveillance Plan

Contract Number: < Upon award, Government will enter contract number> Contract Description: Contracted Radiology staffing services for the Las Vegas VA Imaging Services, 6900 North Pecos Road, North Las Vegas, Nevada 89086.This contract is for temporary staffing services for the following vacant positions in the Radiology Department:

· Diagnostic Radiology Technologist (CT)

· Diagnostic Radiology Technologist (MRI)

· Diagnostic Radiology Technologist (US)

· Medical Support Assistant

Contractor’s name:

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.

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. 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.

Assigned CO: <Upon award, Government will enter name.> Organization or Agency: Department of Veterans Affairs, Network Contracting Office (NCO) 21

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

Assigned COTR: <Upon award, Government will enter name.>

c. Other Key Government Personnel - <Upon award, Government will enter name, if applicable. This may include Performance Monitors, Clinical Quality experts, etc. who act on behalf of the COTR to monitor performance.>

3. Contractor Representatives The following employees of the contractor serve as the contractor’s program manager for this contract.

a. Program Manager – <Upon award, Government will enter name> (COR) Administrative Officer of Radiology Service

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 5 in the Performance Work Statement (PWS), includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Performance Objective

(The Service required—usually a shall statement)

Method of Surveillance

MRI TECHNOLOGIST

PRS # 1.

The contractor shall Demonstrate appropriate techniques to gather relevant information from the medical record, significant others, and health care providers. PWS paragraph 5.2.2

Per Departmental procedural and local VHA standard guides

PRS # 2

The technologist enforces MRI policy and procedures. PWS paragraph 5.2.6 Per Departmental procedural and local VHA standard guides

PRS # 3

The technologist must meet the criteria for ARRT registration or be ARRT registered, and/or meet the standards to comply with the established HRMS requirements for the position. PWS paragraph 5.2.7 Per Departmental procedural and local VHA standard guides

PRS # 4

Receives patients and ensures proper identification. Provides patient education. Continually assesses the condition and needs of patients to ensure patient safety, comfort and privacy before placing the patient in the MRI scanner. PWS paragraph 5.2.8

Per Departmental procedural and local VHA standard guides

PRS # 5

Employee maintains the cleanliness of the MRI suite and other assigned work areas ensuring cleanliness, proper mechanical operation, and execution of infection control policy and maintenance of supply levels for each exam. PWS paragraph 5.2.23 Per Departmental procedural and local VHA standard guides

CT TECHNOLOGIST

PRS # 6

Performs computed axial tomography (CT) scanning of head and/or body, to perform a variety of complex diagnostic examinations. Performs a variety of specialized CT examinations through experience obtained from in-house training and additional outside training should the individual require said training. Familiarity with CT cross-sectional anatomy and computerized technical factors as well as the ability to recognize abnormalities and masses in CT studies, as well as, the ability to determine their consistency (region of interest - ROI) and their relationship to adjacent structures is basic. The acquisition of CT images requires that the Medical Instrument technologist continues her maintenance of up-dating new technological advances, for this technology is constantly evolving, thus the complexity is always changing. PWS paragraph 5.3.12

Per Departmental procedural and local VHA standard guides

PRS # 7

Image and assist with invasive studies to include needle localizations, biopsy procedures, and, CT angiography studies. Monitor and maintain an emergency crash cart, oxygen, and suction apparatus and assist emergency teams with utilization in clinical and emergency settings. Monitor and safeguard sedation and emergency drugs. PWS paragraph 5.3.14

Per Departmental procedural and local VHA standard guides

PRS # 8

Independently interprets and carries out the requests made by physicians. As higher skilled radiologic technologist, interprets and directs the accomplishment of the most difficult requests. Confers with radiologist or a more senior technologist to establish requirements of non-standard examinations. PWS paragraph 5.3.24

Per Departmental procedural and local VHA standard guides

PRS # 9

Properly identifies the patient, and the images. This is essential so that mistaken identity of images to patients does not occur. The technologist must be certain that patient identification and the requests are identical.

Per Departmental procedural and local VHA standard guides

PRS # 10

Selects and sets technical factors for very difficult radiographic examinations. Sets up the general X-ray room. Assures that contrast materials, or other required equipment and supplies are present and labeled appropriately. Sets up and adjusts accessory equipment required and makes exposures necessary for requested procedures. As required by procedure or patient's condition, monitors vital signs and notifies radiologist of significant changes. Administers first aid and basic life support (BLS) commensurate with skill level and/or training. PWS paragraph 5.3.29

Per Departmental procedural and local VHA standard guides

US TECHNOLOGIST

PRS # 11

Performs ultrasound examinations of the abdomen, neck, chest and extremities, retroperitoneal space for the purpose of acquiring high-quality examinations that assist in the diagnosis and treatment of patient medical disorders. PWS paragraph 5.4.15

Per Departmental procedural and local VHA standard guides

PRS # 12

Makes multiple simultaneous settings and adjustments in operation of equipment to insure accurate results. On the basis of Radiologic findings, determines necessary ultrasonic procedures to yield definitive diagnostic findings. PWS paragraph 5.4.18

Per Departmental procedural and local VHA standard guides

PRS # 13

Receives and interprets radiology requests. Inputs pertinent radiology information into computer. A register, requests, cancels and edits exams via the computer radiology information system (RIS). PWS paragraph 5.4.23

Per Departmental procedural and local VHA standard guides

PRS # 14

Properly identifies the patient and the images. This is essential so that mistaken identity of images to patients does not occur. The sonographer must be certain that patient identification and the requests are identical. PWS paragraph 5.4.24

Per Departmental procedural and local VHA standard guides

PRS # 15

Utilizing the PCR Reader (computerized image reader) enters procedure images into the Imaging Network (PACS) and validates its accuracy. Through the Easy Vision workstation (a computerized post-processing terminal), manipulates images/processes raw data to finely-tune quality. Upon completion of post-processing and quality control process, transmits completed studies to archive via the imaging network (PACS) for subsequent interpretation by the radiologist(s). PWS paragraph 5.4.47

Per Departmental procedural and local VHA standard guides

PRS # 16

Incumbent must perform all duties necessary to comply with regulatory agencies to include, but not limited to, ACR, FDA MQSA, SOARS, NHPP, NRC, SNM. PWS paragraph 5.4.54 Per Departmental procedural and local VHA standard guides

Medical Support Assistant

PRS # 17

Making appointments accurately based upon order or consult. PWS paragraph 5.5.2

Per Departmental procedural and local VHA standard guides

PRS # 18

Ability to create notes, refer consults, modify and retrieve sensitive information/data into the Veteran’s Electronic Medical Record. PWS paragraph 5.5.3

Per Departmental procedural and local VHA standard guides

PRS # 19

Communicates with all internal and external customers in a courteous, positive, open, honest, cooperative manner, and treats all with dignity and respect. PWS paragraph 5.5.7 Per Departmental procedural and local VHA standard guides

PRS # 20

Informs supervisor/lead or appropriate management official of any issue or potential indictment where a customer may be dissatisfied or angry as a result of information provided. PWS paragraph 5.5.9

Per Departmental procedural and local VHA standard guides

PRS # 21

Builds customer confidence by professional dress and demeanor in accordance with the MCM-05-28 Dress Code/Staff Image Policy. PWS paragraph 5.5.12

Per Departmental procedural and local VHA standard guides

PRS # 22

Sends administrative notes to the requesting provider when applicable concerning changes to veteran order or scheduling. PWS paragraph 5.5.16

Per Departmental procedural and local VHA standard guides

PRS # 23

Completes front desk open/close procedures. Provides Veterans with required forms as needed for exams. Refills/requests supplies, forms, CD’s as needed for work area. Reviews protocols, advises Veteran as needed. PWS paragraph 5.5.17

Per Departmental procedural and local VHA standard guides

5. Methods of QA Surveillance Various methods exist to monitor performance. The COTR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. (Can be performed periodically or through 100% surveillance.)

a. PRS #6, PRS #7, PRS #9, PRS #16, PRS #21, PRS #23

b. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

a. PRS #1, PRS #3, PRS #5, PRS #10, PRS #12, PRS #15, PRS #17, PRS #18, PRS #22

c. USER SURVEY. (Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. May also generate inspections and sampling.)

a. PRS #13,

d. VALIDATED USER/CUSTOMER COMPLAINTS. (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.)

a. PRS #2, PRS #4, PRS #11, PRS #14, PRS #19, PRS #20

6. 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 ratings shall be used:

7. DOCUMENTING PERFORMANCE

a. Acceptable Performance The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

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

When the COTR determines formal written communication is required, the COTR shall prepare a Contract Discrepancy Report (CDR) and present it to the contractor's program manager.

The contractor shall 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 COTR. The Government shall review the contractor's corrective action plan to determine acceptability.

Any CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

8. Frequency of Measurement

a. Frequency of Measurement.

During contract performance, the COTR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COTR shall meet with the contractor periodically as agreed upon by the COTR and contractor, to assess performance and shall provide a written assessment.

<After award, both the contractor’s Program Manager and the COTR shall sign this document.>

Signature – Contractor Program Manager

Signature – Contracting Officer’s Representative

Direct Observation, Periodic Inspection, User Survey, Validated Users/Customer Complaints

A rating of Fully Successful or Unacceptable will be used for all performance standards as it pertains to the performance threshold.