QASP.docx

DOCX document 32 KB Posted

Attached to
Off Site Medical Support Office Service Federal contract opportunity
Solicitation number
36C26125Q0593
Issued by
Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 21

About this file

This document is a Quality Assurance Surveillance Plan (QASP) for an Off Site Medical Support Office Service contract with the VA Pacific Islands Health Care System (VAPIHCS) located in Lanai, Hawaii. The QASP outlines performance monitoring for a medical services contract, with specific requirements including providing clinic space for one primary care/mental health provider, clinical exam rooms, administrative personnel (one clerk/receptionist and one medical assistant), and quarterly performance evaluations. The document details surveillance methods such as dashboards, direct observation, periodic inspections, and customer complaint validation.

The performance evaluation will use a rating system ranging from Exceptional to Unsatisfactory, with key metrics focused on clinic space availability, staffing, and invoicing accuracy. Contractor performance will be assessed quarterly by VA traveling providers and the Contracting Officer's Representative (COR), with the primary program managers identified as Jerry Thompson (primary) and Joshua Hullsiek (alternate). The QASP serves as a systematic method to evaluate contractor performance, with the understanding that the contractor is responsible for managing quality control and meeting all contract terms.

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36C26125Q0593 0001.pdf PDF
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Quality Assurance Surveillance Plan (QASP) The contractor shall be evaluated in accordance with the following:

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 shall be monitored?

· How shall monitoring take place?

· Who shall conduct the monitoring?

· How shall monitoring efforts and results 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 VA’s responsibility to be objective, fair, and consistent in evaluating performance.

This QASP is a “living document” and the VA may review and revise it on a regular basis. However, the VA shall coordinate changes with the contractor through contract modification. Copies of the original QASP and revisions shall be provided to the contractor and VA officials implementing surveillance activities.

2. VA 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:

Organization or Agency:

b. Contracting Officer’s Representative (COR) – The COR is responsible for technical administration of the contract and shall assure proper VA 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 VA’s behalf.

Assigned COR:

Organization or Agency:

3. CONTRACTOR REPRESENTATIVES

The following employee(s) of the contractor serve as the contractor’s program manager(s) for this contract:

Primary Program Manager: Jerry Thompson Alternate Program Manager: Joshua Hullsiek

Revision 06/12/2024 Page 13 of 29

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract. CORs shall 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. Performance standards define desired services. The VA performs surveillance to determine the level of contractor performance to these standards.

The Performance Requirements are listed below in Section 6. The VA shall 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 shall be used, in part, to establish the past performance of the contractor on the contract.

5. METHODS OF QA SURVEILLANCE

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

a) DASHBOARDS. (Use the corresponding dashboards for measures that include a dashboard. For example: DASHBOARD: PCMHI Penetration (PACT21): COR will monitor progress quarterly using data from the PACT Compass. COR will send reports to the contractor and CO quarterly to notify them of current performance.)

b)

c) DIRECT OBSERVATION. 100% surveillance: Surveillance will be completed by on site staffing by Veteran Affairs employees.

d)

e) PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. Periodic inspections to coincide with Environmental of Care Rounds.

f)

g) VALIDATED USER/CUSTOMER COMPLAINTS. Inspections with customers.

h)

6. QASP PERFORMANCE REPORT DATE: __________________

Veteran Affairs Offsite Quality Assurance Surveillance Plan (QASP) Template

METRIC
PWS PARA
Performance Requirement
Standard
Acceptable Quality Level

(tailor to meet your requirements) Method of Surveillance and frequency Met AQL/Did Not Meet AQL (Add comment)

CLINIC SPACE AVAILABILITY
PWS para.

4.7.1

Contractor shall provide clinic space: 1) one office for Primary Care/Mental Health provider(s) and 2) one to two clinical exam/treatment rooms as needed for one day per month.
Contractor’s score shall meet 100%
Contractor’s score shall meet 100%

VA will monitor progress quarterly by review with VA travelling provider(s)

STAFFING
PWS para.

4..7.1.

Contractor shall provide services of clinic personnel: 1) one administrative clerk/receptionist and 2) one medical assistant to provide assistance to VA provider(s).
Contractor’s score shall meet 100%
Contractor’s score shall meet 100%

VA will monitor progress quarterly by review with VA travelling provider(s)

INVOICING
PWS para.
Contractor shall provide accurate and timely invoices.
Contractor’s score shall meet 100%
Contractor’s score thall meet 100%

VA will monitor progress quarterly through COR

7. CPARS RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual: https://www.cpars.gov/documents/CPARS-Guidance.pdf.

EXCEPTIONAL:
Performance meets contractual requirements and exceeds many to the VA’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

Note: To justify an Exceptional rating, you should identify multiple significant events in each category and state how it was a benefit to the VA. However, a singular event could be of such magnitude that it alone constitutes an Exceptional rating. Also, there should have been NO significant weaknesses identified.

VERY GOOD:
Performance meets contractual requirements and exceeds some to the VA’s benefit. The contractual performance of the element or sub-element being assessed was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

Note: To justify a Very Good rating, you should identify a significant event in each category and state how it was a benefit to the VA. Also, there should have been NO significant weaknesses identified.

SATISFACTORY:
Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

Note: To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract. Also, there should have been NO significant weaknesses identified.

MARGINAL:
Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions. The contractor’s proposed actions appear only marginally effective or were not fully implemented.

Note: To justify Marginal performance, you should identify a significant event in each category that the contractor had trouble overcoming and state how it impacted the VA. A Marginal rating should be supported by referencing the management tool that notified the contractor of the contractual deficiency (e.g., Management, Quality, Safety or Environmental Deficiency Report or letter).

UNSATISFACTORY:
Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub-element being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

Note: To justify an Unsatisfactory rating, you should identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the VA. However, a singular problem could be of such serious magnitude that it alone constitutes an unsatisfactory rating. An Unsatisfactory rating should be supported by referencing the management tools used to notify the contractor of the contractual deficiencies (e.g., Management, Quality, Safety or Environmental Deficiency Reports, or letters).

DOCUMENTING PERFORMANCE

a. The VA shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and preparing annual past performance using CONTRACTOR PERFORMANCE ASSESSMENT REPORTING SYSTEM (CPARS).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor. This shall normally be in writing unless circumstances necessitate verbal communication. In any case the CO shall document the discussion and place it in the contract file. When the COR and the CO determines formal written communication is required, the COR shall prepare a Contract Report (CR), and present it to CO. The CO shall in turn review and shall present to the contractor's program manager for corrective action.

The contractor shall acknowledge receipt of the CR in writing. The CR shall 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 CR shall also state how long after receipt the contractor has to present this corrective action plan to the CO. The VA shall review the contractor's corrective action plan to determine acceptability. The CO shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance and the acceptability of the Contractor’s corrective action plan.

Any CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO. See Sample on following page.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER
2. REPORT NUMBER
3. TO: (Contracting Officer)
4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY CONTRACTOR:
c. ACTION COMPLETE

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR
Date:
8. SIGNATURE OF CONTRACTING OFFICER
Date:
9a. TO (Contracting Officer)
9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE
Date:

12. VA EVALUATION.

13. VA ACTIONS

14. CLOSE OUT

NAME
TITLE
SIGNATURE
DATE

CONTRACTOR NOTIFIED

COR

CONTRACTING OFFICER

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