QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Low Demand Safe Haven (LDSH)

1 INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled Low Demand Safe Haven (LDSH). This plan sets forth the procedures and guidelines the Central Texas Veterans Health Care System (CTVHCS), Healthcare for Homeless Veterans (HCHV) program will use in ensuring the required performance standards or services levels are achieved by the contractor.

1.1 Purpose

1.1.1 The purpose of the QASP is to describe the systematic methods used to monitor performance and identify required documentation and resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the PWS and the contractor’s quality control plan (QCP), and ensure the government pays only for the level of services received.

1.1.2 This QASP defines the roles and responsibilities of all members of the integrated project team (IPT), identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

1.2 Performance Management Approach

1.2.1 The PWS structures the acquisition around what service or quality level is required, 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 Central Texas Veterans Health Care System (CTVHCS), Healthcare for Homeless Veterans (HCHV), Low Demand Safe Haven (LDSH) to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives 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 whether expected outcomes for the project are being achieved by the contractor.

1.2.2 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, if the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract if the critical outcomes expected are being achieved and/or the desired performance levels are being met.

1.3 Performance Management Strategy

1.3.1 The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or subcontractors. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will also set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the government to take advantage of the contractor’s QC program.

1.3.2 The government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The government will make determinations regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer (CO/KO)

The CO is responsible for monitoring contract compliance, contract administration, and cost control, and resolving any differences between observations documented by The Central Texas Veterans Health Care System (CTVHCS), Healthcare for Homeless Veterans (HCHV) program:

Luis R. Ovalle, LCSW, contracting officer representative (COR), administrative contracting officer (ACO), and Paula Wood, LCSW, program/project manager (PM) and the contractor. The CO will designate one full-time COR as the government authority for performance management. The number of additional representatives serving as technical 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.

2.2 The COR

The COR is designated in writing by the CO to act as their authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or authorize any contractual changes on the government’s behalf.

Any changes the contractor deems may affect contract price, terms, or conditions must be referred to the CO for action. The COR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and Attachment 1, Performance Requirements Summary. If the contractor meets the required service or performance level, it will be paid the monthly amount agreed on in the contract.

METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

To minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are:

Random monitoring Periodic unscheduled inspections Annual yearly unscheduled inspection

4.2 Customer Feedback

The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems, but the customer always has the option to communicate complaints to the CO or COR, as opposed to the contractor.

Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR will accept those customer complaints and investigate.

Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

4.3 Acceptable Quality Levels

The acceptable quality levels (AQLs) included in Attachment 1 for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. For certain critical activities, such as those involving Social Work Services, Nutrition, Safety and Police Services, the desired performance level is established at 100 percent. Other levels of performance are keyed to the relative importance of the task to the overall mission performance at The Central Texas Veterans Health Care System (CTVHCS), Healthcare for Homeless Veterans (HCHV) program.

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and assessed using the performance monitoring techniques shown in Attachment 1.

5.2 Monitoring Forms

The government’s QA surveillance, accomplished by the Contract Officer Representative will be reported using the monitoring form in Attachment 2. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure the required results are being achieved.

5.2.1 The Contract Officer Representative will retain a copy of all completed QA surveillance forms.

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.1.1 The government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

6.2 Reporting

6.2.1 At the end of each month, the Contracting Officer Representative will prepare a written report for the Program Manager summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This report, which includes the contractor’s submitted monthly report and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

6.3 Reviews and Resolution

6.3.1 The Contract Officer Representative may require the contractor’s project manager or designated alternate to meet with the Program Manager and other government IPT personnel as deemed necessary to discuss the performance evaluation. The Contract Officer Representative will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the Program Manager as often as required or per the contractor’s request. The agenda of the reviews may include:

Monthly performance assessment data and trend analysis Issues and concerns of both parties Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis Recommendations for improved efficiency and/or effectiveness

6.3.2 The QAR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

6.3.3 The Contract Officer Representative and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the procuring Administrative Contracting Officer.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Required Services (Tasks)

Performance Standards

Acceptable Quality Levels

Methods of

Surveillance

Incentive (Positive and/or Negative)

(Impact on Contractor Payments)

Management Services

Supportive Services

Housing

Contractor shall provide rapid, often times same day residential placement

Contractor provides Progress Reports in the delineated format and in accordance with timelines established by the COR

Contractor shall schedule open office hours and periodic visits with each Veteran to discuss progress towards discharge goals

Contractor conducts discharge planning with Veterans and in collaboration with HCHV Staff and submits plan to COR upon actual discharge of Veteran.

Contractor will provide Veterans with secure place to store their medications for self-administering.

Provide self-care

Contractor will provide Veteran instruction in self-care to include health and personal hygiene.

Contractor provided room and board shall include a minimum per Veteran / family member of one single bed, storage space, and one dresser; indoor lounging/recreation area, and self-service laundry

95%

100%

80%

Observation and random inspection

Review and Evaluation of all Required Reports

Observation and Veteran queries/ complaints

Periodic Review and Evaluation of Discharge Plans inspection.

and Veteran

All Payments will be paid timely in accordance with services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero allocation of monies to said contract.

services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero

Records and Reports

Dietetic Services

Qualifications/ Accreditation/ Licensing of Contractor Staff

Facility

Veteran Resident Safety

Client records will include all information required in accordance with the SOW and be updated as necessitated by Veteran progress

If applicable, Contractor will utilize and update these systems as directed by the COR/HCHV program staff

Veteran residents shall be provided three nutritious meals and two snacks per day; Food shall be prepared, served, and stored under sanitary conditions

Contractor shall possess a Texas Business License; Any professional staff shall be certified or licensed by the Texas Board of Examiners;

All technical and professional staff shall be Basic Life Support certified

Per the SOW, facility shall:

maintain conformance to all city, county, state and federal licensing requirements and health codes;

meet Fire Safety and Joint Commission standards; have a current occupancy permit; meet ADA requirements

Any incident involving an injury or severe illness to a Veteran shall be reported immediately after occurrence to the COR. Initial

100% inspection of documentation inspection of data systems inspection

Periodic Inspections

Observation, random inspection, and Veteran services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero allocation of monies to said contract.

All Payments will be paid timely in accordance with services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero services rendered. Failure to meet program

Patient Satisfaction notification shall be via telephone with a follow-up written report provided within 24 hours.

All patient complaints regarding quality of care are reported to the COR within 24 business hours

Veteran complaints performance standards will result in Veterans being moved out of LDSH Contract resulting in zero services rendered. Failure to meet program performance standards will result in Veterans being moved out of LDSH Contract resulting in zero

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint

LEVEL OF SURVEILLANCE (check):

Monthly Quarterly As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: ______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (check): Meets Standards

Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: _________________