QASP for Medical Physicist Services.doc

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

MEDICAL PHYSICIST SERVICES

#662-27-1-147-0004, #36C26125AP-1091

JULY 2026

662-SAN FRANCISCO VAMC

The Department of Veterans Affairs Sierra Pacific Network (VISN 21)

1. Objective: The contract requirement is to provide medical physics services for the Radiation Safety Protection Program of the SFVA Health Care System in San Francisco, in accordance with the Statement of Work (SOW). The Radiation Safety Protection Program oversees the use of radioactive material and machines producing ionizing radiation in research and clinical applications. The Contractor shall furnish all equipment, supplies, personnel, supervision, transportation, and software to provide medical physicist testing/reporting services in support of medical and dental X-Ray equipment, including CT scanners for Radiology and/or Nuclear Medicine (mobile and/or fixed), PET scanners, SPECT/CT scanners, D-SPECT scanner, ultrasound, DEXA, and MRI scanners. The services are to be provided at the San Francisco Veterans Affairs Health Care System (SFVAHSC) located at 4150 Clement Street, San Francisco, California, 94121 the Santa Rosa Clinic CBOC, the Eureka Clinic CBOC, and the Oakland Clinic CBOC. Specifically, the Contractor’s primary responsibilities include overall testing and evaluation of all medical X-Ray equipment, annual quality assurance review and certification of all X-Ray procedures, and ensuring compliance with X-Ray testing standards and regulations by VHA federal organizations. This QASP has been developed to evaluate contractor actions while implementing the Performance-based SOW. It is designed to provide an effective surveillance method of monitoring contractor performance for each item listed under Description of Services in the SOW. The QASP provides a systematic method to evaluate the services and products the contractor is required to furnish. This QASP is based on the premise that the contractor, and not the government, is responsible for management and quality control actions to meet the terms of the contract. The role of the government quality assurance personnel is to ensure contract standards are achieved. Careful application of the process and standards presented in the remainder of this document will ensure a robust quality assurance program.

2. Government Roles and Responsibilities. The goals and responsibilities of the government are outlined below.

2.1. Contracting Officer (CO) Responsibilities: 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.

2.2. COR Responsibilities:

1. Ensures supplies or services rendered by Contractor meet contract requirements.

2. Notifies the CO and the Contractor of any performance deficiencies in writing or e-mail.

3. Assists with contract/order closeout.

4. Ensures discrepancy reports are accurate and reported properly.

5. Identifies areas that warrant a change in assessment method, frequency, or performance threshold and provides suggestions about the surveillance plan to the CO.

6. Maintains accurate documentation of Contractor assessment activities as required by the surveillance plan and reports the results of Contractor assessment activities to the CO.

7. Works with the Contractor and the CO to resolve issues.

8. Maintains files in accordance with the Surveillance Plan and requests CO disposition at the completion of the contract or termination of COR appointment (if applicable). Files include a copy of the contract/order and all modifications (unless readily available electronically); a copy of COR designation memorandum (if applicable); correspondence between you and the Contractor; copies of correspondence to or from CO; minutes of all meetings; copies of all invoices submitted and paid; and all other documentation of actions taken by COR.

9. Submits all requests for corrective action to the CO.

10. Inspects and accepts Contractor services at the completion of each contract payment period, usually monthly. The COR will certify services received, unless the CO retains the authority for acceptance.

3. Performance Assessment: The required performance objectives can be found in the Consultation Services section in the SOW. The contractor service requirements are summarized into 3 performance objectives. The performance threshold describes the minimum acceptable levels of service for each requirement. The contractor shall be aware that the absence of any contract requirement from the service summary does not detract from its enforceability nor limit the rights or remedies of the Government under any other provision of the contract.

Method of Surveillance:

SATISFACTORY

(Acceptable Quality Level):

Performance meets contractual requirements. The contractual performance may involve some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

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

Note: An Unsatisfactory rating involves multiple significant events that the contractor had trouble overcoming and which impacted the GOVERNMENT.

4. Procedures: The government COR will periodically perform inspections to ensure Contractor compliance with the appropriate paragraphs of the SOW and will record the results of inspections, noting the date and time. If inspection indicates a performance threshold is not met, the COR will notify the Contractor and the contracting officer of the deficiency for correction. The Contractor shall be given a reasonable time after notification to correct the unacceptable performance if such correction is possible. The length of time allowed to correct the problem will depend upon the requirement and the deficiency, and the Contractor will be notified by the CO of the time allowed for correction when the deficiency is reported to the Contractor. The COR will not consider the services complete until all deficiencies have been rectified. Deficiencies not corrected or estimated dates of completion that are not acceptable to the COR will be forwarded to the CO for action.

Performance of the contracted services will occur on site at a government facility at the SFVAHCS, CBOC’s, and other VA facilities, such as the Research campus at Mission Bay.

The COR will certify services received under this contract in accordance with its terms and conditions, unless the CO retains authority for acceptance. Format is at the discretion of the COR.

Upon notification from the contractor that the defect has been corrected, the COR will re-inspect the area/task associated with the deficiency. The COR will verify the root cause, and corrective/preventative actions submitted by the contractor will be identified to prevent reoccurrence.

4.1. Corrective Action Report (CAR): A CAR shall be used by the COR to document contract requirement findings and subsequent corrective actions to be taken. See attachment for template of CAR.

4.2. Definitions of Major Findings & Minor Findings. Major findings are contract non-conformances which are considered critical or major. IAW FAR 46.101, a major non-conformance means a non-conformance, other than critical, that is likely to result in failure or reduce the usability of the services for their intended purpose. A critical non conformance means a non-conformance that is likely to result in a hazardous or unsafe condition for individuals using, maintaining, or depending upon the services; or is likely to prevent performance of a vital agency mission. If, at any time, the COR identifies a condition as having a significant adverse effect on the quality of the activity, such as those stated below, the COR shall document their findings and notify the Contracting Officer immediately in writing (email is acceptable).

A. Contractor failure to meet a performance objective or threshold.

B. Failure to provide adequate corrective action to preclude reoccurrence of Government identified findings.

C. Failure to provide corrective action to deficiencies identified by the contractor within a prescribed suspense period.

D. Any failure to adhere to security and/or safety regulations that results in a security or safety incident.

A Minor Finding or a minor non-conformance (IAW FAR 46.101) means a non-conformance that is not likely to materially reduce the usability of the services for their intended purpose, or is a departure from established standards having little bearing on the effective use or operation of the services. When the COR identifies a minor finding, the COR shall document the findings, but is not required to notify the Contracting Officer. However, if the same minor finding is repeatedly identified, it may be an indication that a major finding is occurring, or has occurred, because the Contractor has not taken proper steps to prevent recurrence. In this case, the COR shall notify the Contracting Officer in writing (email is acceptable).

4.3. Methods of Surveillance: 1) Periodic Monitoring/Observation, and 2) Quarterly Review

4.3.1. Periodic Monitoring/Observation: Contractor performance will be monitored or observed as satisfactory or unsatisfactory.

4.3.2. Quarterly Review: Contractor performance in quarterly Radiation Safety Committee meetings will be reviewed as satisfactory or unsatisfactory.

4.4. Remedies for Non-Conformance. If mode of surveillance indicates unsatisfactory performance, the COR will notify the Contractor of the deficiencies for correction. The Contractor shall be given an appropriate time frame (depending on the discrepancy identified) after notification to correct the unsatisfactory or unacceptable performance. If deficiencies are not corrected within the required time frame, the COR should notify the CO for action. If the Contractor disagrees with the noted discrepancy, and an agreement cannot be reached, the CO shall be notified for a final decision.

5. Revisions to this Surveillance Plan. Revisions are the joint responsibility of the CO and COR. This document can be changed at any time.

COR NAME:

Stephen Fong, COR II

TITLE:

Associate Radiation Safety Officer

SIGNED:

Stephen Fong 7/6/26

_1376214526.doc

CORRECTIVE ACTION REPORT (CAR)

(If more space is needed, use reverse and identify by number)

1. CONTRACTOR

2. CONTRACT NUMBER

3. TYPE OF SERVICES

4. FUNCTIONAL AREA

5. SUSPENSE DATE

6. CONTROL NUMBER

7. DEFICIENCY FORMCHECKBOX

MAJOR FORMCHECKBOX

MINOR

FINDING:

FINDING IMPACT:

Please respond with a written corrective action plan that details the corrective action of the cited deficiency, the cause of the deficiency, and actions taken to prevent recurrence by Suspense Date in Block 5. If date was not entered in Block 5, the contractor is not required to provide a response.

8. CONTRACTING OFFICER REPRESENTATIVE (COR)

TYPED NAME AND GRADE

SIGNATURE AND DATE

9. ISSUING AUTHORITY

TYPED NAME AND GRADE

SIGNATURE AND DATE

10. COR RESPONSE TO CONTRACTOR CORRECTIVE ACTION AND ACTION TAKEN TO PREVENT RECURRENCE

11. COR DETERMINATION

FORMCHECKBOX

ACCEPTED FORMCHECKBOX

REJECTED

12. CLOSE DATE

Corrective Action Report (CAR) Template, Feb 05 (SAF/AQCP)

CORRECTIVE ACTION REPORT (CAR)

Continuation Sheet

(Number to correspond with applicable Item Number on reverse)

Corrective Action Report (CAR) Template, Feb 05 (SAF/AQCP)

Corrective Action Report (CAR) Instructions

Block 1. Enter Contractor Name.

Block 2. Enter Contract Number.

Block 3. Enter Contract Name or Type of Services.

Block 4. Enter Functional Area of the Contract.

Block 5. Enter the assigned suspense date given the contractor to provide a response to the CAR. A date must be entered for a Major CAR. A date is optional at the discretion of the Contracting Officer Representative (COR) initiating the CAR if the finding is Minor.

Block 6. All CARs will be tracked with a Control Number. The functional commander/functional director is the Issuing Authority for his/her contract Quality Assurance Evaluators (CORs) generating CARs. By providing the control number to the COR originating the CAR, the Issuing Authority demonstrates concurrence with the finding. The control number will be made up of the first two letters of the name of the site or contract, the last two digits of the calendar year, and a three digit number starting with 001 and progressing upward throughout the calendar year (e.g., WP04-001).

Block 7.

1. Check the block that indicates whether the identified deficiency is assigned as a Major or Minor finding. See Quality Assurance Surveillance Plan (QASP), paragraph 6.1.4, for the definitions of Major and Minor findings and associated explanations.

2. Finding: Clearly state the details of the finding followed by a reference to the stated contractual requirement. The reference must state the portion of the contract, part, section, paragraph and subparagraph and must make a complete brief quotation of the contract reference.

3. State the impact that the finding has or could have on the accomplishment of the mission that the contract provides.

4. When determining how long to give the contractor to respond to the identified finding, the normal is 10 working days. The suspense date should reflect this unless the finding requires a greater amount of time to come to solution. Major findings require a contractor response. Minor findings may require a contractor response at the discretion of the COR initiating the CAR and/or the Issuing Authority.

Blocks 8 and 9. Contract CORs initiating a CAR must sign in Block 8 and the Issuing Authority signs in Block 9. Each annotates the date at the time of signature.

Block 10. Upon review of the contractor’s reply, the originator of the CAR will enter comments regarding acceptance or rejection of the contractor’s response. This block may also contain any comments regarding follow-on inspections conducted or needed at a later date to validate that the finding has not reoccurred.

Block 11. The COR selects Accept or Reject after reviewing the contractor’s response.

Block 12. The COR enters a close date after advising the Issuing Authority that the contractor’s response is acceptable and the Issuing Authority concurs. The Issuing Authority will then forward the closed CAR to the contractor and report accordingly in the monthly Certificate Of Service (COS) or other applicable contracting officer services report. This routing remains the same if the contractor response is unacceptable and the CAR remains open until an acceptable response is received except that the Issuing Authority forwards the open CAR back to the contractor for additional information.

Continuation Sheet. The Continuation Sheet is to be used to expand on any information that will not fit in the applicable numbered block.