QASP - ND SD PRCDA Expansion Study FY25 ORAP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Office of Resource Access and Partnerships Statewide Purchased/Referred Care Deliver Area Study for

North Dakota and South Dakota

FY2025

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Indian Health Service Rockville MD 20857

TABLE OF CONTENTS

1 INTRODUCTION

1.1 Purpose

1.2 Performance Management Approach

1.3 Performance Management Strategy

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer

2.2 The Contracting Officer’s Technical Representative

2.3 The Program Manager

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

4.2 Acceptable Quality Levels

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

5.2 Monitoring Forms

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.2 Reporting

6.3 Reviews and Resolution .............................................................................................................. 5,6

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY ................................................. 7,8

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Office of Resource Access and Partnerships

Statewide Purchased/Referred Care Delivery Area Study for North Dakota and South Dakota

INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance work statement (PWS) entitled Statewide Purchased/Referred Care Delivery Area Study for North Dakota and South Dakota. This plan sets forth the procedures and guidelines for the inspection of services in ensuring the required performance standards or services levels are achieved by the contractor.

Purpose

The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the 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 to ensure that the government pays only for the level of services received.

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

Performance Management Approach

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 Office of Resource Access and Partnerships (ORAP) 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.

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. 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. 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 as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

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 regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the 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 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.

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 determination 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.

ROLES AND RESPONSIBILITIES

The Contracting Officer

The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the assigned contracting officer's representative (COR), program 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.

The Contracting Officer’s Representative

The contracting officer’s representative COR is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for the 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 to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect the contract price, terms, or conditions shall 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. The COR will conduct a final review of deliverables and recommend approval of invoices.

2.3 The Program Manager

The program manager (PM) will work with the contractor to provide technical and programmatic oversight of the contract. The PM will review all deliverables to ensure performance standards and quality levels have been reached in accordance with the performance requirements summary in Attachment 1. The PM will participate in monthly conference calls with the contractor and/or contractor’s staff. Purpose of communications is to review project progress, discuss issues or problems, and develop recommendations.

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary.” If the contractor meets the required service or performance level, it will receive a positive CPARS report. Failure to meet the required service or performance level will result in a negative CPARS report.

METHODOLOGIES TO MONITOR PERFORMANCE

Surveillance Techniques

In an effort 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 (include those that apply).

100% Inspection – For each deliverable, the PM and/or COR, shall review the generated documentation and enter summary results into the Surveillance Activity Checklist.

Acceptable Quality Levels

The acceptable quality levels (AQLs) included in PWS for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. Levels of performance are keyed to the relative importance of the task to the overall mission.

QUALITY ASSURANCE DOCUMENTATION

Monitoring Forms

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

The COR will retain a copy of all completed QA surveillance forms.

ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

Determining Performance

Government shall use the monitoring methods cited to determine whether the performance standards/ deliverables 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. Failure to meet the the deliverables may result in a negative CPARS report in Attachment 1.

Reporting

At the end of each Quarter, the PM will prepare a written report for the COR summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the contractor’s submitted deliverables and 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.

Reviews and Resolution

The COR may require the contractor’s project manager, or a designated alternate, to meet with the CO, PM and other government IPT personnel as deemed necessary to discuss performance evaluation. The CO 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 PM or COR as often as required or per the contractor’s request. The agenda of the reviews may include:

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

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

The PM and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the CO.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Deliverables and Required Tasks

Performance and Timeliness

Deliverables

Acceptable Quality Levels

Methods of Surveillance

Impact on Contractor

CPARS

A001 Provide minimum requirements according to deliverables and time schedule to include monthly calls and communication issues.

100% - A call schedule will be identified to discuss progress, clarify questions and communicate issues or problems updates, ask questions and share issues or concerns.

90% 100% inspections

Posivtive or negative CPARS report.

B001 Detailed analysis or report of the PRC implications of a statewide PRCDA in the states of North Dakota and South Dakota that addresses PWS 2A-G according to deliverable and time schedule.

100% - The report/analysis must be timely and responsive to PWS specifications.

95% 100% inspections

Posivtive or negative CPARS report.

C001 Detailed analysis of the cost implications of an expansion to a statewide PRCDA in the states of North Dakota and South Dakota that addresses PWS 3A-F according to deliverable and time schedule.

100% - The report/analysis must be timely and responsive to PWS specifications.

95% 100% inspections

Posivtive or negative CPARS report.

D001 Prepare a map of North Dakota and South Dakota showing the current PRCDAs and AI/AN population in each county according to deliverable and time schedule.

100% - The report/map must be timely and responsive to PWS specifications.

100% 100% inspections

Posivtive or negative CPARS report.

Deliverables and Required Tasks

Performance and Timeliness

Deliverables

Acceptable Quality Levels

Methods of Surveillance

Impact on Contractor

CPARS

E001 Provide a final draft report/study for IHS review that includes all of the deliverable elements listed above and according to the deliverables and time schedule.

100% - The report/analysis must be timely and responsive to PWS specifications.

90% 100% inspections

Posivtive or negative CPARS report.

E002 Upon IHS feedback, provide a final report/study to IHS that includes all of the deliverable elements listed above, with all IHS edits incorporated, and according to the deliverables and time schedule.

100% - The report/analysis must be timely and responsive to IHS comments and feedback.

100% 100% inspections

Posivtive or negative CPARS report.

E003 Provide ORAP and Agency Leadership with a detailed briefing and presentation of the analysis for decision-making purposes.

100% - The briefing materials/presentation must be timely and responsive to PWS specifications.

99% 100% inspections

Posivtive or negative CPARS report.

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE

MONITORING FORM (Quarterly)

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

Random Sampling 100% Inspection Periodic Inspection

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: _________________