QASP Neuromonitoring.pdf

Quality Assurance Surveillance Plan (QASP)

Neuromonitoring Services

The contractor will 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 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 through contract modification. 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 contr actor 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: Emily Trinh, Contracting Specialist, Health Care Resources II

Organization or Agency: NCO 21

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

Assigned COR: Carla Daniels, Business Manager, Dept of Surgery

Organization or Agency: SFVAHCS

3. CONTRACTOR REPRESENTATIVES

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

PRIMARY: DAN LIM, CHIEF, NEUROSURGERY SERVICE

ALTERNATE: HUBERT KIM, MD, CHIEF, DEPT OF SURGERY

4. PERFORMANCE STANDARDS

The contractor is responsible for performance of ALL terms and conditions of the contract.

CORs will 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 Government performs surveillance to determine the level of Contractor performance to these standards.

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

5. INCENTIVES/DEDUCTS

The Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards.

6. 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. DIRECT OBSERVATION. 100% surveillance: (if this method is used, define how surveillance will be accomplished.)

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed.

In order to adequately document services provided under this contract, a record keeping system of contractor employee workload done shall be established and implemented by the COR. The COR is responsible for verifying all clinical activities including the number of procedures done and hours worked by each contract person through a Management Report menu and/or o ther appropriate methods and for

Contract#_____662-17-1-412-0003__________________________

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Surgical QI Committee. Documentation of workload must be sufficient to ensure proper payment and to allow audit verif ication that services were provided.

c. VALIDATED USER/CUSTOMER COMPLAINTS. If this method is used, explain how data will be collected and reported.

d. RANDOM SAMPLING. If this method is used, define what and how often it will be sampled. (For example, ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

e. Verification and/or documentation provided by Contractor.

All record keeping and documentation collected and maintained by the COR shall be accurate, complete and current, and is subject to review by the Contracting Officer at any time. After contract award, any incidents of contractor noncompliance with the terms of this contract, as supported by record-keeping documentation, shall be forwarded immediately to the Contracting Officer. Quarterly, the COR will provide a written statement to the

VA Contracting Officer to include a summary of contractor employee actions and a statement indicating whether all requirements of the contract have been fulfilled as agreed.

SAMPLE PERFORMANCE MEASURES

The table below is a sample that can be tailored – note that the table must identify where in the PWS the standards are found for monitoring performance. Check the MSO Customer Resource Center for approved mandatory QASPs.

Measures PWS

Refere nce

Performance

Requirement

Standard Acceptable

Quality Level

Surveillan ce

Method

Incentive Disincentive/Deduct

1 - Key

Personnel

2.4 Provide

neuromonitoring services as specified in the requirements.

Qualified personnel are available and in location as needed to properly perform tasks as specified.

Availability to be in the OR Mon-Fri from

7AM to 6:30PM

90% or greater of requested dates are covered by contractor

Random

Inspection, Time and

Attendance

Sheets

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation

2 - Patient

Safety

5.1 Patient safety incidents

must be reported using

Patient Safety Report.

All incidents reported immediately (within 24 hours.)

Patient safety incidents occurring while contractor is on service will be reported to SFVA

Chief Surgery within

24 hours, along with a completed complication form as

100% compliance Direct

Observatio n

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation

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3 -

Maintains licensing, registration, and certification

2.2.1 Updated Licensing, registration and

certification will be provided as they are renewed. Licensing and registration information kept current.

Technicians under contract will remain current and maintain all required certifications

100%

Compliance Periodic

Sampling and

Random

Sampling

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation

4 -

Mandatory

Training

6.3 Contractor completes

all mandatory required training Contractor will complete all required training per VAMC policy

Technicians under contract will remain current with all required VAMC training

100%

Compliance Contractor to provide documente d evidence

Favorable contactor performance evaluation.

Suspension or termination of all physical and/or electronic access privileges and removal from contract until such time as the training is complete

5 - Privacy, Confidentiali ty and

HIPPA

4.4.2 Contractor is aware of

all laws, regulations, policies and procedures relating to

Privacy, Confidentiality and HIPPA and complies with all standards Zero breaches of privacy or confidentiality

Technicians under contract will remain current with all required VAMC training regarding privacy, confidentiality, and

HIPPA with no breaches of privacy or confidentiality

100%

Compliance Contractor to provide evidence of annual training required by

VAMC,

reports violations per VA

Directive

6500.6.

Favorable contactor performance evaluation.

Immediate removal from contract

6 - Timely

Invoicing

9.1.2 Within 30 days of the

end of each month services were provided, as described above, the contractor shall provide itemized invoicing .All itemized invoices provided within 30 days of end of each month services delivered

Within 30 days of the end of each month services were provided, as described above, the contractor shall provide itemized invoicing .All itemized invoices provided within 30 days of end of each month services delivered

100%

Compliance Inspection Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation

7. RATINGS

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

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EXCEPTIONAL: Performance meets contractual requirements and exceeds many to the Government’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 GOVERNMENT. 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 Government’s benef it. 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 ef fective.

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 GOVERNMENT. 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 GOVERNMENT. 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 inef fective.

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 GOVERNMENT. 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).

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8. DOCUMENTING PERFORMANCE

a. The Government shall document positive and/or negative performance. Any report may become a part of the supporting documentation for any contractual action and perparing annual past performance using

CONTRACTOR PERFORMANCE ASSESSMENT REPORT (CPAR).

b. If contractor performance does not meet the Acceptable Quality level, the CO shall inform the contractor.

This will 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 Discrepancy Report (CDR), and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

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

9. FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Reporting.

The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor performance.

10. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

03/01/22

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CONTRACTOR NAME/TITLE DATE