Quality Assurance Surveillance Plan.docx

Quality Assurance Surveillance Plan

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. 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 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: Rachel Beason Assigned CS: Safa Shleiwet Organization or Agency: Department of Veterans Affairs, RPO East, VISN 2

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: Anthony Maldonado, Organization or Agency: James J. Peters Medical Center.

3. CONTRACTOR REPRESENTATIVES

The following employees of the contractor serve as the contractor’s program manager for this contract.

A. Program Manager: To Be Determined upon vendor selection

B. Dispatcher: To Be Determined

4. PERFORMANCE STANDARDS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Performance Requirements Summary Matrix, paragraph (N/A) in the Statement of Work (SOW), includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

Contractor agrees to maintain an on-going Quality Management/Assurance Program which include the following activities Quality Assurance: The contractor will be evaluated throughout the contract period in regard to their compliance with all VA quality performance measures and monitors as it pertains to Wheelchair van/ambulette Services; proper documentation, adherence to performance measures, timely access, excessive waits/delays, pickup and delivery of special mode. Additionally patient safety and patient complaints will be researched and addressed as necessary.

Quality Checkpoints The table below describes the areas to be reviewed in the QASP process. Quality assurance will be conducted by the Contracting Officer’s Representative (COR), MAS Dept. and the Administrative Officer of the Day. The results of the QASP will be approved by the COR.

Incentive/Penalty

Work Hours

Negative past performance rating for failure to comply.

Environment of Care

Periodic Review of Contractor On-Site Vehicle and Equipment Maintenance/Inspection Records validating compliance with all State requirements.

Contractor will be required to provide annual compliance logs for all vehicles/equipment utilized to provide service to the VA.

Contractor vehicles will also subject to physical inspection by the VA at any time during the contract.

Contractor will be fully responsible to ensure that all vehicles in operation under this agreement meet all requirements.

Contractor shall be responsible to maintain on-site records that document competence/performance level of Contractor employees working on this contract, in accordance with NJS Joint Commission and other regulatory requirements.

If it is determined that a Contractor operator failed to meet all specified requirements, VA may provide negative past performance information and choose not to exercise any remaining option periods. Additionally, VA may issue a cure notice and potentially terminate the contract for default.

If it is determined that a Contractor operator failed to meet requirements regarding the reporting of patient safety incidents, VA may provide negative past performance information and choose not to exercise any remaining option periods. Additionally, VA may issue a cure notice and potentially terminate the contract for default..

If it is determined that a Contractor operator failed to meet requirements regarding the reporting of patient safety incidents, VA may provide negative past performance information and choose not to exercise any remaining option periods.

VA will not pay for services not requested or for any charges which exceed agreed upon base and mileage rates.

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. DIRECT OBSERVATION. (Can be performed periodically or through 100% surveillance.)

B. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.)

C. 100% INSPECTION. (Evaluates all outcomes.)

D. RANDOM SAMPLING. (Designed to evaluate performance by randomly selecting and inspecting a sample of cases.

E. CUSTOMER FEEDBACK/COMMENT CARDS (Evaluates feedback from Veterans receiving transportation service) Insert performance standard(s)

6. RATINGS

Metrics and methods are designed to determine if performance exceeds, meets, or does not meet a given standard and acceptable quality level. A rating scale shall be used to determine a positive, neutral, or negative outcome. The following ratings shall be used for measurement will be: meets standards/does not meet standards Wheelchair van/ambulette Procurement Funding ID: 526-22-1-826-0002

7. DOCUMENTING PERFORMANCE

A. Acceptable Performance

The Government shall document positive performance. Any report may become a part of the supporting documentation for any contractual action.

B. Unacceptable Performance

When unacceptable performance occurs, the COR shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the COR shall document the discussion and place it in the COR file.

When the COR determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to the contractor's program manager.

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 COR. The Government shall review the contractor's corrective action plan to determine acceptability.

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

8. FREQUENCY OF MEASUREMENT

A. Frequency of Measurement.

During contract performance, the COR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed

B. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor monthly to assess performance, discuss concerns, and troubleshoot existing problems.

Staffing The COR, JJP VAMC Transportation Dept., Administrative Officer of the Day and a representative from the JJP VAMC Transportation Department will be responsible for conducting QA functions as follows:

1. The COR has overall responsibility for all aspects of the QA process and will personally review all personnel qualification documents and address all issues concerning personnel performance.

1. The Transportation Dept. will be the primary section for scheduling transportation requirements and will be responsible for monitoring the delivery of services in accordance with the performance standards.

1. The AOD will be responsible for after hours service requests and will monitor and report on the performance of any service they request in accordance with the performance standards.

1. A representative of the Transportation Dept. will conduct periodic “spot” inspections of all vehicles under this agreement

Upon receipt of the previous day’s trip tickets the Transportation Dept. will match the trip tickets with scheduled and same day transportation request logs. The Transportation Dept. will make note of the time that the trip tickets and reports are delivered to ensure that they are delivered in accordance with performance standards. All documentation will be provided to the COR who will prepare a weekly report. The report will summarize the quantity for each task and percent completed to standard. A copy of this report will be maintained in the COR’s contract file.

The COR will provide contract oversight on a daily basis and submit a QA report to the Contracting Officer no later than the 15th of each month. The report will identify the total number of tasks performed and the total percentage of tasks completed to standard. A copy of the monthly invoice shall be submitted with the QA report.

Resource Estimates It is estimated that the COR will spend 1 hour a day and the assigned travel clerk will spend 1.5 hours a day conducting QA. It is estimated that one mechanic will spend approximately 20 minutes per vehicle when inspections are conducted.

Contractor Controls The Contractor shall turn-in trip tickets for each trip. The ticket shall at a minimum contain the patient’s name, date and time of pick-up, place and time of delivery, price of the trip, and any wait time that has been approved.

Corrective Action The Contractor will be notified any time a performance standard is missed or of any complaints related to services provided or personnel performance issues. The Contractor will be given an opportunity to correct any deficiency noted. The timeframe for correcting deficiencies will be determined on a case by case basis by the Contracting Officer or COR depending of the circumstances.