Quality Assurance Surveillance Plan (QASP).pdf

Quality Assurance Surveillance Plan (QASP)

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 will monitoring take place?

• Who will conduct the monitoring?

• How will monitoring efforts and results 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 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: Emily Trinh

Organization or Agency: Department of Veteran’s Affairs, Network Contracting Office 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: Chickitita Manalo

Organization or Agency: Department of Veteran’s Affairs, VA Northern California Healthcare System

(VANCHCS)

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager:

Name: ____________________________

Title: _____________________________

Email: ____________________________

Phone: ____________________________

Alternate Program Manager:

Name: ____________________________

Title: _____________________________

Email: ____________________________

Phone: ____________________________

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. 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. Performed periodically or through 100% surveillance:

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

c. VALIDATED USER/CUSTOMER COMPLAINTS. If complaint is made against Contractor, random sampling will be used to observe or inspect performance of Contractor.

d. RANDOM SAMPLING. Performed periodically based on complaints or random inspections.

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. Documents provided by contractor personnel will be reviewed by COR/COR Designee upon receipt.

DATE: 9/22/2023

Measures PWS

Reference

Performance

Requirement

Standard Acceptable

Quality Level

Surveillance

Method

Met AQL/DID NOT

MEET AQL-

CPARS RATING/ADD

COMMENTS

Contractor Quality

Performance

1.1 Provide all supervision, personnel, transportation and

equipment to perform inpatient acute dialysis treatments as stated in the PWS

Comply with all applicable VA guidelines; medical center medical staff bylaws, rules and regulations; hospital policies/procedures;

and in accordance with current Joint

Commission Standards

98% If complaint is made against

Contractor, random sampling will be used to observe or inspect performance of

Contractor

Qualifications of Key

Personnel

2.1 The contractor shall be

responsible for ensuring that each registered nurse providing services under this contract is fully trained and completely competent to perform the required services covered by this contract. Copy of the competency record and completed training must be provided to

VAMC. The registered nurses must have a

Basic Life Support

(BLS) certification.

Documentation must be

All (100%) licensing, registration(s) and certification(s) for

Contractor’s nurse (s) shall be provided prior to being credentialed.

as they are renewed.

100% Documents will be reviewed by

COR/COR

designee prior to submission to CO, Credentialing, and HR updated on an annual basis.

Maintains licensing, registration, and certification

2.1.1 Contract personnel

shall submit evidence of current, full and unrestricted licenses, registration, certification, and other relevant credentials for verification prior to appointment and throughout the employment process as requested by the COR.

All (100%) licensing, registration(s) and certification(s) for

Contractor’s personnel shall be provided as they are renewed.

Licensing and registration information kept current.

100% licensing, registration(s) and certification(s) for Contractor’s personnel shall be provided as they are renewed.

Licensing and registration information kept current.

No acceptable deviation.

Periodic

Inspection or

Random

Sampling

Mandatory Training 2.1.5 Contractor shall complete all required training on time per facility policy

All (100%) of required training is complete on time by contract personnel

100% Mandatory

Training

Contractor

Responsiveness &

Timeliness

2.9.1 The contractor will

provide Registered

Nurses (RN)s to perform inpatient dialysis at VANCHCS as stated in this PWS.

Contractor will respond within six hours of notification for the initial treatment for non-emergency dialysis. For urgent and emergent dialysis, the DaVita RN will

Respond within six hours of notification for the initial treatment for non-emergency dialysis. Respond to the VA facility within two hours of notification, and ready to begin emergency dialysis treatment when required by the ordering VA physician.

Emergency care coverage is 24 hours-

100% The COR shall establish and implement a record-keeping system to monitor the response of contract personnel to all

VA calls, pages, and requests for call-back.

report within two hours of being called. For

STAT dialysis, DaVita

RN will arrive within

(2) hours following the receipt of an order from the hospital of the physician for treatment, or within a later specified time frame as specified by the patient’s physician.

per-day, seven days-per-week.

Standards of Care 4.2 The Contractor’s personnel shall cover the range of

Nephrology dialysis services as would be provided in a state-of-the-art civilian medical treatment facility and shall be of a quality that meets or exceeds community standards.

Care shall be compliant with all related VHA kidney health policies and recognized TJC standards.

Comply with all applicable VA guidelines, medical center staff bylaws, rules and regulations;

hospital policies/procedure; and in accordance with current Joint

Commission standards.

100% Direct observation

6. CPARS RATINGS ASSIGNED TO QASP ITEMS:

Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used (Reference: CPARS User Manual https://www.cpars.gov/documents/CPARS-Guidance.pdf)

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 benefit. 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 effective.

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 ineffective.

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).

https://www.cpars.gov/documents/CPARS-Guidance.pdf

7. 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 preparing annual past performance using

CONTRACTOR PERFORMANCE ASSESSMENT REPORTING SYSTEM (CPARS).

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 Report (CR), 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 CR in writing. The CR 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 CR 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 CRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

See Sample CR on the following page.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CR PREPARED

b. RETURNED BY

CONTRACTOR:

c. ACTION COMPLETE

6. Issue Identified (Describe in detail. Include reference to PWS Directive; attach continuation sheet if necessary.)

7. SIGNATURE OF COR Date:

8. SIGNATURE OF CONTRACTING OFFICER Date:

9a. TO (Contracting Officer) 9a. FROM (Contractor)

10. CONTRACTOR RESPONSE AS TO CAUSE AND ACTIONS TO PREVENT RECURRENCE.

(Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER