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 monitoring will take place.

• Who will conduct the monitoring?

• How monitoring efforts and results will be documented.

• How the measurement is related (or tied to) the Performance Work Statement

(PWS)

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: < Government will enter name>

Organization or Agency: Department of Veterans Affairs, Office of Acquisition and Logistics

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: Janie Fleming

3. CONTRACTOR REPRESENTATIVES

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

Name: _ ______

Name: __________________________

4. PERFORMANCE STANDARDS

Performance quality levels are detalined in the PWS which defines the desired services.

The Government performs surveillance on specified standards to determine if the contractor exceeds, meets or does not meet 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.

5. INCENTIVES/DEDUCTS

The Government shall use past performance as incentives. Incentives or deducts shall be based on exceeding, meeting, or not meeting performance standards (if you include any monetary incentives, this requires approval through the Department’s Senoir Procurement Executive (SPE)).

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.

Acceptable Quality Levels (AQL)

The acceptable quality levels (AQLs) included herein for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls. For certain critical activities such as those involving any Cardiac EP Services provided, the desired performance level is established at 100 percent. Other levels of performance are keyed to the relative importance of the task to the overall mission performance at Ralph H. Johnson VAMC, Charleston.

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.

Measures PWS

Reference

Performance

Requirement

Standard Acceptable Quality Level

Surveillance

Method

Incentive Disincentive

(Deduct)

1 - Key Personnel

2.4 Provide required

medical service as specified in the requirements.

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

100% Random Inspection, Time and Attendance Sheets, Quality Assurance Reports

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.)

100% Direct Observation

Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation

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.

Contract Provider records will be kept 100% up-to-date

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

100% Contractor to provide documented 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

100%

Contractor to provide evidence of annual training required by VAMC, reports violations per policy

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 vendor shall

All itemized invoices provided within 30 days of end of each month services delivered

100% Inspection Favorable contactor performance evaluation.

Unfavorable contractor performance evaluation provide itemized invoicing

Other performance factors will be monitored that are not quantified by numerical measurements which include: no inappropriate prescriptions; patient customer service comments; provider and Contractor relationship with hospital staff/government contracting personnel; compliance with hospital policy and procedures.

The contractor is responsible for performance of ALL terms and conditions of the contract, the elements herein represent those that will be subject to ongoing reporting by the COR in accordance with the QASP.

a. DIRECT OBSERVATION. 100% surveillance

b. PERIODIC INSPECTION. Inspections scheduled annually or as needed. 10 randomly selected patient files per inspection period.

c. VALIDATED USER/CUSTOMER COMPLAINTS. Customer complaint data is compiled quarterly and reviewed by Service Chief – any validated complaints against a Contractor that are not resolved within the required seven day period will be further investigated.

d. RANDOM SAMPLING. Patient treatment files to be reviewed will be randomly selected and cover the period of service.

e. Verification and/or documentation provided by Contractor.

7. 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:

EXCEPTIONAL: Performance significantly exceeds contract requirements to the Government’s benefit.

SATISFACTORY: Performance meets contractual requirements.

UNSATISFACTORY: Performance does not meet contractual requirements.

8. 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. When unacceptable performance occurs, 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 CO determines formal written communication is required, the CO 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 CO. 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.

9. 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 semi-annually to assess performance and shall provide a written assessment.

10. REVIEWS AND RESOLUTION

The [CO or COR] may require the contractor’s project manager, or a designated alternate, to meet with the [insert CO, ACO, COR] and other government personnel as deemed necessary to discuss performance evaluation. The agenda of the reviews may include:

Monthly 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

[insert if appropriate: Issues arising from the performance monitoring processes]

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

SIGNED CONTRACTOR DATE

SIGNED COR DATE