Quality Assurance Surveillance Plan (QASP).pdf

Quality Assurance Surveillance Plan (QASP)

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. 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 Contracting Officer (CO): Joleo Dianala

• Assigned Contract Specialist: Emily Trinh

• Organization: U.S. Department of Veterans Affairs, Network Contracting Office (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(S): William Rubio III

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager: [NAME, PHONE]

b. Other Contractor Personnel: [NAME, PHONE]

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.

QUALITY ASSURANCE SURVEILLANCE PLAN

Physical Therapy Services

No.

Paragraph in SOW

Indicator/Performance

Standard

Standard for Quality

Level

Acceptable

Quality

Level

Method of

Surveillance1 Incentive

1 4.4.16 Meets productivity expectations with respect to Productivity

Measure and

Encounters expected for full performance level physical therapist.

RVU:

1,295- 1,568/annum

Or

Encounters:

1,431 – 1,859/annum

Treats 6-8 patients per day

VSSC

Reports;

periodic inspection

2 4.4 Performs all element so the clinical work as outlined in PWS

Follows APTA and

VHA guidelines for the practice of physical therapy.

Follows facility guidelines for infection control.

No valid complaints

Direct observation;

valid complaints by staff/patients

3 4.7 Completes all clinical documentation following PT section, VHA and professional guidelines

Notes are signed withing 24 hours of patient visit; encounter documentation reflects care provided

Standard to be met 97% of the time

Random sampling of clinical documentation

4 4.8 Meets expectations for communication: written and verbal

• Responding to emails

• Return phone calls

• Responds to pages

Uses TEAMS appropriately

Accepts feedback graciously

3 working days

Within 24 hours

Within 1 hour

Direct observation

5 4.5 Completes

Administrative Duties

Assists with daily triage of consults

Demonstrates flexibility with schedule

Completes all other record keeping as instructed

No more than 1 supervisory counseling to correct performance

Periodic

Inspection

1 See “Methods of Surveillance,” paragraph 6 of this QASP, for additional methods of monitoring performance.

6. 4.6 Complies with VHA confidentiality, security and privacy practices

Logs off computer.

Safeguards passwords, GFE, PIV card

Protects all printed records containing sensitive information

Maintains IT security at all times

Keeps only current work sheets containing sensitive information and disposes of them via shredding bins

No more than 1 supervisory counseling to correct performance

Periodic

Inspection

5. INCENTIVES/RATING STANDARDS

Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

Various methods exist to monitor performance.

a. DIRECT OBSERVATION

b. PERIODIC INSPECTION

c. VALIDATED USER/CUSTOMER COMPLAINTS

d. RANDOM SAMPLING

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:

8. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

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

b. UNACCEPTABLE PERFORMANCE

See above Acceptable Quality Level & Method of Surveillance located in QASP

When unacceptable performance occurs, the COR shall work with the Contracting Officer (CO) 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. In order to assure that the contractor receives impartial, fair, and equitable treatment under this contract, the COR will work with the contractor to increase performance to an acceptable level.

When the COR and CO determines formal written communication is required, the COR and 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

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.

9 . FREQUENCY OF MEASUREMENT

a. Frequency of Measurement.

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

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature – Contractor

Signature – Contracting Officer Representative