Quality Assurance Surveillance Plan ( QASP) Home Oxygen Services Bay Pines VAMC.pdf

ATTACHMENT C

QUALITY ASSURANCE SURVEILLANCE PLAN

Home Oxygen Services Bay Pines VAMC

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 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: Undetermined

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: Cheryl Brandt, Prosthetic Representative

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager – Undetermined

4. PERFORMANCE REQUIREMENT STANDARDS

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.

Description

PWS

Reference Numerator and Denominator Quantity of

Surveillance AQL Method of

Surveillance

Emergency Calls deliver by 6hrs of call place Page 5

Number (N)=# of VA patients (pts) delivered

Randomly pull 5% of files 100% Random Sampling

Patient Travel memos Page 5

N=# of memos that will hold the veterans financially responsible for GFP non-returned

Randomly pull 10% of files 100% Random Sampling

Audit of VA patient (pts) satisfaction to be issue specific, including comments and complaints Page 5

N=# of VA pts satisfied with contractors service. Satisfaction survey developed by vendor, but approved by VA. N=# of VA patients audited for pt satisfaction

Random survey results quarterly 90% 100% Review

Audit of VA pt records for proof of receipt of equipment installation within 6hrs of notification Pages 5

N=# of VA pt files with documentation of pt and/or caregiver signing for receipt of DME equipment. N=# of VA pts receiving DME equipment.

Randomly pull 10% of files 95% Random Sampling

Audit of government furnished property inventory held by vendor Page 5

N=# of VA owned items on Vendor property ready for issue.

N=# of VA owned items signed for (Quarterly or as manufacture’s requirement)

Randomly pull 10% of files 95% Random Sampling

Audit of all accidents, malfunctions, injuries, deaths and sentinel events associated with the provisions, delivery and use of home oxygen equipment. Page 5

N=# of VA pts who had an incident related to DME equipment to include fires, accidents, malfunctions, injuries, deaths, and sentinel events. N=# of VA pts receiving DME equipment 100% 100% 100% Review

Home Oxygen Welcome Packet and Initial Care plan Page 5

N=# of patients who received the packet the first visit. Initial Care plan assessment completed within 7 days. Assessment of veterans home in patient’s folder.

Randomly pull 10% of files 95% Random Sampling

Home Oxygen Theraphy Program checklist and 6

N=# of patients who received the Initial and Reassessments chelist should be in file

Randomly pull 10% of files 95% Random Sampling

Audit of VA patient treatment files for proper documentation of pt education Page 6

N=# of VA pt files with doc of pt and caregiver education to include return demonstration of equipment use equip. N=# of VA pt files

Randomly pull 10% of files 90% Random Sampling

Audit of warehouse and delivery vehicles, employees for compliance with infection control protocols Page 6

N=# of deficiencies observed in infection control protocol in warehouse and delivery vehicles, employees. N=# observed infection control protocols. N=# Employee vaccination files 100% 100%

Periodic Inspection

Delivery and Set-ups Page 6

N=# of patients discharge and delivery done within 5hrs. New delivery within 24hrs of order and contractor notify the veteran withi

2hrs.

Randomly pull 5% of files 100% Random Sampling

a. PERIODIC INSPECTION. (Evaluates outcomes on a periodic basis. Inspections may be scheduled monthly or unscheduled, as required.)

b. USER SURVEY. (Combines elements of validated user complaints and random sampling.

Random survey is conducted to solicit user satisfaction. May also generate inspections and sampling.)

c. VALIDATED USER/CUSTOMER COMPLAINTS. (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.)

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

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

f. Progress or status meetings. Quarterly meetings with Contractor as needed.

g. Analysis of contractor's progress reports. (Evaluate cost, schedule, etc.)

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:

7. DOCUMENTING PERFORMANCE

a. ACCEPTABLE PERFORMANCE

The Government shall document positive performance.

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 frequency of surveillance is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

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

Signature – Contracting Officer

Signature – Contracting Officer’s Representative