Quality_Assurance_Surveillance_Plan_-_OBGYN_Services.doc

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QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Services contract for the OB/GYN Services Contract Services for the Pine Ridge Comprehensive Health Care Facility

TABLE OF CONTENTS

INTRODUCTION

11.1 Purpose

11.2 Performance Management Approach

11.3 Performance Management Strategy

ROLES AND RESPONSIBILITIES

22.1 The Contracting Officer

22.2 The Contracting Officer’s Technical Representative

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

METHODOLOGIES TO MONITOR PERFORMANCE

24.1 Surveillance Techniques

34.2 Customer Feedback

34.3 Acceptable Quality Levels

QUALITY ASSURANCE DOCUMENTATION

35.1 The Performance Management Feedback Loop

35.2 Monitoring Forms

ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

36.1 Determining Performance

46.2 Reporting

46.3 Reviews and Resolution

5ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

6ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

QUALITY ASSURANCE SURVEILLANCE PLAN

(QASP)

1 INTRODUCTION

This quality assurance surveillance plan (QASP) is pursuant to the requirements listed in the performance based Scope of Work (SOW) titled "OB/GYN Services". This plan sets forth the procedures and guidelines the Indian Health Service Pine Ridge Comprehensive Health Care Facility will use in ensuring the required performance standards or services levels are achieved by the contractor.

1.1 Purpose

1.1.1 The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the SOW and the contractor’s quality control plan (QCP), and to ensure that the government pays only for the level of services received.

1.1.2 This QASP defines the roles and responsibilities of all members of the integrated project team (IPT), identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

1.2 Performance Management Approach

1.2.1 The Scope of Work structures the acquisition around “what” service or quality level is required, as opposed to “how” the contractor should perform the work (i.e., results). This QASP will define the performance management approach taken by the Pine Ridge Comprehensive Health Care Facility to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives/tasks communicated in the performance based scope of work are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

1.2.2 Performance management represents a significant shift from the more traditional quality assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, as long as the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

1.3 Performance Management Strategy

1.3.1 The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own quality control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or by subcontractors. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the Scope of Work. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated government representative. The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the Scope of work. This QASP enables the government to take advantage of the contractor’s QC program.

1.3.2 The government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The government will make a determination regarding incentives based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer

The contracting officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the contracting officer's representative (COR) and the contractor. The CO will designate one COR as the government authority for performance management. There will be an additional representative named the Subject Matter Expert – OB Nursing Supervisor who will be gathering the performance data on the contractor’s performance and submitting this information to the COR monthly, quarterly, semi- annually and annually.

2.2 The Contracting Officer’s Representative

The contracting officer’s technical representative (COR) is designated in writing by the CO to act as his or her authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor deems may affect contract price, terms, or conditions shall be referred to the CO for action. The COR and the Subject Matter Expert (SME) – (OB Nursing Supervisor) will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract.

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

The required performance standards and/or quality levels are included in the performance based Scope of work and in Attachment 1, “Performance Requirements Summary.” If the contractor meets the required service or performance level, it will be paid the monthly amount agreed on in the contract. Failure to meet the required service or performance level will result in a deduction from the monthly amount.

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

In an effort to minimize the performance management burden, simplified surveillance methods shall be used by the government to evaluate contractor performance when appropriate. The primary methods of surveillance are:

· Random monitoring – Monthly, Quarterly, Semi-Annual, Annually which shall be performed by the SME who will submit the data to the designated COR.

· Document/Record Inspection – Monthly, Quarterly, Semi-Annual, Annually which shall be performed by the SME who will submit the data to the designated COR whom shall review generated documentation and enter summary results into the appropriate Quality Assurance Monitoring Form for each element.

4.2 Customer Feedback

The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems but the customer always has the option to communicate complaints to the SME or COR, as opposed to the contractor.

Customer/patient complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR, the designated Health Center Administration and Subject Matter Expert will accept and review those customer/patient complaints.

Customer feedback may also be obtained either from the results of formal OB Satisfaction Surveys or from random customer complaints.

4.3 Acceptable Quality Levels

The acceptable quality levels (AQLs) are shown in Attachment 1, Performance Requirements Summary, 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 positive patient outcomes, 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 the Pine Ridge Comprehensive Health Care Facility.

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes during the orientation of the contractor to the Dental department. Performance standards are expressed in the Scope of Work and is assessed using the performance monitoring techniques shown in Attachment 1.

5.2 Monitoring Forms

The government’s QA surveillance, accomplished by the COR in collaboration with the Subject Matter Expert, will be reported using the monitoring forms in Attachment 2. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results are being achieved.

5.2.1 The COR will retain a copy of all completed QA surveillance forms.

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.1.1 Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, they may be asked to develop a corrective action plan to show how and by what date they intend to bring performance up to the required levels.

6.2 Reporting

6.2.1 At the end of each quarter, the COR will prepare a written report for the Service Unit Contracting Officer (SUCO) summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the SME’s submitted monthly, quarterly data and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards.

6.3 Reviews and Resolution

6.3.1 The COR may require the contractor’s project manager, or a designated alternate, to meet with the Service Unit Contracting Officer (SUCO) and other government personnel as deemed necessary to discuss performance evaluation. The SUCO will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor; however, if the need arises, the contractor will meet with the COR as often as required or per the contractor’s request. 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

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

6.3.3 The COR and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the SUCO.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Required Services (Tasks) Performance

Standards Acceptable Quality

Levels Methods of Surveillance Incentive (Positive and/or Negative)

(Impact on Contractor Payments)

Qualification of Key Personnel

Scope of Practice/Privileging Medical Record/EHR Deficiencies Patient Safety

Maintains Certifications in ACLS, BLS, NRP Mandatory Training and competencies Privacy, Confidentiality and HIPAA. Department and Hospital Wide Policies

100% of OB/GYN contractors shall be licensed during contract period 100% of OB/GYN contractors performs within their scopes of practice 100% of OB/GYN contractors will complete all Medical Record/EHR deficiencies immediately upon notification 100% Patient safety incidents shall be reported using Patient Safety Report (Webcident). All incidents reported immediately (within 24 hours) 100% of Certifications for OB/GYN contractors shall be provided as they are renewed and kept current.

100% of OB/GYN contractors shall completed all required training on time.

100% OB/GYN contractors comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality/HIPAA and Department and Hospital Wide Policies

100% 100% 100% 100% 100%

100% 100%

Random inspections of qualification documents upon initial entry along with verification of licensure.

At the time of hire and during licensure renewal.

5% Random Chart Reviews of OB Medical Records/EHR will be conducted monthly on each contract OB/GYN, by the OB/GYN Supervisor.

MR/EHR deficiencies submitted are corrected within the designated timeframe to remain in compliance with the Internal Control Policy. Validated by the HIM Supervisor.

Weekly reviewed by the OB/GYN Supervisor Direct Observation and during Shift Reports.

The OB/GYN Supervisor will review the incident at the time of notification to provide follow up and documented on the Webcident section of the report form. In addition to meeting with the Grievance Committee the actions taken to resolve the issue.

Periodic Sampling, Random Sampling

Periodic Sampling: Initial Training provided through a variety venues like Policy Stat, HQ mandatory training, annual competencies and Annually thereafter Periodic Sampling, Contractor shall provide evidence of annual training required by IHS

Monthly monitoring by Information Security Officer and Privacy Officer

Compliance with all department and Hospital Wide Policies Incentive: Favorable contractor performance evaluation.

Disincentive:

Unfavorable contractor performance evaluation.

Incentive: Favorable contractor performance evaluation.

Disincentive:

Unfavorable contractor performance evaluation.

Incentive: Favorable contractor performance evaluation.

Disincentive:

Unfavorable contractor performance evaluation.

Incentive: Favorable contractor performance evaluation.

Disincentive:

Unfavorable contractor performance evaluation.

Incentive: Favorable contractor performance evaluation.

Disincentive:

Unfavorable contractor performance evaluation.

Incentive: Favorable contractor performance evaluation.

Disincentive:

Unfavorable contractor performance evaluation.

Suspension or termination of all physical and/or electronic access privileges and removal from contract until such time as the training is completed.

Incentive: Favorable contractor performance evaluation.

Disincentive:

Unfavorable contractor performance evaluation.

Immediate removal from contract.

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE

MONITORING FORM

SERVICE/ STANDARD:____________________________________________________________________________________________

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

(Random Sampling 100% Inspection Periodic Inspection Customer Complaint

LEVEL OF SURVEILLANCE (Check):

Monthly Quarterly As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD:

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (Check):

Meets Standards

Does Not Meet Standards

Narrative of Performance during Survey Period:_______________________________________________________________________

PREPARED BY:

DATE

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