S02 - Attachment D.1 QASP.pdf

ATTACHMENT D. 1 – 36C25623Q1573

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Contract Number:

Contract Description: Physician Anesthesiologist and Certified Registered Nurse Anesthetists (CRNAs) services for the Michael E. DeBakey VA Medical Center (MEDVAMC).

Contractor’s name:

1. PURPOSE

This Quality Assurance Surveillance Plan (QASP) and Ongoing Professional Practice Evaluation (FPPE) 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 and the FPPE does not detail how the contractor accomplishes the work. Rather, the QASP/FPPE 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 FPPE 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/FPPE 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: Stephanie Keo, Network Contracting Office 16 (NCO 16)

Organization or Agency: ……….

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: Jenifer Davis Organization or Agency: MEDVAMC, Houston, TX

3. CONTRACTOR REPRESENTATIVES

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

A. Program Manager:

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/FPPE 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.

Task

PWS ID

Indicator

Standard

Acceptable

Quality Level

(AQL)

Method of Surveillance

Rating:

Met AQL/did not meet

AQL- CPAR

Rating

Hours of Operation

And Uniforms

20.3

Hours of Operations and Uniforms.

Neat and clean OR teal surgical scrubs are to be worn. Not to be worn going to home or coming to work. No artificial nails, visible body piercing, no false eye lashes, report to duty on time

100%

95%

Daily Observation

Exercise of Option Period(s)/;

Positive Past Performance

Quality Care

20.4

Quality Care

Documentation, Shift report, Orders signed off completed by end of tour daily.

95%

Direct Observation

Period(s)/;

Task

PWS ID

Indicator

Standard

Acceptable

Quality Level (AQL)

Method of Surveillance

Rating:

Met AQL/did not meet

AQL- CPAR

Rating

Patient Safety

20.5

Patient safety incidents must be reported to the authorizing VA Medical Center and the COR with 24 hours. No patient causative events. 2.

Patient safety incidents must be investigated, confirmed and resolved.

All 100% of patient safety incidents are reported using Patient Safety Report within 24 hours of incident. 2.

All 100% of patient safety incidents will be investigated, confirmed, and resolved. Findings will be reported to the contractor upon completion

98%

Periodic Inspection

Period(s)/;

Patient Satisfaction

20.6

Patient complaints about the quality of service will be reported to the COR, and the Contractor.

The COR shall notify the contractor in writing of any complaints made by the patients. 100%

98%

Customer Feedback Random Sampling

Period(s)/;

Positive Past Performance

Mandatory Training

20.7 Contractor shall

complete all required trainings, per MEDVAMC policy.

Maintain current CPR & ACLS (required).

All 100% of required trainings are completed on time by contract

100% At the discretion of COR.

Random sampling.

Exercise of Option Period(s)/;

Positive Past Performance

License and Board Certification.

20.8 Contractor’s license

must be current, full and unrestricted. All staff must have current BLS and ACLS

All (100%) license must be current, full and unrestricted.

100% Annually once a year

Exercise of Option Period(s)/;

Positive Past Performance

Testing Required

20.9 TB Test, HepB Test

Background Checks

TB Test required annually. HepB required annually or declination form.

Background checks done prior to employment. 100%

Review annually once a year

Exercise of Option Period(s)/;

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 / DAILY OBSERVATION. 100% surveillance

B. PERIODIC INSPECTION. Insert performance standard(s)

C. 100% INSPECTION. Evaluates all outcomes. Immediately, when a patient safety incident is reported.

Insert performance standard(s)

D. RANDOM SAMPLING. Designed to evaluate performance by randomly selecting and inspecting a sample of evaluations. All mandatory trainings are recorded in TMS, which will be reviewed.

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 an Excellent, Satisfactory, Unsatisfactory or Not Applicable listed below.

Scale Explanations E) Excellent= Exceeds Standards; S) Satisfactory = Meets Standards; U) Unsatisfactory = Does not meet standards (Address in comment section on back)

U S E NA

Performs patient(s) ASSESSMENT/REASSESSMENTS.

Documents accordingly.

Establishes priorities and uses good decision making in delivery of patient care.

Responds to patient needs with appropriate INTERVENTION correctly and accurately implements.

Orders as prescribed by the physician.

Demonstrates knowledge of patient age related needs in planning and intervention.

Communicates patient information to appropriate staff person(s) and seeks assistance when necessary.

Assesses family / patient LEARNING NEEDS, and provides inform-ation resources as needed.

Adheres to hospital policy pertaining to Patient Rights, especially as pertains to the RIGHT OF PRIVACY.

DOCUMENTS in medical records according to established guide- lines. Also completes all other related documentation in BCMA/MAR the Narcotic record, etc.

Follows established INFECTION CONTROL guidelines for Universal Precautions, blood borne pathogens, etc, as well as for routine procedures.

Responds appropriately to EMERGENCY SITUATIONS.

Follows established guidelines to ensure a SAFE ENVIRONOMENT for patients, co-workers guests and self.

7. 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. 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 negotiated frequency of surveillance is appropriate for the work being performed.

B. Frequency of Performance Reporting. The COR shall communicate with the Contractor and will provide written reports to the Contracting Officer quarterly (or as outlined in the contract or COR delegation) to review Contractor’s performance.

9. CPAR 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/pdfs/CPARS-Guidance.pdf p. A2-1):

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).

10. 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 REPORT (CPAR).

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.

9. 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)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER