S02 - Attachment D1 - QASP Saginaw Physicist.pdf

Attachment D1 – Quality Assurance Surveillance Plan (QASP)

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Medical Physicist - Saginaw

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 CO: Michelle C. Ford

Organization or Agency: Network Contracting Office 10

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: Timothy Jackson, Radiation Safety Officer/COR

c. Other Key Government Personnel – Key personnel are any personnel on call for the contracted service.

3. CONTRACTOR REPRESENTATIVES

The following employee of the contractor is to serve as the contractor’s program manager for this contract.

Program Manager: <to be announced upon awarding contract>

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.

The Performance Requirements Summary Matrix below, in the Performance Work Statement (PWS), includes performance standards. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the Acceptable Quality Level (AQL).

5. INCENTIVES

The following incentives shall be implemented when the contractor meets or exceeds the performance standards and contract requirements:

1. Favorable Past Performance Evaluation.

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.

a. INSPECTION - COR evaluates outcomes through documentation/dictation and results as documented above.

b. PERIODIC SAMPLING - Sample is taken when a problem/deficiency is suspected. Sample results are applicable only for the specific work inspected.

Measure PWS Para Performance Requirement Standard Acceptable

Quality Level Surveillance

Method Disincentive/Deduct

Key Personnel Qualifications

3.7, 4.0, 4.7, 9.3, 11.11.1

Medical Physicist shall be board certified in accordance with ACR Standards 100% 100% Periodic sampling of certification Unfavorable contractor performance evaluation

Diagnostic Imaging equipment physics testing

1.0, 3.3

11.11.2

Certify physics testing of diagnostic imaging equipment meeting TJC requirements.

100% of diagnostic imaging equipment tested annually.

95%

Periodic sampling of physics testing reports

Unfavorable contractor performance evaluation

Standard Operating

Procedures (SOP) for all ACR accredited modalities

3.3 11.11.3

SOPs shall maintain for diagnostic imaging modalities with ACR accreditation; CT, MRI, PET, Ultrasound, Nuclear medicine and mammography.

100% of SOPs are reviewed & updated annually.

90% Periodic sampling of SOPs Unfavorable contractor performance evaluation

Continuous Quality

Improvement

(CQI)

11.10.1 11.11

11.11.4 11.11.5

Quarterly CQI reports documenting all requirements of ACR QC guidance for each modality with ACR accreditation

100% of CQI reports meeting ACR guidance 95% Periodic sampling of CQI reports Unfavorable contractor performance evaluation

Dose Tracking for CT & fluoroscopy 11.11.5

Quarterly reports documenting TJC dose tracking for CT & fluoroscopy equipment

100% of dose tracking meeting TJC standards quarterly 95%

Periodic sampling of dose tracking reports

Unfavorable contractor performance evaluation

Mandatory Training

11.11.6.

12.0

Contractor completes all mandatory required training

All Training (100%) completed as required per VAMC policy annually

95%

Contractor to provide documented evidence

Suspension or termination of all physical and/or electronic access privileges and removal of CDMP from contract until the training is complete

Privacy, Confidentiality and HIPAA

11.9.1 11.9.2 11.9.3 11.9.5

11.11.7 12.0

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 Quarterly

100%

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

Depending on severity of offense, suspension or termination of all physical and/or electronic access privileges and removal of CDMP from contract until the training is complete

Professionalism/ Conduct

11.9.4 11.11 11.12

Contract CDMP maintains excellent relationships with patients, AELVAMC staff members staff members, and vendors.

Zero complaints from AELVAMC staff members related to the contract CDMP interfering with patient care or the ordinary operation of the facility.

100% COR notification of complaints

Removal of contractor CDMP from contract.

7. RATINGS

a. Metrics and methods are designed to determine rating for a given standard and acceptable quality level. The following ratings shall be used:

EXCEPTIONAL:

Contractor always meets the standard. 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:

Contractor almost always meets the standard, always performs over the Acceptable Quality Level.

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:

Contractor occasionally meets the standard, but more often meets the Acceptable Quality Level.

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:

Contractor most often meets the Acceptable Quality Level, occasionally does not meet the Acceptable Quality Level and CDRs have been reported.

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:

Contractor has history of not meeting Acceptable Quality Level. Significant efforts have been made to bring Contractor into performance. 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).

8. DOCUMENTING PERFORMANCE

a. Acceptable Performance: The Government shall document 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 shall 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 Contracting Officer (CO). In turn, the CO shall present the CDR to the Contractor.

The Contractor shall acknowledge receipt of the CDR in writing. The CDR shall 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 shall 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 shall become a part of the supporting documentation for any contractual action deemed necessary by the CO.

9. PROCEDURES

The COR shall inspect to ensure Contractor compliance with the appropriate section of the Statement of Work (SOW) periodically. The evaluator shall record results of inspection, noting the date and time of inspection. If inspection indicates unacceptable performance, the COR shall notify the CO of the deficiencies within 3 business days. Contractor shall be given notification to correct the deficiencies within a reasonable amount of time, on a case-by-case basis. The CO shall have the final authority on the amount of time the Contractor has to correct the deficiency.

10. FREQUENCY OF MEASUREMENT

During contract performance, the COR shall periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed. Performance Assessment Meetings shall be conducted quarterly. The Government may, at its discretion, choose any time, announced or unannounced, to have VA personnel inspect the contractor’s files

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

11. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

COR NAME/TITLE DATE

CONTRACTOR NAME/TITLE DATE

CONTRACT DISCREPANCY REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER FOR THIS DISCREPANCY

3. TO: (Contracting Officer) 4. FROM: (Name of COR)

5. DATES

a. CDR PREPARED

b. RETURNED BY CONTRACTOR: c. ACTION COMPLETE

6. DISCREPANCY OR PROBLEM (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)

10. CONTRACTOR RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT

RECURRENCE. (Cite applicable quality control program procedures or new procedures. Attach continuation sheet(s) if necessary.)

11. SIGNATURE OF CONTRACTOR REPRESENTATIVE Date:

12. GOVERNMENT EVALUATION. (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

13. GOVERNMENT ACTIONS (Acceptance, partial acceptance, reflection. Attach continuation sheet(s) if necessary.)

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER