S02 - Attachment D3 - QASP Quality Assurance Surveillance Plan Radiation Oncology 02.pdf

Quality Assurance Surveillance Plan Radiation Oncology Physician Services for Fort Wayne, IN.

The contractor will be evaluated in accordance with the following:

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 will monitoring take place?

• Who will conduct the monitoring?

• How will monitoring efforts and results 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 through contract modification. 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, Contracting Officer

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: Alexander Pierzynski, Northern Indiana Healthcare System Organization or Agency: VA Northern Indiana Health Care System (NIHCS)

3. CONTRACTOR REPRESENTATIVES

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

Primary Program Manager:_________________________________________

Alternate Program Manager: ________________________________________

ATTACHMENT D3

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 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.

4. 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 OBSERVATION. 100% surveillance: 100% surveillance: observation of direct patient care episodes, monitoring of patient records and charting, and peer review.

b. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. (semi-annually). For example, ten (10) randomly selected patient files will be reviewed per inspection period. All inspections and reports will be conducted in compliance with VA Privacy and Information security standards.)

c. VALIDATED USER/CUSTOMER COMPLAINTS.

d. RANDOM SAMPLING. Semi-annual (For example, ten (10) randomly selected patient files will be reviewed per quarter. All reviews and reports will be conducted in compliance with VA Privacy and Information security standards.)

e. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR.

5. QASP PERFORMANCE Report DATE: _______________________________

Measure

PWS

Para.

Performance Requirement

Standard Acceptable

Quality Level

Surveillance Method

Met

AQL/DID

NOT MEET

AQL-

CPARS

RATING/

ADD

COMMENTS

Provider Quality

4.6.4.1

Per TJC standards, ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), or to revoke an existing privilege prior to or at the time of renewal.

OPPE documentation for all (100%) staff providing services under the contract. All staff (100%) meet 100% Standards

98% meet

ACR

Standards

Ongoing Provider Performance Evaluation (OPPE) data pertinent to Radiation Therapy care performed for each provider working under this contract.

The Contractor shall furnish OPPE data on new providers added to the contract at three months, six months and semi-annual thereafter. The OPPE data shall be provided to the ACOS or COR for Acute Medical Service VAMC Staff.

OPPE data should include the following elements:

A. Patient Care Performance

B. Medical/Clinical knowledge

C. Practiced Based Learning and Improvement

D. Interpersonal and Communica Skills

E. Professionalism

F. System Based Practice

Yes ☐

No ☐

Qualifications and Availability of Key Personnel

Requirement

4.6.4.2 Radiation Oncology Physicians

shall be board certified and in accordance with national recognized accrediting body standards. The Contractor shall provide evidence that workload is distributed between 2 or more providers within the group and that treatment is provided in compliance within standard of care outlined in this PWS.

All (100%) of Radiation Oncology Physicians shall be board certified and in accordance with national recognized accrediting body standards; and available to provide the required scheduled services to veterans 100% of the time.

No deviations from the standard (100%).

Periodic Sampling of qualification documentation and medical records submitted in accordance with contractor reporting requirements.

Patient Access 4.6.4.3 The Contractor shall provide Contractor’s physician(s) in accordance with the operating hours and VA clinical schedule outlined in this PWS.

All (100%) Contractor’s physician(s) are on time and available to perform services.

Contractor’s physician(s) are on-time and available to perform services 98% of the time.

Periodic Inspection of Time and Attendance Sheets Yes ☐

Maintains licensing, registration, and certifications

4.6.4.4 Updated Licensing, registration and certifications will be provided as they are renewed.

100% Licensing registration information kept current.

100% Periodic Inspection and Random Sampling

Mandatory Training 4.6.4.5 Contractor completes all mandatory required training

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

95% Contractor to provide documented evidence

Privacy, Confidentiality and HIPAA

4.6.4.6

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

100%

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

Professionalism/ Conduct

4.6.4.7 Contractor employees

maintain excellent relationships with patients, Radiation Oncology staff members, VA Medical Center staff members, and vendors.

Zero complaints from VA Medical Center staff members related to the contractor’s employee interfering with patient care or the ordinary operation of the facility.

100% COR notification of complaints Yes ☐

Patient Reports and Documentation

4.6.4.8 All notes must be electronically signed, and all encounters closed within 24 hrs.

Compliance with VA Rules and Regulations 95% Random Sampling and

Periodic Inspection

Chart Review /Consults 4.6.4.9

Completion deadlines met as assigned by Radiation Oncology Service Administration/COR

Chart Review/Physics Check/Consults are completed weekly

90% Random Sampling and Periodic Inspection

Peer Review Conferences/Ch art Rounds

4.6.4.10 Conduct Weekly Peer Review Conferences/Chart Rounds as required by the PWS.

Peer Review Conferences/Chart Rounds conducted, documented, and reported as required.

90%

Periodic Inspection and verification and/or documentation provided by contractor

6. CPARS 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/documents/CPARS-Guidance)

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 https://www.cpars.gov/documents/CPARS-Guidance 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).

7. 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

REPORTING SYSTEM (CPARS).

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. See Sample CR below.

8. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

COR NAME/TITLE DATE

SIGNED:

CONTRACTOR NAME/TITLE DATE

CONTRACT REPORT

1. CONTRACT NUMBER 2. REPORT NUMBER

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)

10. CONTRACTOR RESPONSE AS TO CAUSE 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.

13. GOVERNMENT ACTIONS

14. CLOSE OUT

NAME TITLE SIGNATURE DATE

CONTRACTOR

NOTIFIED

COR

CONTRACTING

OFFICER

Various methods exist to monitor performance. The COR shall use the surveillance methods listed below in the administration of this QASP.