S02 - Attachment D3 - Quality Assurance Surveillance Plan.pdf

ATTACHMENT D3 - QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

The contractor shall 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 monitoring will take place.

• Who will conduct the monitoring?

• How monitoring efforts and results will be documented.

2. GOVERNMENT ROLES AND RESPONSIBILITIES: The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer/Contract Specialist (CO/CS): The CO/CS 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/CS shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO/CS is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned CO/CS: Alexander J. Daniel, Contracting Officer / Michelle C. Ford, Contract Specialist Organization or Agency: Department of Veterans Affairs, 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: Catherine Gnau, VISN 10 Supply Systems Analyst

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

Primary: _______________________________________

Alternate: ______________________________________

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 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.

5. INCENTIVES/DEDUCTS: The Government shall use past performance as incentives. Incentives shall be based on ratings received on the performance standards (Inclusion of any monetary incentives requires approval through the Department’s Senior Procurement Executive (SPE).

6. METHODS OF QA SURVEILLANCE: Various methods exist to monitor performance. The COR will use the surveillance methods listed below in the administration of this QASP.

a. PERIODIC INSPECTION. Inspections scheduled and reported quarterly per COR delegation or as needed. COR will meet with facility Points of Contact

(POCs) to ensure that patient reports are meeting the requirements of the PWS.

b. VALIDATED USER/CUSTOMER COMPLAINTS. Complaints made by patients or VA staff will be reported to the COR for review and will be sent to the contractor to address/correct.

c. VERIFICATION AND/OR DOCUMENTATION PROVIDED BY CONTRACTOR. COR will audit and review invoices monthly for accuracy of documentation, timeliness of submission, proper invoice number referenced, and accurate dollar amount relating to patient services.

7. MEASURES:

METRIC PWS Paragraph Reference

Performance Requirement Standard Acceptable Quality Level

(tailor to meet your requirements)

Method of Surveillance and frequency

Met AQL/Did Not Meet AQL

(Add comment)

1 – Clinical Information Return

Section 2.3, para. s & t

Contractors will provide Holter and Event monitor data reports to the VA within 48 hours after completion of the study in accordance with SOW requirements.

100% of reports are reviewed for timeliness and completeness.

95% compliance Quarterly Review by COR

2 – Volume Section 2.3, para. q & r

Contractor is able to meet volume/inventory needs of the VISN 10 Medical Centers, as outlined in the SOW.

100% of inventory needs are met for all facilities throughout life of the contract

No more than 3 instances of not meeting inventory levels per facility, per quarter

Quarterly

3 – Access Section 2.3, para. l

Section 2.6, para. a-d

Contractor provides 24/7 coverage for telephone access for both patients and VISN 10 Medical Center employees.

There are no reports of failure to respond to.

No more than 3 documented instances of inadequate telephone coverage per facility per quarter

Input from patients & clinical staff to

COR

4 – Quality of Care Section 2.3, paragraph n

Contractor will electronically provide clear and precise rhythm tracings within 24 hours of receipt, as outlined in the SOW.

All (100%) tracings are reviewed by EKG personnel and/or Cardiologist, where applicable

95% compliance 10% Random sampling of records monthly

5 – Quality of Care Section 2.3, para. p

Contractor will provide notification upon receiving abnormal tracings no later than one hour after receipt and recognition, as outlined in the

SOW.

There are no reports of failure to respond.

95% compliance Input from clinical staff to

6 – Patient Safety Section 3.1, para. a-j

Contractor-owned equipment will be maintained in good working order and ensures proper cleaning before reissuing monitors to patients.

All (100%) equipment maintenance demonstrates compliance as required.

No more than 3 documented instances of defective and/or unclean equipment per facility per quarter.

Random selection every two weeks by COR or designee

7 – Communication & Training

Section 2.5, para. a-e

Contractor shall provide contingency plan, list of contacts for emergencies and document site training

There are no reports of failure to respond.

No more than 2 instances of non-compliance per facility per year.

8 – Invoicing Section 3.2 Contractor shall submit monthly itemized invoices via IPPS with no PII. Invoices shall include all specs IAW the SOW

All properly annotated invoices submitted monthly to sites

No more than 2 documented instances of inadequate invoicing per facility per year.

8. RATINGS:

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

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).

9. DOCUMENTING PERFORMANCE: 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). If contractor performance does not meet the Acceptable Quality level, the CO/CS shall inform the contractor. This will normally be in writing unless circumstances necessitate verbal communication. In any case the CO/CS shall document the discussion and place it in the contract file. When the COR and the CO/CS determines formal written communication is required, the COR shall prepare a Contract Discrepancy Report (CDR), and present it to CO/CS. The CO/CS will in turn review and will present to the contractor's program manager for corrective action. 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 CO/CS.

The Government shall review the contractor's corrective action plan to determine acceptability. The CO/CS shall also assure that the contractor receives impartial, fair, and equitable treatment. The CO/CS 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO/CS. See sample CDR in Section D of the solicitation.

10. FREQUENCY OF MEASUREMENT: The frequency of measurement is defined in the contract or otherwise in this document. The government (COR or CO/CS) will periodically analyze whether the frequency of surveillance is appropriate for the work being performed.

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 performance.

11. COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

SIGNED:

Catherin Gnau DATE

VINS 10 Supply Systems Analyst & COR

SIGNED:

CONTRACTOR NAME/TITLE DATE

Attachment D4 – CONTRACT DISCREPANCY REPORT

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

CONTRACTING

OFFICER