S02 D.5 QASP.docx

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Pathology Services

Contract Number: TBD

Contract Description: The Amarillo Veterans Affairs Health Care System (AVAHCS) Pathology and Laboratory Medicine Service (P&LMS) located in Amarillo, Texas has a need for the provision of professional services to include Anatomical and Clinical Pathology services. This is a specialized service to maintain a high level of Pathology services for our Veterans and the current pathology position is a solo Pathologist with no support for heavy workload or when the VA Pathologist is on leave or out of town.

Contractor’s name:

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: Marisela Galarza Assigned CS: Nesha Nelson Organization or Agency: Department of Veterans Affairs, RPO West, NCO 17

b. Contracting Officer’s Technical 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: Brenda Brock 1-806-355-9703 X 7510

c. Other Key Government Personnel: Anthony W. Benderman, MD., MBA 1-806-354-7867

3. CONTRACTOR REPRESENTATIVES

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

a) Program Manager: TBA

b) Other Contractor Personnel: N/A

Title:

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, paragraph 7.6.A 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).

Performance Standards

Section 2.1

Performance Standards

Section 2.1.c

Performance Standards

Section 2.5

Committee codes for all cases finalized for Amarillo VAHCS. Completed CAP synoptic reports will be provided on all malignant cases as requested by the VA, if applicable.

Performance Standards

Section 2.6

program amongst the APG pathologists.

Performance Standards

Section 2.8.h

Performance Standards

Section 9.1, and 9.3

Privacy of Individually identifiable health information. Contractor shall provide documented proof to the contracting officer that all employees assigned work and/or having access to Protected Health Information have received annual training. Proof of training is to be forwarded to the Contracting Officer. Information on fulfilling the training requirement as stated in this paragraph can be found at https://www.ees-learning.net. For contractors and sub-contractors who do not have access to VHA computer systems, this requirement is met by receiving VHA National Privacy Training, other VHA approved privacy training or contractor furnished training that meets the requirements of the HHS standards. Completed within 30 days of contract approval and yearly thereafter.

9.2 doesn’t apply to this contract since they do not have physical access to VA Computer system.

9.3 VA Cyber Security Awareness Training: Each contractor assigned work under the contract is required to receive and document completion of VA training on Cyber Security. The requirements for fulfilling this provision can be found at https://www.ees-learning.net Contractor shall provide documented proof to the Contracting Officer that all contractor employees servicing a VA contract have received annual training. Completed within 30 days of contract approval and yearly thereafter.

Performance Standards

Section 2.8.j

Performance Standards

Section 2.8. k

5. INCENTIVES

The Government shall continue contract performance based on past performance and/or any other incentive that was proposed as incentives. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

6. METHODS OF QA SURVEILLANCE

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

a) DIRECT OBSERVATION: Performed by COR, Chief of Surgery or O.R. Clinical Nurse Manager/O.R. Assistant Clinical Nurse Manager.

b) PERIODIC INSPECTION: Performed by either pulling up reports available in the electronic package, pulling log sheets and doing periodic audits.

c) VALIDATED USER/CUSTOMER COMPLAINTS: (Relies on the patient to identify deficiencies. Complaints are then investigated and validated.)

7. 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 a positive, neutral, or negative outcome. The following ratings shall be used:

· Favorable

· Satisfactory

· Unsatisfactory

8. 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.

9. FREQUENCY OF MEASUREMENT

a) Frequency of Measurement.

b) During contract performance, the COTR will periodically analyze whether the negotiated frequency of surveillance is appropriate for the work being performed.

c) Frequency of Performance Assessment Meetings.

d) The COR shall meet with the contractor as needed to assess performance and shall provide a written assessment.

Signature – Contractor Program Manager

Signature – Contracting Officer’s Technical Representative