S02. Attachment D.1 - QASP - Quality Assurance Surveillance Plan.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN:

Task Indicator Standard Acceptable

Quality Level

Method of Surveillance Incentive

Access

Patients must receive treatment in a timely manner.

Staff on-site and available during all scheduled clinic hours.

95% Direct observation and random inspection

Satisfactory or better past performance

Quality Care

Staff Registered and/or Licensed

Nurses must be Registered and/or Licensed.

100% Direct Observation by Verification of documentation

Satisfactory or better past performance

Chart audits completed timely by Contractor

Contractor will complete 10 chart audits per month

90% Direct observation and Periodic inspection

Satisfactory or better past performance

Quality indicators identified:

Pre/Post Vital Signs Present for Time On, Pre/Post Vital Signs Present for Time Off, Post Bruit Thrill Note Present, Medication Read Back Complete on all Verbal/ Telephone Orders, and Vital Signs with UFR documented q15 minutes during treatment

Each quality indicator must meet standard of 90%

95% Direct observation by review of documentation

Satisfactory or better past performance

Patient Safety

Patient safety incidents must be reported to the SLVHCS (via Incident Reports through VISTA) and COR.

All incidents reported immediately (within 24 hours).

100% Direct observation and random inspection

Satisfactory or better past performance

Patient safety incidents must be investigated, confirmed and resolved.

All incidents are investigated, confirmed and resolved.

100% Direct observation and random inspection

Satisfactory or better past performance

Quality Level

Method of Surveillance Incentive

Comply with all applicable requirements of Federal, State, and local hazardous waste regulations.

Provide documentation upon request.

98% Random Inspection Satisfactory or better past performance

Patient Satisfaction

Immediate reporting of patient care quality complaints to

COR.

All complaints 100% Direct observation and random inspection of review of complaints

Satisfactory or better past performance

Clinical Information Return

Staff will be responsible to check and document dialysis treatments.

All Cases 100% Direct Observation and random inspection

Satisfactory or better past performance

Documentation in Electronic Medical Record

Medical record documentation completed same day a procedure is performed

All Cases 95% Random Audit/ Inspection

Satisfactory or better past performance

Training Requirements

Contractors will be required to complete all VA yearly mandatory training.

Complete all mandatory training

100% Periodic Inspection of VA Training Reports

Satisfactory

Contractor shall comply with all relevant regulatory agencies and standards including but not limited to Joint Commission (JC) or equivalent program, the Occupational Safety and Health Administration, and the state of Louisiana, for all HD services rendered.

Contractor shall provide documentation, upon request.

98% Random Inspection Satisfactory

Quality Level

Method of Surveillance Incentive

Timeliness

Dialysis treatment records will be maintained in accordance with current standards, and will be available for review by attending nephrologists during dialysis rounds.

Be available to initiate STAT dialysis orders within 4 hours of the order.

100%

Direct observation and random inspection of charts to compare the time the Contractor was notified to the time the dialysis nurse started the treatment.

Satisfactory or better past

Disincentive for all tasks includes unfavorable Contractor performance evaluation and/or removal from contract.

QUALITY ASSURANCE SURVEILLANCE PLAN

For: Hemodialysis Services

Contract Number: _____________________________

1. Contract Description: Requirement is for an onsite Hemodialysis Services at the Veterans Health Care System of the Ozarks Hospital, 1100 North College Avenue, Fayetteville, Arkansas.

Contractor’s name and address:

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: Billy Morris

Organization or Agency: Veterans Health Care System of the Ozarks Hospital, 1100 North College Avenue, Fayetteville, Arkansas.

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: Doris Diehn-Key

3. CONTRACTOR REPRESENTATIVES

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

a. Program Manager:_________________________________________________________

b. Other Contractor Personnel:__________________________________________________

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, in the Statement of Work (SOW), includes performance standards. The Government shall use these standards to determine contractor performance.

5. INCENTIVES

The Government shall use Exercise of Option Period and past performance as incentives and are based on exceeding and/or meeting performance standards.

6. METHODS OF QA SURVEILLANCE

The COR shall use the surveillance methods listed below in the administration of this QASP.

a. DIRECT OBSERVATION. Can be performed periodically or through 100% surveillance.

ID #: 1, 2, 3, 4, 5, 6, 7, 8, 11

b. PERIODIC INSPECTION. Evaluates outcomes on a periodic basis. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.

ID #: 3, 9, 10

c. RANDOM INSPECTION: Evaluates outcome on a random basis.

ID #s: 1, 4, 5, 6, 7, 8, 9, 11

d. Progress or status meetings.

Performance standard - Held twice a year or more often if required

e. Analysis of contractor's progress reports.

Performance standard - Random inspection of reports

8. 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:

1. Exceeds

2. Meets

3. Failed to meet

9. 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.

10. 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 Assessment Meetings.

The COR shall meet with the contractor Bi-annually or as needed to assess performance and shall provide a written assessment.

________Concur ________Non-concur ________See comments

Signature – Contractor Program Manager

________Concur ________Non-concur ________See comments

Signature – Contracting Officer’s Representative