S02. Attachment D.2 Quality Assurance Surveillance Plan.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

1 INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) is pursuant to the requirements listed in the Performance Work Statement (PWS) entitled Veterans Health Care System of the Ozarks VAMC, Special Mode of Transportation Service, Wheelchair Transportation Service. This plan sets forth the procedures and guidelines Veterans Transportation Service (VTS), Veterans Health Care System of the Ozarks (VHSO) VAMC will use in ensuring the required performance standards or services levels are achieved by the contractor.

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.

1.1 Purpose

1.1.1 The purpose of the QASP is to describe the systematic methods used to monitor performance and identify required documentation and resources to be employed. The QASP provides a means for evaluating whether the contractor is meeting the performance standards/quality levels identified in the PWS and the contractor’s Quality Control Plan (QCP), and ensure the Government pays only for the level of services received.

1.1.2 This QASP defines the roles and responsibilities of all members of the Integrated Project Team (IPT), identifies the performance objectives, defines the methodologies used to monitor and evaluate the contractor’s performance, describes quality assurance documentation requirements, and describes the analysis of quality assurance monitoring results.

1.2 Performance Management Approach

1.2.1 The PWS structures the acquisition around what service or quality level is required, as opposed to how the contractor should perform the work (i.e., results, not compliance).

This QASP will define the performance management approach taken by VHSO VTS to monitor and manage the contractor’s performance to ensure the expected outcomes or performance objectives communicated in the PWS are achieved. Performance management rests on developing a capability to review and analyze information generated through performance assessment. The ability to make decisions based on the analysis of performance data is the cornerstone of performance management; this analysis yields information that indicates whether expected outcomes for the project are being achieved by the contractor.

ATTACHMENT D.2

1.2.2 Performance management represents a significant shift from the more traditional Quality Assurance (QA) concepts in several ways. Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the contractor to play a large role in how the work is performed, if the proposed processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the contractor flexibility to continuously improve and innovate over the course of the contract if the critical outcomes expected are being achieved and/or the desired performance levels are being met.

1.3 Performance Management Strategy

1.3.1 The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s Quality Control (QC) program. QC is work output, not workers, and therefore includes all work performed under this contract regardless of whether the work is performed by contractor employees or subcontractors.

The contractor’s QCP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The contractor will develop and implement a performance management system with processes to assess and report its performance to the designated Government representative. The contractor’s QCP will also set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. This QASP enables the Government to take advantage of the contractor’s QC program.

1.3.2 The Government representative(s) will monitor performance and review performance reports furnished by the contractor to determine how the contractor is performing against communicated performance objectives. The Government will make determinations regarding ratings based on performance measurement metric data and notify the contractor of those decisions. The contractor will be responsible for making required changes in processes and practices to ensure performance is managed effectively.

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer (CO)

The CO is responsible for monitoring contract compliance, contract administration, cost control, and resolving any differences between observations documented by the Contracting Officer's Representative (COR) and the contractor. The CO will appoint one full-time COR as the Government authority for performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the CO.

2.2 The COR

The COR is designated in writing by the CO to act as their authorized representative to assist in administering a contract. COR limitations are contained in the written appointment letter. The COR is responsible for technical administration of the project and ensures proper Government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or authorize any contractual changes on the Government’s behalf. Any changes the contractor deems may affect contract price, terms, or conditions must be referred to the CO for action. The COR will have the responsibility for completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance.

Government surveillance may occur under the inspection of services clause for any service relating to the contract.

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY

LEVELS

The required performance standards and/or quality levels are included in the PWS and Attachment 1, Performance Requirements Summary.

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

To minimize the performance management burden, simplified surveillance methods shall be used by the Government to evaluate contractor performance when appropriate. The primary methods of surveillance are:

Random monitoring, which shall be performed by the COR designated inspector 100 percent inspection – Each month, the COR shall review the generated documentation and enter summary results into the Surveillance Activity Checklist Periodic inspection – the COR typically performs the periodic inspection Direct Observation – COR shall perform surveillance by physically observing contract performance.

4.2 Customer Feedback

The contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction.

Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems, but the customer always has the option to communicate complaints to the CO or COR, as opposed to the contractor.

Customer complaints, to be considered valid, must set forth clearly and in writing the detailed nature of the complaint, must be signed, and must be forwarded to the COR. The COR will accept those customer complaints and investigate.

Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

4.3 Acceptable Quality Levels

The Acceptable Quality Levels (AQLs) are included in Attachment 1. Contractor performance is structured to allow the contractor to manage how the work is performed while providing appropriate ratings for performance shortfalls. For certain critical activities, such as those involving Wheelchair Transportation Service, the desired performance level is established at 100 percent. Other levels of performance are keyed to the relative importance of the task to the overall mission performance at VHSO VTS.

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and assessed using the performance monitoring techniques shown in Attachment 1.

5.2 Monitoring Forms

The Government’s QA surveillance, accomplished by the COR, will be reported using the monitoring form in Attachment 2. The forms, when completed, will document the Government’s assessment of the contractor’s performance under the contract to ensure the required results are being achieved.

5.2.1 The COR will retain a copy of all completed QA surveillance forms.

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.1.1 The Government shall use the monitoring methods cited to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, 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 Discrepancy Report (CDR) in Attachment 3, and present it to CO. The CO will in turn review and will present to the contractor's program manager for corrective action.

6.1.2 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. 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 CDRs may become a part of the supporting documentation for any contractual action deemed necessary by the CO.

6.2 Reporting

6.2.1 The COR shall communicate with the contractor and will provide written reports to the

CO quarterly (or as outlined in the contract or COR delegation) to review contractor performance. This report, which includes the contractor’s submitted monthly report and the completed quality assurance monitoring forms (Attachment 2), will become part of the QA documentation. It will enable the Government to demonstrate whether the contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

6.3 Reviews and Resolution

6.3.1 The COR may require the contractor’s project manager or designated alternate to meet with the CO or COR and other Government IPT personnel as deemed necessary to discuss the performance evaluation. The CO or COR will define a frequency of in-depth reviews with the contractor, including appropriate self-assessments by the contractor;

however, if the need arises, the contractor will meet with the CO or COR as often as required or per the contractor’s request. The agenda of the reviews are not limited to but may include:

Monthly performance assessment data and trend analysis Issues and concerns of both parties Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis.

Recommendations for improved efficiency and/or effectiveness Issues arising from the performance monitoring processes.

6.3.2 The COR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

6.3.3 The COR and contractor should jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels should be clearly documented. Changes to service levels, procedures, and metrics will be incorporated as a contract modification at the convenience of the procuring CO.

7 RATINGS.

Contractor performance will be rated using the Contractor Performance Assessment Reporting System (CPARS) in accordance with FAR 42.1503. Performance will be evaluated in the applicable areas of:

• Quality of Product or Service

• Schedule

• Cost Control

• Regulatory Compliance

• Management

• Small Business Subcontracting

• Other

The following rating elements will be used to evaluate each area:

Evaluation Ratings Definition

Rating Definition Notes

Exceptional

Performance meets contractual requirements and exceeds many to the Government’s benefit. The contractual performance of the element or sub-element being evaluated was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

To justify an Exceptional rating, identify multiple significant events and state how they were of benefit to the Government. A singular benefit, however, 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 evaluated was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

To justify a Very Good rating, identify a significant event and state how it was a benefit to the Government. 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.

To justify a Satisfactory rating, there should have been only minor problems, or major problems the contractor recovered from without impact to the contract/order.

There should have been NO significant weaknesses identified. A fundamental principle of assigning ratings is that contractors will not be evaluated with a rating lower than Satisfactory solely for not performing beyond the requirements of the contract/order.

Marginal

Performance does not meet some contractual requirements. The contractual performance of the element or sub-element being evaluated 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.

To justify Marginal performance, 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 contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

To justify an Unsatisfactory rating, identify multiple significant events in each category that the contractor had trouble overcoming and state how it impacted the Government. A singular problem, however, 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).

NOTE 1: Plus or minus signs may be used to indicate an improving (+) or worsening (-) trend insufficient to change the evaluation status.

NOTE 2: N/A (not applicable) should be used if the ratings are not going to be applied to a particular area for evaluation.

8 COR AND CONTRACTOR ACKNOWLEDGEMENT OF QASP

COR DATE

Contractor DATE

MICHAEL

BUSH

Digitally signed by

MICHAEL BUSH

Date: 2025.02.04 14:26:13 -06'00' 2/4/25

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

Measure No. Required Services (Task) PWS ID Measurable

Performance Standard Acceptable Quality Level (AQL)

Method of Surveillance

SS 1 Area of Coverage 1.2.2 The contractor shall provide Wheelchair service, 24 hours per day, 365/366 days per year, as required in accordance with the terms and conditions contained herein.

100% 100% Inspection

SS 2 Vehicles and Equipment 1.3.11 The lift shall incorporate an emergency method of deploying, lowering to ground level with a lift occupant, and raising and stowing the empty lift if the power to the lift fails and have a backup for all lift capacity.

100% Periodic Inspection

SS 3 Standard for Maintenance 1.4.1 The objective of Standards for Maintenance is to protect veterans and to cause no harm to all parties. The contractor shall maintain all vehicles in a clean and orderly condition, free from debris and accumulations which may create an accident, injury, or fire hazard.

100% Periodic Inspection

SS 4 Standard for Maintenance 1.4.7 The contractor shall maintain (and furnish upon request) procedures that outline preventive maintenance and/or repairs on each vehicle in an individual vehicle file and in chronological order, latest service on top. A statement from the Contractor indication compliance of vehicle maintenance files is in place should be submitted at time of offer for evaluation purposes. Requested submission and verification of these documentation requirements will be a quality assurance procedure during the contract period.

100% Random Monitoring

SS 5 Driver Qualifications 1.5.5 The contractor shall furnish qualified personnel as required by contract specifications to accomplish all services under this contract.

100% Periodic Inspection

SS 6 Passenger Transportation 1.6.1 Upon delivery or pick-up of a patient, the contractor shall log in the patient on a log sheet at the location designated at the facility.

100% 100% Inspection

Measure No. Required Services (Task) PWS ID Measurable

Performance Standard Acceptable Quality Level (AQL)

Method of Surveillance

SS 7 Response Time

1.9.2

1.18

The contractor shall respond to all calls for wheelchair transport service by being on-site at the designated VA facility within 45-minutes after notification. STAT notifications require a 15-minute response time.

Should the time period for pick-up, stated herein, be physically impossible due to location of veteran beneficiary, the Contractor shall contact the appropriate individual at the VA and proceed to inform him/her of the anticipated time required for pick-up and delivery of said patient.

100% 100% Inspection

SS 8 Safety Requirements 1.17.4 A licensed MTO shall ensure that sanitation procedures are provided to all personnel in a written document that conforms with current standards as set forth in occupational safety and health administration-blood borne pathogens protocol.

100% Random Monitoring

1.9.1

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (check):

Random Sampling 100% Inspection Periodic Inspection Customer Complaint

Other ________________________

LEVEL OF SURVEILLANCE (check):

Monthly Quarterly As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: ______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Service Provider’s Performance (check): Meets Standards

Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: _________________

ATTACHMENT 3: SAMPLE 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

COR

CONTRACTING

OFFICER