S09 QASP.docx

Attachment – Quality Assurance Surveillance Plan (QASP)

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

Prescription Eyeglasses and Optician Services For VA Reno, Northern California, Central California and San Francisco

Issued [Insert Date]

(This QASP is a sample document. The final QASP will be developed jointly by the Contractor and the Government prior to contract performance. The final QASP will not be incorporated into and made a part of the contract.)

Table of Contents

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP)

(a). INTRODUCTION

This Quality Assurance Surveillance Plan (QASP) is established pursuant to the requirements listed in the Performance Work Statement (PWS). This plan sets forth the procedures and guidelines the VA Pacific Islands Health Care System (VAPIHCS) will use in ensuring the required performance standards or services levels are achieved by the contractor.

(1). Purpose (A). The purpose of the QASP is to describe the systematic methods used to monitor performance and to identify the required documentation and the 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).

(B). This QASP defines the roles and responsibilities of all members of the contracting team , 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.

(2). Performance Management Approach 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 the VAPIHCS 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.

(3). Performance Management Strategy (A). The contractor is responsible for the quality of all work performed. The contractor measures that quality through the contractor’s own 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 by 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 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.

(B). 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 incentives 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.

(b). ROLES AND RESPONSIBILITIES

(1). The Contracting Officer The Contracting Officer (CO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the Contracting Officer's Representative (COR) and the contractor. The CO will designate 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 Contracting Officer.

(2). The Contracting Officer’s Representative The Contracting Officer’s Representative (COR) is designated in writing by the CO to act as his or her 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 contract and ensures proper Government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the Government’s behalf. Any changes that the contractor deems may affect contract price, terms, or conditions shall 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 clauses, terms and conditions of the contract for any service relating to the contract.

(c). IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS The required performance standards and/or quality levels are included in the PWS and in Attachment 1, “Performance Requirements Summary” to this document. Failure to meet the required service or performance levels may be documented in the contractor’s performance evaluation and will be used in considering a determination of suitability for future contract option renewals and extensions of service.

(d). METHODOLOGIES TO MONITOR PERFORMANCE

(1). Surveillance Techniques In an effort 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:

(A). Random monitoring, which shall be performed by the COR or his designated inspector.

(B). Periodic Inspection – COR typically performs the periodic inspection on a monthly or quarterly basis.

(C). Feedback from beneficiaries, satisfaction or complaints.

(D). Monthly review of invoices, reports, and documents.

(E). Contractor quality assurance reports.

(2). Customer Feedback .

(A). 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.

(B). 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 COR, as opposed to the contractor.

(C). 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 using the Quality Assurance Monitoring Form identified in Attachment 2.

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

(3). Acceptable Quality Levels The acceptable quality levels (AQLs) included in Attachment 1, Performance Requirements Summary Table, for contractor performance are structured to allow the contractor to manage how the work is performed while providing negative incentives for performance shortfalls.

(e). QUALITY ASSURANCE DOCUMENTATION

(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 are assessed using the performance monitoring techniques shown in Attachment 1.

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

(B). The COR will retain a copy of all completed QA surveillance forms.

(f). ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

(1). Determining Performance The Government will use the described monitoring methods to determine whether the performance standards/service levels/AQLs have been met. If the contractor has not met the minimum requirements, it may be asked to develop a corrective action plan to show how and by what date it intends to bring performance up to the required levels.

(2). Reporting (A). Semi-annually the COR will prepare a written report summarizing the overall results of the quality assurance surveillance of the contractor’s performance. This written report, which includes the 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.

(3). Reviews and Resolution (A). The COR may require the contractor’s project manager, or a designated alternate, to meet with the CO, COR, and other Government personnel as deemed necessary to discuss performance evaluation. The 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 COR as often as required or per the contractor’s request. The agenda of the reviews may include:

(i). Monthly performance assessment data and trend analysis (ii). Issues and concerns of both parties (iii). Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis (iv). Recommendations for improved efficiency and/or effectiveness (B).The COR must coordinate and communicate with the contractor to resolve issues and concerns regarding marginal or unacceptable performance.

(C). 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 when deemed necessary by the CO.

APPENDIX 1: PERFORMANCE REQUIREMENTS SUMMARY

1. Timeliness and Accuracy of Delivery. Delivery of all items to the location specified on the order no later than seven (7) business days after receipt of both prescription and purchase order issued by Government authorized personnel against the contract.

Prosthetic COR Responsibility:

Review reports Contractor Responsibility:

Provide reports Paragraph 2

14.1 b xiii

14.3 a

30.2 g Numerator = number of correct/timely orders delivered within 7 days in the quarter.

Denominator = total number of orders delivered in the quarter.

Analysis of QA Quarterly Report When AQL is not met: 1st offense is written notice to the Contractor to correct the deficiency. 2nd offense will result in a negative CPARS evaluation.

1. Timeliness and Accuracy of Fabrication Billing Report.

No later than 10 calendar days after each month, the Contractor shall submit to the Prosthetic COR at each facility, a summary for al for all eyeglasses delivered the previous month for payment processing.

COR Responsibility:

Review reports Contractor Responsibility:

Provide reports Paragraphs 12.2c 14.2 Numerator = number of timely/accurate Fabrication Billing Reports submitted Denominator = total number of Fabrication Billing Reports required

3. Timeliness and Accuracy of Billing. No later than 10 calendar days after each month the Contractor shall submit to the Clinical COR a comprehensive invoice for all optician services provided during the previous month for payment processing.

COR Responsibility:

Review reports Contractor Responsibility:

Provide reports Paragraphs 12.1 Numerator = number of timely/accurate invoices submitted.

Denominator = total number of invoices required.

When AQL is not met: 1st offense is written notice to the Contractor to correct the deficiency. 2nd offense will result in a negative CPARS evaluation.

4. Accuracy of Eyeglass Fabrication and Prescriptions.

Prosthetic and Clinical COR Responsibility:

Review reports and Random Samples

Contractor Responsibility:

Provide reports

Paragraphs 4.1 5.1 5.2 6.1 6.6

14.1 b xii

14.3 d Numerator = number of correct orders delivered quarterly.

Denominator = total number of orders delivered quarterly.

Numerator = number of eyeglasses with correct prescription and frame in the sample Denominator = number of eyeglasses sampled

95%

95% Analysis of QA Quarterly Report Analysis of Eyeglass Order/ Delivery Report Random Sampling When AQL is not met: 1st offense is written notice to the Contractor to correct the deficiency. 2nd offense will result in a negative CPARS evaluation.

5. Timeliness of Weekly Reports.

The Contractor shall submit a weekly Eyeglass Order/Delivery Report to the Prosthetic COR at each facility.

COR Responsibility:

Review reports Contractor Responsibility:

Provide reports Paragraphs

12.2 b 14.1a 14.1b Numerator = number of timely reports submitted weekly for each facility in a quarter.

Denominator = total number of reports submitted weekly for each facility required in the quarter.

6. Verification of Licensing/Training/Certifications.

Contractor will submit the Quality Assurance Report (Quarterly) verifying licensing, certification, training, and competencies of all employees to the Clinical COR at each facility.

Clinical COR Responsibility:

Review report and supporting documentation.

Contractor Responsibility:

Provide reports and supporting documentation.

Paragraphs 9.2

14.3 f 21.1 21.2 25.1 25.3 Numerator = number of employees with current licensing/certification, training and competencies. (Quarterly) Denominator = total number of employees (Quarterly)

7. Timeliness of Quality Assurance Report (Quarterly) submission and Quarterly Contract Utilization Report Prosthetic and Clinical CORs Responsibility:

Review reports Contractor Responsibility:

Provide reports 13.3 14.3 14.4 Numerator = number of timely quarterly reports submitted Denominator = total number of quarterly reports required.

8. Quarterly Patient Satisfaction Prosthetic and Clinical CORs Responsibility:

Review reports Contractor Responsibility:

Provide reports 13.3

14.3 h Numerator = number of satisfied survey respondents Denominator = total number of survey respondents (surveys received) in the quarter

Analysis of Quality Assurance Report (Quarterly) When AQL is not met: 1st offense is written notice to the Contractor to correct the deficiency. 2nd offense will result in a negative CPARS evaluation.

APPENDIX 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

Contract #:____________________________________ Contractor:____________________________________

SERVICE or STANDARD: _______________________________________________________________ SURVEY PERIOD: _____________________________________________________________________

SURVEILLANCE METHOD (Check):

[__] Periodic Inspection [__] Customer Complaint [__] Review of documents

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:___________________