Attch_0011_Quality_Assurance_Surveillance_Plan_1-24-18.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

JANUARY 24, 2018

Attachment No. 0011

For Reserve Health Readiness Program (RHRP)-3

Solicitation Number: W15QKN-18-R-1000

Contract Number: TBD, Contract Description: Provide health readiness support services to DoD Service Components.

1. PURPOSE.

In Accordance With (IAW) FAR 46.103, the purpose of this Quality Assurance Surveillance

Plan (QASP) is to identify the methods and procedures the Government will use to evaluate contractor performance while concurrently determining the contractor is meeting the terms and conditions of the contract. The QASP is designed to provide an effective surveillance method by monitoring contractor performance for each listed performance objective in the Performance

Requirements Summary. This QASP is a Government developed document by the requiring activity used to provide direction to personnel performing the contractor surveillance activities and 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 and Performance Work Statement. It is the

Government’s responsibility to be objective, fair, and consistent in evaluating performance. The

QASP provides guidelines and methods for the Government’s oversight of the Contractor’s quality control efforts to assure timely, effective services are provided IAW the PWS and contract proposal. In addition, the QASP recognizes that unforeseen and uncontrollable situations may occur.

This QASP is a “living document” and the Government may review and revise it on a regular basis. The COR will submit recommended changes to the KO for approval and the Government shall coordinate changes with the contractor. Updates shall ensure that the QASP remains a valid, useful, and enforceable document. Copies of the original QASP and revisions shall be provided to the contractor and Government officials implementing surveillance activities.

Personnel surveying the contract terms and conditions and PWS requirements will periodically review the QASP throughout the life of the contract.

2. GOVERNMENT ROLES AND RESPONSIBILITIES.

The following personnel shall oversee and coordinate surveillance activities.

a. Contracting Officer (KO) - The KO is duly appointed with the authority to enter into, administer and terminate contracts on behalf of the Government. The KO is the only person who can legally commit the Government and only the KO, as the Government’s agent, can modify the contract/order. The KO 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 KO shall also assure that the contractor receives impartial, fair, and equitable treatment under this contract. The KO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Assigned KO: Demetra Lynardakis

Organization or Agency: Army Contracting Command-New Jersey

Telephone: 609-562-5014

Email: demetra.h.lynardakis.civ@mail.mil

b. Contract Specialist (KS) - The KS acts as an acquisition consultant and serves as liaison between the Army Contracting Command-New Jersey and the requesting program office, as well as liaison between the Defense Health Agency and the supporting contracting office.

Assigned KS: TBD

TelephoneTBD

Email: TBD

c. Contracting Officer’s Representative (COR) - The COR is designated in writing by the KO to perform specific technical and administrative functions within the scope and limitations of their written appointment (e.g., accept services). The COR is not empowered to make any contractual commitments or authorize any changes to the order/contract or in any way obligate additional funds by the Government; such authority rests solely with the KO. 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, which will be reviewed by the Purchasing Contract Officer PCO at least annually. At the conclusion of the contract or when requested by the KO, the COR shall provide final performance evaluation report to the

KO. The contractor shall refer any changes they deem may affect contract price, terms, or conditions to the KO for action. Additionally, the COR when designated provides the following:

The COR develops and creates the QASP.

The COR serves as the eyes and ears for the KO at the contractor’s site.

The COR monitors contractor performance to ensure contract requirements are met for:

Performance, Cost, and Schedule.

The COR ensures that contract quality requirements, provisions, standards, and thresholds are defined, practical, enforceable, necessary, and verifiable.

The COR evaluates and documents contractor performance in accordance with this

QASP and the PWS and refer any changes they deem may affect contract price, terms, or conditions to the KO for action.

The COR notifies the KO of any significant performance deficiencies using a Contractor

Discrepancy Report with supporting documentation.

The COR recommends improvements to the QASP and PWS throughout the life of the contract.

Assigned COR: Mark Chin

RHRP Deputy Chief and ACOR

Telephone: 703-681-8464

Email: mark.a.chin2.civ@mail.mil

Other Key Government Personnel – Brian W. Sugden, Ph.D.

Title: Reserve Health Readiness Program Manager (ACOR)

Telephone: 703-681-8429

Email: brian.w.sugden.civ@mail.mil

3. DESCRIPTION OF SERVICES

The DHA RHRP requirement is for a single award IDIQ contract to issue Firm Fixed Price and

Cost Reimbursable (CR) task orders to provide health readiness support services to the Reserve

Components, Active Duty Components and Department of Defense civilians to include but not limited to immunizations, physical examinations, periodic health assessments, pre-deployment health assessments, post deployment health re-assessments, mental health assessments, dental examinations, laboratory services and other services necessary to satisfy the Service

Components’ health readiness mission.

4.0 QUALITY REQUIREMENTS

4.1 Quality Control Program. The contractor, not the Government, is responsible for management and quality control actions to meet the terms of the contract.

4.2 Level of Performance Evaluation. The contractor will be evaluated in the following areas:

Customer Satisfaction surveys; consistent, availability of providers, timely delivery of high quality services and deliverables; timely entry of medical readiness data; timely reporting of adverse events; availability of appointments; call center access; invoice documentation; IT

Support Systems and provider credentialing.

4.3 Timely Feedback to Contractor: Timely feedback to the contractor on unacceptable performance will be provided by the COR and documented in writing. Prompt feedback is essential so that the contractor can develop and implement a corrective action plan. The contractor's corrective action must be reported to the contracting officer for tracking purposes.

5.0 METHODS OF QA SURVEILLANCE

Surveillance is performed by the Government to provide objective quality evidence that there is a reasonable level of confidence that the services provided by the Contractor have met all the requirements of the contract before authorizing payment. Various methods exist to monitor performance such as 100% inspection, user surveys, periodic sampling, periodic inspections, planned-direct observation, Contract Performance Assessment Reporting, Contractor

Management Information System Reporting, and validated user/customer complaints. The COR shall use the surveillance methods listed below in the administration of this QASP.

Regardless of the surveillance method, the COR shall always contact the contractor's task manager when a defect is identified and inform the manager of the specifics of the problem. The

COR, with assistance from the Contracting Officer and Contracting Specialist shall be responsible for monitoring the contractor’s performance in meeting a specific performance standard.

6. DOCUMENTING PERFORMANCE.

a. ACCEPTABLE PERFORMANCE.

The Government shall document positive performance in CPARS and Contracting Officer

Monthly Reports.

b. UNACCEPTABLE PERFORMANCE.

If the number of complaints/defects exceeds the minimum level of performance standard for any objective, the COR will determine the possible cause of this unacceptable performance.

Government-caused complaints/defects will not be counted against the contractor. The same applies to any other requirement of the contract when Government-caused complaints/defects are the cause of unacceptable contractor performance. If the contractor’s performance is judged unacceptable for any requirement by the COR, the COR will document the discrepancy as a non-conformance and inform the Contracting Officer (if needed) for resolution. Significant (major non-conformance) performance deficiencies must be submitted to the Contracting Officer using a Contractor Discrepancy Report (CDR) and include supporting documentation.

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 contract payment deductions, fixed fee deductions, award fee nonpayment, or other actions deemed necessary by the KO.

The Government shall document negative performance in CPARS. Any report may become a part of the supporting documentation for past performance in future source selections.

7. FREQUENCY OF MEASUREMENT.

a. Frequency of Measurement.

During contract/order performance, the COR shall take periodic measurements as specified in the Method of Surveillance and Frequency column of the Performance Standards Summary

Matrix, and shall analyze whether the negotiated frequency of measurement is appropriate for the work being performed.

b. Frequency of Performance Assessment Meetings.

The COR shall meet with the PCO and contractor on a quarterly basis to assess performance and shall provide a written assessment.

8. DOCUMENTION REQUIREMENTS

8.1 Deliverable # 1 Status Report (PWS 3.1.1) CDRL DI-MGMT-80368A

8.2 Contract Manpower Reporting Application: The COR is responsible for validating the contractor’s input into the Contract Manpower Reporting Application (CMRA) website at http://www.ecmra.mil/. The COR is to obtain a user name and password, and validate that the contractor has completely filled in required contractor information at the CMRA web site by November 30 of the first year of the contract and annually by November 30 thereafter for the duration of the contract, or sooner if the contract is closed out. The COR shall perform this validation during the month of November each year. The COR shall report the CMRA results in the November Monthly COR Report (due in December of each year) to the KO each year. Discrepancy Reports are as required.

9. PERFORMANCE OBJECTIVES, STANDARDS, AND SURVEILLANCE METHODS.

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 details and identifies the contractor requirements by tasks that relate directly to mission essential elements of the PWS. The Government shall use these standards to determine contractor performance and shall compare contractor performance to the minimum level of performance standards.

10. INCENTIVES.

The Government shall use past performance as incentives through the CPAR System. Incentives shall be based on exceeding, meeting, or not meeting performance standards.

11. 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:

EXCEPTIONAL:

Performance significantly exceeds contract requirements to the Government’s benefit.

SATISFACTORY: Performance meets contractual requirements.

UNSATISFACTORY: Performance does not meet contractual requirements.

http://www.ecmra.mil/

Performance

Objective

Performance

Threshold

Minimum Level of

Performance Standards

Method of

Surveillance and

Frequency

Remedy

1. Report Unusual

Incidents /Adverse

Reactions/

Emergent (PWS

4.4.4.1, 4.4.7.1, 4.4.7.1.1)

Delivery of report to COR

Reports are delivered to

COR within one business day of contractor notification.

100% Inspection

(as received)

Note will be made to CPAR Past

Performance.

2. Vaccine Handling

(PWS 2.14 –

2.14.2; 4.4.4.9)

Compliance with

FDA, CDC and

Manufacturer guidelines

Compliance with FDA, CDC and Manufacturer guidelines for the handling and administration of all vaccines

Periodic Inspection

(at least annually) and

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

3. In-Clinic Customer

Satisfaction. (PWS

4.4.4.4)

Satisfaction

Survey

Customer satisfaction is reported to the COR and

Program Manager.

Validated User/

Customer

Complaints (as received) and

Contractor

Management

Information

System Reports

(monthly) and User

Survey

(statistically valid sampling)

Note will be made to CPAR Past

Performance.

4. Group Event

Customer Satisfaction.

(PWS 4.4.4.4)

Satisfaction

Survey

Customer satisfaction is reported to the COR and

Program Manager.

Validated User/

Customer

Complaints (as received) and

Contractor

Management

Information

System Reports

(monthly) and

Direct Observation

(periodic) and User

Survey

(statistically valid sample)

Note will be made to CPAR for Past

Performance Information.

5. Group Event POC

Customer Satisfaction

(PWS 4.4.4.4)

Satisfaction

Survey

Customer satisfaction is reported to the COR and

Program Manager.

Validated User/

Customer

Complaints (as received) and User

Survey (per encounter) and

Direct Observation

(periodic) and

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR for Past

Performance Information.

6. Call Center

Customer Satisfaction.

(PWS 4.4.3.1)

Satisfaction

Survey

Call center customer satisfaction is reported to the COR and Program

Manager.

Validated

User/ Customer

Complaints (as received) and

Contractor

Management

Information

System Reports

(monthly) and User

Survey

(statistically valid sample)

7. Bulk

Documentation

Updates. PWS

(4.4.4.13)

Number of hard copy files received in bulk not entered into data system

Number of hard copy files received in bulk not entered into data system within 4 weeks of receipt

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

8. Adverse Survey

Resolution. (PWS

4.4.4.5)

Satisfaction

Survey Report

Contractor attempt to resolve complaint

Validated User/

Customer

Complaints (as received) and

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

9. Data Entry All

Group Events

. (PWS 2.16.1,

4.4.4.3)

Number of services not entered into data system

Number of services that have not been entered into the appropriate military data system within 5 business days after provision of the service

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

10. Data Entry All

Group Events –

Number of services not

Number of services that have not been entered into

Contractor

Management

External Labs.

(PWS 2.16.1,

4.4.4.3) entered into data system the appropriate military data system within 8 business days after provision of the service

Information

System Reports

(monthly)

11. Data Entry In-

Clinic, including

Occupational Health

Labs. (PWS

2.16.1, 4.4.4.3)

Number of services not entered into data system

Number of services that have not been entered into the appropriate military data system within

8business days after provision of the service

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

12. Data Entry Dental

Exam, Dental ATP, Physical Exams, and

Physical Exams with

Comprehensive

Audiology Exams In-

Clinic. (PWS

2.16.1, 4.4.4.3)

Number of services not entered into data system

Number of services that have not been entered into the appropriate military data system within 12 business days after provision of the service

Contractor

Management

Information

System Reports

(monthly)

13. Invoice

Documentation

(PWS 4.4.4.2,

4.4.4.7)

Number of invoices with incomplete documentation

Number of invoices reviewed quarterly which have incomplete documentation

Periodic Sampling

(quarterly)

Note will be made to CPAR Past

Performance.

14. Historical updates

. (PWS 4.4.4.14,

4.5.1 through

4.5.2.2)

Number of historical update documents received from individuals not uploaded into data system

Number of documents that have not been uploaded into the appropriate military data system within 5 business days after Contractor’s receipt

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

15. Reports. (PWS

4.4.2 – 4.4.6.2)

Reports loaded on portal or delivered to the COR

Number of reports mutually agreed to by the

Contractor and COR which are not loaded or delivered to the by the agreed time

Direct Observation

(weekly) and

Analysis of

Reports (monthly)

Note will be made to CPAR for Past

Performance Information.

16. In-Clinic

Scheduling(PWS

2.12.4.2)

Number of services requested monthly

Initial contact with

Service Member attempted within 1 business day of request

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

17 In-Clinic

Appointments

Scheduling. (PWS

2.12.4.2.1, 4.4.4.40)

Number of services requested monthly

Appointments will be scheduled for date NLT

15 business days after first date of Service

Member availability

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

18. Group Event

Scheduling(PWS

2.12.3.4 , 4.4.4.12)

Number of group events requested monthly

Group Event services requested are accepted within 1 business day of request

Contractor

Management

Information

System Reports

(monthly)

19. Call Center Access

– Average Speed to

Answer (ASA) (PWS

Service Level Average speed for live answer for incoming calls at each of the RHRP Call

Contractor

Management

Information

4.4.4.8) Center service lines System Reports

(monthly)

20. Call Center Access

- Abandonment.

(PWS 4.4.4.8)

Call Abandon Number of incoming calls terminated by Caller

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

21. Dental

Reclassifications.

(PWS 4.4.4.29).

Number of initial group event dental classifications changed after quality assurance

Dental reclassifications and notification of unit

Contractor

Management

Information

System Reports

(monthly)

Note will be made to CPAR Past

Performance.

22. Provider

Credentials. (PWS

2.13.1.1)

Provider personnel files with required information

Files with all required information (current license, CPR, HIPAA, current training for service provided)

Periodic Inspection

(quarterly) and

Direct Observation

(annually)

24. (PWS

4.2.14.2.1 –

4.2.14.2.2) Mental

Health Assessment

Outreach

Outreach attempts made within 24 hours (critical), seven days

(priority), and

21 days

Correspondence and communication with

SM.

Contractor

Management

Information

System Reports

(monthly) and

Periodic

Sampling (at least semi-annually)

Note will be made to CPAR

Past Performance.

CONTRACT DISCREPANCY REPORT (CDR)

1. Contract Number: <insert number>

2. TO: (Contractor Task Manager or on-site representative) <insert name>

3. FROM: CAPT April D. Kidd

4. Date and time observed discrepancy:

5. DISCREPANCY OR PROBLEM:

<Describe in detail. Identify any attachments.>

5. Corrective action plan:

A written corrective action plan < is / is not > required.

< If a written corrective action plan is required include the following. > The written Corrective

Action Plan will be provided to the undersigned not later than < # days after receipt of this

CDR. >

Prepared by:

Signature – Contracting Officer’s Representative Date

Received by:

Signature - Contractor Task Manager or on-site representative Date

< The COR may initiate a CDR at any time, including whenever the number of monthly recorded defects for a performance standard exceeds the allowable number of defects; anytime unacceptable performance is determined critical in nature and requires formal corrective action; and whenever an unfavorable trend is detected in contractor performance.>