A.01.02_Attachment_2-QASPwPRS-Tidewater.pdf

Attachment 2

Quality Assurance Surveillance Plan (QASP)

For

Patient Appointing Services (PAS)

Enhanced Multi-Service Market Tidewater, Virginia

1. Purpose.

This Quality Assurance Surveillance Plan (QASP) is a government developed and applied document used to provide standard of surveillance for Patient Appointing Services (PAS) in support of various Military Treatment Facilities (MTFs) in the Tidewater, Virginia area. The referenced MTFs in the Tidewater area are: Naval Medical Center Portsmouth (NMCP) and its nine branch medical clinics (BMCs); Langley Air Force Base Hospital; McDonald Army Health Clinic and its two troop medical clinics (TMCs) and Fort Story Health Clinic. It provides the approach the government will use to conduct surveillance over the performance aspects of the effort. The intent is to ensure that the contractor performs in accordance with performance metrics set forth in the contract documents, that the government receives the quality of services called for in the contract, and that the government only pays for the acceptable level of services received.

2. Scope.

The QASP is put in place to provide government surveillance oversight of the contractor’s quality control efforts to assure they are timely, and effective, and results are performed as specified in the contract. The QASP is not a part of the resulting contract nor is it intended to duplicate the contractor’s internal quality management efforts.

3. Govnment Roles and Responsibilities.

The following personnel shall oversee and coordinate surveillance activities.

3.1. Contracting Officer (KO). The KO 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 KO will designate a COR as the government representative for performance management. The number of additional government representatives serving as inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the KO.

3.2. COR. The COR is designated in writing by the KO to act as his or her authorized representative. The COR will assist the KO with the technical administration of the contract to ensure proper government surveillance of the contractor’s performance. Any COR limitations will be identified with the designation letter. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes the contractor deems may affect contract price, terms, or conditions shall be referred to the KO for action. The COR is responsible for quality assurance (QA) monitoring and completion of forms/reports used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the terms and conditions of the contract for inspection.

3.3. Other Key Government Personnel. Upon award, the government may enter performance monitors, clinical quality experts, subject matter experts (SMEs), who may provide input to the COR for reporting purposes.

3.4. The following contract service provider will serve as the contractor’s representative for this contract: (Upon award, government will enter name(s)).

4. Inspection Instructions.

4.1. The contractor shall provide and maintain an inspection system acceptable to the government covering the services under this contract. Complete records of all inspection work performed by the contractor will be maintained and made available to the government during contract performance.

4.2. If any of the services do not conform to contract requirements, the government may require the contractor to perform the services again in conformity with contract requirements, at no additional cost to the government. When the defects in services cannot be corrected by reperformance, the government may require the contractor to take necessary action to ensure that future performance conforms to contract requirements and reduce the contract price to reflect the reduced value of the services performed.

4.3. The government has the right to inspect and test all services called for by the contract, to the extent practicable at all times and places during the term of the contract. The government shall perform inspections and tests in a manner that will not unduly delay the work.

4.4. If the contractor fails to promptly perform the services again or to take the necessary action to ensure future performance in conformity with contract requirements, the government may, by contract or otherwise, perform the services and charge to the contractor any cost incurred by the government that is directly related to the performance of such service; or terminate the contract for default.

4.5. If the government performs inspections or tests on the premises of the contractor or a subcontractor, the contractor shall furnish, and shall require subcontractors to furnish, at no increase in contract price, all reasonable facilities and assistance for the safe and convenient performance of these duties.

5. Methods of Inspection. (The method of inspection and the level of surveillance used will be reflected in the PRS under the “Monitoring/Surveillance Method” column and must match what is selected in Enclosure 1 to QASP, QASP Checklist.)

5.1. The below listed methods of surveillance may be used in the administration of this QASP. They can occur quarterly, monthly, or as needed:

a. 100% Inspection. The COR may conduct 100% inspections of the work defined in the performance work statement (PWS). The COR will also review information submitted in the required reports defined in the PWS (if applicable).

b. Periodic Inspection. The government may conduct periodic inspections monthly, quarterly, or on an as-needed basis. The periodic inspection shall be conducted by the COR.

c. Random Inspection. The government may conduct random monitoring by reviewing information/reports required and submitted in accordance with the contract. The random monitoring shall be performed by the COR.

d. Performance Evaluation Meetings. The contractor and the COR will meet as often as necessary to review the contractor’s performance and address any contract discrepancy reports (CDRs) issued during the period. A mutual effort will be made to resolve identified issues.

e. Customer Feedback – The COR may provide and collect customer surveys or complaints regarding performance. A mutual effort will be made to resolve any problems/issues identified.

5.2. Level of surveillance may be conducted on a monthly, quarterly or as-needed basis and an analysis of the results will determine if the contractor met the standards or did not meet the standards identified in the PWS/contract.

6. Performance Requirements Summary (PRS).

Performance Objective Performance Standard

Acceptable Quality Level

(AQL)

Method of Inspection

Incentive/Disincenti ve

Contract employees shall meet agency requirements for access to DoD IM/IT systems to include CHCS

PWS Section 1.4 Prior to any contract or employees executing any service; 100% of the time the contractor employees shall: (1) comply with agency personal identity verification procedures;

(2) comply with all MHS communications, IT/IM, security standards and policies.

annual Review of reports

COR observations

Contract employees shall obtain training and remain current in required training and/or standards to meet the deliverables/requirements of this contract

PWS Section 5 Prior to any contractor employees executing any service; 100% of contractor employees shall: (1) participate in all required staff orientation and/or training and complete MTF orientation training; (2) be trained and remain current in MTS appointing rules and

(3) be knowledgeable in and be able to use telephony applications as specified in the contract.

annual Attendance rosters

Updated records

Review of reports

COR observation

Maintain beneficiary/patient privacy and confidentiality.

PWS Items 1.4.1.1, 1.4.1.2, 1.4.1.3

The beneficiary/patient privacy will be maintained 100% of the time as required by

HIPAA.

annual COR observation

Calls Monitored Report

Maintain a level of appointing service meeting the contract telephone appointing standards.

This is the requirement criteria; as referenced in PWS Sections 4 and 5

At least 98% of the time:

(1) Patient appointing is accomplished in accordance with MTF instructions in CHCS; (2) Accurately document patient appointment/appointment daily Review of CHCS appointing reports

Review of reports

COR observations

Monitoring of calls search; (3) Patient’s appointment request is matched to the appropriate Access To Care (ATC) category.

Appointing errors shall not exceed those percentages identified in the contract.

Contractor employees shall perform registration updates or mini registration in CHCS for all patients requesting a MTF appointment.

PWS Attachment 3 Item 2

At least 98% of the time daily Review of reports

COR observation calls shall be answered with 2 rings; which could be by an automated response unit

(ARU). 2.1.4. , 5.2.

This is the requirement criteria; as reference in the PWS Sections 4 and 5

100% of the time daily Review of reports

Calls past an ARU or live operator shall be received by an appointing scheduler/clerk

Maintain a level of call service meeting the contract telephone standards.

within 90 seconds 98% of the time.

Maintain a level of call service meeting the contract telephone standards.

This is the requirement criteria; as reference in the PWS Sections 4 and 5

Calls shall not be placed on hold more than 90 seconds 95% of the time.

daily Review of reports

Monitoring of calls

Maintain a level of call service meeting the contract telephone standards.

This is the requirement criteria; as reference in the PWS Sections 4 and 5

Call blockage rates shall not exceed 5%.

service meeting the contract telephone standards.

This is the requirement criteria; as reference in the PWS Sections 4 and 5

Contractor shall not excel an abandoned call rate of 2% of all calls received.

service meeting the contract telephone standards.

This is the requirement criteria; as reference in the PWS Sections 4 and 5

Contractor shall warm transfer calls, as required, and stay on the line with the caller for a minimum of 45 seconds 98% of the time.

daily Review of reports

Monitoring of calls

Maintain a level of call service meeting the contract telephone standards.

This is the requirement criteria; as reference in the PWS Sections 4 and 5

90% of all calls shall be fully and completely dispositioned during the initial telephone call.

daily Review of reports

Monitoring of calls

Maintain a level of service meeting the contract telephone standards and customer service.

PWS Attachment 3 Item 5

Contractor shall monitor a minimum of 1% of all calls received on a monthly basis.

daily Review of reports

Deliver required reports

Weekly Reports:

Call Wait Time

Call Abandonment

Blocked Call Rates

Call Volume

Call Processing Time

Calls That Do Not Result in an Appointment

Call Hold Time

PWS Item 5.4.1 Contractor shall supply the required weekly reports by COB on the 2nd (second) business day following the week reported or based on the contract.

weekly Review of reports

A. 100 % Inspection: One Hundred Percent Inspection is exactly what the title implies – inspecting a requirement every time it occurs.

B. Customer Complaint: A customer complaint is a valid complaint when the Quality Assurance Plan (QAP), after a thorough investigation, determines that 100% of Medical Standards of Care have not been met.

C. Other Primary Surveillance Methods – Random sampling, customer complaints, 100% surveillance, inspections, reports, etc.

7. Successful Performance.

7.1. Successful performance can be incentivized with favorable past performance ratings and award of follow-on opportunities.

7.2. Acceptable services for performance is demonstrated by an accepted and executed certified invoice and receiving report, as applicable.

7.3. The acceptable quality level (AQL) consists of the performance standards established for the services required by the government to meet contract requirements. The AQL will be measurable and structured to permit an assessment of the contractor’s performance.

8. Documentation of Surveillance.

8.1. Effective contract surveillance relies on the COR identifying and documenting discrepancies during performance of routine daily services, or through the contractor’s quality control program. The COR will report discrepancies to the contractor for timely resolution. Survelliance may consist of periodic reports, and customer feedback and timeliness of contract deliverables/reports.

8.2. The COR will maintain a complete QA file which will be retained by the COR for the life of the contract.

Information in the QA file will be considered when completing the annual CPARS report.

8.3. Documented surveillance will consist of inspections performed by the COR. Examples of documentation that supports contract surveillance consist of details of inspections or data gathering, conversations or meetings with the contractor, notes and comments that support inspection paperwork, to include quality assurance surveillance reports.

Deliver required reports

Monthly Reports:

Customer Service and Satisfaction of Appointing Services

PWS Item 5.4.3 Contractor shall supply the requited monthly report by COB on the 5th (fifth) business day following the last day of the month reported or based on the contract.

monthly Review of reports

Deliver required reports

Quarterly Reports:

Calls Monitored Report

PWS Item 5.4.3 Contractor shall supply the required quarterly report by COB on the 5th (fifth) business day following the last day of the month reported or based on the contract.

quarterly Review of reports

If performance is deemed unacceptable, the COR will inform the contractor about possible reperformance soultions.

Disagreements or disputes will be referred to the KO for review.

8.4. All documentation resulting from surveillance will be made a part of the contract file. The COR must keep the QA files during the surveillance period, but at the conclusion of the contract, and as directed by the KO, the COR must give the files to the KO for inclusion in the official contract file.

9. Corrective Actions.

9.1. The contractor will be provided the opportunity to submit proposed corrective action to resolve the discrepancy.

The COR will review proposed corrective action and determine whether or not it is acceptable and whether or not the discrepancy has been corrected. If the discrepancy has been resolved, the COR will notify the contractor and document the quality assurance surveillance checklist.

9.2. The COR will notify the contracting officer of unacceptable performance if any services do not conform to contract requirements. The contracting officer may require the contractor to re-perform the services to conform with contract requirements at no additional cost to the government.

9.3. When unacceptable performance cannot be corrected by re-performance, the government may require the contractor to take action necessary to ensure future performance conforms with contract requirements.

9.4. The government may, by separate contract or otherwise, perform the services and charge the contractor any cost incurred that is directly related to the performance of such service, or issue:

9.4.1. Cure Notice

9.4.2. Show Cause

9.4.3. Terminate the contract for convenience of the government

9.4.4. Terminate the contract for cause

10. Certification of Services. Certification of services is performed by the COR via Wide Area Work Flow (WAWF) system. At the end of each billing period, the contractor inputs invoice information into WAWF system. WAWF automatically notifies the appropriate COR via email of pending invoice. COR accesses WAWF and verifies the accuracy of services provided by the contractor. The COR will certifiy the invoice and payment is conducted by the Defense Finance Accounting System (DFAS). If the COR encounters errors in the contractor’s invoice, the COR will reject the invoice, state the reason for rejection and WAWF will send the invoice back to the contractor. If the contractor disagrees with the COR, the issue will be forwarded to the KO for resolution.

11. QASP Checklist, Enclosure 1 to QASP

12. Contract Discrepancy Report (CDR), Enclosure 2 to QASP (Optional)

Enclosure 1 to QASP QASP Checklist

Service or Standard:

Survey Period: ___________________________________________________________

Surveillance Method: (Check) (The method of inspection and the level of surveillance selected must match what is reflected in the PRS under the “Method of Inspection” column.)

_____ 100% Inspection

_____ Periodic Inspection

_____ Random Monitoring (reports)

_____ Performance Evaluation Meetings

_____Customer Feedback

Level of Surveillance: (Check): _____ Monthly

_____ Quarterly

_____ As needed

Analysis of Results:

Contract Service Provider’s Performance (Check): _____ Meets Standards

_____ Does Not Meet Standards

Narrative of Performance During Survey Period:

Prepared by____________________________________________ Date_____________________