Quality_Assurance_Surveillance_Plan.pdf

(Ver Jun 2014)

QUALITY ASSURANCE

SURVEILLANCE PLAN (QASP)

Periodic Health Assessment/Soldier Readiness Event

Services

Issued 28 January 2019

TABLE OF CONTENTS

1 INTRODUCTION

1.1 Purpose

1.2 Performance Management Approach

1.3 Performance Management Strategy

2 ROLES AND RESPONSIBILITIES

2.1 The Contracting Officer

2.2 The Contracting Officer’s Technical Representative

3 IDENTIFICATION OF REQUIRED PERFORMANCE STANDARDS/QUALITY LEVELS

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 Surveillance Techniques

4.2 Customer Feedback

4.3 Acceptable Quality Levels

5 QUALITY ASSURANCE DOCUMENTATION

5.1 The Performance Management Feedback Loop

5.2 Monitoring Forms

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.2 Reporting

6.3 Reviews and Resolution

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE MONITORING FORM

ATTACHMENT 3: SERVICES REQUEST FORM……………………………………………………… 7

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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 Laboratory Services. This plan sets forth the procedures and guidelines

PRNG Medical Command will use in ensuring the required performance standards or services levels are achieved by the contractor.

1.1 Purpose

1.1.1 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), and to ensure that 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 PRNG Medical Command 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.

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, as long as 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 as long as 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 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.

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 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

The contracting officer (KO) is responsible for monitoring contract compliance, contract administration, and cost control and for resolving any differences between the observations documented by the PHA

NCOIC SFC Felix Rivera and the contractor. The KO will designate one full-time COR SFC Felix Rivera 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 KO.

2.2 The Contracting Officer’s Technical Representative

The contracting officer’s technical representative (COTR) is designated in writing by the KO to act as his or her authorized representative to assist in administering a contract. COTR limitations are contained in the written appointment letter. The COTR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COTR 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 KO for action. The COTR 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 in Attachment 1, “Performance Requirements Summary”. If the contractor meets the required service or performance level, it will be paid the monthly amount agreed on in the contract.

4 METHODOLOGIES TO MONITOR PERFORMANCE

4.1 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 (include those that apply)

Y Random monitoring, which shall be performed by the COTR/COR designated inspector.

Y 100% Inspection – Each month, the COTR/COR, shall review the generated documentation and enter summary results into the Surveillance Activity Checklist.

Y Periodic Inspection – COTR/COR typically performs the periodic inspection on a monthly basis.

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 MAJ Rivera, Carlos or SFC Rivera, Felix, 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 COTR/COR. The COTR/COR will accept those customer complaints and investigate using the Quality Assurance Monitoring Form – Customer

Complaint Investigation, identified in Attachment 4. Provided by CPT Cedeño, Edalia

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) 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. For certain critical activities such as those involving immunizations, 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 MEDCOM Bldg. 587, Camp Santiago, Salina PR 00751.

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

5.2 Monitoring Forms

The government’s QA surveillance, accomplished by the SFC Felix Rivera, will be reported using the monitoring forms in Attachments 2 and 3. The forms, when completed, will document the government’s assessment of the contractor’s performance under the contract to ensure that the required results of

Laboratory tests are being achieved.

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

6 ANALYSIS OF QUALITY ASSURANCE ASSESSMENT

6.1 Determining Performance

6.1.1 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, 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. Failure to meet the AQL may result in a deduction from the monthly payment, using the deduction percentages shown in Attachment 1.

6.2 Reporting

6.2.1 At the end of each month, the PHA NCOIC SFC Felix Rivera – 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 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,SFC Felix Rivera may require the contractor’s project manager, or a designated alternate, to meet with him and other government IPT personnel as deemed necessary to discuss performance evaluation. SFC Felix Rivera 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 SFC Felix Rivera as often as required or per the contractor’s request. The agenda of the reviews may include:

Y Monthly performance assessment data and trend analysis

Y Issues and concerns of both parties

Y Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis

Y Recommendations for improved efficiency and/or effectiveness

Y Issues arising from the performance monitoring processes

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

6.3.3 SFC Felix Rivera 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 KO.

ATTACHMENT 1: PERFORMANCE REQUIREMENTS SUMMARY

PWS Paragraph Task Performance

Standard Acceptable Quality

Levels (AQL) Surveillance Method /

By Whom

5.1.2/5.1.2 Health Assessments and physical examination

Exams are performed in accordance with all regulations in

PWS

100% 98%

Periodic Inspection - COR will review monthly work order logs.

5.6 Visual Acuity Testing

Testing is performed in accordance with Army Regulation

100% 98%

Periodic Inspection - COR will review monthly work order logs.

5.3 Management of

Profiles

Contractor will maintain files and follow-up on profiled soldiers

100% 98%

Periodic Inspection - COR will review monthly work order logs.

5.2.3 Administrative

Functions

All reports and documents are submitted and input appropriately as defined

In-Out Processing

Report

100% 100%

Periodic Inspection - COR will review monthly work order logs.

5.1.3 Electrocardiogram

Testing

Testing is performed in accordance with Army Regulation

100% 100%

Periodic Inspection - COR will review monthly work order logs.

5.1 Immunization

Administration of Vaccine IAW

Regulation 40-

100% 100%

Periodic Inspection - COR will review monthly work order logs.

5.1.1 – 5.1.10

The contractor shall perform restorative maintenance within the established timeframes.

The contractor shall perform restorative maintenance within the established timeframes 100% of the time each month.

0% failure to perform restorative maintenance within the established timeframes each month.

Periodic Inspection - COR will review monthly work order logs.

1.4.10 Contractor Employee

Identification

Contractor Shall Have Badges Identifying Contractor Status within 30 days of start of Contract

100% at Every event

100% Periodic Inspection - COR will review at each event.

ATTACHMENT 2: SAMPLE QUALITY ASSURANCE

MONITORING FORM

SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

D Random Sampling D 100% Inspection D Periodic Inspection D Customer Complaint

LEVEL OF SURVEILLANCE (Check):

D Monthly D Quarterly D As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD: %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: %

Service Provider’s Performance (Check): D Meets Standards

D Does Not Meet Standards

Narrative of Performance During Survey Period:

PREPARED BY: DATE:

ATTACHMENT 3: REQUEST FOR SERVICES FORM

NOTE: Events per year could consist of 1-3 days depending on the need of the government. Request for services from the government will include required personnel services and days.

TEAM'S Qty of Personnel Qty of Personnel Qty of Personnel

Medical Provider 0 0 0

Dentist 0 0 0

Admin

In-processing (Admin) 0 0 0

Out-processing (Admin) 0 0 0

Computer Lab (Admin) 0 0 0

Laboratory (Admin) 0 0 0

Vital / Immunization (Nurses) 0 0 0

Case Manager (Nurses) 0 0 0

Optometry Tech 0 0 0

Dental Tech 0 0 0

Total of Personnel: 0 0 0

Approved By: SFC Rivera Felix

Date: