QASP.pdf

QUALITY ASSURANCE SURVEILLANCE PLAN

(QASP)

MEDICAL GAS SERVICES

1. PURPOSE.

a. This Quality Assurance Surveillance Plan (QASP) provides a standard of surveillance for monitoring the medical gas service and provides the approach the government will use to conduct surveillance over the performance aspects of the effort. The QASP is used by the contracting officer’s representative (COR) to ensure the standards of the contract are being met.

b. This plan uses efficiency and quality metrics to evaluate the services the contractor is required to furnish. This surveillance assures the government that the contractor’s performance is acceptable.

c. Any noncompliance with contract performance requirements is deemed unacceptable.

The term unacceptable refers to required services that do not meet the specified standard of performance. The QASP is based on the premise that the contractor, not the government, is responsible for management and quality control actions to meet the terms of the contract.

d. The methods of surveillance recognize that unforeseen and uncontrollable problems and issues do occur. The COR is expected to be objective, fair and consistent in evaluating contractor performance against the standards. Effective management and use of a contractor generated quality control plan will allow the contractor to operate within the specified surveillance requirements.

2. SURVEILLANCE.

a. The COR will inspect contractor performance by:

- Reviewing customer comments provided that are submitted to highlight either superior or degraded performance of this requirement.

- Conducting visits during contractor provided training and periodical confirmation survey of customer training.

- Conducting a periodical audit of on-site inventory provided by the contractor.

- Verifying contact information provided by contractor for ordering, services calls, and contract POC’s.

- Conducting site visits during contractor-led training.

- Auditing contract service providers (CSPs) certifications as provided by the contractor

b. In all cases, surveillance will not be so intrusive as to impact the contractor’s successful accomplishment of the mission.

c. Surveillance observations/inspections made by the COR will be recorded to document the contractor’s performance. This documentation becomes an official government record of the contractor’s performance. The government will use the following terms to document the recorded assessment for CPARS.

STANDARD MEASUREMENT PAST PERFORMANCE ASSESSMENT

Major Mission Excellent Contractor contributes major improvement of Enhancement DDEAMC mission through non-requirement contributions.

Minor Mission Very Good Contractor contributes minor improvement of Enhancement DDEAMC mission through non-requirement contributions.

95% to 100% Satisfactory Contractor meets all standards with no or minor performance issues that were correctable without impact to the DDEAMC mission or risk to staff or patients.

91% to 94% Marginal Contractor meets most of the standards with minor performance issues that resulted in minor DDEAMC mission impact, but did not put staff or patients at risk.

90% or Less Unsatisfactory Contractor did not meet standards; performance resulted in significant DDEAMC mission impact or placed staff or patients at risk.

d. When surveillance detects unacceptable service, the contractor will be notified. If the service can be re-performed, the COR will request the contractor to attempt the service or task again. If the service cannot be or is not successfully re-performed, the deficiency will be considered unacceptable performance. Regardless of whether the task can or cannot be re-performed, the results will be documented. Any unacceptable service that results in significant adverse mission impacts, places staff or patients at risk, or otherwise complete failure to perform a task that is mandated in the contract, will result in a unsatisfactory performance rating for that period of performance.

e. Customer complaints. The COR may receive customer complaints about the quality of services. The COR will make a determination if the customer complaint concerns services provided by the contractor and if so, will make a determination if the complaint is a minor or a major complaint. The COR will notify the contractor of the nature and severity of the complaint.

- Minor complaints – isolated incidents of minor complaints will be addressed by the COR at DDEAMC. The COR will notify the contractor representative of the complaint and the contractor will work with the COR to ensure the complaint is addressed or resolved. Minor complaints will be documented if the COR determines that a pattern of minor complaints has developed, or that there is an alarming increase in frequency of minor complaints. In that case, the severity level of the complaints would be designated as a major complaint.

- Major complaints – these complaints will be documented. The COR will make a determination on the validity of the complaint(s) against the contractor and will notify the contractor of that determination. The contractor will be required to address or resolve complaints determined to be valid. Unresolved major complaints will be deemed unacceptable performance and will be forwarded to the contracting officer.

3. INSPECTIONS.

Periodic inspections may occur on a pre-determined basis (e.g., daily, weekly, monthly) as determined by the COR. The results of periodic inspections may be used as the basis for unacceptable report documentation. Random inspections may occur at any time and location. Surveillance checklist will be used to document inspection findings.

4. UNACCEPTABLE PERFORMANCE/DEFICIENCY IDENTIFICATION.

a. When performance is deemed unacceptable, the COR will inform the contractor’s representative or the contractor. Disputes will be referred to the contracting officer.

b. Effective contract surveillance relies on the COR identifying discrepancies during performance of routine daily services or through the contractor’s quality control program.

- The COR will document the discrepancy and contact the contractor.

- 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.

- The COR will determine whether or not the discrepancy has been corrected. If the discrepancy has been resolved, notify the contractor and document the Quality Assurance Surveillance Checklist.

c. The COR will notify the contracting officer of unacceptable performance. The contracting officer may require reperformance of nonconforming services at no increase in contract price. If reperformance will not correct the defects or is not possible, the government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services. The contracting officer may also

- Issue a Cure Notice

- Issue a Show Cause

- Terminate the contract for convenience of the government

- Terminate the contract for cause

5. PERFORMANCE OBJECTIVES.

a. Performance Objective. : Provide pick-up, refill and delivery of all medical gases cylinders. Paragraph 5.6

Performance Standard. Comply initially and as required 100% of the time.

Method of surveillance. 100% surveillance. Customer Complaint/COR Review

Incentive. CPARS.

b. Performance Objective. Test inspect, and Perform maintenance on gas cylinder.

Paragraphs 5.9/5.14

Performance Standard. Comply initially and as required 100% of the time.

Method of surveillance. Customer Complaint/COR Review

Incentive. CPARS.

c. Performance Objective. Deliver to EAMC once every week and to all outlying clinics at least twice a month. Paragraph 5.5.

Performance Standard. Comply initially and as required 100% of the time as requested.

Method of surveillance. Customer Complaint/COR Review.

d. Performance Objective. Contractor shall be available 24/7 to include holidays to accommodate emergency requirements. Paragraph 5.7.

Performance Standard. Comply initially and as required 100% of the time. At a minimum, some form of training must be provided to the facility by a trained vendor representative quarterly.

Method of surveillance. COR review of documentation. As required.

6. SURVEILLANCE GUIDE.

The QASP Surveillance Guide consists of Attachment 1, Quality Assurance Surveillance Checklist.

QUALITY ASSURANCE SURVEILLANCE CHECKLIST

PERFORMANCE STANDARD, IAW paragraph(s) __________________________________.

SURVEY PERIOD: ___________________________________________________________

SURVEILLANCE METHOD (Check): _____ Reports

_____ 100% Inspection

_____ Periodic Inspection

_____ 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

CPARS Equivalent Rating: __________________________

SUPPORTING NARRATIVE OF PERFORMANCE DURING SURVEY PERIOD:

PREPARED BY: ____________________________________ DATE: _______________________

QASP ATTACHMENT 1