236.12 Quality Assurance Reviews

Key Points

Forms
Quality Assurance Review Report - Front Page	_

236.12.1 Introduction

The Central Office right of way staff members coordinate periodic reviews of district office operating procedures to promote and ensure quality assurance of the acquisition process, reality asset activities and compliance with The Uniform Act.

236.12.2 Organization and Job Functions

236.12.2.1 Authority

Each June, the Director of Right of Way will approve the annual Quality Assurance Plan for the following fiscal year. Consideration should be given to scheduling these routine reviews so that over a four-year period all districts are reviewed in at least one functional area. Districts scheduled for review are to be advised well in advance of the review date to ensure appropriate personnel are available.

The Director of Right of Way may substitute a Quality Assurance Review (QAR) with comparable reviews similar to the following:

• Joint Process Review,
• Peer Review,
• Internal Audit or
• External Audit.

If comparable reviews are conducted the Director of Right of Way may waive a QAR at their discretion.

236.12.2.2 QAR Administration

The QAR Team is lead by a designated field liaison officer (FLO) within the Right of Way Division Office. The FLO will coordinate the QAR and be responsible for identifying Division/District participants and ensure completion in a timely manner.

The FLO has the overall responsibility for selection, training and supervising QAR Teams and shall coordinate the following:

• Yearly QAR Plan;
• Schedule;
• Sampling;
• Exit Interview; and
• Report

The FLO will also be responsible for ensuring the QAR recommendations are monitored for implementation.

236.12.3 Quality Assurance Review Process

236.12.3.1 Purpose

To develop policies and methods of continuously evaluating the quality of all right of way functions statewide through a quality assurance process.

236.12.3.2 Background

This article contains the regulations, requirements, and procedural directives governing the operation of the Right of Way Division.

Federal regulations governing right of way acquisition are found in 23 CFR (Code of Federal Regulations) and 49 CFR Part 24. Compliance with these regulations are required if federal funds are to be used in any part of a project. The policies and procedures outlined in the above-mentioned manual are written to include all the federal requirements.

236.12.3.3 Definitions

Critical Requirement: A measurable activity in a departmental process that indicates whether or not the process is being properly carried out and if the quality of the product is being controlled. A critical requirement could reveal significant problems or indicate beneficial results for the department.

Critical Problem Area: An area where critical requirements indicate a process is not in compliance with predetermined criteria.

Outstanding Quality Area: An area of unique superior performance due to magnitude of effort or innovation in concept or application.

Quality Assurance: Conformance to predetermined criteria. Quality Assurance refers primarily to process requirements in this procedure.

Quality Assurance Database: A central data source for the various data elements of the division's records management programs. Pertinent data is recorded for the purpose of planning, performing and tracking of quality assurance reviews.

Quality Assurance Monitoring Plan: A monitoring plan based on critical requirements prepared by the Right of Way Quality Assurance Administrative Team Leader to outline the criteria, frequency and methods for conducting Quality Assurance Reviews.

Quality Assurance Guidelines: Step by step guideline for conducting Quality Assurance Reviews.

Quality Assurance Review Report: The written report of the results of a Quality Assurance Review.

Recommendations: Significant issues/items that require action.

Source Documents: Document in which data collected for a QAR is first recorded.

236.12.3.4 Procedure

The Director of Right of Way will designate a Quality Assurance Administrative Team lead by a field liaison officer who will establish and direct Quality Assurance Reviews of all districts and certain division office units, which implement the Missouri Department of Transportation’s Right of Way Program.

The Division of Right of Way through the Quality Assurance Administrative Team Leader will establish and maintain complete, current and usable directives, and respective guidelines.

The Quality Assurance Administrative Team Leader will establish and maintain current Review Plans based on critical requirements identified in each functional area or process.

The Quality Assurance Administrative Team Leader will develop and provide the Director of Right of Way a fiscal year schedule of planned Quality Assurance Reviews by June 1, of each preceding year, and revise as changes occur.

The Quality Assurance Administrative Team Leader will select Quality Assurance Review Teams of not more than four (4) people, each with expertise in the respective QAR. Members shall not monitor their own district. One person per district per team will be permitted to assist. Team members are to be selected in June from the appropriate right of way personnel including the FHWA Reality Officer.

District and Division Office participants in Quality Assurance Reviews will identify for the Quality Assurance Administrative Team, possible need for training; improvements to procedures, guidelines; and problems or innovations of statewide significance.

The Quality Assurance Administrative Team will report the final results of Quality Assurance Review to the Director of Right of Way.

The Division of Right of Way will evaluate the Quality Assurance results, make improvements to procedures and processes, conduct appropriate training, circulate to all districts applicable outstanding results, record the summary of the results and responses to each review and track problem areas until they are corrected or resolved.

236.12.4 Quality Assurance Review Plan

236.12.4.1 Quality Assurance Review Plan

This document establishes the minimum standard for Right of Way Division’s Quality Assurance Review Plan on a fiscal year basis.

236.12.4.2 Schedule

A schedule will show the dates of review by the Quality Assurance Review Teams for the upcoming fiscal year.

236.12.4.3 Notice

Two weeks prior to the review, a notice shall be sent to the right of way manager to ensure that all parties are aware of the review. This notice will contain the following:

• Identify team members
• The anticipated arrival and departure times and dates
• The functional areas that will be reviewed
• The desired time for scheduling of the exit interview

236.12.4.4 Reviews

The purpose of each review is to determine compliance with right of way processes and procedures in each of the functional areas being reviewed. At the discretion of the reviewer, the review may include onsite inspection of the subject projects, review of files and/or interviews. If interviews are desired, they will be coordinated with the supervisor.

Each review will be conducted in accordance with the approved source documents. Compliance with the functional area will be determined by examination of each. It will be the responsibility of the FLO Team Leader to ensure that the scope of the review is sufficient to support a determination regarding compliance or noncompliance with the functional areas being reviewed.

236.12.4.5 Exit Interviews

An exit interview will be held at the conclusion of each review. The right of way manager will be requested to attend along with any other supervisory personnel responsible for the functional area being reviewed. The review team will advise the district/division office of factual findings of the review. No conclusions regarding compliance or recommendations for corrective action will be provided at this interview.

Each exit interview will include a discussion of current procedures. The Right of Way Manager will be provided an opportunity to discuss the procedures and make recommendations for changes. A discussion of these recommendations and the actions taken will be included in the Quality Assurance Review Report.

236.12.4.6 Reports

Within fifteen (15) working days of completion of the review, a written draft report will be provided to the right of way manager. The format of this report will be in accordance with the format adopted for all Quality Assurance Review Reports. The district will be permitted fifteen (15) working days within which to comment regarding the accuracy of the factual data in the draft report. It is not expected that the district will fully respond to the conclusions or the recommendations as reflected in the draft report.

A final report will be completed within fifteen (15) working days of receipt of the comments or expiration of the review period. Extensions to the review period may be granted at the discretion of the Director of Right of Way, upon request from the district.

The final report will be provided to the Director of Right of Way, District and FHWA and the findings and recommendations will be retained in the division office. A review period of thirty (30) days will be allowed for response to the findings and recommendations within the report. It is the responsibility of the QAR Administrative Team leader to ensure that appropriate responses are obtained to each recommendation contained in the report. The agreed upon responses are to be filed with the report.

236.12.5 Quality Assurance Review Guideline

236.12.5.1 Plan

Schedule Annual QARs

Prior to June of each year, coordinate with appropriate units and develop a fiscal year schedule for reviews. Revise as necessary.

Schedule QARs Visit

Check current QA schedule, avoiding overlapping reviews or overloading, and adjust if necessary.

Combine QARs into one visit if possible.

QAR Team

Assign the most knowledgeable staff from the QAR Team Selection Pool.

Team members conducting the review should adequately prepare prior to the execution of the review.

Review Past QARs

Review reports from management, Audits and Investigations, Federal Highway Administration (FHWA) and others.

Identify unresolved areas of noncompliance and areas marked for improvement

Plan QAR Content

Base the QAR on right of way procedures and processes. Be sure supporting procedures, rules, statutes and critical requirements are current, correct and available to participants.

Prepare a list of activities and/or documentation that supports critical requirements.

236.12.5.2 Conduct

Notify district/division office Of QAR Content

Two weeks prior to QAR, notify districts/division office of all areas to be covered.

Conduct Review

Focus on right of way processes and procedures.

Cover critical requirements and source documents.

At the initial meeting reconfirm:

• Where the work will be performed.
• Procedures for obtaining files and copies.
• District contact person for assistance.

Seek information that may not be contained in the file.

Look for positive areas as well as noncompliance.

Base the QAR on critical requirements and unresolved issues from earlier visits.

Verify that previous corrective action is effective.

When the critical requirements indicate a problem exists, follow up and verify the problem and its magnitude.

Review parallel issues identified in audits performed by Audits and Investigations (AI), by the Federal Highway Administration (FHWA) and other performance reports.

Talk with district/division office staff.

Take complete notes of specifics and impressions.

Prepare for Exit Interview(s). QAR team leader and team members should review and analyze information; organize presentation.

236.12.5.3 Conduct Exit Interview with District/Division Office Staff

Arrange a meeting for all participants.

Prepare a list of general impressions; cite specifics only when necessary to illustrate the magnitude of the praise or issue. Avoid detail.

Clearly state urgent or high impact issues.

Be prepared for discussion (anticipate questions, develop appropriate responses, etc.).

Agree on appropriate items for district and division office action.

Take notes to help with development of the written QAR Report.

Include general items (impressions, findings that indicate lack of quality control or attention to detail).

If an issue can be immediately corrected, report the corrective action rather than a negative finding.

Discuss all issues you expect to include in the QAR Report.

Ask district/division office staff for specific recommendations to improve procedures, meeting requirements, training, and statewide problems. Identify areas that are inefficient or that adversely impact other areas.

Emphasize steps that will follow the visit. For example, clarification or additional information may be requested during report preparation.

236.12.5.4 Prepare QAR Report

Prepare draft report and send to the district/division office within 15 working days. Content of the report should reflect what was discussed at exit interview.

Address action items in report.

Work to resolve disagreements regarding report contents.

Contact the district/division office if a response is not received within 15 working days after receipt of draft report.

Prepare final report and send to district/division office within 15 working days after receipt of comments to the draft report.

Recommend issues to be included in the Quality Assurance database.

Share outstanding methods or issues without identifying the source of the issue.

236.12.5.5 Track Critical Issues until Remedied or Resolved

Track the corrective action and/or make a follow up visit. Disagreements with report recommendations are resolved through upper management. The Director of Right of Way is the final arbiter.

Upon satisfactory resolution, update the QA database to reflect the disposition.

236.12.5.6 Act

To Continually Improve

Solve problems. Form task teams to solve difficult problems.

Provide specific technical information needed or requested.

Begin writing, revising or combining procedures or guidelines if necessary. Division Office should quickly remedy procedure/guideline problems identified in the QAR Report.

Identify problems, which can be resolved by source documents (forms, checklist, etc.), office or management systems, training, workshops or other means.

As appropriate, compile a general summary of outstanding methods and issue areas. Share this summary with right of way personnel and others as determined by the Director of Right of Way.

Periodically review the QAR Plan. Change the frequency and content of QARs as necessary to focus on continuing problems or new areas.

236.12.6 Quality Assurance Review Report

236.12.6.1 Purpose And Scope Of Review

This report summarizes the results of the quality assurance review conducted in the district. The review was done to assess process performance relating to critical functions such as:

• Administration

• Appraisal

• Negotiations

• Realty Asset

• Relocation

Identify those areas in which there may be a need for closer adherence to existing process standards or indications that the existing process standards warrant modification.

Identify good ideas that may be shared with other Districts to the benefit of the overall right of way program.

236.12.6.2 QAR Team Members

List the names of those that performed the review.

236.12.6.3 Background

Titles 23 and 49 of the Code of Federal Regulations broadly mandate the state's responsibilities for compliance with the provisions of the Uniform Relocation Assistance and Real Property Acquisition Regulations for Federal and Federally Assisted Programs. To assure proper recognition of, and adherence to, those regulations, the Missouri Highways and Transportation Department has developed, with the approval of the Federal Highway Administration, procedures covering all aspects of right of way acquisition, management, and disposition. These procedures provide the basis for the periodic quality assurance review of all current processes.

Provide the date of the Last Review.

Follow-up of recommendations from previous reviews:

236.12.6.4 Methodology and Findings

Sampling Technique

A letter notifies all right of way managers of the scheduled reviews. This letter identifies the critical functions that are to be reviewed, the calendar period that would be covered, and the dates and specific time schedules for the district office review team visits.

In the schedule, the Administration, Appraisal, and Negotiation files have been reviewed in the Division Office prior to the district team visits. The Realty Asset and Relocation files are being reviewed in the district and all functions are then discussed during the district office exit interview.

Sample Reviewed and Findings

Samples may be reviewed from any or all of the following categories: Administration, Appraisals, Negotiations, Realty Assets, and Relocation. The files reviewed for each category shall be documented.

Note the following information for the files that were reviewed:

• Project No.
• Route
• County
• Parcel No.
• Findings

Exit Interview

At the conclusion of the Review a brief exit interview is conducted.

Note the following items in the report:

• Names of district personnel who were present
• Who conducted the interview?
• A discussion of positive/negative findings in the report.
• Exit interview responses.
• Follow-up on previous recommendations.

236.12.6.5 Conclusion and Recommendations

Clearly state the conclusions and recommendations contained in the report.