1. Draft PWS 10-2-2024 Mock Survey.docx

Performance Work Statement (PWS)

JOINT COMMISSION ACCREDITATION MOCK SURVEY

Purpose:

This service is being requested to provide personnel and materials including all items for an Accreditation Mock Survey in accordance with the Joint Commission’s 2025 Comprehensive Accreditation Manual for Hospitals, Behavioral Health, and Home Care. This service is for the Harry S. Truman Memorial Veterans Hospital located at 800 Hospital Drive, Columbia, Missouri 65201.

Scope of Work:

The contractor shall provide comprehensive expertise on-site consultation for a total of Four (4) days each with a nurse, physician, and environment of care consultant. Two (2) days each with a behavioral health consultant and a home care consultant for a total of a total of 16 consulting days. Service required is between December 1, 2024, through February 28, 2025. A written report will be provided after the on-site consultation.

· The contractor shall come on the premises to the Columbia, MO Veteran’s Administration Medical Center (VAMC) to assess compliance with the Joint Commission’s 2025 Comprehensive Accreditation Manual for Hospitals, Behavioral Health, and Home Care.

· Pre-visit information gathering; and discussion with the Columbia, MO VAMC about current view of TJC accreditation, any potential timeline for accreditation being attained by the Columbia, MO VAMC, key organization subject matter-experts, and the facilities current knowledge of TJC 2025 Comprehensive Accreditation for Manual for Hospital, Behavioral Health and Human Services, and Home Care.

· The contractor employees shall present a neat appearance and be easily identified as contractor employees by wearing appropriate badges that contain the company name and employee name and obtain a Facility Visitor Pass for all employees who perform work at the Columbia, MO VAMC.

· The contractor shall perform an assessment using the latest published TJC (as applicable) guidelines noted in the Comprehensive Accreditation Manual.

· The contractor shall review facility processes, focus on identified risk points, and the facilities development of strategies to minimize these risks.

· The contractor will assist the Columbia, MO VAMC to understand gaps between its current state and compliance with TJC accreditation requirements.

· Observe, assess, and evaluate current health care operations in relationship to meeting organizational goals of quality and patient safety.

· Identify important organizational and systems issues related to safety, qualify of care, treatment and services and interfaces between those processes.

· The contractor shall collaborate with the Columbia, MO VAMC to help it structure effective TJC accreditation self-assessment activities.

· The contractor shall provide use of tracer methodology for evaluation of processes and practices as they relate to the organization and its services.

· The contractor shall provide utilization of individual and system tracers for evaluation of determined areas of focus and to review direct care processes, across services and disciplines, in key inpatient and outpatient clinical areas and the environment, with focus on understanding gaps between the Columbia, MO VAMC and Joint Commission requirements. Information will be gathered by making observations, conducting interviews, and reviewing selected documents.

· The services to be performed by the contractor will be performed in accordance with the Department of Veterans Affairs (VA) policies and procedures and the regulations of the medical staff by laws of the Department of Veterans Affairs (VA)Medical Facility

Deliverables:

· A written report will be provided after each on-site consultation.

· Provide consultative and educational information and summarize during the daily debriefings.

· The contractor shall provide a summary of consultative and educational information during the daily debriefings, followed by a written summary of the services, findings, and recommendations.

· The contractor shall provide assessments of organizational approach in areas such as leadership, patient safety, infection prevention and control, medication management, emergency management, use of data and medical staff through interactive conferences (as identified in organization-specific agenda).

Qualification Requirement Contractor shall have served on TJC staff and/or to have conducted at least three TJC surveys on all 3 (three) Hospital, Behavioral Health and Human Services, and Home Care 2024 TJC manuals or most current version. Contractor shall be able to identify clinic(s) or section(s) out of compliance. Contractors shall have either clinical experience (i.e. a licensed nurse or physician) or Health Facilities experience. Experience assessing comprehensive medical treatment centers/organizations with complex programs is a must. Contracted assessor shall be familiar with the TJC Comprehensive Accreditation Manual to include hospital, behavioral health, and home care.

Quality Control The Department of Veterans Affairs (VA) shall establish and maintain a record keeping system.

· Department of Veterans Affairs (VA) staff shall send documentation to the Contracting Officer Representative (COR) with the below information.

· Date of when the service was conducted.

· If the service met the criteria of the statement of work and /or performance standards.

· The service was acceptable.

· When unacceptable performance occurs, written notice shall be sent to the Contracting Officer’s Representative (COR) with the below information.

· What service performance was unacceptable.

· What may correct the issue.

· If the issue may not be correct what is the recommended acting.

· 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 increase in contract amount. When the defects in services cannot be corrected by re-performance, the Government may require the Contractor to take necessary action to ensure that future performance conforms to contract requirements at no additional cost to the Government.

Contractor Damage Agreement

· The contractor shall take all possible precautions to prevent damage to Government property. All damaged areas shall be repaired at no additional cost to the Government as directed by the contracting Officer. The job site shall, be maintained to always provide a reasonably clean and uncluttered appearance.

Assessment Scheduling

· Service required is between December 1, 2024, through February 28, 2025.

· The assessment scheduling will be coordinated with the Accreditation Coordinator/Program Specialist;

Hours of Operations Business hours for the VAMC follow:

· Administrative hours: Monday through Friday, 8:00 a.m. - 4:30 p.m. during regular Federal business working days unless noted below.

· National Holidays: Holidays observed by the Federal Government are:

· New Year’s Day.

· Martin Luther King’s Birthday.

· Presidents Day.

· Memorial Day.

· Juneteenth.

· Independence Day.

· Labor Day.

· Columbus Day.

· Veterans Day.

· Thanksgiving.

· Christmas.

· Any other day specifically declared by the President of the United States to be a national holiday.

· Off-Duty hours: Monday through Friday, 4:30 pm – 8:00 am this include being closed on Saturday and Sunday.