1b. Justification Approval - Healthcare Accreditation Services . Approved by HCA -redacted.pdf

DEPARTMENT OF VETERANS AFFAIRS

Office of Procurement, Acquisition and Logistics (OPAL)

Strategic Acquisition Center (SAC) 10300 Spotsylvania Ave, Suite 400

Fredericksburg, VA 22408

JUSTIFICATION AND APPROVAL

FOR OTHER THAN FULL AND OPEN COMPETITION

(1) Identification of the agency and the contracting activity, and specific identification of the document as a "Justification for Other Than Full and Open Competition."

This Justification and Approval (J&A) for Other Than Full and Open Competition is executed by the Strategic Acquisition Center (SAC), on behalf of the Department of Veterans Affairs (VA), External Accreditation Services and Programs, Office of Quality and Patient Safety.

(2) Nature and/or description of the action being approved.

This proposed action is for a sole source Firm Fixed-Price (FFP), Indefinite Delivery Indefinite Quantity (IDIQ) follow-on contract for the procurement of Healthcare Accreditation Services with:

The Joint Commission (TJC) 1 Renaissance Blvd, Oakbrook Terrace, IL 60181-4294

This requirement covers healthcare accreditation for all Veteran Health Administration (VHA) Medical Facilities, Ambulatory Care Facilities, Consolidated Mail Outpatient Pharmacies (CMOPs), and Opioid Treatment Programs (OTPs).

Programs that fall under this requirement include accreditation of: Hospital, Ambulatory, Behavioral Health, Home Care, other specialties, and special programs.

(3) A description of the supplies or services required to meet the agency’s needs (including the estimated value).

The VA facilities have been accredited for over 35 years. The healthcare accreditation process is a complex system of related and dependent activities.

The objective of this acquisition is to supply accreditation services for VHA healthcare facilities, maintaining healthcare accreditation consistent with one of VA strategies to "continuously improve the quality and safety of health care for veterans." Healthcare accreditation confers recognition that healthcare organizations meet certain standards of quality and safety, in addition to maintaining compliance with healthcare quality standards of payors, both public (e.g., Medicare) and private.

Recognized as an approved accrediting body by all of the following: the Centers for Medicare and Medicaid Services (CMS), Accreditation Council for Graduate

Medical Education (ACGME), and Substance Abuse and Mental Healthcare Services and Administration (SAMHSA) for Opioid Treatment Programs (OTP).

The Joint Commission is a SAMHSA approved accreditor and the only accrediting body that can provide the full scope of healthcare accreditations. The Joint Commission is also recognized by CMS and the ACGME. The Joint Commission currently provides Triennial Surveys, Out-of-Cycle surveys, Accreditation Manager Plus Licensing, VHA Annual Corporate Summation, Corporate Licensure and Publication Delivery, meeting contract requirements.

The Contractor provides all personnel, equipment, supplies, transportation, tools, materials, supervision, and non-personal services necessary to perform Accreditation of VHA Healthcare Programs, as defined in the Performance Work Statement.

The period of performance includes an eight month base period with Four, Twelve month options periods, and a six-month option per the FAR Subpart 52.217-8, Option to Extend Services clause. The estimated ceiling for this contract action is $41,386.998.00.

(4) An identification of the statutory authority permitting other than full and open competition.

The statutory authority permitting other than full and open competition is 41 U.S.C.3304(a)(1) as implemented by the Federal Acquisition Regulation (FAR) Subpart 6.302-1 entitled, “Only One Responsible Source and No Other Supplies or Services Will Satisfy Agency Requirements.”

(5) A demonstration that the proposed contractor’s unique qualifications or the nature of the acquisition requires use of the authority cited.

In accordance with, VHA directive 1100.16 VA medical facilities and programs must maintain continuous compliance with associated accreditation program standards and required processes. In addition, this requirement also requires that the contractor be approved as an Opioid Treatment Program accrediting body by the SAMHSA. Per the SAMHSA website, the Joint Commission was the only contractor listed, that can meet all the requirements.

The Joint Commission’s accreditation process guides organizations in achieving, maintaining, and demonstrating consistent excellence in quality and safety. Key components of the accreditation process are standards, evaluations, performance measurement, and continuous compliance. They are the only known vendor that provides healthcare accreditation meeting all criteria as required in this acquisition for VA by a comprehensive program to monitor and evaluate the quality of healthcare furnished by the VHA and in accordance with authority 38 U.S.C §§ 7301(b); 7311(a). They are recognized by the CMS and the ACGME and are approved as the only Opioid Treatment Program accrediting body by SAMHSA.

The Joint Commission currently owns the intellectual property on these standards and processes and, therefore no other contractor can meet the needs of this requirement.

(6) A description of efforts made to ensure that offers are solicited from as many potential sources as is practicable, including whether a notice was or will be publicized as required by subpart 5.2 and, if not, which exception under 5.202 applies.

Market research was performed, however there is no competition anticipated for this acquisition, due to the fact, The Joint Commission is the only contractor on SAMHSA’s approved accrediting bodies list that can perform all the services of this requirement. Therefore, there is no reasonable expectation that market research would yield any additional sources that are legally authorized to meet the Government's requirement. This J&A will be synopsized on SAM.gov in accordance with FAR 5.201.

(7) A determination by the contracting officer that the anticipated cost to the Government will be fair and reasonable.

In accordance with FAR 15.404-1(b)(2), the Government may use various price analysis techniques to ensure a fair and reasonable price before making any award. The Contracting Officer utilized the previous contract and added inflation by 3% to establish an acceptable range for price determination.

Additionally, historical pricing and the Independent Government Cost Estimate (IGCE) was reviewed and will be utilized to assist in the determination of a fair and reasonable price.

(8) A description of the market research conducted (see part 10) and the results or a statement of the reason market research was not conducted.

Market Research was conducted from June 20, 2024 through July 15, 2024 by the Program Office. Market research included internet searches to identify appropriate rehabilitation accreditation services available in the marketplace. Other contractors in the marketplace were identified as providing accreditation services.

However, website review revealed alternate contractors did not provide the full scope of service to meet all criteria of this requirement. Specifically, other contractors do not provide accreditation services of all programs required to evaluate rehabilitation programs throughout the VHA enterprise. The VA requires the contractor be approved as an Opioid Treatment Program accrediting body by

SAMHSA.

Other Accreditation contractors reviewed are as follows:

1. Commission on Accreditation of Rehabilitation Facilities (CARF)

2. Council on Accreditation (COA)

3. Missouri Department of Mental Health (Division of Behavioral Health (DBH)

4. National Commission on Correctional Health Care

5. Washington State Department of Health (Health Services Quality Assurance)

The Joint Commission accredits and certifies over 22,000 health care organizations and programs in the United States. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards setting and accrediting body in healthcare. To earn and maintain “The Gold Seal of Approval®” from The Joint Commission, an organization undergoes an on-site survey by a Joint Commission survey team at least every three years (Laboratories are surveyed every two years).

The market analysis revealed there are no SDVOSBs or VOSBs capable of performing the accreditation services required or any other contractor. The Joint Commission is the only known entity that can meet VA’s requirements to accredit VHA Healthcare Programs.

(9) Any other facts supporting the use of other than full and open competition.

Current accreditation standards and requirements applied within VHA, are proprietary to TJC, ensuring the highest standard of care is being delivered.

Contract award to an alternative contractor will result in the immediate loss of all TJC accreditation, resulting in unaccredited facilities.

The transition will result in a lapse in accreditation status, as currently TJC accreditation would expire at the end of each organization’s survey cycle. This will present a vulnerability for enterprise-wide decrease in quality of care, treatment, and services, directly impacting patient outcomes and organizational performance.

(10) A listing of the sources, if any, that expressed, in writing, an interest in the acquisition.

On November 1, 2024, an Intent to Sole Source Notice was publicized on SAM.gov, to notify vendors of the Governments intent and gauge market availability of capable and responsible vendors that can successfully satisfy this requirement, however no responses were received.

(11) A statement of the actions, if any, the agency may take to remove or overcome any barriers to competition before any subsequent acquisition for the supplies or services required.

At present, no market changes have occurred to result in competition that meets all elements required by VA. As The Joint Commission accreditation confer VHA’s programs and facilities provide care that meets national safety and quality standards, we will maintain our present strategy and monitor changes in policy and/or regulatory guidelines for any changes that will allow for an alternative in obtaining and maintaining healthcare accreditation.

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(12) Evidence that any supporting data that is the responsibility of technical or requirements personnel (e.g., verifying the Government’s minimum needs or requirements or other rationale for an exception to fair opportunity) and which form a basis for the justification have been certified as complete and accurate by the technical or requirements personnel.

I certify that the supporting data under my cognizance, which are included in this justification, are accurate and complete to the best of my knowledge and belief.

Signature: _________________________________ Date: ____________ Heather L. Carreiro, MSN, MHA, RN Director, External Accreditation Services Programs Office of Quality, Patient, Safety (VACO)

(13) Contracting officer certification that the justification is accurate and complete to the best of the contracting officer ’s knowledge and belief.

I certify that this justification is accurate and complete to the best of my knowledge and belief.

Signature: _________________________________ Date: ____________ Mauricio Vazquez Chief, Acquisition Services Division 4A Office of Procurement, Acquisition and Logistics (OPAL) Strategic Acquisition Center (SAC)

01/08/2025

Approval

Based on the foregoing justification, I hereby approve this acquisition on an “other than full and open competition” basis pursuant to the statutory authority cited in paragraph four above, subject to availability of funds, and provided that the property and services herein described have otherwise been authorized for acquisition. As this action does not exceed $75M, the certification below required by FAR 6.304 serves as approval.

Signature: _________________________________ Date: ____________ Sharon E. Chang Deputy Director of Office of Procurement, Acquisition and Logistics Interim HCA for Strategic Acquisition Center and National Acquisition Center

Date4_af_date: 1/30/25