3. PWS Pediatric Ward Nursing Services.pdf

Attachment A – Performance Work Statement (

PERFORMANCE WORK STATEMENT (PWS)

NON-PERSONAL SERVICE – Pediatric Ward Nursing Services Table of Contents

Page

1.0 General 2

1.1 Background 2

2.0 Scope 2-3

3.0 Applicable Documents 3

4.0 Definitions 3-6

5.0 Government Furnished Information, Property & Services 6

6.0 Protection of Government Buildings, Equipment and Vegetation 6

7.0 Contractor Furnished Equipment 6-7

8.0 Performance-Work Statement (PWS) Requirements 7-9

8.1 Nursing Duties

8.2 Work Schedule

8.3 Leave Requests

8.4 Timesheets

8.5 Ethics & Conduct

8.6 Performance Evaluation

8.7 Identification of Contractor

8.8 Management of Medical Information

8.9 IHS Information Technology Systems

9.0 Contractor Qualification Requirements 9-10

10.1 Experience

10.2 License/Registration Certifications

10.3 Motor Vehicle Operator’s License

10.4 Certifications

10.5 Health Requirements/Conditions of Employment

10.6 Immunization

10.7 Language Requirement and Cultural Awareness

10.8 Information Technology Skills

10.9 Orientation

10.10 Background Checks

10.0 Technical Direction 10-11

11.0 List of Attachments and Exhibits 11

Performance Work Statement (PWS) – Summary Requirements 12

1. General: This performance work statement describes the requirements for Non-Personal Service Contract for Nursing Services in the Pediatric department to support the mission of the Indian Health Service

(IHS).

1.1. Background: IHS is an agency within the U.S. Department of Health and Human Services and is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government to government relationship between the federal government and Indian tribes. The IHS is the principal federal health care provider and health advocate for the Indian people. The goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indians and Alaska Natives. The IHS currently provides health services to approximately 1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 34 states.

There is a nationwide shortage of nurses which is amplified by the remote and rural areas served by the Indian Health Service. This performance work statement covers requirements for the Navajo Area and Shiprock Service Unit which includes Northern Navajo Medical Center (NNMC), Dzilth-Na-O- Dith-Hle Health Center (DZHC), and Four Corners Regional Health Center (FCRHC). The positions to be filled include Registered Nurse (RN) for the provision of Pediatric nursing services for inpatient pediatric and medical surgical care.

2. Scope: The Contractor shall provide nursing services in accordance with section 8.0, performance work statement requirements.

2.1. Duties and responsibilities may encompass inpatient nursing services to Pediatric and/or Medical

Surgical IHS patients. Performing nursing duties for the care of adult and pediatric patients.

2.1.1. Pediatric & Medical Surgical patient care

2.1.1.1. Care of patients with diabetes, hypertension, cardiovascular disease, kidney & liver disease, sepsis, developmental delays in children, respiratory illness in both adults and pediatric patients.

2.1.1.2. Must have knowledge of medical administration of both adults and pediatric patients, IVACs, cardiac monitors, phototherapy for newborns, knowledge of PICC lines, high flow oxygen delivery for both adults and pediatric patients.

2.1.1.3. Develops individualized patient care plans or participates in patient care planning, which involves the assessment and evaluation of patient needs, a determination of the nursing procedures and practices to be included; and periodic evaluation of plans to ensure that intended results are being achieved.

2.1.1.4. Interviews patients and family members and consult with attending physicians and other staff members to determine and evaluate the kind of health and physical care needed.

2.1.1.5. Reviews and interprets findings to distinguish between normal and abnormal conditions.

2.1.1.6. Observes and documents patient's conditions, changes, and reactions to medications and medical treatment

2.1.1.7. In the event of an emergency, i.e. code blue/Rapid Response Team (RRT), follows algorithms and procedures per established American Heart Association (AHA) and SSU policy.

2.2. Place of Performance: Services are to be performed at hospitals, clinics and other healthcare facilities of the Navajo Area Indian Health Service within the Northern Navajo Medical Center.

Location: Northern Navajo Medical Center, US Hwy 491 North, Shiprock, NM 87420

2.3. Department: Pediatric Ward

2.4. Period of Performance: Shall be 1 Base Period + 4 Option Periods. Each contract period of performance shall contain a 6-month period of performance.

3. Applicable Documents: Please see the web link listed unless document is listed as an attachment.

3.1. The Joint Commission (TJC) http://www.jointcommission.org

3.2. Centers for Medicare and Medicaid Services (CMS) Standards http://www.cms.hhs.gov

3.3. Accreditation Association for Ambulatory Health Care(AAAHC) https://www.aaahc.org

3.4. Section 231 of Public Law 101-647, the Crime Control Act of 1990.

http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf

3.5. Section 4087 of Public Law 101-630, the Indian Child and Family Violence Act http://www.icctc.org/IHS-BIA%20CPT%Handbook/PL%201101-630.pdf

3.6. Health Insurance Portability and Accountability Act (HIPAA) of 1996.

http://www.cms.gov/HIPAAGeninfo/

3.7. Privacy Act of 1974. http://www.justice.gov/opcl.privacyact1974.htm

3.8. Revised American Nurses Association Code of Ethics and Standards of Practice and Care (1996) http://www.nursingworld.org

3.9. State Nurse Practice Act for the Contractor's licensing state. http://www.medi-smart.com/

3.10. IHS Service Unit and Health Center Policies, Procedures and Protocols. (See section 11.0 for a list of attachments and exhibits)

3.11. Computer Security Act of 1980 http://security.ihs.gov/index.cfm

3.12. Federal Code of Conduct: Contractor Code of Business Ethics and Conduct eCFR :: 48 CFR 52.203-13 -- Contractor Code of Business Ethics and Conduct. (FAR 52.203-13)

3.13. IHS General Directives http://www.ihs.gov/index.cfm?module=AtoZ&option=index

3.14. IHS Computer Security Directives: http://security.ihs.gov/index.cfm

4. Definitions

4.1. Acceptance: Constitutes acknowledgement that the supplies or services conform to the applicable contract quality and quantity requirements, except as provided in FAR subpart 46.5 and subject to http://www.jointcommission.org/ http://www.cms.hhs.gov/ http://www.aaahc.org/ http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf http://www.icctc.org/IHS-BIA%20CPT%25Handbook/PL%201101-630.pdf http://www.cms.gov/HIPAAGeninfo/ http://www.justice.gov/opcl.privacyact1974.htm http://www.nursingworld.org/ http://www.medi-smart.com/ http://security.ihs.gov/index.cfm https://www.ecfr.gov/current/title-48/chapter-1/subchapter-H/part-52/subpart-52.2/section-52.203-13 http://www.ihs.gov/index.cfm?module=AtoZ&option=index http://security.ihs.gov/index.cfm other terms and conditions of the contract.

4.2. Approval: Acknowledgment by the designated Government official that submittals, deliverables, or administrative documents (e.g., insurance certificates, installation schedules, planned utility interruptions, etc.) conform to the contractual requirements. Government approval does not relieve the Contractor from responsibility for compliance with contract requirements.

4.3. Area: A defined geographical region for Indian Health Service administrative purposes. Each Area Office may administer several Service Units.

4.4. Code of Ethics: The Revised American Nurses Association Code of Ethics and Standards of Practice and Care, published in 1996 by the American Nurses Association which makes explicit primary goals, values and obligations of the nursing profession.

4.5. Contracting Officer {CO): A Government employee with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings.

4.6. Contractor: The individual awarded a legal binding contract to provide supplies and services.

4.7. Contracting Officer's Representative (COR): A federal employee who assists the ordering/issuing activity contracting officer in the administration of task orders issued under this contract. The COR is primarily responsible for the technical assistance and day-to-day program management of the ordering activity's task orders. Ordering activities may have different designators for this employee (e.g. COR- contracting Officer's Representative or GTR-Government Technical Representative,).

4.8. Contractor Performance Assessment Report: A report that assesses a contractor's performance and provides a record, both positive and negative, on a given contract for specific period of time.

4.9. Cooperative Attitude: Behavior that is positive and displays a willingness to perform assigned patient care tasks and to be a team player.

4.10. Cultural Awareness: Realization and respect for American Indian and Alaska Native practices.

4.11. Customer: Patients, staff and visitors of an IHS service unit and health center.

4.12. Customer Evaluation/Input: Written comments made to the Contracting Officer regarding the Contractors performance. This is one of the criteria used to evaluate the Contractor's performance.

4.13. Dependability: Qualities of being trusted and being able to repeat the same task to yield the same result.

4.14. Federal Acquisition Regulation (FAR): The FAR is the primary regulation for use by all Federal Executive agencies in their acquisition of supplies and services with appropriated funds.

4.15. Government Vehicle: An IHS owned motor vehicle or a vehicle leased by IHS through agreements with the General Services Administration (GSA) or through commercial rental agreements.

4.16. Health Center: A facility physically separated from a hospital, with a full range of ambulatory services including at least primary care providers, nursing, laboratory, and x-ray which are available at least 40 hours a week for outpatient care.

4.17. Health Insurance Portability and Accountability Act (HIPAA): A US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

4.18. Non-Personal Service Contracts: means a contract under which the personnel rendering the services are not subject, either by the contract's terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees as defined in FAR 37.

4.19. Orientation: An activity designed to provide basic familiarization of the facility and transition the nurse into the IHS Service Unit and/or Health Center and the nursing unit where the services will be provided.

4.20. Past Performance Information: Relevant information regarding a contractor's actions under previously awarded contracts. This includes the contractor's record of conformance to specifications and to standards of good workmanship; the contractor's record of containing and forecasting costs on any previously performed cost reimbursable contracts; the contractor's adherence to contract schedules, including the administrative aspects of performance; the contractor's history for reasonable and cooperative behavior and commitment to customer satisfaction; and generally, the contractor's business-like concern for the interest of the customer.

4.21. Patient Outcome: End result of nursing care.

4.22. Performance Work Statement Matrix: lists the services to be monitored and the standards to be applied.

4.23. Personal Protective Equipment (PPE): The equipment used to protect medical personnel from exposure to biological, chemical, and radioactive hazards.

4.24. Service Unit: The local administrative unit of IHS.

4.25. Standards of Practice and Standards of Care: Authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable. The standards provide direction for professional nursing practice and a framework for the evaluation of practice. The standards of professional nursing practice may pertain to general or specialty practice.

4.26. Technical Direction: A directive to the Contractor that approves approaches, solutions, designs, or refinements; fills in details or otherwise completes the general description of work or documentation items; shifts emphasis among work areas or tasks; or furnishes similar instruction to the Contractor.

Technical direction includes requiring studies and pursuit of certain lines of inquiry regarding matters within the general tasks and requirements in Section 5 of this contract.

4.27. Tour of Duty: The time of day the nurse is scheduled to perform nursing care duties; also considered the shift of the day. The time can vary according to the needs of each facility and/or clinic, (e.g. 12-hour Tour of Duty, 8-hour Tour of Duty, 10-hour Tour of Duty). Includes weekends and holidays.

4.28. Valid Patient Complaint: Justifiable accusation made by a patient and supported by investigation.

4.29. Verifiable Emergency: An unexpected/unplanned absence by the contractor requiring valid documentation to confirm the occurrence.

5. Government Furnished Information, Property and Services

5.1. Information: Government unique information related to this requirement, which is necessary for

Contractor performance, will be made available to the Contractor. The Contracting Officer or designee will be the point of contact for identification of any required information to be supplied by the Government.

5.2. Joint Use by the Government and the Contractor: The Government will provide, for joint use by the Government and the Contractor, all necessary equipment, supplies, and clinic space to perform the services under this contract.

5.2.1. Government Vehicle: If required by the position, authorization shall be in accordance with IHS Manual, Chapter 9, Part 1 - Motor Vehicle Safety.

5.3. Contractor Exclusive Use:

5.3.1. Personal Protective Equipment (PPE). The Government will furnish the Contractor with appropriate PPE other than specified in section 7 of the PWS. The Government will be responsible for any repair, cleaning, and inventory required for the PPE. This does not include any type of uniform or laboratory coat.

5.3.2. The Government will provide facility specific contractor identification badges for each contractor. A minimum fee of $20.00 will be charged for lost or destroyed badges.

5.4. Training: Facility specific training necessary for the Contractor to perform the required duties, e.g., IHS information technology (IT) systems and operational procedures. Training will be provided ONLY if the subject matter is necessary to improve or enhance the quality of nursing services or includes mandates made by the service unit while the nurse is working under this contract. Training will not be provided for the purpose of continuing education, career development or individual development.

6. Protection of Government Buildings, Equipment, and Vegetation

6.1. The Contractor shall use reasonable care to avoid damaging existing buildings, equipment and vegetation on the Government installation. If the Contractor's failure to use reasonable care causes damage to any of this property, the Contractor shall replace or repair the damage at no expense to the Government as the Contracting Officer directs. If the Contractor fails or refuses to make such repair or replacement, the Contractor shall be liable for the cost, which may be deducted from the contract price.

7. Contractor Furnished Property

7.1. Except for the property specified in section 5 as government furnished, the Contractor shall provide all uniforms and other personal medical instruments subject to the following:

7.1.1. Uniforms and Lab Coats: Uniforms and Lab Coats shall conform to the requirements of the Indian

Health Service Manual, Part 3, Chapter 6, and meet the approval of the SCN within the Shiprock Service Unit or Northern Navajo Medical Center.

7.1.2. Other personal medical instruments: "Other personal medical instruments" are defined as

Contractor owned items may include but not limited to stethoscope, scissors, as appropriate to the work unit. The Contractor shall not use unsafe equipment or supplies at any time during performance of this contract. All Contractor furnished equipment and supplies shall be subject to inspection by the Government and must be approved by the Supervisory Clinical Nurse (SCN) prior to use by the Contractor. The Government reserves the right to prohibit the use of any materials, supplies, or equipment.

8. Performance Work Statement (PWS) Requirements.

8.1. Nursing Duties:

8.1.1. The Contractor shall perform nursing duties and managing pediatric and medical surgical patient needs as described in this PWS and in accordance with technical direction provided by NNMC's Clinical Nursing Supervisor otherwise known as Supervisory Clinical Nurse (SCN) herein this PWS.

8.1.2. The Contractor shall be flexible and be willing to allow nursing service rotations in other nursing departments as needed to support patient care needs (e.g., float as a sitter, go on transport, and or float in another department).

8.1.3. The Contractor shall perform in accordance with the following competency standards:

8.1.3.1. Pediatric and Medical Surgical Competencies

8.1.3.2. Written Competency Standards

8.1.3.2.1. Confidentiality/HIPAA/Patient's Rights

8.1.3.2.2. EMTALA Compliance Exam, 2004

8.1.3.2.3. Age Specific Competency Verification

8.1.3.2.4. RN Medication Administration Competency Examination

8.1.3.2.5. RN Medication Administration Competency Verification

8.1.3.2.6. Intravenous Therapy Exam

8.1.3.2.7. Venipuncture Procedure Skills Competency Verification

8.1.3.2.8. Pain Management Competency Verification

8.1.3.2.9. Restraints

8.1.3.2.10. Soft Restraint Application Competency

8.1.3.3. Contract Nurse Orientation Check List I Health Stream

8.1.3.4. Contract Nurse Orientation Competency Verification Instructions

8.1.3.5. Contract Nurse Billing Information

8.1.3.6. Standard Emergency Codes

8.1.3.7. Confidentiality: Legal and Ethical Concerns in Healthcare

8.1.3.8. EMTALA- Emergency Medical Treatment and Labor Act

8.1.3.9. What are Age-Specific Competencies?

8.1.3.10. An Introduction to the Navajo Culture

8.1.3.11. Verbal and Telephone Orders

8.1.3.12. Medication Administration

8.1.3.13. Pain Management

8.1.3.14. Latex Allergy

8.1.3.15. Charting

8.1.3.16. Patient Restraints

8.1.3.17. Charge Nurse Duties: Responsibility and Expectation

8.1.3.18. Nursing Standards

8.1.3.19. Standards of Nursing Practice

8.2. Work Schedule:

8.2.1. The contractor shall work 12 hours per shift. Shifts begin at 7:00 AM/PM, 3 shifts one week and 4 shifts the other week. This will be a total of 7 days (84 hours) each 2 weeks.

8.2.2. The Supervisory Clinical Nurse (SCN) for each department will provide technical direction on the specific tour of duty the contract nurse will work.

8.3. Leave Requests

8.3.1. The Contractor shall coordinate with the department SCN or designee prior to any absence from work. If the length of the absence exceeds eight (8) work hours and beyond, the Contractor shall coordinate and provide notification to the department SCN (the exception is verifiable emergencies) in advance of the desired absence.

8.3.2. Approval of leave is contingent upon the availability of adequate staffing.

8.3.3. The Contractor shall provide written documentation from a qualified health care provider for absences of three (3) or more consecutive days, due to illness, stating:

8.3.3.1. The cause of the current illness or incapacitation AND

8.3.3.2. Indicating the Contractor as contagious or non-contagious.

8.4. Timesheets: The contractor shall track time sheets and ensure accurate tracking of hours worked to allow for correct billing. The government shall provide a blank timesheet template for use to track hours for billing. The contractor shall use a blank template or provide the nursing contractor a blank timesheet copies for accurate tracking.

8.4.1. Timesheets shall be verified by SCN each week for correct billing purposes.

8.5. Ethics & Conduct: The Contractor shall meet standards as listed in the Federal Code of Conduct:

Contractor Code of Business Ethics and Conduct.

8.5.1. The Government reserves the right to examine and or re-examine any Contractor who meets the criteria of unplanned absences and does not meet performance standards as listed herein this PWS.

8.6. Performance Evaluations:

8.6.1. The Contractor's performance will be evaluated in accordance with the standards set forth in the contract and Performance Work Statement Matrix on page 16.

8.6.2. Substantiated reports written by any customer dealing with patient safety, infection control, or other procedure that adversely affects patient outcome constitutes a breach of contract.

8.7. Identification of Contractor:

8.7.1. The Contractor shall wear a government issued contractor identification badge during performance of duty. The identification badge, any other assigned keys or badges that are given upon starting the contract must be returned to the supervisor upon completion of contract or service end date.

8.8. Management of Medical Information: The Contractor shall manage all patient information in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards, Privacy Act, and IHS Service Unit and/or Health Center specific policies and protocols.

8.8.1. The Contractor shall ensure adherence to DHHS IT system security policies and procedures. The IT policies and procedures will be made available to the Contractor.

8.8.2. The Contractor shall immediately report to the Contracting Officer or COR any information or circumstances that may violate any statute, policy, or procedure.

8.9. IHS Information Technology Systems:

8.9.1. ln performance of this contract, the Contractor shall adapt to and successfully utilize IHS information technology systems that are deemed by the SCN as necessary for acceptable contractor performance.

8.9.2. The Contractor shall ensure that IHS information technology system security policies and procedures are adhered to. The IT policies and procedures will be made available to the Contractor at each IHS facility.

9. Contractor Qualification Requirements:

9.1. Experience: The Contractor shall have twenty-four (24) months of nursing experience, with a minimum of two (2) years in Pediatric with Medical Surgical experience as required by the contract.

9.2. License/Registration: All nurses shall possess a current, valid, unrestricted nursing license in a state, the District of Columbia, the Commonwealth of Puerto Rico, or a Territory of the United States, throughout the term of this contract.

9.3. Motor Vehicle Operator's License. If required by the position, the Contractor shall possess a valid state driver's license throughout the term of this contract.

9.4. Certifications:

9.4.1. Current Basic Life Support (BLS) is mandatory for all specialties.

9.4.2. Pediatric Advanced Life Support (PALS),

9.4.3. Neonatal Resuscitation Program (NRP),

9.4.4. Advanced Cardiac Life Support (ACLS)

9.4.5. The contractor shall ensure that the contract nurse's certifications remain valid throughout the term of this contract.

9.5. Health Requirements/Conditions of Employment:

9.5.1. Medical Evaluation. The Contractor shall provide a fitness for duty certificate issued by a licensed physician to perform the proposed job without significant risk to personal health or the health and safety of others.

9.6. Immunization. The Contractor shall also provide the following documentation prior to RN Candidate selection:

9.6.1. Immunity to Rubella, Mumps, and Rubeola (Measles);

9.6.2. Proof of Hep B vaccination x3 OR positive titer OR a signed declination of the Hep B vaccinations will also be accepted;

9.6.3. Documented history of chicken pox OR varicella vaccination x2 OR positive varicella titer;

9.6.4. History of Tdap vaccination, with subsequent Td vaccination if older than 10 years;

9.6.5. Documentation of Tuberculosis testing (TB skin test or IGRA) within the past 12 months with documentation of chest x-ray and follow-up for a positive history;

9.6.6. 12 months with documentation of follow-up for a positive test.

9.6.7. Proof of influenza vaccination from October -1 thru March 31, per IHS Mandatory Influenza

Vaccination Policy.

9.7. Language Requirements and Cultural Awareness. The Contractor shall read, understand, speak, and write English to effectively communicate with patients and other health care workers, and shall be respectful of the local, American Indian and Alaska Native culture.

9.8. Information Technology Skills. The Contractor shall possess basic knowledge, skills, and abilities to use a computer.

9.9. Orientation. All nurses providing service under this contract shall attend mandatory orientations and training specified by the government.

9.10. Background Checks: As directed by the Contracting Officer, the Contractor shall provide all requested information necessary to perform background checks. The Contractor shall comply with the requirement to obtain security investigations. The Contractor shall work with the IHS to ensure that the pre-employment screening process includes the appropriate investigation questionnaires and forms to be completed. All completed forms will be reviewed by the Contractor and forwarded to the Government Personnel. The Contractor will be immediately removed from the position if at any time the investigation receives unfavorable adjudication, or, if other unfavorable information that would affect the investigation becomes known.

10. Technical Direction:

10.1. Performance of the work under this contract is subject to the written and verbal technical direction of the SCN.

10.2. The SCN does not have the authority to, and shall not, issue any instructions outside the terms and conditions of this contract or technical direction that:

10.2.1. Constitutes an assignment of additional work outside the performance work statement;

10.2.2. Constitutes a change as defined in the changes;

10.2.3. In any manner causes an increase or decrease in the total estimated contract cost, fixed fee (if any), or the time required for contract performance;

10.2.4. Changes any of the expressed terms, conditions, or specifications of the contract; or the terms and conditions of the contract.

10.2.5. Technical direction shall be issued verbally or in writing by the SCN.

10.3. The Contractor shall proceed promptly with any challenges of performance or of technical direction duly issued by the SCN in the manner prescribed by this paragraph and within authority. If, in the Contractor's opinion, any instructions or direction by the SCN falls outside of the contract terms and conditions, the Contractor shall proceed with a written notice to the Contracting Officer in writing within 5 working days after receiving it and shall request the Contracting Officer to take action as described in this paragraph. Upon receiving this notification, the Contracting Officer shall provide guidance, clarify technical direction, execute an appropriate contract modification within a reasonable time or advise the Contractor in writing that the instruction or direction is within the requirements of the contract and does not constitute a change under the changes clause of the contract and that the contractor shall proceed promptly with its performance.

10.4. A failure of the Contractor and Contracting Officer to agree that the instruction or direction is both rescinded in its entirety; or within the requirements of the contract and does not constitute a change under the changes clause, or a failure to agree upon the contract action to be taken with respect to the instruction or direction shall be subject to the Disputes clause of this contract.

10.5. Any action taken by the Contractor in response to any direction given by any person other than the Contracting Officer or the SCN shall be at the Contractor's risk.

11. List of Attachments:

1. Pediatric Competency

2. Medical Surgical competency

3. Blank RN timesheet

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Northern Navajo Medical Center: PEDIATRIC INPATIENT UNIT [RN] Annual Competency

Employee Name/Title: ____________________________ Date completed: _______________

Permanent: □ Contract:

Please consult provided Competency Book or PDF File to view/review each competency listed.

SELF EVALUATION HOW COMPETENCY/SKILL IS VALIDATED EXPERIENCE LEVEL

1. Have not experienced before

2. Know principle, but have not performed

3. Have performed but not recently, need review

4. Feel comfortable and competent in activity/skill

Competency will be validated by:

Direct observation (D) Simulation (S) Return Demonstration (RD) Test (T) Class (C) Verbalize (V)

Use the appropriate letter in the column “How Validated”

1. Acquired some experience (may require practice, assistance) = Fail

2. Competent and/or can perform independently = Pass

3. Competent, performs independently, and is able to teach and/or assess the competency of others = Pass

Use the appropriate number in the column “Experience Level”

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

Equipment Competencies

1. Defibrillator

2. Kangaroo Pump

3. Patient Controlled Analgesia (PCA) Pump

4. Vapotherm

Skills & Procedures

5. PICC line dressing change

6. Port-a-cath access and management

7. Point of Care Glucose Testing (Accu-chek Inform II)

8. Chest tube

9. Wound Vac

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

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Northern Navajo Medical Center: PEDIATRIC INPATIENT UNIT [RN] Annual Competency

Medication Administration

10. Fentanyl Drip

IVs, Phlebotomy, Blood Administration

11. Blood Products Administration

Infection Control

12. Hand Hygiene

13. Personal Protective Equipment

14. Instrument Care Process

Communication & Safety

15. Sitter

16. Restraints

17. Fall Prevention

Validating Initials & Signatures:

Initials Signature Initials Signature

Acknowledgement:

By signing this competency validation, I attest that I take responsibility for the contents therein. I have to the best of my knowledge and skills, verbalized and or demonstrated my competency for all topics and skills listed above. I will actively seek out resources for review of skills, as needed, in regular clinical practice.

Print Name: _________________________________________ Signature: ________________________________ Date: ___________

Clinical Coach Signature: _____________________________________ Date: _____________________

Supervisor Signature: (only required if multiple failed attempts) ______________________________________ Date: ___________________

Comments:

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Northern Navajo Medical Center: MEDSURG NURSE Annual Competency

Employee Name/Title: Date: Dept:

Permanent: Contract:

Please consult provided Competency Book or PDF File to view/review each competency listed.

SELF EVALUATION HOW COMPETENCY/SKILL IS VALIDATED EXPERIENCE LEVEL

1. Have not experienced before

2. Know principle, but have not performed

3. Have performed but not recently, need review

4. Feel comfortable and competent in activity/skill

Competency will be validated by:

Direct observation (D) Simulation (S) Return Demonstration (RD) Test (T) Class (C ) Verbalize (V)

Use the appropriate letter in the column “How Validated”

1. Acquired some experience (may require practice, assistance) = Fail

2. Competent and/or can perform independently = Pass

3. Competent, performs independently, and is able to teach and/or assess the competency of others = Pass

Use the appropriate number in the column “Experience Level”

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

Equipment Competencies

1. Defibrillator

2. Kangaroo Pump

3. Patient Controlled Analgesia

Skills & Procedures

4. Chest Tube

5. Wound Vac

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

Medication Administration

6. Peripheral Parenteral Nutrition

7. Total Parenteral Nutrition

8. Fentanyl Drip

9. Lasix Drip

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Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

IVs, Phlebotomy, Blood Administration

10. Point of Care/Accu-check

11. Port-a-cath Insertion, Care, and Management

12. Peripherally Inserted Central Catheter Care and Management

Infection Control

13. Hand Hygiene

14. Personal Protective Equipment – Donning/Doffing

15. Instrument Care Process

Communication & Safety

16. Restraints

17. Sitter

18. Fall Prevention

19. Post-Fall Huddle

Validating Initials & Signatures:

Initials Signature Initials Signature

Acknowledgement:

By signing this competency validation, I attest that I take responsibility for the contents therein. I have to the best of my knowledge and skills, verbalized and or demonstrated my competency for all topics and skills listed above. I will actively seek out resources for review of skills, as needed, in regular clinical practice.

Printed Name:___________________________________________ Signature: _________________________________________ Date: ___________

Clinical Coach Signature: _____________________________________ Date: _____________________

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Supervisor Signature: (only required if multiple failed attempts) ______________________________________ Date: ___________________

Quizzes/tests can be added here and graded in addition to skill assessment. Duplicate as needed.

Comments:

Knowledge Assessment

WEEKLY NURSING TIMESHEET

WEEK OF:

FACILITY NAME:

NORTHERN NAVAJO MEDICAL CENTER

EMPLOYEE NAME: CONTACT INFO:

PO NUMBER: PCN #:

DEPARTMENT: SUPERVISOR:

REGULAR HOURS

DATE DAY

START

TIME

LUNCH

(mins)

END

TIME

TOTAL

HOURS NOTES

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

WEEKLY

TOTALS

EMPLOYEE: I CERTIFY THAT THE HOURS SHOWN ABOVE REPRESENT MY TOTAL HOURS

WORKED AND THAT THEY ARE PROPERLY VERIFIED.

EMPLOYEE SIGNATURE: DATE:

SUPERVISOR SIGNATURE: DATE:

COMPANY NAME

Use increments of .25

Use increments of .25

BILL TO LINE:

PERFORMANCE WORK STATEMENT (PWS) SUMMARY

REQUIREMENTS

2. IDENTIFICATION OF REQUIRED PERFORMANCE STANDARD/QUALITY LEVELS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Government shall use these standards to determine contractor performance in accordance with this PWS.

TASK ID INDICATOR STANDARD ACCEPTABLE

QUALITY LEVEL

METHOD OF

SURVEILLANCE

INCENTIVE

Contractor shall provide Nursing services for the delivery of patient care in accordance with this PWS in the Pediatric Ward at the Northern Navajo Medical Center, Shiprock, NM.

A Patient Care Contractor services are fully successful or deemed excellent patient care as rated under Element 1 & Element 3 of the Peer Review NAO Provider Exit Profile (refer to Section

10.1 of the PWS). No reports of breached safety or other procedures that may have adversely affect patient outcomes.

A rating or “Fully Successfully or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract price for satisfactory service.

Favorable CPAR report

B Compliance No reprimands or disciplinary actions or violations of published Policies;

Procedures; Standards of Care or Hospital Protocols

No reprimands or disciplinary actions

Periodic inspection, 100% inspection and an analysis of contractor’s progress reports

Payment of

C Culturally Sensitivity

Contractors were compassionate culturally sensitive

A rating or “Fully Successful” or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of

D Documentation Contractors completed require documentation in clear and legible form in a timely manner. (Element 6)

A rating or “Fully Successful” or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Periodic inspection, 100% inspection and an analysis of contractor’s progress reports

Payment of

E Professionalis m

Contractors presented in professional appearance demonstrated exceptional ethical conduct with effective communication, and exhibited exemplary attitude by being flexible and being adaptable. (Element 4, Element 5 Element 8)

A rating or “Fully Successful” or “Exceptional” must be attain on the Peer Review NAO Provider Exit Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of

PERFORMANCE WORK STATEMENT (PWS) SUMMARY REQUIREMENTS