ATTACHMENT 1 - Performance Work Statement - ORTHO - MEMPHIS - PRE-S0LICITATION.pdf

B.3 PERFORMANCE WORK STATEMENT – Orthopedic Physician Services

1. GENERAL:

1.1. Services Provided: The Contractor shall provide 1.5 FTE Board Certified/Board Eligible Orthopedic Physician Services onsite in accordance with the specifications contained herein to beneficiaries of the VA and the Lt. Col. Luke Weathers Jr. Veterans Affairs Medical Center (VAMC) also referred to as the “Memphis VAMC”).

1.2. Place of Performance: Contractor shall furnish services at the Lt. Col. Luke Weathers, Jr. Veterans Affairs Medical Center (VAMC), 116 N. Pauline Street, Memphis, TN 38105.

1.3. Authority: Title 38 USC 8153, Health Care Resources (HCR) sharing Authority using FAR Parts 12 and 15.

1.4. Policy/Directives/Handbooks. The contractor shall be subject to the following policies, including any subsequent updates during the period of performance. The policies listed below can be accessed electronically at the following: VA Publications VHA Publications

1.4.1. VA Directive 1663: Health Care Resources (HCR) Contracting – Buying Title 38 U.S.C. 8153

1.4.2. VHA Directive 1003.04: VHA Patient Advocacy

1.4.3. VHA Directive 1065: Productivity and Staffing Guidance for Specialty Provider Group Practice

1.4.4. VHA Directive 1088(1): Communicating Test Results to Providers and Patients

1.4.5. VHA Directive 1100.18: Reporting and Responding to State Licensing Boards

1.4.6. VHA Directive 1100.20 Credentialing of Health Care Providers

1.4.7. VHA Directive 1100.21 Privileging

1.4.8. VHA Directive 1192.01: Seasonal Influenza Vaccination Program for VHA Health Care Personnel

1.4.9. VHA Directive 1220(1): Facility Procedure Complexity Designation Requirements to Perform Invasive Procedures in Any Clinical Setting

1.4.10. VHA Directive 1605.01: Privacy and Release of Information

1.4.11. VHA Directive 1907.01: VHA Health Information Management and Health Records

1.4.12. VHA Handbook 1100.17: National Practitioner Data Bank (NPDB) Reports

1.4.13. Privacy Act of 1974 (5 U.S.C. 552a) as amended:

http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm

1.5. Acronyms/Definitions: Terms used in this contract shall be interpreted as follows unless the context expressly requires a different construction and/or interpretation. In case of a conflict in language between the Definitions and other sections of this contract, the language in this section shall govern.

1.5.1. AAOS: American Academy of Orthopedic Surgery http://www.aaos.org/

1.5.2. ABOS: American Board of Orthopedic Surgery https://www.abos.org/

1.5.3. ACGME: Accreditation Council for Graduate Medical Education https://www.va.gov/vapubs/ https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm http://www.aaos.org/ https://www.abos.org/

1.5.4. ACLS: Advanced Cardiac Life Support

1.5.5. AJIC: American Journal for Infection Control

1.5.6. AQL: Acceptable Quality Level

1.5.7. BAA: Business Associate Agreement

1.5.8. BBA: Balanced Budget Act

1.5.9. BLS: Basic Life Support

1.5.10. CDC: Centers for Disease Control and Prevention

1.5.11. CDR: Contract Deficiency Report

1.5.12. CEU: Certified Education Unit

1.5.13. Clinical Privileging: Clinical Privileging is the process by which a practitioner, licensed for independent practice; e.g., without supervision, direction, required sponsor, preceptor, mandatory collaboration, etc.; is permitted by law and the facility to practice independently, to provide specific medical or other patient care services within the scope of the individual’s license, based upon the individual’s clinical competence as determined by peer references, professional experience, health status, education, training and licensure. Clinical privileges must be facility-specific and provider-specific, and within available resources.

1.5.14. CME: Continuing Medical Education

1.5.15. CMP: Civil Monetary Penalty

1.5.16. CMS: Centers for Medicare and Medicaid Services

1.5.17. CO: Contracting Officer: The person executing this contract on behalf of the Government with the authority to enter into and administer contracts and make related determinations and findings.

1.5.18. COI: Conflict of Interest

1.5.19. COR: Contracting Officer’s Representative: A person appointed by the CO to take necessary action to ensure the Contractor performs in accordance with and adheres to the specifications contained in the contract and to protect the interest of the Government. The COR shall report to the CO promptly any indication of non-compliance in order that appropriate action can be taken.

1.5.20. COS: Chief of Staff

1.5.21. CPARS: Contractor Performance Assessment Reporting System

1.5.22. Credentialing: Credentialing is the process of obtaining, verifying, and assessing the qualifications of a health care provider to provide care or services in or for the VA health care system. Credentials are documented evidence of licensure, education, training, experience or other qualifications.

1.5.23. DEA: Drug Enforcement Agency

1.5.24. EPA: Environmental Protection Agency

1.5.25. EHR: Electronic Health Record - electronic health record system used by the VA.

1.5.26. FAPIIS: Federal Awardee Performance and Integrity Information System

1.5.27. FAR: Federal Acquisition Regulation

1.5.28. FOIA: Freedom of Information Act

1.5.29. FPPE: Focused Provider Practice Evaluation

1.5.30. FSMB: Federation of State Medical Boards

1.5.31. FTE: Full Time Equivalent: VA’s standard definition is for full time working the equivalent of 80 hours every two weeks, 2080 hours per year. However, providers may propose using their standard FTE definition.

1.5.32. HHS: Department of Health and Human Services

1.5.33. HICPAC: Hospital Infection Practices Advisory Committee

1.5.34. HIPAA: Health Insurance Portability and Accountability Act

1.5.35. IGRA: Interferon-gamma Release Assays

1.5.36. ISO: Information Security Officer

1.5.37. Key Personnel: The individuals specified in this contract who are essential to work performance.

1.5.38. MRI: Magnetic Resonance Imaging

1.5.39. MST: Military Sexual Trauma

1.5.40. NPI: National Provider Identifier: NPI is a standard, unique 10-digit numeric identifier required by HIPAA. The VHA must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers).

1.5.41. NPPES: National Plan and Provider Enumeration System

1.5.42. NSO: National Surgery Office

1.5.43. OGC: Office of General Counsel

1.5.44. OIG: Office of Inspector General

1.5.45. OPPE: Ongoing Provider Practice Evaluation

1.5.46. OR: Operating Room

1.5.47. POP: Period of Performance

1.5.48. PPD: Purified Protein Derivative

1.5.49. PPIRS: Past Performance Information Retrieval System

1.5.50. PWS: Performance Work Statement

1.5.51. QA/QI: Quality Assurance/Quality Improvement

1.5.52. QM/PI: Quality Management/Performance Improvement

1.5.53. QASP: Quality Assurance Surveillance Plan

1.5.54. RFP: Request for Proposal

1.5.55. SCS: Specialty Care Services

1.5.56. SSAC: Sole Source Affiliate Contract

1.5.57. TJC: the Joint Commission

1.5.58. TST: Tuberculosis Skin Test

1.5.59. USC: United States Code

1.5.60. VA: Department of Veterans Affairs

1.5.61. VA-FSC: VA Financial Services Center

1.5.62. VAAR: VA Acquisition Regulation

1.5.63. VETPro: is VHA’s mandatory credentialing software platform to document the credentialing of VHA health care Providers. This system facilitates completion of a uniform, accurate and complete credentials file.

1.5.64. VHA: Veterans Health Administration

1.5.65. VistA: Veterans Integrated Systems Technology Architecture

2. QUALIFICATIONS:

2.1 Staff/Facility

2.1.1. License: The Contractor’s physician(s) assigned by the Contractor to perform the services covered by this contract shall have a current license to practice medicine in any State, Territory, or Commonwealth of the United States or the District of Columbia when services are performed onsite on VA property.

All licenses held by the key personnel working on this contract shall be full and unrestricted licenses. Contractor’s physician(s) who have current, full and unrestricted licenses in one or more states, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application will not be considered for the purposes of this contract.

2.1.2. Board Certification: All contractor’s physician(s) shall be Board Certified/Board Eligible by the American Board of Orthopedic Surgery by the ABOS http://www.abos.org/, and be currently certified in Basic Life Support (BLS) Advanced Cardiac Life Support (ACLS) or equivalency. All continuing education courses required for maintaining certification must be kept up to date at all times.

Documentation verifying current certification shall be provided by the Contractor to the VA COR on an annual basis for each year of contract performance.

2.1.3. Credentialing and Privileging: Credentialing and privileging is to be done in accordance with the provisions of VHA Directive 1100.20 and VHA Directive

1100.21 referenced above. The Contractor is responsible to ensure that proposed physician(s) possesses the requisite credentials enabling the granting of privileges.

No services shall be provided by any Contractor’s physician(s) prior to obtaining approval by the Facility Medical Executive Board and Medical Center Director.

2.1.3.1. If a Contractor’s physician(s) and/or other contract provider(s) are not credentialed and privileged or has credentials/privileges suspended or revoked, the Contractor shall furnish an acceptable substitute without any additional cost to the government.

2.1.4. Technical Proficiency: Contractor’s physician(s) shall be technically proficient in the skills necessary to fulfill the government’s requirements, including the ability to speak, understand, read and write English fluently. Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, https://vaww.vashare.vha.va.gov/sites/PLOMSO/MSO%20Staff/MSO%20MGMT%20ANALYST%20PROGRAM%20FOLDER/VABIT/Updated%20Documents/Feb%20-%202021/%20http:/www.abos.org/ https://vaww.vashare.vha.va.gov/sites/PLOMSO/MSO%20Staff/MSO%20MGMT%20ANALYST%20PROGRAM%20FOLDER/VABIT/Updated%20Documents/Feb%20-%202021/%20http:/www.abos.org/ treatment and/or services performed. Contractor shall provide verifiable evidence of all educational and training experiences including any gaps in educational history for all contractor’s physician(s) and contractor’s physician(s) shall be responsible for abiding by the Facility's Medical Staff By-Laws, rules, and regulations (referenced herein) that govern medical staff behavior.

2.1.5. Continuing Medical Education (CME)/Certified Education Unit (CEU) Requirements: Contractor shall provide the COR copies of current CMEs as required or requested by the facility. Contractor’s physician(s) registered or certified by national/medical associations shall continue to meet the minimum standards for CME to remain current. Contractor shall report CME hours to the credentials office for tracking. These documents are required for both privileging and re-privileging. Failure to provide shall result in loss of privileges for contractor’s physician(s).

2.1.6. Training (ACLS, BLS, EHR and VA MANDATORY): Contractor shall meet all VA educational requirements and mandatory course requirements defined herein; all training must be completed by the contractor’s physician(s) as required by the VA.

Other training may become required. VA will communicate any changes to the training requirement to the contractor.

Training Frequency Annual Hours

ACLS/BLS Annually

Active Threat Training Annually

Blood Administration:

Complications

Annually

Annual Government Ethics Annually

Military Sexual Trauma (MST) for Medical Providers

Annually

Moderate Sedation In- Service Training

Annually

PACT Act 2022 Toxic Exposure Screening (TES)

Annually

Prevention/Management of Disruptive Behavior/Violence Prevention Level I

Annually

Prevention of Workplace Harassment/No Fear Act

Annually

Suicide Prevention: Suicide Risk Management Training for Clinicians

Annually

VA Privacy and Information Security Awareness and Rules of Behavior

Annually

VHA Privacy and HIPAA Focused Training

Annually

Mandatory Training for Transient Clinical Staff

Compliance & Business Integrity Annually

2.1.7. STANDARD INFECTION CONTROL MEASURES (PPD, IMMUNIZATIONS, ETC.):

Contractor shall provide proof of the following for physicians within five (5) calendar days after contract award and prior to the first duty shift to the COR and (CO). Tests shall be current within the past year.

2.1.7.1. TUBERCULOSIS TESTING: Contractor shall provide proof of a negative Tuberculosis Skin Test (TST) or interferon-gamma release assays (IGRA) for all Contractor’s physician(s) upon hire in accordance with CDC guidance.

(This is applicable to all health care workers). A negative chest radiographic report for active tuberculosis shall be provided in cases of positive TST or IGRA results.

2.1.7.2. MEASLES, MUMPS, & RUBELLA TESTING: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}.

2.1.7.3. VARICELLA: Contractors shall provide proof of immunity for all Contractor physicians {This is applicable to all health care workers}.

2.1.7.4. ACELLULAR PERTUSSIS: Contractors shall provide proof of 1 dose of Tdap vaccination for all Contractor physicians {This is applicable to all health care workers}.

2.1.7.5. INFLUENZA: Contractors shall provide proof that all Contractor physicians have received the annual Influenza vaccine unless it is contraindicated. If the Contractor physician has a medical contraindication to the vaccine, they shall be required to wear a mask during the Influenza season. {This is applicable to all health care workers}.

2.1.7.6. COVID-19: Contractors shall be vaccinated against COVID-19 or have obtained an approved accommodation/exception. This is applicable to all health care workers.

2.1.7.7. OSHA REGULATION CONCERNING OCCUPATIONAL EXPOSURE TO

BLOODBORNE PATHOGENS: Contractor shall provide evidence of completing and passing generic self-study blood-borne pathogen training for all Contractor’s physician(s) {This is applicable to all health care workers};

provide their own Hepatitis B vaccination series and hepatitis B surface antigen test results following the hepatitis B vaccination series; maintain an exposure determination and control plan; maintain required records; and ensure that proper follow-up evaluation is provided following an exposure incident.

2.1.8. National Provider Identifier (NPI): NPI is a standard, unique 10-digit numeric identifier required by HIPAA. The VHA must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers). The Contractor shall have or obtain appropriate NPI and if pertinent the Taxonomy Code confirmation notice issued by the Centers for

Medicare and Medicaid Services (CMS) National Plan and Provider Enumeration System (NPPES) be provided to the CO with the proposal.

2.1.9. DEA : Contractor shall provide copy of current DEA certificate.

2.1.10. Conflict of Interest (COI): The Contractor and all contractor’s physician(s) are responsible for identifying and communicating to the CO and COR conflicts of interest at the time of proposal and during the entirety of contract performance. At the time of proposal, the Contractor shall provide a statement which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided. The Contractor shall also provide statements containing the same information for any identified consultants or subcontractors who shall provide services. The Contractor must also provide relevant facts that show how it’s organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest. These statements shall be in response to the VAAR provision 852.209-70 Organizational Conflicts of Interest and fully outlined in response to the subject attachment in Section D of the solicitation document.

2.1.11. Citizenship related Requirements:

2.1.11.1. The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to VA patient referrals.

2.1.11.2. While performing services for the VA, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the Contractor is required to comply with all “E-Verify” requirements consistent with “Executive Order 12989” and any related pertinent Amendments, as well as applicable FAR.

2.1.11.3. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the VA may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor’s place of business that services VA patient referrals; or other place where the Contractor provides services to veterans who have been referred by the VA; and shall form the basis for termination of this contract for breach.

2.1.11.4. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.

2.1.11.5. The Contractor agrees to obtain a similar certification from its subcontractors.

The certification shall be made as part of the offerors response to the RFP using the subject attachment in Section D of the solicitation document.

2.1.12. Annual OIG Statement: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the HHS OIG has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs.

2.1.12.1. Therefore, Contractor shall review the HHS OIG List of Excluded Individuals/Entities on the HHS OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that the proposed contractor’s physicians (s) are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a Federal health care program, or causes such a claim to be submitted, may be subject to a Civil Monetary Penalty (CMP) for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service.

CMP’s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries.

2.1.12.2. By submitting their proposal, the Contractor certifies that the HHS OIG List of Excluded Individuals/Entities has been reviewed and that the Contractors are and/or firm is not listed as of the date the offer/bid was signed.

2.2. Clinical/Professional Performance: The qualifications of Contractor personnel are subject to review by VA Medical Center COS or his/her clinical designee and approval by the Medical Center Director as provided in VHA Directive 1100.20 and VHA Directive

1100.21. Clinical/Professional performance monitoring and review of all clinical personnel covered by this contract for quality purposes will be provided by the facility COS and/or the Chief of the Service or his designee. A clinical COR may be appointed, however, only the CO is authorized to consider any contract modification request and/or make changes to the contract during the administration of the resultant contract.

2.3. Non-Personal Healthcare Services: The parties agree that the Contractor and all contractor’s physician(s) shall not be considered VA employees for any purpose.

2.4. Indemnification: The Contractor shall be liable for, and shall indemnify and hold harmless the Government against, all actions or claims for loss of or damage to property or the injury or death of persons, arising out of or resulting from the fault, negligence, or act or omission of the Contractor, its agents, or employees.

2.5. Prohibition against Self-Referral: Contractor’s physicians are prohibited from referring VA patients to contractor’s or their own practice(s).

2.6. Inherent Government Functions: Contractor and Contractor’s physician(s) shall not perform inherently governmental functions. This includes, but is not limited to, determination of agency policy, determination of Federal program priorities for budget requests, direction and control of government employees (outside a clinical context), selection or non-selection of individuals for Federal Government employment including the interviewing of individuals for employment, approval of position descriptions and performance standards for Federal employees, approving any contractual documents, approval of Federal licensing actions and inspections, and/or determination of budget policy, guidance, and strategy.

2.7. No Employee status: The Contractor shall be responsible for protecting Contractor’s physician(s) furnishing services. To carry out this responsibility, the Contractor shall http://oig.hhs.gov/exclusions/index.asp provide or certify that the following is provided for all their staff providing services under the resultant contract:

2.7.1. Workers’ compensation

2.7.2. Professional liability insurance

2.7.3. Health examinations

2.7.4. Income tax withholding, and

2.7.5. Social security payments.

2.8. Tort Liability: The Federal Tort Claims Act does not cover Contractor or contractor’s physician(s). When a Contractor or contractor’s physician(s) has been identified as a provider in a tort claim, the Contractor shall be responsible for notifying their legal counsel and/or insurance carrier. Any settlement or judgment arising from a Contractor’s (or contractor’s physician(s)) action or non-action shall be the responsibility of the Contractor and/or insurance carrier.

2.9. Key Personnel:

2.9.1. The VA Full Time Equivalent (FTE) for the services required is 1.5 FTE. (3,040 hours per year). One FTE is defined by VA as a minimum of 80 hours every two weeks and does not include holidays.

2.9.2. The minimum number of Board Certified/Board Eligible Orthopedic physicians required to be onsite daily is 1 FTE to be onsite at the same time as defined in paragraph Hours of Operation in this section.

2.9.3. The Contractor shall be responsible for providing coverage to the VA during periods of vacancies of the Contractor’s personnel due to sick leave, personal leave, vacations and additional coverage as required. In the event a scheduled physician is unable to complete an assigned shift, the Contractor shall provide replacement physician coverage within 2 hours and notify the Contracting Office Representative (COR) immediately of the schedule change.

2.9.4. Personnel Substitutions: During the first ninety (90) calendar days of performance, the Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death or termination of employment. The Contractor shall notify the CO, in writing, within _1__ calendar day(s) after the occurrence of any of these events and provide the information required below.

After 90 days, the Contractor shall submit the information required below to the CO at least _7__ calendar days prior to making any permanent substitutions.

2.9.4.1. The Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the CO. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The CO will notify the Contractor within __7_ calendar days after receipt of all required information of the decision on the proposed substitutes.

The contract will be modified to reflect any approved changes of key personnel.

2.9.4.2. For temporary substitutions where the key person shall not be reporting to work for three consecutive workdays or more, the Contractor shall provide a qualified replacement for the key person. The substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above.

2.9.4.3. The Government reserves the right to refuse acceptance of any Contractor personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care or interferes with the regular and ordinary operation of the facility. Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives. Standards for conduct shall mirror those prescribed by current federal personnel regulations. Should the VA COS or designee show documented clinical problems or continual unprofessional behavior/actions with any Contractor’s physician(s), s/he may request, without cause, immediate replacement of said Contractor’s physician(s). The CO and COR shall deal with issues raised concerning Contractor’s physician(s) conduct.

The final arbiter on questions of acceptability is the CO.

2.9.4.4. Contingency Plan: Because continuity of care is an essential part of Facility’s medical services, The Contractor shall have a contingency plan in place to be utilized if the Contractor’s physician(s) leaves Contractor’s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

3. VA HOURS OF OPERATION/SCHEDULING:

3.1. VA Business Hours: The Orthopedic Clinic is open Monday through Friday from 8:00 am - 4:30 pm. Orthopedic Clinic Days/Hours required are Monday, Tuesday, and Wednesday from 8:00 am - 4:30 pm. Surgery Days/Hours required are Monday, Tuesday, Thursday and Friday from 8:00 am - 4:30 pm. Clinic and surgery hours may vary during the term of the contract.

3.1.1. Patients must be seen by a contractor’s physician(s) onsite at the facility in a timely manner in accordance with VA Rules and Regulations on clinic wait times and consult completion. Contractor shall notify the COR at least monthly about any obstacles to meeting this performance measure.

3.1.2. Contractor’s physician(s) shall be available and present in clinic during normal facility clinic hours, which will be established, and may be revised, as deemed appropriate for patient care by the COS. Currently, normal clinic hours are Monday through Friday from 8:00 am – 4:30 pm, however as stated in paragraph 3.1, the Contractor’s physician(s) is only required to cover clinic Monday, Tuesday, and Wednesday from 8:00 am – 4:30 pm.

3.1.2.1. Contractor’s physician(s) will provide coverage for VA staff physicians when they are on leave. A thirty-day notice will be given to the contractor physician(s) of the date VA staff will be on leave. VA staff work full-time and parttime scheduled.

Annual leave days will also be covered.

3.1.3. Off-hours Coverage: Contractor must make the contractor’s physician(s) available on-call during all hours when the facility clinic is closed, including evenings, weekends and holidays. The historic number of after-hours surgeries performed on an annual basis is 5. Physician Assistants will take the first call if emergency surgery is necessary and cannot wait until the next day.

3.1.3.1. On-call contractor’s physician(s) must be available at all times for phone consultations with VA physicians and physician assistants.

3.1.3.2. On-call providers must be available within 15 minutes by phone and onsite within 60 minutes.

3.2. Federal Holidays: The following holidays are observed by the VA:

• New Year’s Day

• President’s Day

• Martin Luther King’s Birthday

• Memorial Day

• Juneteenth

• Independence Day

• Labor Day

• Columbus Day

• Veterans Day

• Thanksgiving

• Christmas

• Any day specifically declared to be a national holiday

If the holiday falls on a Saturday or Sunday, it is recognized either the previous Friday or following Monday by the Department of Veterans Affairs and the VA will be close

3.3. Cancellations:

3.3.1. Unless a state of emergency has been declared, the Contractor shall be responsible for providing services.

4. CONTRACTOR RESPONSIBILITIES:

4.1. Clinical Personnel Required: The Contractor shall provide contractor’s physician(s) who are competent, qualified per this performance work statement and adequately trained to perform assigned duties.

4.1.1. Contractor’s physician(s) shall be responsible for signing in and out when in attendance. Time sheets will be used by the COR to confirm hours/day and services provided against the contractor’s invoices.

4.1.2. The Department of Veterans Affairs reserves the right to refuse employment under this contract or require dismissal from contract work of any contract physician(s) for unsatisfactory performance at the VAMC, Memphis, TN or any other objectionable reason considered by the Contracting Officer. The contract physician(s) shall receive a ninety (90) day written notification of unsatisfactory performance with ninety (90) days to cure the problem. If a disagreement about performance still exists at the end of the ninety (90) day period, the Contracting Officer will make a final determination with the input of the VAMC, Director within a reasonable period.

4.2. Standards of Care: The contractor’s physician(s)’ care shall cover the range of Orthopedic services as would be provided in a state-of-the-art civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceeding currently recognized the Joint Commission (TJC), VA and national standards as established by:

4.2.1. AAOS Guidelines: http://www.aaos.org/

4.2.2. The professional standards of The Joint Commission (TJC):

http://www.jointcommission.org/standards_information/standards.aspx

4.2.3. The standards of the American Hospital Association (AHA):

http://www.hpoe.org/resources?show=100&type=8

4.2.4. The requirements contained in this PWS

4.3. EDUCATION AND SUPERVISION OF HEALTH PROFESSIONS TRAINEES (HPTS):

RESIDENT WILL NOT BE APPLICABLE TO THIS REQUIREMENT.

4.4. Medical Records:

4.4.1. Authorities: Contractor’s physician(s) providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the 5 U.S.C.552a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R.

Parts 160, 162, and 164 (HIPAA).

4.4.2. HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health Information to a health care provider for treatment of VA patients. Based on this exception, a BAA is not required for this contract. Health records generated by this contract or provided to the Contractors by the VA are covered by the VA Privacy Act system of records entitled ‘Patient Medical Records-VA’ (24VA10A7).

Contractor generated VA Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that all records pertaining to medical care and services provided to VA patients are captured in the VA electronic health record system as required by VA policy as discussed in 4.4.4.

4.4.3. Disclosure: Contractor’s physician(s) may have access to patient medical records for the purpose of providing medical care and services to VA patients and performing services under the contract; however, Contractor shall obtain permission from the VA before disclosing any patient information outside VA. VA authorizes the Contractor to discuss patient health information for coordination of care within community health care providers in compliance with VA regulations, HIPAA and VHA Directive 1605.01, Privacy and Release of Information. The VA will provide the contractor with a copy of VHA Directive 1907.1, Health Information Management and Health Records and VHA Directive 1605.1, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

4.4.4. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and guidelines established by VHA Directive 1907.01 Health Information http://www.aaos.org/ http://www.jointcommission.org/standards_information/standards.aspx http://www.hpoe.org/resources?show=100&type=8 http://www.rms.oit.va.gov/SOR_Records/24VA19.asp https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=3233

Management and Health Records:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 and all guidelines provided by the facility.

4.4.5. Release of Information: The VA shall maintain control of releasing any copies of patient health information or health records and will follow policies and standards as defined, but not limited to Privacy Act requirements. The Contractor will not release or disclose copies of records and will refer all such requests to the Release of Information Department at the VA facility where assigned.

4.4.6. Management for Medical Records: National Archives and Records Administration record disposition requirements are found in RCS 10-1 Chapter 6, 6000 series.

4.5. Direct Patient Care: Estimated 95 % of the time involved in direct patient care.

4.5.1. Per the qualification section of this PWS, the Contractor shall provide the following:

4.5.1.1 Board Certified / Board Eligible Orthopedic Surgeon:

Inpatient Care

• Admit

• Diagnosis

• Develop a Treatment Plan

• Manage, including the performance of surgery timely

• Timely ordering of surgical supplies prior to date of surgery

• Discharge, including all needed medical record documentation

Outpatient Care

• Seeing all new patient referrals with accompanying medical record

• documentation in the Spine Surgery Clinic

• Seeing patients with new surgical complications

• Approving proposed surgeries

• Post-operative visits

• Patients must be seen within 30 days

Upon request of the VA, the Contractor shall be responsible for providing any of the following services:

4.5.1.1. Contractor shall provide contract physician(s) to support the Orthopedic surgery clinic. The Orthopedic surgery clinic is open Monday – Friday from 8a- 430p. The contract physician(s) will be required to operate the clinic, examine patients, and interpret reports as required by the VA. The contractor physician(s) will be required to work with VA staff. Should clinic hours need to be changed, VA will provide the contractor a four (4) month advance notice of the change. Physician(s) shall be provided as needed.

4.5.1.2. Contractor shall staff the Operating Room (OR) on Monday, Tuesday, Thursday, Friday, and on-call. OR days subject to change in concurrence with https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235

Chief of Surgery and Chief of Anesthesia. Contractor shall coordinate with inpatient attending physician to effect timely completion of medically necessary surgery.

4.5.1.3. The Contractor shall furnish the services of Orthopedic Surgeon. In addition, the Contractor physician(s) must be present at the VA facility and must perform the required services as specified in the contract. At least one surgeon should be available during off duty hours in case of emergencies.

Historically the average number of emergency cases performed annually are five. Emergency cases would be such as but not limited to compartment syndrome, irrigation & debridement procedures, arthroplasty, closed vs open reduction, intermedullary nailing, right intertrochanteric femur fracture, and CRPP femoral neck fractures. The Contractor shall be responsible for always providing replacement staff to ensure complete coverage.

4.5.1.4. All problems are to be reported to the VA Chief, Surgical Service. Contractor and VA Chief of Surgery shall prepare monthly call schedules for coverage of on-call coverage and orthopedic surgery emergencies, in which the Contractor physician(s) are listed as staff. A draft schedule shall be submitted to the office of the VA Chief, Surgical Service/Administrative Officer within five (5) working days prior to the end of each month.

4.5.1.5. Contractor shall designate a physician to attend and provide delegated responsibilities of Medical Center committee meetings as assigned by VA Chief, Surgical Service. The VA Chief, Surgical Service will delegate the responsibility of committee memberships to the contractor.

4.5.1.6. Contractor shall ensure that contract physicians contribute to the ongoing quality improvement programs in the organization as described in Medical Center Policy Memorandum No. 00-12, Enterprise Framework for Quality, Safety, and Value. This policy may be reviewed upon request from Surgical Service at the Memphis VAMC. In addition, the services to be performed by the Contractor will be done so in accordance with compliance with VA mandates, policies and procedures, The Joint Commission, Federal and State laws, and regulations of the Medical Staff by-laws of the VA Medical Center.

Note: The Joint Commission manuals may be reviewed upon request from Surgical Service at the Memphis VAMC.

4.5.2. Scope of Care: Contractor’s physician(s) shall be responsible for providing Orthopedic care, including, but not limited to:

4.5.2.1. Clinic and Surgical Care: Contractor’s physician(s) shall provide clinical orthopedic services. Contractor’s physician(s) shall be present on time for any scheduled clinics/surgeries as documented by physical presence in the clinic or operating room at the scheduled start time.

4.5.2.2. and the Contractor’s staff for off-site procedures one (1) week in advance as a

4.5.2.2.1. Operative Services: Contractor’s physician(s) shall provide comprehensive clinical Orthopedic services. Typical procedures include but are not limited to the following CPT codes. Billing shall be in accordance with the schedule of services.

4.5.2.2.2. Intraoperative Follow-up: The Contractor’s physician(s) shall be present in the operating suite for all orthopedic procedures.

4.5.2.2.3. Postoperative Follow-Up: Contractor’s physician(s) rounds shall be conducted on postoperative patients in the Surgical Intensive Care Unit (SICU) and on the wards. All cases will be discussed in morbidity and mortality conferences, and the contractor’s physician(s) will provide appropriate information to the COR for inclusion in departmental reports.

4.5.2.2.4. Consultative Services: Contractor’s physician(s) shall provide consultative services at the patient’s bedside if the patient is not ambulatory and in the clinic setting if the patient is able to report to the outpatient clinic. Procedures shall be scheduled for completion within 30 days of the date of the consult.

4.5.2.2.5. Communication of Test Results: Mechanisms must be in-place to provide notification of test results for patients receiving care in accordance with VHA Directive 1088, Communicating Test Results to Providers and Patients.

4.5.2.2.6. Medications: Contractor’s physician(s) shall follow all established medication policies and procedures. No sample medications shall be provided to patients.

4.5.2.2.7. Discharge Education: Provide discharge education and follow up instructions that are coordinated with the next care setting for all orthopedic clinical or surgical patients.

4.5.3. ADMINISTRATIVE: Estimated 5% of time not involved in direct patient care

4.5.3.1. Quality Improvement Meetings: The contractor’s physician(s) shall participate in continuous quality improvement activities and meetings with committee participation as required by the facility Chief of Service, COS, or designee.

4.5.3.2. Staff Meetings: The contractor’s physician(s) shall attend staff meetings as required by the facility Chief of Service, COS, or designee. Contractor to communicate with COR on this requirement and report any conflicts that may interfere with compliance with this requirement.

4.5.3.3. QA/QI documentation: The contractor’s physician(s) shall complete the appropriate QM/PI documentation pertaining to all procedures, complications and outcome of examinations.

4.5.3.4. Patient Safety Compliance and Reporting: Contractor’s physician(s) shall follow all established patient safety and infection control standards of care.

Contractor’s physician(s) shall make every effort to prevent medication errors, falls, and patient injury caused by acts of commission or omission in the delivery of care. All events related to patient injury, medication errors, and other breeches of patient safety shall be documented in the medical record of those impacted and disclosed to the patient or surrogate. As soon as practicable (but within 24 hours) Contractors shall notify COR of incident and submit an entry in the VA Patient Safety Reporting System, following up with COR as required or requested.

4.6. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY

IMPROVEMENT(QI):

4.6.1. Quality Management/Quality Assurance Surveillance: Contract personnel shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance:

Focused Provider Practice Evaluation (FPPE) and Ongoing Provider Practice Evaluation (OPPE). Contractor performance will be monitored by the government using the standards as outlined in this PWS and methods of surveillance detailed in the QASP. The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted.

4.6.2. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. If the Contractor is involved and named in a validated patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel. This does not preclude refusal in the event of incidents involving physical or verbal abuse.

4.6.3. The Government reserves the right to refuse acceptance of any Contractor personnel at any time after performance begins, if personal or professional conduct jeopardizes patient care or interferes with the regular and ordinary operation of the facility. Breaches of conduct include intoxication or debilitation resulting from drug use, theft, patient abuse, dereliction or negligence in performing directed tasks, or other conduct resulting in formal complaints by patient or other staff members to designated Government representatives.

Standards for conduct shall mirror those prescribed by current federal personnel regulations. The CO and COR shall deal with issues raised concerning Contractor’s conduct. The final arbiter on questions of acceptability is the CO.

4.6.4. Performance Standards:

4.6.4.1. Measure: Provider Quality Performance

Performance Requirement: All Contractor’s physician(s) shall perform in accordance with clinical standards.

Standard: OPPE documentation for all (100%) staff providing services under the contract. All staff (100%) meet standards.

AQL: 90% meet standards

Surveillance Method: OPPE data pertinent to care performed for each provider working under this contract. OPPE data will review the following elements:

A. Patient Care Performance B. Medical/Clinical knowledge C. Practiced Based Learning and Improvement D. Interpersonal and Communication Skills E. Professionalism F. System Based Practice

Frequency: 2 times per year

4.6.4.2. Measure: Qualifications of Key Personnel

Performance Requirement: All Contractor’s physician(s) shall be Board Certified/Board Eligible Orthopedic Surgery in accordance with ABOS Standards

Standard: All (100%) Contractor’s physician(s) are Board Certified/Board Eligible

AQL: 100%

Surveillance Method: Periodic Inspection or Random Sampling of qualification documents

Frequency: 2-4-times per year

4.6.4.3. Measure: Scope of Practice/Privileging

Performance Requirement: Contractor’s physician(s) perform within their individual scopes of practice/privileging.

Standard: All (100%) Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time

AQL: 90% Contractor’s physician(s) perform within their scope of practice/privileges 100% of the time

Surveillance Method: Random Sampling of records

Frequency: 2-4- times per year

4.6.4.4. Measure: Patient Access

Performance Requirement: The Contractor shall provide Contractor’s physician(s) in accordance with the operating hours and VA clinical schedule outlined in this PWS.

Standard: All (100%) Contractor’s physician(s) are on time and available to perform services

AQL: Contractor’s physician(s) is on-time and available to perform services 90% of the time

Surveillance Method: Periodic Inspection of Time and Attendance Sheets and Attending OR Report

Frequency: Monthly

4.6.4.5. Measure: Patient Safety

Performance Requirement: Patient safety incidents shall be reported using VA Patient Safety Reporting System. All incidents reported immediately (within 24 hours.)

Standard: All (100%) of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident

AQL: 90% of patient safety incidents are reported using VA Patient Safety Reporting System within 24 hours of incident

Surveillance Method: Periodic Inspection or Random Sampling

Frequency: As needed

4.6.4.6. Measure: Maintains licensing, registration, and certification

Performance Requirement: Updated licensing, registration and certification shall be provided as they are renewed. Licensing and registration information kept current.

Standard: All (100%) licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current.

AQL: 90% licensing, registration(s) and certification(s) for Contractor’s physician(s) shall be provided as they are renewed. Licensing and registration information kept current.

Surveillance Method: Periodic Inspection or Random Sampling

Frequency: Annually

4.6.4.7. Measure: Mandatory Training

Performance Requirement: Contractor shall complete all required training on time per VAMC policy.

Standard: All (100%) of required training is complete on time by Contractor’s physician(s)

AQL: 90 % completions

Surveillance Method: Periodic Inspection or Random Sampling

Frequency: Annually

4.6.4.8. Measure: Privacy, Confidentiality and HIPAA

Performance Requirement: Contractor is aware of all laws, regulations, policies and procedures relating to Privacy, Confidentiality and HIPAA and complies with all standards Zero breaches of privacy or confidentiality.

Standard: All (100%) Contractor’s physician(s) comply with all laws, regulations, policies and procedures relating to Privacy, Confidentiality and

HIPAA

AQL: 90% compliance

Surveillance Method: Periodic Inspection; Contractor shall provide evidence of annual training required by VAMC, reports violations per VA Handbook 6500.6

Frequency: Annually

4.6.5. Registration with Contractor Performance Assessment Reporting System

4.6.5.1. As prescribed in Federal Acquisition Regulation (FAR) Part 42.15, the VA evaluates Contractor past performance on all contracts that exceed the Simplified Acquisition Threshold and shares those evaluations with other Federal Government contract specialists and procurement officials. The FAR requires that the Contractor be provided an opportunity to comment on past performance evaluations prior to each report closing. To fulfill this requirement VA uses an online database, CPARS, which is maintained by the Naval Sea Logistics Center in Portsmouth, New Hampshire. CPARS has connectivity with the Past Performance Information Retrieval System (PPIRS) database, which is available to all Federal agencies. PPIRS is the system used to collect and retrieve performance assessment reports used in source selection determinations and completed CPARS report cards transferred to PPIRS. CPARS also includes access to the Federal Awardee Performance and Integrity Information System (FAPIIS). FAPIIS is a web-enabled application accessed via CPARS for Contractor responsibility determination information.

4.6.5.2. Each Contractor whose contract award is estimated to exceed the Simplified Acquisition Threshold requires a CPARS evaluation. A government Focal Point will register your contract within thirty days after contract award and, at that time, you will receive an email message with a User ID (to be used when reviewing evaluations).