SOW Mock Ed and Survey Quote Houston MEDVAMC.docx

Statement of Work/Performance Work Statement Education Sessions and Mock Joint Commission Survey Department of Veterans Affairs Michael E. DeBakey Medical Center (MEDVAMC), Houston, TX

1. Introduction.

The Office of Quality and Patient Safety (OQPS), Michael E. DeBakey Medical Center (MEDVAMC), Houston, TX. requests an accreditation preparation consultant team to assess the health care system’s readiness for The Joint Commission Survey for 1 base year and 4 option years. The consultant will need to provide an interdisciplinary team of at least 5 members to conduct an in-person mock survey of 4 days of the health care system under the Hospital, Home Care and Behavioral Health manuals covering all chapters including but not limited to Environment of Care, Infection Control, Medication Management, National Patient Safety Goals, Rights and Responsibilities, Provision of Care, Life Safety, Medical Staff, Leadership and Performance Improvement. Virtual mock surveys may be approved by the VA depending on operational requirements.

2. Scope of Work.

The accreditation education sessions shall be scheduled with the facility at least two weeks prior to the initiation of the educational sessions. The content of the education sessions shall be provided to the facility electronically at least two weeks prior to the initiation of the educational sessions. There shall be at least three different education sessions focused on: clinical care, environment of care, and life safety. Each session shall be at least one hour in length and shall be offered at least two staggered times of the day. Attendance records of all staff who attended education sessions shall be provided in writing no less than two weeks after the education session was completed. Quotes should consider (2) presenters conducting (1) day of training on site.

The accreditation assessments should cover all aspects of accreditation preparedness within the scope of the services provided by MEDVAMC. The contractor shall utilize individual and system tracers for the evaluation of determined areas of focus which include but are not limited to: dialysis, suicide prevention, sterile compounding, and sterile processing. The contractor shall provide a leadership, data management and emergency preparedness system tracer session. The contract shall provide feedback during the assessments and a summary at the end of the survey to include findings scored on a scoring system similar to that of The Joint Commission’s Safer Matrix. Additional information to assess the status of the organization’s accreditation readiness may be collected during the mock survey include but are not limited to staff and Veteran interviews, review of policies and standard operating procedures, committee meeting minutes, risk assessments and plans.

The contractor shall assess important organizational and systems issues related to providing safe patient treatment, working environments and any other identified safety concerns. The contractor shall provide all labor, tools, materials, equipment and transportation necessary to conduct the assessments and education program. Contractor personnel shall have extensive operational experience in all health care settings and have hands-on experience in The Joint Commission Hospital Accreditation Program standards and experience with the accreditation survey process.

The survey team will consist of (5) surveyors comprised of physician, nurse, life safety, and specialty consultants as required by MEDVAMC. Each mock survey will be 4 days in length. A daily summary brief will be provided to MEDVAMC leadership at the beginning of each survey day.

3. Site Conditions.

Medical Center address is Michael E. DeBakey Medical Center (MEDVAMC), 2002 Holcombe Blvd, Houston, TX 77030 Parking will be provided in or near 2002 Holcombe Blvd., Houston, TX, 77030 Audio/ Visual aids/ teleconferencing will be provided.

4. Time for completion.

The education sessions must be initiated and completed prior to the beginning of the mock survey. Attendance records of all staff who attended education sessions shall be provided in writing no less than two weeks after the education session is completed. The mock surveys must be initiated and completed within the following period of performances:

· Base Year – Mar 30, 2023 – Mar 29, 2024

· Option Year 1 – Mar 30, 2024 – Mar 29, 2025

· Option Year 2 – Mar 30, 2025 – Mar 29, 2026

· Option Year 3 – Mar 30, 2026 – Mar 29, 2027

· Option Year 4 – Mar 30, 2027 – Mar 29, 2028 The report of findings shall be in writing and include at least a list of findings in a Microsoft Excel file and the findings scored on a scoring system similar to that of The Joint Commission’s Safer Matrix. Additional surveys may be necessary every 5 months following the initial survey during a given period of performance and will be coordinated with the COR at least 30 days in advanced.

5. Basis of Award.

The Government intends to make award without discussions. The quotes will be evaluated based on the evaluation factors listed below. However, it may be determined necessary to conduct discussions if award cannot be made on initial proposals submitted.

Contract will be made based on both price and technical considerations most advantageous to the Government IAW FAR Part 13.

FACTOR 1: TECHNICAL CAPABILITY

The contractor shall provide a written statement addressing each of the following items. The written statement must describe each point and must provide enough detail to determine minimum qualifications.

Provide a written plan detailing your firm’s experience and capability of performing work similar to what is being required in the Statement of Work. Written plan should address 1-6. Your firm shall address the minimum requirement as follows:

1. Each consultant shall have a minimum of three years of surveying experience. Each of the consultants shall have experience, education, and knowledge of Joint Commission Hospital, Behavioral Health, Home Care, Life Safety and Ambulatory Care standards and Hospital Safety with Infection Control practices.

2. The consultants shall possess the appropriate qualifications and credentials for conducting the surveys. They shall have surveyor and consultant experience and be knowledgeable of the unique challenges faced by VA Medical Centers.

3. The surveyors shall have knowledge of VA’s Electronic documentation system and history of data security compliance with VA medical records. Must guarantee consistent team membership unless for an approved emergency.

4. Members must possess previous experience as or with Joint Commission certified surveyors.

5. The surveyors shall have expertise in Infection Control and Hospital Safety Practices.

6. Each consulting team must consist of comparable team credentials as a TJC team to include a combination at the discretion of the facility that can include physician consultant(s), a nurse consultant(s), life safety consultant(s) and other subject matter experts as needed.

FACTOR 2: PRICE

Contractor shall complete B.3 Price/Cost Schedule. The schedule may be altered, or an alternate schedule used where appropriate in order to express quote detail.

Base Year price, each Option Year Price, and Total price will be evaluated by the Government. In evaluating the offeror’s proposed price for this project. The techniques and procedures described under FAR 12.209, Determination of Price reasonableness, will be the primary means of assessing proposal reasonableness.

Provide prices on all line items listed on the Price/Cost Schedule.