Attachment_J.2-A_TO_0001_Statement_of_Work_BFCC_NCORC.docx

Attachment J.2-A NCORC SOW

Centers for Medicare & Medicaid Services

Center for Clinical Standards & Quality Quality Improvement & Innovation Group

Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) 12th Scope of Work (SoW)

BFCC National Coordinating & Oversight Review Center (BFCC NCORC)

Contract No. _____________________

Task Order No. __________________

Table of Contents

ATTACHMENTS

Attachment J.2-B, Schedule of Deliverables Attachment J.2-C, Evaluation Measures Table

Introduction The Centers for Medicare & Medicaid Services (CMS) requires expert healthcare quality improvement (QI) services to establish a National Coordinating & Oversight Review Center (NCORC) to support the Beneficiary and Family Centered Care (BFCC) provisions of the Medicare Quality Improvement Organization (QIO) Program. This Task Order (TO) is issued under the terms and conditions of the BFCC-QIO Indefinite Delivery/Indefinite Quantity (IDIQ) contract. Independently, and not as an agent of the Government (except if noted herein), the BFCC-NCORC shall furnish all the necessary services, qualified personnel, material, equipment, and workspace facilities, not otherwise provided by the Government, as needed to perform the requirements of this TO.

Personnel Requirements The BFCC-QIO shall provide personnel for this TO in accordance with Section C.3 BFCC-QIO IDIQ SOW. Qualifications for Key Personnel will be provided in this TO.

2.1. Designation of Key and/or Other Recommended Personnel

Certain positions may be designated as “Key Personnel”, within the meaning of Health and Human Services Acquisition Regulation 352.270-5. For this TO, the following positions are determined as Key or Other Recommended Personnel:

Key Personnel A. Project Director (1 FTE)

1. Demonstrated experience in healthcare quality improvement and the ability to provide quality services and deliverables in a timely manner.

2. Demonstrated experience with process improvement and PDSA approach in developing, implementing and revising QI initiatives.

3. Demonstrated skill and experience working closely with project management leadership team, project managers, liaise with cross functional teams to complete a variety of tasks integral to the timely and successful launch and completion of both internal and external projects.

4. Proven skill and experience in project management, managing people, project planning and coordination of daily activities, data analysis, constructive reporting, project management techniques and tools.

5. Proven skill and experience in critical-thinking, innovation, and problem-solving, recommending successful solutions, including the spread and implementation of such solutions for large scale change.

6. Proven skill and experience in excellent oral and written communication spanning executives to the general public.

B. Medical Director (1 FTE)

1. Demonstrated experience overseeing the medical care and other designated care and services in a health care organization or facility.

2. Demonstrated experience and responsibility for coordinating medical care and helping to develop, implement and evaluate resident care policies and procedures that reflect current standards of practice and new or proposed treatments, practices, and approaches to care.

3. Demonstrated knowledge of existing and emerging healthcare industry trends, practices and requirements that impact all domains of quality.

4. Proven ability to provide input to surveyors on physician issues, individual clinical issues, and clinical practices.

5. Proven ability to ensure that appropriate systems exist to facilitate sound medical care, establish and apply capable monitoring systems and effective documentation and follow up of findings, and help improve physician compliance with regulations, including required visits.

6. Ability to influence, facilitate, coach and mentor others to affect positive change.

7. Demonstrated experience and skills in excellent oral and written communication spanning executives to the general public.

C. Case/Claims Review Lead (1 FTE)

1. Demonstrated experience in healthcare quality improvement and the ability to motivate and lead a team to provide quality services and deliverables in a timely manner

2. Demonstrated experience within the Medicare case/claims domain

3. Proven skill and experience in project management, managing people, project planning and coordination of daily activities, data analysis, constructive reporting, project management techniques and tools

4. Proven skill and experience in critical-thinking, innovation, and problem-solving, recommending successful solutions, including the spread and implementation of such solutions for large scale change

5. Proven skill and experience in excellent oral and written communication spanning executives to the general public D. Quality Improvement (QI) Coordinator (1 FTE)

1. Proven skill and in-depth experience in healthcare quality improvement with demonstrated results.

2. Proven skill in design, direction and oversight of implementation of clinical quality improvement programs.

3. Demonstrated experience supporting the accomplishment of quality improvement strategic plans that achieve high impact and significant improvements in performance.

4. Demonstrated experience in program evaluation and extensive knowledge of industry-leading quality improvement methods and tools.

5. Proven skill, in-depth knowledge and experience in the concepts underlying methodologies and evaluation in quality improvement.

6. Proven skill and experience in performance measurement, refinement, and analysis.

7. Proven skill and experience in excellent oral and written communication spanning executives to the general public.

E. Senior Data Analyst (1 FTE)

1. Demonstrated experience in conducting literature searches for background information on the latest trends in health policy affecting pharma, insurers and the health care delivery system.

2. Proven skill in analyzing state and federal reports on the health care industry and translating and synthesizing this information for industry reports, policy papers, presentations, as well as legislative and regulatory testimony using data, statistics and analysis to support the industry’s position.

3. Demonstrated experience as the lead for analytic and information technology solutions to support population health including leadership around technology, applications, reporting, and analysis to identify and implement solutions to increase care efficiencies, to reduce the total cost of care, and improve the health of patient populations.

4. Proven skill in utilizing statistical and other data modeling; financial and actuarial analysis and discipline; integrate clinical data including social determinants of disease to inform opportunities.

5. Demonstrated experience interfacing with leaders and experts and stakeholder groups (e.g., clinical operations, consultants, employer groups, government agencies, payers).

6. Demonstrated experience identifying opportunities and actionable solutions from data; effective partnering with quality, finance, operations, and other population health stakeholders to identify/implement improvement programs; and monitor associated process and outcomes.

7. Proven skill and experience managing teams that collaborate with quality, clinical operations, and medical leadership to provide analytic and technology services to support improved total cost of care and quality improvement.

8. Proven analytic skills that include risk adjustment, new and ongoing product evaluation, Return on Investment (ROI) calculations, business development and financial modeling, process and technology/tool development, forecasting, and cost management and revenue maximization strategies.

9. Demonstrated experience in establishing and maintaining a formal discipline for population health IT initiatives, including electronic health record (EHR) solutions such as population health registries, reporting, analytics, clinical decision support, and other levers to improve care processes, as well as care coordinator technology solutions around populations.

Other Recommended Personnel A. Communications Specialist (1 FTE)

1. Demonstrated leadership experience in both creative communications strategy development and implementation.

2. Proven ability to build and maintain awareness of a program by using a variety of communications tools (including social media) and tactical methods to spread information about a program and its work within local communities.

3. Demonstrated excellent organizational and interpersonal skills.

4. Proven skill in superior written and verbal communications.

5. Demonstrated expertise in analyzing complex health policy issues and communicating those concepts to various audiences.

B. Information Technologist (IT) Lead (1 FTE)

1. Demonstrated experience in facilitating technology goals of a healthcare organization

2. Proven skill in defining technology direction, goals and priorities and development of initiatives to accomplish those goals

3. Demonstrated experience in analyzing workflows and communications with managers and staff to identify and evaluate technology needs

4. Demonstrated experience in management and monitoring progress of technology projects, coordinating the activities of the parties involved and preparing status reports as needed; overseeing all stages of the lifecycle for technology projects

5. Demonstrated experience in up-to-date knowledge of current trends and issues in healthcare as they relate to information technology, including but not limited to HIPAA requirements, Joint Commission standards and general trends in healthcare informatics

6. Demonstrated experience in development and initiation of policies and guidelines covering utilization of IT resources, acceptable usage standards, security and HIPAA compliance and industry best practices; development of protocols and standards for the selection and acquisition of technology assets

7. Proven skill in defining and creating mechanisms for measuring the performance of technology while ensuring desired goals behind the technology have been reached

8. Demonstrated experience and skill in development and implementation of programs of user support for information systems including technical assistance, problem solving, training, documentation and education

Definitions See Attachment J.6, Glossary of Terms and Acronyms of the IDIQ Contract for definitions of terms and the list of acronyms associated with this contract and all TOs.

Comprehensive Task Order Work Plan The BFCC NCORC shall provide a comprehensive task order work plan which includes the Contract Start-Up Plan, Comprehensive Contract Management Plan, and the NCORC Comprehensive Work Plan as attachments.

Task Order Requirements The BFCC NCORC shall perform the following tasks as described below.

Contract Start-Up The BFCC NCORC must perform contract start-up activities including but, not limited to the following:

a. Contract Start-Up Plan: Develop a comprehensive Contract Start-Up Plan that includes all activities necessary to establish contract operations and ensure smooth transition from the BFCC NCC to start full performance of NCORC services.

b. Comprehensive Contract Management Plan: Develop and maintain a results-oriented Comprehensive Contract Management Plan for overall contract operations as required in BFCC-QIO IDIQ Services (See IDIQ SOW) which at a minimum, includes effective lines of communication, budget and cost controls, Internal Quality Improvement Program (IQIP), project schedule management, development of comprehensive task order work plans, disaster response coordination and recovery plan, resource management to include staffing matrices by task/subtask, progress reviews and performance monitoring, risk management, change management, timely delivery and reporting, and clearly defined roles, responsibilities, lines of authority, resources appropriately aligned to services and deliverables, and compliance with IDIQ SOW Sections on Collaboration, Accountability, and Transparency; Contractor Performance Measurement; Transition Requirements; Technical Considerations; and General Requirements.

c. Contract Start-Up Meetings: Within 5 calendar days of task order award, the BFCC NCORC shall participate in a CMS Contract Kick-Off/Planning Meeting to confer with the Contracting Officer’s Representative (COR)/Subject Matter Expert (SME) by conference call to discuss the award. This will include a discussion of the BFCC NCORC’s proposal and CMS’s expectations for project objectives and goals, the project design, expected timeframes, project staff, and the project tasks. The discussion shall also include the transition process from previous SOWs to current SOW, if applicable for the BFCC NCORC. For this meeting, the BFCC NCORC shall prepare discussion materials for its Comprehensive Task Order Work Plan which includes Contract Start-Up Plan, Comprehensive Contract Management Plan (includes the IQIP) and NCORC Work Plan. The BFCC NCORC will submit the final Comprehensive Task Order Work Plan to the COR/SME within 10 calendar days after the Contract Kick-Off/Planning Meeting.

d. Internal Quality Control Plan: Develop and maintain an IQIP, also known as an Internal Quality Control (IQC) program or a Continuous Internal Quality Improvement Program (CIQIP), which complies with provisions in Chapter 13 of the QIO Manual. The purpose of the IQIP requirement is to support and foster an environment of continuous quality improvement within the QIO through ongoing assessment and improvement in areas that are critical for successful contract performance. The IQIP should be included in the Comprehensive Contract Management Plan.

e. Task Order Work Plans: Establish operational requirements for development of Comprehensive Task Order Work Plan(s) which at a minimum, will include the following:

· Resource planning activities, key milestones (including due dates), risk mitigation strategies to ensure success, plan to avoid duplication of effort, and task descriptions including a detailed description of activities necessary to complete each task;

· The identification of the appropriate personnel resources available to ensure completion of the work outlined in the task order. Consultants may be utilized only upon receiving permission from the COR/SME and CO;

· The integrated communication plan, which will include names of potential partners/stakeholders, dates, and timeframes for the task order work;

· Task Order Work Plan Timetable that details the schedule for completion of each task;

· Strategies for Person/Patient and Family Engagement; and

· Any additional strategies or plans required under an individual task order.

f. BFCC NCORC Website: Establish and maintain a QIO section 508/504 compliant website in accordance with CMS communications requirements

1) Follow the CMS Contractor Website Guidelines located at https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/contractorwebguidlines.html. The BFCC NCORC shall refer to this website at least every 90 calendar days for the current standards and guidelines.

2) The website is NOT intended to be accredited or maintained within a CMS FISMA ATO’s system boundary. However, in addition to the Contractor Website guidelines, the BFCC NCORC website shall follow general industry security standards and practices while maintaining the website.

· Refrain from allowing user login or maintain unique identifiers for end users (static content ONLY)

· Ensure the website and supporting servers are patched against vulnerabilities and threats.

· Ensure the website is configured to follow standard industry practices for security outlined in the Open Web Application Security Project (OWASP) guide.

· Ensure proper industry standard cryptography is utilized when applicable (SSL/TLS, PKI or HTTPS)

3) The Website must have the following functional elements:

· How to contact CMS when a beneficiary or caregiver has a complaint about the BFCC-QIO

· Hyperlink to the BFCC-QIOs for Electronic Submission of Complaints and Appeals;

· Provider Related Information;

· Information about Person and Family Engagement Programs;

· A link to the BFCC-QIO Experience Survey administered by the BFCC-SC;

· A link to the BFCC-QIO Experience Survey Results/Report card;

· Information about BFCC- Survey Center Focus Groups; and

· Assist CMS’ public health efforts by disseminating information and messages as directed by the COR/SME.

g. Compliance with Technical Considerations: as specified in Section C of the IDIQ SOW which covers requirements such as:

1) Appoint a Security Point of Contact (SPOC) within 90 calendar days of Task Order award.

2) Conduct Security Awareness Training (SAT) for all employees utilizing or accessing CMS data within the Health Care Quality Information System (HCQIS) environment on an annual basis. The training shall be tracked and a log maintained of employees trained. A QNET SAT Certification Letter shall be provided to CMS 90 calendar days after Task Order award and annually thereafter in accordance with the Task Order Schedule of Deliverables.

3) Visit the CMS security website http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html and the QualityNet security website http://qionet.sdps.org at least every 30 calendar days for updates. [Note: The QualityNet security website is an Intranet website; thus, access is restricted to only active users within the QualityNet Enterprise.]

4) Provide upon request, all related artifacts, in the format and method prescribed by CMS, resulting from compliance with CMS, FISMA, OIG, and other relevant audits, reviews, evaluations, tests, and assessments of BFCC NCORC systems, processes, and facilities as it relates to program security and compliance.

5) Provide a BFCC NCORC System Security Plan (SSP) and Information Security (IS) Risk Assessment (RA) within 90 calendar days of after task order award, annually thereafter, and updates 30 calendar days after any major changes.

6) Develop, in conjunction with CMS, Corrective Action Plans (CAP) for all identified weaknesses, findings, gaps, or other deficiencies in the IS Program (e.g., those items identified during a FISMA audit or similar activity) in accordance with IOM Pub. 100-17 (BPSSM) or as otherwise directed by CMS. Submit CAPs within 30 calendar days after the audit or finding in accordance with the Task Order Schedule of Deliverables.

7) Submit the Plan of Action & Milestones (POA&M) within 15 calendar days of approval of a CAP and monthly thereafter until the CAP is closed.

8) Maintain a list of all purchased and leased equipment in a HHS 565 submission Final Report.

9) Comply with all CMS system and software maintenance procedures. All digital media must be encrypted before physically leaving the BFCC NCORC. The BFCC NCORC shall perform maintenance of systems and software in compliance with applicable configuration requirements. BFCC NCORC IT staffs are responsible for completion of IT tasks as assigned to the CMS designated IT service manager for BFCC NCORC local systems.

· Comply with CMS Incident Handling Standards and Procedures (RMH Vol III Standard 7-1 Incident Handling, RMH Vol II Procedure 7-2 Incident Handling Procedure) located at http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html and report suspected security breaches within the designated time periods. The BFCC NCORC shall assist the CMS ISSO on active investigations and provide requested documentation as needed for all security incidents.

h. Compliance with General Requirements: as specified in Section C of the IDIQ SOW which covers requirements such as:

1) Adhere to the privacy, confidentiality, and disclosure requirements set forth in Section 1160 of the Act, and in Title 42 of the Code of Federal Regulations (CFR) Part 480, and be prepared to document adherence to these privacy, confidential and disclosure requirements. http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr480_02.html.

2) Be prepared, if required to provide a copy of training materials developed or used to meet the confidentiality training requirement specified in 42 CFR 480.115. CMS may request documentation that users of the QIO review system have been trained in the proper handling of confidential information prior to being given access to that information and review system.

3) Obtain all Data Use Agreements (DUAs) necessary to comply with contract requirements and to execute required services.

4) Execute a data abstraction subcontract with the Clinical Data Abstraction Centers (CDACs).

5) Copy the COR/SME on all communication between the BFCC NCORC and the CDAC related to these subcontracting arrangements.

6) At a minimum, participate annually in collaborative activities that are sponsored by the applicable CMS Regional Office and focus on CMS-identified priority initiatives.

7) Develop and provide to CMS two different plans to address emergency preparedness: (1) a Continuity of Operations Plan (COOP) and (2) Contingency Plan (CP), which includes a Disaster Recovery (DR) Plan.

8) Conduct periodic national emergency exercises and natural disaster drills.

9) Prepare a “Table Top” test to evaluate the effectiveness of the COOP/CP/DR Plans, annually. At a minimum, this test shall include a structured walk-thru of each Plan with all BFCC NCORC and CMS staff needed for CMS to evaluate each Plan.

10) Fully cooperate with and provide, subject to the QIO confidentiality provisions in Section 1160 of the Social Security Act and 42 CFR Part 480, requested data for any evaluation of the QIO program that the Secretary, or CMS on behalf of the Secretary, chooses to conduct. Such evaluations may be conducted by a CMS contractor.

11) Fully comply with all conflict of interest requirements as outlined in Section H.1 of the IDIQ Contract.

i. Compliance with Contractor Performance Measurement: as specified in Section C.3 of the IDIQ SOW.

j. Compliance with Contract Phase-Out: as specified in Section C.3 of the IDIQ SOW which covers requirements such as:

1) The incumbent BFCC NCORC will provide transition/ phase-out support to the successor BFCC NCORC Contractor selected by CMS (refer to FAR 52.237-3 Continuity of Services).

2) Transition will begin no more than 120 days before the end of the 12th SoW QIO contract and the aim will be for it to end at the incumbent BFCC NCORC contract’s end date. During this period, the incumbent BFCC NCORC shall work with the successor BFCC NCORC, CMS Staff, and other identified CMS contractors to assure continued operation of the BFCC-QIO program.

3) Before the transition begins, the incumbent BFCC NCORC will provide CMS with a transition plan. The transition plan will provide adequate coverage to assure uninterrupted service of BFCC NCORC services for the BFCC-QIO program. The BFCC NCORC’s Transition Plan shall provide detailed methods that will be used to ensure a smooth transition from the incumbent BFCC NCORC’s operation to operation by the successor BFCC NCORC. At a minimum, the Transition Plan shall include the following:

· Organizational Chart that

1. Displays internal and external organizational relationships

2. Identifies the individuals (at all organizational levels) who will be responsible for the transition and their respective roles; detail the lines of communication and how the incumbent BFCC NCORC will interface with CMS during this phase of contract performance.

· A milestone chart detailing the timelines and stages of transition

4) Prior to the 60th day before the last day of the incumbent BFCC-QIO’s contract, the incumbent BFCC-QIO will follow all actions identified within the current QualityNet Startup and Shutdown Procedures. The incumbent BFCC-QIO will transition information systems activities as directed by CMS.

BFCC NCORC Services Section A. Overview/Background A BFCC NCORC’s work is derived from provisions in the QIO statute in Part B of Title XI of the Act and the QIO regulations in 42 CFR Parts 475, 476 and 480. The BFCC-NCORC must be familiar with these provisions.

The scope of the BFCC-QIO work includes numerous review functions that include, but are not limited to the following:

· Quality of care reviews, including beneficiary complaint reviews, general quality of care reviews and Immediate Advocacy;

· Quality Improvement Initiatives (QIIs)

· Beneficiary appeals of denials of hospital admissions, discharge and terminations of services decisions, commonly referred to as Grijalva, BIPA, and Weichardt appeals, etc.;

· Medical necessity reviews;

· Appropriateness of setting reviews;

· Discrimination Reviews

· Focused Reviews

· Reviews of Emergency Medical Treatment and Labor Act (EMTALA);

· Sanctions; and

· Monitoring of Physician Acknowledgement Statements under section 1156(a) of the Act and 42 CFR § 412.46.

The NCORC will support the case review structure for the 12th SoW with service areas aligned to the 10 CMS Regions as follows:

The BFCC services includes four core functions:

1) Beneficiary Oversight;

2) Beneficiary Protection;

3) Beneficiary and Stakeholder Engagement; and

4) BFCC Data Analytics and Management.

These core functions incorporate analytics, data driven improvements, innovation, and collaboration to measurably improve the quality of health care for Medicare beneficiaries and ensure proper implementation of Medicare coverage requirements for payment purposes. In addition to the BFCC-QIO’s review activities, the BFCC-NCORC will be responsible for using the results of all activities to make recommendations to the BFCC Survey Center (SC), QIN NCC, QIN-QIOs, QIO Independent Evaluation Center, End Stage Renal Disease (ESRD) Networks, Hospital Improvement & Innovation Networks (HIINs), Transforming Clinical Practice Initiative (TCPI), and other Network of Quality Improvement and Innovation Contractors (NQIIC) on quality improvement initiatives, develop recommendations to CMS for focused reviews, and engage beneficiaries and stakeholders in quality improvements and outreach.

The purpose of this task order is to establish a National Coordinating & Oversight Review Center (NCORC) to support the Beneficiary and Family Centered Care (BFCC) provisions of the Medicare Quality Improvement Organization (QIO) Program. The Beneficiary and Family Centered Care National Coordinating & Oversight Review Center (BFCC NCORC) supports the work of Quality Improvement Organizations (QIOs) as they work to improve the quality of care available to Medicare beneficiaries in the U.S. health care system. QIOs, and by extension, the BFCC NCORC, do this in a manner that aligns with the work that Centers of Medicare & Medicaid Services (CMS) does in its efforts towards achieving the goals of the National Quality Strategy (NQS) and the CMS Quality Strategy along with the other strategies, goals, recommendations, and priorities listed in the IDIQ Statement of Work.

Specifically, the BFCC NCORC shall work with BFCC-QIOs to improve healthcare services for Medicare beneficiaries by coordinating numerous statutory review functions, including but not limited to, quality of care reviews, beneficiary complaint reviews, discharge and termination of service appeals in various provider settings, medical necessity reviews, and Emergency Medical Treatment and Labor Act (EMTALA) reviews.

In carrying out its responsibilities to provide support and expertise to all BFCC-QIOs’ functions, the BFCC NCORC shall collaborate with CMS contractors and other entities, including but not limited to the BFCC-QIOs, the QIN-QIOs, QIN NCC, the Program Collaboration Center for Integrated Communications (PCC-IC), State Survey Agencies (SSAs), Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Qualified Independent Contractors (QICs), Unified Program Integrity Contractor (UPIC), Zone Program Integrity Contractor (ZPIC), OIG, Office for Civil Rights (OCR), the Office of Medicare Hearings and Appeals, the Departmental Appeals Board, pertinent state-based organizations and appropriate federal grant partners.

In addition to the BFCC NCORC’s activities, the BFCC NCORC will be responsible for using the results of all activities to make recommendations to QIOs on quality improvement initiatives and to develop recommendations to CMS for focused reviews.

Section B. Desired Outcomes

The BFCC-QIO work is an effort to measurably improve the quality of health care for Medicare beneficiaries as well as all individuals protected under EMTALA and to provide peer review for purposes of determining the appropriateness of payment under Medicare.

The results of all case review activities shall also be used to identify and recommend quality improvement efforts and make recommendations to CMS for approval of focused reviews to be conducted by BFCC-QIOs.

The four BFCC Program Core Functions and the Strategic Goals listed below are aligned with nine AIMs to reflect the desired outcomes. Performance under this task order may span across all of the listed BFCC core functions and AIMs.

1) Beneficiary Oversight

· Strategic Goal - Protect the Medicare Trust Fund

· BFCC AIM 1 - Achieve 95% accuracy of BFCC-QIO reviews of Medicare claims (Short Stay, HWDRG, Readmission) during contract period of performance.

· BFCC AIM 2 - Achieve 95% compliance with CMS requirements for Memorandums of Agreement and physician acknowledgement statements over the contract period of performance.

2) Beneficiary Protection

· Strategic Goal – Support an improved quality healthcare system

· BFCC AIM 3 - Generate a baseline measure for provider satisfaction with the BFCC-QIOs and establish an AIM for improvement, after the first year of contract period of performance.

· BFCC AIM 4 - Achieve 85% Medicare beneficiary satisfaction with BFCC-QIOs case review process over the contract period of performance.

3) Beneficiary and Stakeholder Engagement

· Strategic Goal – Improve beneficiary experience

· BFCC AIM 5 - Achieve 85% Medicare beneficiary satisfaction with BFCC-QIOs Patient and Family Engagement (PFE) process over the contract period of performance.

· BFCC AIM 6 - Improve the appropriate utilization of health care facilities/services among beneficiaries participating in health care navigation by (15%) over the contract period of performance.

4) BFCC Data Analytics and Management

· Strategic Goal – Support an improved quality healthcare system

· BFCC AIM 7 - Utilize state-based BFCC program data to identify trends and patterns to propose at least three improvements per year, for each contracted region over the contract period of performance.

· BFCC AIM 8 - Utilize QII data to identify trends and patterns to propose at least three improvements per year, for each contracted region, over the contract period of performance.

· BFCC AIM 9 - Utilize BFCC program data and analytics to propose at least three focused reviews per year, for each contracted region, over the contract period of performance.

The BFCC NCORC work under this BFCC NCORC SOW is an effort to measurably improve the quality of health care for Medicare beneficiaries, as well as, all individuals protected under EMTALA.

Specifically, the BFCC NCORC shall:

1) Support and assist CMS as the BFCC NCORC for all BFCC-QIO-related activities;

2) Identify problematic issues, perform root cause analysis, and make recommendations regarding solutions for all BFCC-QIO activities;

3) Provide recommendations to CMS regarding implementation of national initiatives and Task Orders that are effective in producing results related to all BFCC-QIO activities;

4) Provide assistance and support upon request to CMS related to the use of the CMS- designated Case Review Systems and applications to support all BFCC-QIO activities;

5) Assist CMS in providing the BFCC community with CMS-approved instructions and guidance related to all BFCC-QIO activities;

6) Assist CMS in answering all BFCC-related questions and upon CMS approval provide answers to the BFCC community, stakeholders, providers and other CMS contractors as directed by CMS;

7) Collaborate with national experts, CMS leadership, CMS partners, stakeholders and beneficiaries through any CMS implemented initiative such as, a National Patient and Family Engagement Campaign, or any other campaign or initiative per CMS direction and guidance.

Section C. Task Requirements Task 1 NCORC Comprehensive Work Plan The BFCC NCORC shall provide a comprehensive work plan for NCORC services, that at a minimum will include the following:

1) Resource planning activities, key milestones (including due dates), risk mitigation strategies to ensure success, plan to avoid duplication of effort, and task descriptions including a detailed description of activities necessary to complete each task;

2) The identification of the appropriate personnel resources available to ensure completion of the work outlined in the task order. Consultants may be utilized only upon receiving permission from the COR/SME and CO;

3) The integrated communication plan, which will include names of potential partners/stakeholders, dates, and timeframes for the task order work;

4) Task Order Work Plan Timetable that details the schedule for completion of each task;

5) Strategies for Person/Patient and Family Engagement; and

6) Any additional strategies or plans required under an individual task order.

Specific Tasks

The BFCC NCORC shall support and provide expertise to CMS and the BFCC-QIOs for all BFCC-related activities by serving as the communicator between CMS and QIOs to ensure QIOs have all information/resources needed to complete the core work of the BFCC-QIO program.

The BFCC NCORC shall provide technical assistance and support to the BFCC-QIOs, CMS and other CMS stakeholders as applicable; and shall work in collaboration with the CO, the Contract Specialist (CS), the COR, the other CMS BFCC-QIO experts to implement and operate the BFCC NCORC. To do this, the BFCC shall perform the following tasks.

Task 1.1 Operational Excellence The BFCC NCORC shall assist CMS in its efforts to collaborate, coordinate and follow-up with the following stakeholders: 1-800-Medicare; the CMS Office of the Medicare Ombudsman; the BFCC-QIOs; the QIN-QIOs; the other QIO NCCs; the BFCC SC the PCC-IC; and other CMS stakeholders, including but not limited to the Partnership for Patients, the MACs, the Office of Medicare Hearings and Appeals (OMHA), and the CMS Regional Offices.

These efforts shall foster integration of Medicare operations to avoid duplicative efforts related to all BFCC-QIO activities, including—but not limited to—working to ensure a smooth transition of services from the previous BFCC-QIO SOW.

Task 1.2 Customer Service

a) The BFCC NCORC shall apply best practices for excellent customer service best practices to assist CMS, the BFCC-QIOs, BFCC SC, and other CMS contractors on all matters and guidance related to the BFCC-QIO activities.

b) The BFCC NCORC shall work with CMS answer questions related to the BFCC-QIO and BFCC SC activities, and with CMS’s approval, release those answers in a timely manner, as instructed by CMS.

Task 1.3 CMS-Designated Case Review System With input and participation of the BFCC-QIO community, the BFCC NCORC shall perform the following CMS-designated Case Review System requirements:

a) Provide recommendations to CMS, including inputs from the BFCC-QIO community, related to the use of the CMS-Designated Case Review System.

b) Participate in--and solicit other BFCC-QIOs to participate in--specific exercises and meetings related to the CMS-Designated Case Review System, in person or via any other means approved by CMS. CMS may also include other stakeholders as participants in such meetings.

c) Ensure that all information and materials collected throughout these meetings are disseminated to the QIO community and users of the system for complete transparency.

d) Document information per CMS approval related to these meetings and exercises, including but not limited to meetings minutes and recorded audio meetings. This documentation and information must be released to the QIO community (all BFCC-QIOs) for complete transparency.

e) Assist CMS in gathering case review user input and recommendations on case review functions and requirements utilized regularly by the BFCC NCORC and the BFCC-QIO community.

f) Make recommendations to CMS regarding improvements to the processes to enhance effectiveness and efficiencies. These recommendations shall be solicited from the BFCC-QIO community, system users and any other stakeholders and shall be based on QIOs lessons learned and experiences.

g) Upon approval of CMS, disseminate all final recommendations, meeting minutes and recorded teleconference calls to the QIO community through CMS-approved media, including but not limited to Listservs, collaboration tools, e-mails, and memos.

h) Ensure that all collected inputs and recommendations from the BFCC-QIO community are kept un-edited and shared with CMS upon receipt.

i) Provide the necessary staff and experts to attend in-person at CMS Baltimore or other locations approved by CMS, the Business Process Modeling (BPM) meetings or any other meeting necessary to provide detailed QIO user input and recommendations at the request of CMS. These meetings shall include TEP (Technical Expert Panels) or any other meetings requiring user input as approved by CMS. The BFCC NCORC shall solicit participation from the BFCC-QIO community for attending these meetings.

j) Assist CMS in gathering and maintaining a panel of BFCC-QIO case review system users who can assist with case review system recommendations, user experiences and testing.

k) Assist CMS in disseminating information related to these TEPs or any other meeting to the entire BFCC-QIO community within a short timeframe; no longer than 36 business hours.

l) Serve as a coordinator and BFCC-QIO contact for user input and testing of the case review system.

m) Collaborate with other BFCC-QIOs who perform user testing for CMS, and coordinate any communication to CMS regarding the effectiveness of the testing for all users of the system.

n) Process all meeting minutes, recording teleconferences, WebEx meetings, and provide such records and documents to CMS for approval and posting on a CMS approved website for future reference for CMS, the BFCC-QIO community and any other CMS stakeholders.

o) Archive, store, protect, or dispose of data in accordance with the QIO Manual.

p) Provide support for BFCC-QIO quality improvement efforts including user input and recommendations from the BFCC NCORC, and from the BFCC-QIO community and other stakeholders to CMS on issues related to the CMS-designated Case Review System.

q) To assist CMS in the testing, piloting and implementation of the CMS-identified case review system, upon the request of CMS the BFCC NCORC shall:

i) Pilot test, along with other BFCC-QIOs and stakeholders’ users of the CMS-identified system, using those BFCC-QIOs and stakeholders CMS designates for such activities.

ii) Coordinate and assist CMS by facilitating the participation of the BFCC-QIO community and other CMS stakeholders in such activities, including but not limited to piloting and testing the CMS-identified case review system.

iii) Work with CMS, the BFCC-QIO community, other stakeholders and the case review development contractors to troubleshoot problems, including testing and resolutions. This includes but is not limited to Tiger Team meetings, TEP work and any on-site testing or troubleshooting meetings CMS approves and convenes. Provide assistance to CMS to ensure participation of the BFCC-QIO community and other stakeholders in these meetings.

iv) Participate in training, on-site at CMS Baltimore or another CMS-designated location, led by the CMS-designated case review system developer to prepare the BFCC NCORC to provide functional case review training to the broader BFCC-QIO user community.

v) Provide case review system training to the broader BFCC-QIO user community at CMS Baltimore, a CMS Regional Office or another CMS-designated location.

vi) Propose and test any work-arounds needed to resolve or mitigate system issues.

r) Following implementation of the CMS-designated case review system, the BFCC NCORC shall continue to collaborate and coordinate BFCC-QIO user input on the productivity of the system based on user experience.

s) The BFCC NCORC shall report these user input findings, un-edited to CMS and, if requested, at meetings held at CMS Baltimore, or any other CMS-approved site.

t) The BFCC NCORC shall work with CORs and CMS to provide training and services for the CMS-designated Case Review System using a Learning Management System (LMS) that will provide an effective, efficient mechanism for the BFCC-QIOs and community to access training.

u) The BFCC NCORC, as related to BFCC-QIO referrals, shall coordinate with the QIOs to analyze findings from the CMS-designated case review system. The BFCC NCORC shall collaborate with the QIOs, as necessary, to identify patterns and trends.

v) In performance of this task the BFCC NCORC shall:

i) Convene and maintain a CMS-designated Case Review System user group to elicit and prioritize their point of access requirements. The user group includes CMS Central Office, Regional Offices, and the QIO community.

ii) Allow the BFCC contractors to register for upcoming events, training, work groups, and user group meetings. This includes a mechanism for polling BFCC contractors, tracking utilization, and providing feedback to the BFCC community members’ queries. Provide drafts and final versions of all material for distribution outside of CMS, or any CMS Contractors. As directed by CMS, post material to this website for review by the BFCC community. This shall include but is not limited to the following aspects of the BFCC-QIO activities:

(1) CMS-designated Case Review System business requirements;

(2) CMS-designated Case Review System Data Dictionary;

(3) CMS-designated Case Review System training information;

(4) CMS-designated Case Review System outreach information;

(5) CMS-designated Case Review System communications; and

(6) CMS communications.

w) The BFCC NCORC shall provide recommendations based on its own experience and expertise, inputs from the BFCC-QIO community, and other stakeholders to CMS regarding any IT-related tasks associated with the CMS-designated case review system to include at a minimum:

i) Provide support to any contractor/vendor for setup, installation, breakdown, etc. of any HW/SW/telecom.

ii) Troubleshooting of any HW/SW/telecom issues related to the CMS-designated case review system.

iii) Participate in elicitation and working sessions and invite other QIOs and other stakeholders with the case review system developer and infrastructure team at CMS Baltimore as needed.

Task 1.4 Focused Reviews & Performance Audits

a) BFCC-Program Improvement Focused Reviews - Focused Reviews will be one of the primary sources for the BFCC-NCORC to identify the need for improvements to the BFCC-QIO program. Through BFCC program data analysis the focused review process will allow BFCC NCORC to target areas of possible concern that are known but may not be the subject of a particular beneficiary complaint with a confirmed concern. BFCC-NCORC shall propose at least three (3) focused reviews per year using the following process:

i. A Focused Review request must be submitted to the COR/SME for approval which includes the topic and data supported justification to initiate the Focused Review.

ii. The Focused Review must be determined from case or claim review data mining and analytics;

iii. The Focused Review is to be limited to a review of up to 50 medical records; and

iv. The Focused review design must be able to identify an opportunity for BFCC-QIO improvement.

v. A report of the Focused Review results and recommendations are to be submitted to the COR/SME within 60 calendar days of completion.

b) CMS Directed Focused Reviews - The BFCC-NCORC shall be required to perform focused reviews as determined by CMS.

c) Performance Audits

i. Expedited Single Case Reviews – The BFCC-NCORC shall review cases/claims referred to the BFCC-NCORC by the COR/SME related to a beneficiary or provider complaints or appeals relative to BFCC-QIO Performance. The results of these reviews are to be provided to the COR/SME, and completed within a timeframe as prescribed by the COR/SME.

ii. Annual Performance Audits – The BFCC-NCORC will conduct an annual performance audit in each of the BFCC-QIO service areas to determine if the BFCC-QIO's operations, programs, or projects are functioning effectively and efficiently to achieve goals established for:

· Short Stay Reviews

· Higher Weighted DRG Reviews

· Appeals of Discharge/ Service Termination Reviews

· Person & Family Engagement (PFE)

· Timeliness of entry of case reviews into the CMS Designated Case Review System The BFCC- NCORC shall use the general standards that guide government auditors, as well as other independent auditors, stated in the GAO Government Auditing Standards (Yellow Book).

Task 1.5: Review for Preventable Patient Safety Events The NCORC will systematically screen medical records for adverse patient safety events that occurred in hospitals and other settings using a standardized process and review each medical record that is positive for an adverse patient safety event to determine “the completeness, adequacy and quality of the care provided.”

a) Engage with CLINICAL DATA ABSTRACTION CENTER

i. The NCORC shall execute a subcontract with a CMS designated Clinical Data Abstraction Center (CDAC). CDACs are CMS contractors that support the QIO program. These entities provide accurate, reliable, efficient, and cost-effective clinical data abstraction to meet CMS' objectives and to provide support to the NCORC as appropriate. (Data abstraction may include data entry.) To ensure the standardization of all patient safety reviews and to efficiently pre-screen medical records that have a high likelihood of having an adverse event, CMS has separately contracted with CDAC to undertake Quality and Safety Review System abstractions to identify patient safety events in an efficient and systematic manner.

ii. Work with CDAC to develop and implement a process to receive data and medical records on a monthly basis to undertake quality of care review. Request and receive imaged copies of medical records from CDAC for 4,000 cases per year. These cases will include all charts that were identified by CDAC as having had an adverse patient safety event. The remainder will be derived from records that CDAC determined did not have an adverse event.

b) Conduct Intensified Reviews.

i. Upon receipt of requested medical records, conduct reviews (blinded to CDAC’s determination) the NCORC will make a determination regarding quality of care provided. Specifically, the NCORC will determine whether an adverse event occurred. For each patient safety event identified, the NCORC will determine whether event could have reasonably been prevented based on professional standards of care. When a preventable event is identified (i.e. a medical error), perform all follow-up functions as defined under 42 CFR 476.

ii. For each completed review, the NCORC will record information regarding the preventability of each event in a manner that allows for linkage with the initial patient safety data set provided by the CDAC(s).

c) Patterns of Preventability.

i. At least annually, the NCORC shall review statistics for individual facilities and/or facility types to identify patterns of care that require referral for technical assistance. Examples of patterns include individual facilities with elevated rates of medical errors or other preventable events, and important non-preventable events for which greater study might yield new methods for prevention.

ii. Report results of all patterns to CMS and to the appropriate BFCC-QIO. When a preventable event is identified (i.e. a medical error). Perform all follow-up functions as defined under 42 CFR 476.

iii. Emerging epidemics. In addition to formal statistical review on an annual basis, the NCORC shall do due diligence in making CMS aware of any obvious patterns that emerge in real time. For example, 4 consecutive preventable patient safety events of the same type in the same facility in a week’s time shall trigger an alert to the CMS COR/SME.

iv. Natural Disasters. The NCORC will provide technical assistance to BFCC-QIOs on any complaints resulting from natural disasters. BFCC-QIOs are required to work with the State Department of Health, CMS contractors in the Medicare Program, healthcare emergency response entities and other relevant parties within their service area. The goal of these relationships is to (1) create and sustain collaborative relationships; (2) improve the resiliency of communication; (3) improve the data retrieval; (4) enhance beneficiary and provider preparedness through education/training.

v. Support the…