Attachment 1 - SQSS PWS.pdf

Performance Work Statement

Strategic Quality Support System (SQSS)

Background Fort Yuma Health Care Center (FYHCC) requires a comprehensive, web-based Strategic Quality Support System (SQSS) to support Accreditation Association for Ambulatory Health Care (AAAHC) accreditation readiness and ongoing healthcare quality management activities.

The contractor shall provide a system capable of tracking, documenting, monitoring, and reporting accreditation and compliance-related activities across all required healthcare quality functions. The system shall support FYHCC’s operational need to manage accreditation tasks efficiently while reducing administrative burden on healthcare personnel.

The contractor shall provide all software, system configuration, implementation support, maintenance, reporting, training, technical support, and related services necessary for successful operation of SQSS throughout the period of performance.

Scope and Performance Requirements The contractor shall provide a secure, fully web-based Strategic Quality Support System (SQSS) that enables FYHCC personnel to manage accreditation, compliance, quality assurance, risk management, and performance improvement activities.

The system shall:

• Track and document up to 4,000–5,000 accreditation and compliance-related tasks;

• Provide automated reminders, alerts, and notifications for due, overdue, and non-compliant tasks;

• Generate compliance, accreditation readiness, and performance reports;

• Allow assignment and reassignment of tasks by department, role, and responsible staff member;

• Support monitoring and trending of deficiencies and corrective actions;

• Provide centralized access to policies, procedures, and supporting accreditation documentation;

• Support all 16 major healthcare quality functions identified by FYHCC;

• Be accessible to authorized staff through a secure web-based platform without requiring local installation; and

• Maintain system availability, security, and technical support in accordance with this

Performance Work Statement.

The contractor shall provide all labor, materials, supervision, equipment, software, hosting, maintenance, and technical support necessary to perform the requirements of this contract.

System Requirements Functional and Performance Requirements

The contractor shall provide a Strategic Quality Support System (SQSS) that shall:

1. Be designed to function within healthcare systems and manage activities across all sixteen (16) major quality functions in a typical healthcare organization, including:

• Infection Control

• Safety

• Corporate Compliance

• Utilization Management

• Patient Clinical Management

• Credentialing and Privileging

• Peer Review

• Performance Evaluation

• Orientation

• Continuing Education

• Patient Complaint Management

• HIPAA Compliance

• Pharmacy and Therapeutics

• Service Recovery

• Patient Satisfaction

• Patient Advocacy

2. Track between 4,000 and 5,000 accreditation and compliance-related tasks.

3. Provide daily task or “to-do” lists for staff to identify required activities, due dates, and pending actions.

4. Send automated messages, reminders, and alerts for tasks that are due, overdue, incomplete, or non-compliant.

5. Provide task instruction fields detailing procedures necessary to complete tasks in accordance with accreditation and regulatory standards.

6. Be accessible to authorized staff members across all departments.

7. Be fully web-based and contractor-hosted, eliminating the need for local installation or routine technical support by the Service Unit IT department.

8. Allow real-time uploading and documentation of task completion activities and generation of compliance reports.

9. Create and assign tasks to individual staff members, groups, departments, or functional areas.

10. Support assignment of primary and secondary responsible individuals and allow reassignment or transfer of tasks when staff are absent or leave the Service Unit.

11. Allow flexibility in scheduling tasks by frequency, interval, department, shift, recurring cycle, or rotating staff assignment.

12. Enable transfer of task completion, validation, and oversight responsibilities without loss of historical documentation.

13. Provide readily retrievable compliance reports sortable by individual, department, task, accreditation function, or reporting category.

14. Display trends, dashboards, graphs, metrics, and outlier analyses for identification of deficiencies and targeting of corrective actions.

15. Provide readily accessible and knowledgeable technical support.

Required System Features

The system shall:

1. Upload documents and supporting materials to provide a centralized location for accreditation-related records and activities.

2. Upload links to training resources, policies, procedures, websites, and reference materials necessary for task completion.

3. Graph data and visually display trends, metrics, dashboards, and other performance activities.

4. Encrypt patient-specific and sensitive information in accordance with HIPAA, HHS, and Federal cybersecurity requirements.

5. Create spontaneous or ad hoc quality improvement initiatives related to existing tasks or as stand-alone projects.

Reporting Requirements

The contractor shall provide monthly compliance and accreditation readiness reports summarizing:

• Task completion rates;

• Overdue items;

• Compliance trends and identified deficiencies;

• Corrective actions taken or pending;

• Department-level performance metrics; and

• Performance and compliance status by responsible staff member.

Reports shall be exportable in PDF and Microsoft Excel formats and shall be available to authorized Government personnel upon request.

Service Level Requirements

1. System uptime shall be at least 99% excluding scheduled maintenance periods.

2. Contractor shall provide at least seventy-two (72) hours advance notice to the Contracting Officer’s Representative (COR) for any scheduled system outages or maintenance activities expected to impact system availability.

3. Contractor shall maintain technical support processes sufficient to address system outages, user access issues, and critical functionality failures in a timely manner.

Data Ownership and Security Requirements

1. All data entered into the Strategic Quality Support System (SQSS) shall remain the sole property of the Government.

2. Contractor shall comply with all applicable Health Insurance Portability and Accountability Act (HIPAA), Department of Health and Human Services (HHS), Indian Health Service (IHS), and Federal cybersecurity and privacy requirements.

3. Contractor shall implement appropriate administrative, technical, and physical safeguards to protect Government information and prevent unauthorized access, disclosure, alteration, or destruction of data.

4. Contractor shall notify the COR within twenty-four (24) hours of discovery of any suspected or confirmed data breach, cybersecurity incident, or unauthorized access involving Government data.

5. Contractor shall not use, disclose, distribute, or retain Government data except as required for performance of this contract.

Period of Performance The period of performance shall consist of:

• One (1) twelve-month base year; and

• Four (4) twelve-month option years.

The contract shall include:

1. An implementation and configuration period beginning at contract award and continuing through successful system deployment and validation.

2. A recurring services period for ongoing system access, technical support, maintenance, updates, reporting, and training support throughout the duration of the contract.

Deliverables and Acceptance Criteria

Deliverable Description Frequency Due Date Acceptance Criteria

System Configuration

Configure SQSS for FYHCC workflows

One-time 30 days ARO COR validation

Initial Training End-user/admin training

One-time 14 days ARO Attendance roster

Refresher Training

Refresher training sessions

Quarterly Quarterly Training completion

Monthly Compliance Reports

Accreditation metrics

Monthly 5th business day

COR approval

Deliverable Description Frequency Due Date Acceptance Criteria

Technical Support

Help desk support

Ongoing Continuous SLA compliance

System Maintenance

Updates/patche s

Ongoing As needed No disruption

Annual Review System effectiveness assessment

Annual Anniversary date

Written report

Transition and Offboarding Requirements Upon expiration, termination, or non-renewal of the contract, the contractor shall:

1. Provide all Government-owned data in a mutually agreed-upon electronic format within thirty (30) calendar days.

2. Assist with transition activities necessary to support migration of data to the Government or a successor contractor.

3. Ensure all Government data remaining in contractor-controlled systems is securely removed or destroyed in accordance with applicable Federal records management and cybersecurity requirements after written Government confirmation of successful transfer.

4. Provide documentation necessary to support continuity of operations and system transition activities.

System Acceptance Final system acceptance shall occur after:

• Successful implementation and configuration of required functionality;

• Validation by the COR that all required quality functions are operational;

• Completion of user training;

• Demonstration of required reporting capabilities; and

• Resolution of critical system deficiencies identified during testing.

The Government reserves the right to require correction of deficiencies prior to final acceptance.

Contract Administration Contracting Officer

TBD

Onsite COR Edmund Thundercloud, Management Analyst, COR II 760-572-4167 Edmund.Thundercloud@ihs.gov

Point of Contact Jill Shubert, Interim COO 760-572-4206 Jill.Shubert@ihs.gov mailto:Edmund.Thundercloud@ihs.gov mailto:Jill.Shubert@ihs.gov