Attachment 5_SOO Trauma Registry Services_25QA217.pdf
PDF 100 KB Posted
- Attached to
- Trauma Registrars
- Solicitation number
- W81K0026QA066
- Issued by
-
Department of the Army Medical Command
About this file
This is a Statement of Objectives (SOO) for Trauma Registry Support Services at Brooke Army Medical Center (BAMC).
BAMC seeks a contractor with a minimum five-year documented history providing comprehensive trauma registry services to American College of Surgeons or State-verified Level 1 and 2 trauma centers. The contractor must provide remote trauma registry services including abstracting, transcribing, verifying, and entering trauma patient data from the Military Health System–Genesis (MHS-G) electronic medical record into the Image Trend Patient Registry web-based platform. Each patient record contains approximately 300 data elements and must be entered within 60 days of discharge. Personnel requirements include a designated project lead who must be CAISS certified, completed ATS Registrar Course, AIS 15, and ICD-10 certified with minimum five years' experience and proficiency in Image Trend. At least 75% of all trauma registrars must hold CAISS certification, while 100% must complete ICD-10 coding course (within five years), AAAM AIS-15 course, and American Trauma Society Trauma Registrar course or equivalent per ACS guidelines. All personnel must pass Tier 1 federal background checks and complete 40–60 hours of government-required training including MHS-Genesis, HIPAA, and Information Assurance prior to production work. The contractor must access government systems via government-supplied Common Access Card (CAC) using contractor-supplied CAC reader and hardware through the Application Virtual Hosting Environment (AVHE).
The contractor must comply with National Trauma Data Standard (NTDS), Trauma Quality Improvement Program (TQIP), State of Texas, and BAMC data standards. Contractor responsibilities include submitting a data quality plan requiring complete re-abstraction of at least 10% of charts (including all death charts) with minimum 90% accuracy and no more than 10% of death charts requiring significant ISS or TRISS score adjustments. All identified errors must be corrected, and all records must undergo Image Trend software validation with Level 1 and 2 errors corrected before completion. Weekly productivity reports and monthly quality assurance reports are required, with the project lead attending monthly BAMC Registry Staff meetings via Microsoft Teams. BAMC will provide initial remote training for registrars using Microsoft Teams and an electronic copy of the BAMC data dictionary, with the contractor responsible for training additional registrars. Work is performed remotely, and all personnel must maintain confidentiality of written and verbal communications, autopsy reports, mortality and morbidity data, and HIPAA requirements.
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PROJECT NAME: Trauma Registry Support Services
1. STATEMENT OF OBJECTIVE (SOO).
The purpose of this requirement is to obtain a company with at least a 5-year history of complete trauma registrar services working with American College of Surgeons or State verified high level
(level 1 & 2) Trauma Centers.
2. PURPOSE.
2.1. The objective of this contract is to obtain qualified Trauma Registry Services with a minimum of 5 years’ experience providing comprehensive trauma registry service to higher level trauma centers (level 1 & 2). They will ensure accurate, timely, and complete abstraction, coding, and data entry of trauma patient information in compliance with all applicable accreditation, regulatory, and organizational requirements as well as full data quality review to support the maintenance and management of a comprehensive trauma registry.
2.2. Appoint a project lead who will be the point of contact with the BAMC Trauma Program
Manager and who will also be responsible for providing any deliverables and disseminating any information to the registrars working on the project. Project lead will attend all BAMC registry staff meetings remotely. In addition to the registrar qualifications, the project lead must be CAISS certified, completed ATS Registrar
Course, AIS 15, ICD-10, and have a minimum of five (5) years of experience in trauma registry data entry and be proficient in Image Trend patient registry.
3. SCOPE
3.1. The Contractor shall provide non-personal service(s). The Contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items necessary to perform services as described in the Performance Work
Statement (PWS) and associated contract documents, except for those items specified in
Part 3 Government Property & Services. The Contractor shall perform to the standards and acceptable quality levels identified in this SOO and associated contract documents.
4. PLACE OF PERFORMANCE
4.1. The work to be performed under this contract will be performed remotely.
5. BACKGROUND
5.1. As a State-designated and American College of Surgeons (ACS) verified Level I trauma center), Brooke Army Medical Center (BAMC) must comply with data collection and reporting as set forth by local, state and federal regulations. Data from all BAMC trauma patients meeting inclusion criteria must be entered into the trauma registry within
60 days of patient discharge in order to maintain compliance. Each record includes approximately 300 data elements. Data is also used to support performance improvement initiatives, conduct research and guide clinical practice guidelines.
6. PERFORMANCE OBJECTIVES
6.1. Task
6.1.1. Provide remote trauma registry services to abstract, transcribe, verify and enter trauma data from the electronic medical record (Military Health System
– Genesis (MHS-G) into the trauma registry.
6.1.2. Access to government systems (Application Virtual Hosting Environment
(AVHE), MHSG, and others as required) will be via government supplied
Common Access Card (CAC) using a contractor supplied CAC reader and hardware.
6.1.3. A minimum of 75% of trauma registrars are Certified Abbreviated Injury
Scale Specialists (CAISS).
6.1.4. 100% of trauma registrars have the following certifications/course completions: ICD-10 coding course within the last five years, Association for the Advancement of Automotive Medicine (AAAM) Abbreviated Injury
Scale (AIS) -15 course, American Trauma Society Trauma Registrar course
(or equivalent per America College of Surgery (ACS) guidelines). In addition, any other requirements outlined in the most current version of
“Resources for Optimal Care of the Injured Patient”
(https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/standards/) must be met.
6.1.5. Registrars will maintain continuing education requirements per the ACS guidelines.
6.1.6. All data entry must be entered in compliance with National Trauma Data
Standard (NTDS), Trauma Quality Improvement Program (TQIP), State of
Texas, and Brooke Army Medical Center standards and requirements in accordance with the BAMC data dictionary and the National Trauma Data
Standard.
6.1.7. Maintain compliance with all applicable federal, state, and local regulations.
6.1.8. The current registry in use at BAMC is Image Trend Patient Registry
(https://elite.stracdata.org/patientregistry ) which is a web based platform.
6.1.9. BAMC Trauma will provide remote training for the initial cadre of registrars
(using Microsoft Teams), training of additional registrars will be the responsibility of the contractor.
6.1.10. BAMC will provide an electronic copy of the BAMC data dictionary.
6.2. Requirements
6.2.1. The contract company will have no less than five years of documented experience providing trauma registry services to high volume trauma centers
(Level I or II)
6.2.2. Abstract, code, and enter trauma patient data into the registry IAW national, state, and organization data standards, ensuring compliance with International
Classification of Diseases (ICD) -10 and AAAM AIS15 guidelines.
6.2.3. Submit a data quality plan for approval to the BAMC Trauma Program
Manager via email. This plan must include at a minimum: complete re-abstraction of no less than 10% of charts (must include all deaths), error rate broken down by registrar, indication if changes to Injury Severity Score (ISS) and/or Trauma and Injury Severity Score (TRISS) resulted, what corrective action will be taken when discrepancies are found. All death charts will be reviewed for accuracy (can count towards the overall 10% requirement) with no more than 10% requiring significant adjustment to ISS (change in severity category) or TRISS (more than 10%) scores.
6.2.4. All identified errors must be corrected.
6.2.5. Ensure 10% of charts are reviewed (re-abstracted) for accuracy with a minimum accuracy rate of 90% (based upon contractor submitted and BAMC approved data quality plan).
6.2.6. All records will undergo registry software validation (Image Trend) with all
Level 1 and 2 errors corrected before marking the record as complete. All level 3 and 4 errors will be reviewed for validity before being closed.
6.2.7. Maintain confidentiality of written and verbal communication, autopsy reports, mortality and morbidity data, performance improvement activities, peer review data and HIPAA requirements.
6.3. Reports
6.3.1. Provide productivity reports no later than every Thursday for the prior week’s work. The productivity report will include the following (at a minimum):
registrar name, number of records completed by registrar, time worked for the period being reported.
6.3.2. Provide QA reports by the tenth business day of the month for the previous month’s work.
6.4 Meetings
6.4.1 Project Lead will meet with BAMC Registry Staff Monthly via MS Teams.
7. OPERATING CONSTRAINTS
7.1. A minimum of 75% of trauma registrars are Certified Abbreviated Injury Scale
Specialists (CAISS).
7.2. 100% of trauma registrars have the following certifications/course completions: ICD-10 coding course within the last five years, AAAM AIS-15 course, American Trauma
Society Trauma Registrar course (or equivalent per ACS guidelines).
7.3. Required Training. All Trauma Registry Support members must have MHS-Genesis training prior to performing work. In addition, all personnel must complete any other government required 40 – 60 hours of training (HIPAA, Information Assurance, etc.) It is expected that all training will be completed prior to production.
7.4. Background Checks. All Trauma Registry Support members must clear Tier 1 federal background check to be issued a Common Access Card (CAC) to government systems access.
7.5. Computer Access. All Trauma Support Members must access government system using
Application Virtual Hosting Environment (AVHE).
8. APPLICABLE DOCUMENTS OR REFERENCES
8.1. BAMC will provide an electronic copy of the BAMC data dictionary.
8.2. American College of Surgeons “Resources for Optimal Care of the Injured Patient”
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