ATTACHMENT A - Performance Work Statement.pdf

Performance Work Statement ( PWS) for N on-Personal Services

Clinical Laboratory Scientist

Table of Contents Section Page

1.0 General 1-2

2.0 Definitions 3-5

3.0 Government Furnished Information, Property, & Services 5

4.0 Contractor Furnished Property 6

5.0 Performance-Based Requirements 6-10

6.0 Contractor Qualification Requirements 11-12

7.0 Challenges to Conflicts 12

8.0 Performance Requirements Summary 12-13

ATTACHMENT QUALITY ASSURANCE MONITORING FORM

PWS No. 10-15

Performance Work Statement ( PWS) for N on-Personal Services

Clinical Laboratory Scientist

1.1 General: This performance work statement describes the requirements for Non-Personal Service Contract, a Clinical Laboratory Scientist/Medical Technologist to support the mission of the Indian Health Service (IHS).

1.2 Background: IHS is an agency within the U.S. Department of Health and Human Services and is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government to government relationship between the federal government and Indian tribes. The IHS is the principal federal health care provider and health advocate for the Indian people. The goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indians and Alaska Natives. The IHS currently provides health services to approximately 1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 34 states.

1.2.1 Navajo Area Indian Health Service (NAIHS) administers health centers and hospitals providing health care to approximately 201,583 members of the Navajo Nation. The Navajo Nation is the largest Indian tribe in the United States and has the largest reservation, which encompasses more than 25,516 square miles in northern Arizona, western New Mexico, and southern Utah, with three satellite communities in central New Mexico. The NAIHS is the primary provider of inpatient, ambulatory care, preventive and community health, and environmental health services for members of the Navajo Nation and the San Juan Southern Paiute Tribe.

1.3 Scope: The Contractor shall provide Clinical Laboratory services in accordance with section 5.0, performance-based requirements.

1.3.1 Duties and responsibilities will encompass outpatient/ inpatient clinical laboratory scientist services to IHS patients.

1.3.2 Place of Performance: Services are to be performed at Northern Navajo Medical Center (NNMC), Laboratory Department, Shiprock, New Mexico. This is to provide service in the main laboratory specimen processing areas (Hematology, Blood Bank, Coag, Microbiology, Chemistry, Immunology, and Urinalysis departments). Contractor key personnel will be responsible for processing all specimens coming from all clinics, ED, and inpatients.

1.3.3 Period of Performance: Ba se o f 12 mo nt hs a nd 2 o pt io n pe r iod s where feasible, include intermittent support to meet unplanned needs that develop on a

PWS No. 10-15 frequent basis, in accordance with the PWS.

1.4 Applicable Documents: Please see the web link listed unless document is listed as an attachment.

1.4.1 The Joint Commission

http://www.jointcommission.org/

1.4.2 Centers for Medicare and Medicaid Services (CMS) Standards http://www.cms.hhs.gov/

1.4.3 Accreditation Association for Ambulatory Health Care (AAAHC) http://www.aaahc.org

1.4.4 Section 231 of Public Law 101-647, the Crime Control Act of 1990.

http://www.policyalmanac.org/crime/archive/crs_federal_crime_policy.shtml

1.4.5 Section 4087 of Public Law 101-630, the Indian Child and Family Violence Act.

http://www.nicwa.org/policy/law/protection/index.asp

1.4.6 Health Insurance Portability and Accountability Act (HIPAA) of 1996.

http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/HIPAALaw.pdf

1.4.7 Privacy Act of 1974.

http://www.usdoj.gov/oip/privstat.htm

1.4.8 IHS Service Unit and Health Center Policies, Procedures and Protocols.

(See section 9.0 for a list of attachments and exhibits)

1.4.9 Computer Security Act of 1987

http://csrc.nist.gov/groups/SMA/ispab/documents/csa_87.txt

1.4.10 Federal Code of Conduct http://www.ihs.gov

1.4.11 IHS General Directives http://www.ihs.gov/adminmggrresouces

1.4.12 IHS Computer Security Directives http://www.ihs.gov/adminmggresources http://www.jointcommission.org/ http://www.cms.hhs.gov/ http://www.aaahc.org/ http://www.policyalmanac.org/crime/archive/crs_federal_crime_policy.shtml http://www.nicwa.org/policy/law/protection/index.asp http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/HIPAALaw.pdf http://www.usdoj.gov/oip/privstat.htm http://csrc.nist.gov/groups/SMA/ispab/documents/csa_87.txt http://www.ihs.gov/ http://www.ihs.gov/adminmggrresouces http://www.ihs.gov/

2.1 Definitions

2.2 Acceptance: Constitutes acknowledgement that the supplies or services conform to the applicable contract quality and quantity requirements, except as provided in RFO subpart 46.5 and subject to other terms and conditions of the contract.

2.3 Approval: Acknowledgment by the designated Government official that submittals, deliverables, or administrative documents (e.g., insurance certificates, installation schedules, planned utility interruptions, etc.) conform to the contractual requirements. Government approval does not relieve the Contractor from responsibility for compliance with contract requirements.

2.4 Area: A defined geographical region for Indian Health Service administrative purposes.

Each Area Office may administer several Service Units.

2.5 Contracting Officer (CO): A Government employee with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings.

2.6 Contractor: The individual awarded a legal binding contract to provide supplies and services.

2.7 Contracting Officer’s Representative (COR) or Project Officer (PO): A federal employee who assists the ordering/issuing activity contracting officer in the administration of task orders issued under this contract. The COR is primarily responsible for the technical assistance and day-to-day program management of the ordering activity’s task orders. Ordering activities may have different designators for this employee (e.g. GTR – Government Technical Representative, COTR–Contracting Officer’s Technical Representative, or PO - Project Officer).

2.8 Cooperative Attitude: Behavior that is positive and displays a willingness to perform assigned patient care tasks and to be a team player. Willingness to work assigned shifts.

2.9 Cultural Awareness: Realization and respect for American Indian and Alaska Native practices.

2.10 Customer: Patients, staff and visitors of an IHS service unit and health center.

2.11 Customer Evaluation/Input: Written comments made to the Contracting Officer regarding the Contractors performance. This is one of the criteria used to evaluate the Contractor’s performance.

2.12 Dependability: Qualities of being trusted and being able to repeat the same task to yield the same result.

2.13 Federal Acquisition Regulation (FAR)/ REVOLUTIONARY FAR OVERHAUL (RFO) : The FAR/RFO is the primary regulation for use by all Federal Executive agencies in their acquisition of supplies and services with appropriated funds.

2.14 Government Vehicle: An IHS owned motor vehicle or a vehicle leased by IHS through agreements with the General Services Administration (GSA) or through commercial rental agreements.

2.15 Health Center: A facility physically separated from a hospital, with a full range of ambulatory services including at least primary care providers, nursing, laboratory, and x-ray which are available at least 40 hours a week for outpatient care.

2.16 Ordering Activity: An authorized user of IHS that may issue a task order to obtain required services under this contract.

2.17 Ordering Activity Contracting Officer: A Government employee of IHS authorized and warranted to issue task orders and to make subsequent task order modification(s) under this contract. The Ordering Activity CO has the authority to make initial determinations on all matters of dispute regarding task orders.

2.18 Orientation: An activity designed to provide basic familiarization of the facility and transition the CLS into the IHS Service Unit and/or Health Center and the nursing unit where the services will be provided.

2.19 Past Performance Information: Relevant information regarding a contractor’s actions under previously awarded contracts. This includes the contractor’s record of conformance to specifications and to standards of good workmanship; the contractor’s record of containing and forecasting costs on any previously performed cost reimbursable contracts; the contractor’s adherence to contract schedules, including the administrative aspects of performance; the contractor’s history for reasonable and cooperative behavior and commitment to customer satisfaction; and generally, the contractor’s business-like concern for the interest of the customer.

2.20 Patient Outcome: Provide accurate and reliable test results for direct patient care.

2.21 Performance based Matrix: Lists the services to be monitored and the standards to be applied.

2.22 Personal Protective Equipment (PPE): The equipment used to protect medical personnel from exposure to biological, chemical, and radioactive hazards.

2.23 Service Unit: The local administrative unit of IHS.

2.24 Standards of Practice and Standards of Care: Authoritative Laboratory Department Policies and Procedures manuals which provide the duties and responsibilities of the Laboratory department staff. The standards provide direction for professional lab scientists practice and a framework for the evaluation of practice. The standards of professional lab scientist practice may pertain to general or specialty practice.

2.25 Task Order: An order issued in accordance with the terms of the contract that details an ordering activity’s specific requirements. An ordering activities written order to obtain services, at a minimum will include the following where applicable: description of services, skill categories, hours, price, period of performance, contract number, and the ordering activities task order number.

2.26 Tour of Duty: The time of day the Clinical Lab Scientist is scheduled to perform laboratory duties; also considered the shift of the day. The time can vary according to the needs of each facility, e.g. 12-hour Tour of Duty, 8-hour Tour of Duty, 10 hour Tour of Duty; 7 on, 7 off nights shifts. Shifts include nights, weekends, holidays and or days.

2.27 Valid Patient Complaint: Justifiable accusation made by a patient and supported by investigation.

2.28 Verifiable Emergency: An unexpected/unplanned absence by the contractor requiring valid documentation to confirm the occurrence by the.

3.1 Government Furnished Information, Property and Services

3.2 Information: Government unique information related to this requirement, which is necessary for Contractor performance, will be made available to the Contractor. The Contracting Officer or designee will be the point of contact for identification of any required information to be supplied by the Government.

3.3 Joint Use by the Government and the Contractor: Except for the property and service listed in 3.3 and 4.0, the Government will provide, for joint use by the Government and the Contractor, all necessary equipment, supplies, and clinic space to perform the services under this contract.

3.3.1 Government Vehicle: If required by the position, authorization shall be in accordance with IHS Chapter 12, Section 13 Motor Vehicle Management.

3.4 Contractor Exclusive Use:

3.4.1 Personal Protective Equipment (PPE). The Government will furnish the Contractor with appropriate PPE (gloves, lab coats, masks) other than specified in section 4 of the PWS. The Government will be responsible for any repair, cleaning, and inventory required for the PPE. This does not include any type of uniform or laboratory coat.

3.4.2 The Government will provide facility specific contractor identification badges for each contractor. A minimum fee of $10.00 will be charged for lost or destroyed badges.

3.5 Training: Facility specific orientation/training necessary for the Contractor to perform the required duties, e.g., IHS information technology (IT) systems and laboratory operational procedures. Training will be provided and is necessary to improve or enhance the quality of CLS service or includes mandates made by the IHS Service Units/Health Centers while the CLS is working under this contract. Training will not be provided for the purpose of continuing education, certification renewal (e.g., ASCP, AMT, BLS, etc.), career development or individual development.

4.1 Contractor Furnished Property

4.2 Except for the property specified in section 3 as government furnished, the Contractor shall provide all uniforms and other personal medical instruments subject to the following:

4.2.1 Uniforms and Lab Coats: Uniforms and Lab Coats shall conform to the requirements of the Indian Health Service Manual, Part 3 Chapter 4 and meet the approval of the Clinical Director at each IHS facility.

4.2.2 Other personal medical instruments: “Other personal medical instruments” are defined as Contractor owned items may include but not limited to scissors, as appropriate to the work unit. The Contractor shall not use unsafe equipment or supplies at any time during performance of this contract. All Contractor furnished equipment and supplies shall be subject to inspection by the Government and must be approved by the COR prior to use by the Contractor. The Government reserves the right to prohibit the use of any materials, supplies, or equipment.

4.2.3 Living accommodations: Contractor shall be responsible for providing own living accommodations. However, if qualified, government quarters may be available at prevailing rental rates, plus utilities, applicable if government quarters are utilized. The contractor shall be responsible and liable for the proper care of government owned or leased property furnished in the occupied quarters.

5.1 Performance-Based Requirements. The Contractor shall provide Clinical Laboratory

Scientist services in the delivery of patient care to the Indian Health Service. Specific tasks include the following:

5.2 Clinical Laboratory Scientist Duties:

5.2.1 The Contractor shall perform Lab Scientist duties and manage patient’s needs as described in the procedure manuals. Serves as a Clinical Laboratory Scientist in the Clinical Laboratory of the Northern Navajo Medical Center (NNMC), of the Shiprock Service Unit IHS, with the duties of performing a variety of standardized routine and specialized procedures in the areas of Chemistry, Immunology, Hematology, Blood Bank, Microbiology, Urinalysis, Send-Outs, specimen processing and Specimen Accessioning after being properly trained and competency assessed by the lead CLS in each department, per CLSI guidelines. Out of the listed areas of the lab, BLOOD BANK, MICROBIOLOGY and PHLEBOTOMY EXPERIENCE IS REQUIRED. Clinical lab scientist will need to be proficient with the hospital information system, RPMS (Resource Patient Management System), and the Electronic Health Record (EHR) which are the method of processing patient specimen and reporting patient test results.

5.2.2 MAJOR DUTIES AND RESPONSIBILITIES:

A. Provision of full range of Laboratory care to patients seen at NNMC including laboratory testing, maintenance of diagnostic equipment, operates automated equipment and performs complex manual procedures in Chemistry, Hematology, Blood bank, Urinalysis, Microbiology, Phlebotomy, special dispatch and specimen requirements, quality controls and other diagnostics required by t h e laboratory.

B. Ability to operate and troubleshoot the Automated Urine analyzer iChem Velocity and the IQ200 Select, Sysmex XE5000, Sysmex XN-2000, Stago Compact Max, Hematek slide stainer, Cepheid GeneXpert Infinity, BacT Virtuo, Vitek 2 Compact, Roche Eplex, Chemistry Vitros 7600s, Beckman Coulter Urinalysis Analyzer, and the Immucor Echo Blood Bank analyzer.

C. Capable of performing phlebotomy on various age-groups: (infants to geriatric ages) and familiar with requirements and equipment for each age group, such as finger sticks, heel sticks and venipuncture with different needle gauges, knowledge of appropriate specimen type to collect for various tests.

D. Performs required recordkeeping procedures and reports discrepancies to appropriate scientist, department lead or supervisor, for patient results, demographics, QC, QA, and performance improvement.

E. Performs start up, shut-down, daily, weekly, monthly, and quarterly preventative maintenance procedures on analyzers and other testing procedures on instrumentation in Chemistry, Hematology, Urinalysis, Blood Bank and Microbiology as assigned or instructed.

F. Performs Q uality C ontrol procedures on analyzers and manual test methods as required; performs semi-annual Calibration verification studies and Method Comparison Studies as assigned; analyzes and monitors significant trends, troubleshoots analyzer problems.

Identifies and recognizes technical and instrumental causes of problems.

G. Recognizes factors which can adversely affect specimens, procedures, and results and is capable of determining whether procedures, specimens, or results have been affected, then performs corrective action as needed (including sequestering patient samples and retesting after the analyzer issues have been resolved).

H. Assures preparation of tests for all patients, including performing the test calibrations and calibration verification studies as needed.

Checks specimens, prepares reagents, and maintains adequate supplies. Electronically enters, or writes clinical reports and descriptions of laboratory care.

I. Examines all patients lab work, reviews all testing (lab) and requests or performs diagnostic tests and refers tests to internal and external Laboratory facilities. Completes all tests requested by physicians and refers out when needed. Makes note of all assessments and records results. Reports results to appropriate individuals, calls critical values to appropriate individuals and recognizes the need for timely reporting of laboratory data and shipment of products and specimens.

J. Follows the Laboratory Department policies and procedures and Clinical practice guidelines when relevant. Follows federal licensing, accreditation and regulating body standards from organizations such as CMS, TJC, CLIA and IHS; and any other agency to which the facility is accountable.

K. Provides specialty laboratory services to patients at NNMC and works as a team with the medical staff. Interacts in a professional manner with patients and co-workers.

5.2.3 FACTORS:

Factor 1 - Knowledge Required by the Position:

Knowledge of Clinical Lab Science principles, concepts and methodology sufficient to perform a broad range of tests, including some complex and non-routine analysis covered by procedure manuals and run quality controls, etc.

Knowledge of mathematics sufficient to perform routine calculations.

Knowledge of CLIA high complexity tests (i.e., body fluid cell counts, manual differentials, type and screens, cross matching, antibody identification, gram stains etc.).

Knowledge and skill sufficient to operate, perform start up analyzers, calibrate, and perform preventative maintenance, and troubleshooting on available instrumentation under guidance of lead Scientist. Knowledge of technical, physiologic, and mechanical indicators of malfunctions sufficient to correct minor problems, to troubleshoot, and to notify technologist of major testing problems. Knowledge and skills necessary to provide laboratory testing to a wide range of age groups (neonate - geriatric).

Knowledge and ability to assess laboratory data and interpret the data to meet the relative needs of each specific age group.

Must have knowledge and be proficient with the RPMS/EHR as all laboratory work revolves around the hospital and laboratory information system.

Factor 2 - Supervisory Controls:

The work is performed in an independent role, but under technical guidance of a department lead tech or lab department lead. The employee uses initiative in carrying out recurring tasks independently and unfamiliar situations are referred to departments leads or higher-level employee for decision or help. Additional instructions are provided for new or unusual assignments. The lab guidance assures finished work and methods used are technically accurate and in compliance with instructions. Review of the work increases with more difficult assignments if the employee has not previously performed similar assignments.

Factor 3 - Guidelines:

Established procedures and specific guidelines are available in the form of policies and manuals; test and controls descriptions; calibration procedures;

instructions on collecting, preserving, transporting, and receiving specimens;

guidance on preparation, labeling, storing, and evaluating reagents. The employee refers situations requiring significant judgment to the lead tech or others for guidance/resolution.

Factor 4 - Complexity:

The work consists of duties that involve related steps, processes, or methods to perform a variety of tests and examinations. Decisions regarding what needs to be done involves various choices that require the employee to recognize the existence of and differences among recognizable situations. The work includes such tasks as discriminating between colors and patterns, recognizing factors that affect procedures and results, and identifying technical or instrument related problems. Actions to be taken or responses to be made differ with the patient’s condition, differences in test of examination ordered, and difference in patient responses.

Factor 5 - Scope and Effect:

The purpose of the work is to perform a range of relatively standardized tests, examinations, and determinations. The procedures and techniques are well-established, but involve many meticulous sequential steps to complete a test.

Work performed affects the accuracy and reliability, as well as timeliness of the procedures.

Factor 6 - Personal Contacts:

Personal contacts are with co-workers, technologists and technicians in other sections of the laboratory, patients, nurses and to a limited degree, physicians.

Factor 7 - Purpose of Contacts:

The purpose of contacts is to report on and clarify test results, orders and instruct and assist others as required.

Factor 8 - Physical Demands:

The work requires regular and recurrent standing to perform tests, walking between the different sections of the laboratory and reading and bending to obtain supplies, troubleshoot and operate instruments. Occasionally lifts 30/40 pound containers of liquid reagents.

Factor 9-Work Environment:

The work involves moderate risks or discomforts associated with working in a chemical laboratory with regular and recurrent exposures to hazards such as infectious materials, chemicals, and electrical appliances. The CLS must use protective clothing and gear such as gloves, facemask, eye protectors, and biological safety hoods as deemed appropriate for the task.

5.2.4 The Contractor shall perform in accordance with the competency standards provided in the TJC guidelines, used as training guide by the department.

5.3 Work Schedule:

5.3.1 The Contract Clinical Laboratory Scientist at NNMC, will primarily work the night shift (8hrs, 10 hrs. or 12 hrs.) depending on the needs of the facility (Monday through Friday, weekends and/ or holidays) with 30 minutes unpaid lunch. The contractor shall qualify for some overtime hours if needed. Shift may vary depending on the patient workload and staffing.

5.3.2 Work Flexibility. As required by the PWS, the Contractor key personnel shall rotate into other duty sections as needed to support patient care.

5.3.3 Key Personnel shall notify the contractor in advance of any upcoming leave requests. The Contractor will in return notify the COR of the said leave.

5.3.4 Approval of leave is contingent upon availability of a qualified replacement.

The Government reserves the right to examine and or re-examine any Contractor who meets the criteria.

5.4 Conduct: The Contractor shall meet standards as listed in the Federal Code of

Conduct.

5.5 Performance Evaluation:

5.5.1 The Contractor key personnel’s performance will be evaluated in accordance with the standards set forth in the contract and Performance Requirements

Summary in table 8.0 See attached QUALITY ASSURANCE MONITORING FORM.

5.5.2 Substantiated reports written by any customer dealing with patient safety, infection control, or other procedure that adversely affects patient outcome constitutes a breach of contract.

5.6 Identification of Contractor:

5.6.1 The Contractor shall wear a government issued contractor identification badge during performance of duty.

5.7 Management of Medical Information: The Contractor shall manage all patient information in accordance with HIPAA standards, Privacy Act, and IHS Service Unit and/or Health Center specific policies and protocols.

5.7.1 Laboratory Records and Other Required Documentation: 100% percent of all laboratory records and other required documentation meets established IHS Medical Facility, Joint Commission, and CMS standards to include, but are not limited to, timeliness, legibility, accuracy, content, date, time, signature and designated profession. (Note: payment will be withheld for inaccurate or incomplete laboratory records per section 8.0 of this performance work statement.)

5.7.2 The Contractor shall ensure adherence to DHHS IT system security policies and procedures. The IT policies and procedures will be made available to the Contractor.

5.7.3 The Contractor shall immediately report to the Contracting Officer or COR any information or circumstances that may violate any statute, policy, or procedure.

5.8 IHS Information Technology Systems:

5.8.1 In performance of this contract, the Contractor shall adapt to and successfully utilize IHS information technology systems that are deemed by the Supervisor as necessary for acceptable contractor performance.

5.8.2 The Contractor shall ensure that IHS information technology system security policies and procedures are adhered to. The IT policies and procedures will be made available to the Contractor at each IHS facility.

5.8.3 The Key Personnel shall complete the Information Systems Security Awareness (ISSA) training within 24 hours of start date.

6.1 Contractor Qualification Requirements:

6.2 Education and Experience. The Contractor shall have proof of completion (e.g., copy of diploma and transcripts) of a Bachelor of Science degree in Medical Technology, Medical Laboratory Science or Clinical Laboratory Science, or a primary science (i.e., Biology, Chemistry, Microbiology, etc.). The Contractor key personnel shall have a minimum of twelve (12) months of Clinical Laboratory experience as a Generalist Medical Technologist, performing CLIA high complexity work in Hematology, Chemistry, Microbiology, Transfusion Medicine, and Urinalysis sections of the Core Laboratory.

6.3 Certification. All Clinical Laboratory Scientists, Medical Technologist, or Medical Laboratory Scientist shall hold a current (non-expired) certification as a Medical Technologist, or Medical Lab Scientist, or as Clinical Lab Scientist by the appropriate certifying agencies (i.e., ASCP, AMT, AAB certification, etc.).

6.2.1 Motor Vehicle Operator’s License. If required by the position, the Contractor shall possess a valid state driver’s license throughout the term of this contract.

6.4 Other Certifications. Current Basic Life Support (BLS)

6.5 Health Requirements/Conditions of Employment:

6.5.2 Immunization. The Contractor shall also provide the following documentation:

Immunity to Rubella, Mumps, Measles Immunity to Hepatitis B series Influenza vaccination History of chicken pox (varicella) disease or positive titer Tetanus Diphtheria (Td) within the last 5 years Documentation of receiving a TB skin test (PPD) within the past 12 months with documentation of follow-up for a positive test.

A signed declination of the Hepatitis B vaccination series will be accepted.

6.6 Language Requirements and Cultural Awareness. The Contractor shall read, understand, speak, and write English to effectively communicate with patients and other health care workers, and shall be respectful of the local, American Indian and Alaska Native culture.

6.7 Information Technology Skills. The Contractor shall possess basic knowledge, skills, and abilities to use a computer.

6.8 Orientation. All CLS, MLS or MTs providing service under this contract shall attend mandatory orientations and training specified by the government.

6.9 Background Checks: The Contractor shall comply with Agency Personal Identity Verification procedures identified in the contract that implement Homeland Security Presidential Directive-12 (HSPD-12), Office of Management and Budget (OMB) Guidance M-05-24, and Federal Information Processing Standards Publication (FIPS PUB) Number 201; this includes fingerprinting guidelines.

Background Checks: As directed by the Contracting Officer, the Contractor shall provide all requested information necessary to perform Level I and Level II background checks. The Contractor key personnel shall comply with the requirement to obtain security investigations. The Contractor shall work with the IHS to ensure that the pre-employment screening process includes the appropriate investigation questionnaires and forms to be completed. All completed forms will be reviewed by the Contractor and forwarded to the Government Personnel. The Contractor will be immediately removed from the position if at any time the investigation receives unfavorable adjudication, or, if other unfavorable information that would affect the investigation becomes known.

7.1 Challenges to Conflicts: For any inconsistency between the department guide’s directions, this Performance Work Statement attachments and exhibits, the following order of precedence will apply:

(a) First Priority: Department Lead

(b) Second Priority: Position Description (attached)

(c) Third Priority: Performance Work Statement Exhibits

(d) Fourth Priority: Performance Work Statement Narrative

8.0 Performance Requirements Summary

Performance-based Task

Indicator Standard Quality Assurance Incentives

Contractor shall provide CLS services in the delivery of patient care to the Navajo Area Indian Health Service at NNMC.

Competency

Compliance

Patient Outcomes

Professionalism

Documentation

Service Quality

Perform 100% required tasks at 100% of the required competencies (refer to 11.0)

100% compliance with IHS Service Units and/or Health Centers published Policies; Procedures;

Standards of Care; and hospital and Laboratory Protocols.

No reports of breached patient safety, infection control, and other procedures that might adversely affect patient outcome.

Performance is characterized by continual cultural awareness and focus on customer service. 100 percent adherence to the Code of Ethics and Federal Code of Conduct.

100% percent of all laboratory records and other required documentation meets established IHS Medical Facility, Joint Commission, and CMS standards to include, but are not limited to, timeliness, legibility, accuracy, content, date, time, and signature.

Satisfaction with quality of service is evidenced by valid customer inputs.

See QASP. Surveillance systems will include periodic inspections and customer complaints.

Payment of contract price for satisfactory service.

No p a y m e n t f o r incomplet e work.

Contractor performance will be evaluated using the Contractor Assessment Performance Report. The evaluation will be considered when future IHS contract selections are made.

PWS No. 10-15 APRIL 20, 2026

QUALITY ASSURANCE MONITORING FORM

This is an official form an MUST be completed by the designated Contracting Officer’s representative (COR)

The information collected on this form is derived from the Peer Review SRSU Provider Exit Profile Form to determine the overall performance of the contractor in meeting the requirements of the contract. The completed Peer Review SRSU Provider Exit Profile Form is a confidential and peer review document. The resultant overall point values, ratings, and performance checks of the Quality Assurance Monitoring Form will be reported onto the Contractor’s Performance Assessment Report

(CPAR).

The following information will be disclosed to the contractor:

1. Conversion of indicators to Summary Ratings

a. Average Score

2. Analysis of results

a. Contractor’s Performance Measurement Rate

b. Contractor’s Performance

i. Meets Requirements

ii. Does Not Meet Requirements

PURCHASE ORDER INFORMATION

Contractor’s Name (last, First, MI):

Specialty:

Vendor Name:

Purchase Order Number:

Appraisal Period: From: To:

MEASURED INICATOR RATINGS

The following guidance will be followed in determining an overall summary rating:

A rating will be ascribe to each indicator. This rating is derive from an the extent of the completed Peer Review Shiprock Service Unit Provider exit Profile to which the contractor’s performance meets the standard define in Section 10 of the Performance Work Statement.

The rating level definitions will be assigned a numerical score as follows:

Indicator Ratings Points Assigned Level 4: Exceptional (E) 4.00 Level 3: Fully successful (FS) 3.00 Level 2: Minimally Successful (MS) 2.00 Level 1: Unacceptable (U) 1.00

Attachment

QUALITY ASSURANCE MONITORING FORM

This is an official form an MUST be completed by the designated Contracting Officer’s representative (COR)

MEASURED INDICATORS

STANDARD: Contractors provided fully successful or excellent patient care rated under Element

1 & Element 3 of the Peer Review SRSU Provider Exit Profile (refer to Section 10.1 of the PWS). No reports of breached safety or other procedures that may have adversely affect patient outcomes.

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

(CHECK):

□ Semi-Annually □ Annually □ As needed

INDICATOR: Patient Care STANDARD: No reprimands or disciplinary actions for violations of published Policies;

Procedures; Standards of Care or Hospital Protocols. Element 1

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

INDICATOR: Compliance

Procedures; Standards of Care or Hospital Protocols.

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

INDICATOR: Cultural Sensitivity STANDARD: Contractors were compassionate and culturally sensitive (Elements 11).

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

INDICATOR: Documentation STANDARD: Contractors completed require documentation in clear and legible form in a timely manner (Element 2)

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

INDICATOR: Professionalism STANDARD: Contractors presented in professional appearance, demonstrated exceptional ethical conduct with effective communication and exhibited by being flexible and being adaptable (Element 4, Element 5 & Element 8).

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

INDICATOR: Productivity/Efficiency

Procedures; Standards of Care or Hospital Protocols. Element 6.

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

INDICATOR: Ability to Work With Oher Hospital Staff

Procedures; Standards of Care or Hospital Protocols. Element 4

RATING: □ E(4) □ FS (3) □ MS (2) □ U (1)

SURVEILLANCE

METHOD (Check):

□ Direct Inspection □ 100% Inspection

□ Periodic Inspection □ Analysis of Contractor’s Progress Reports

LEVEL OF

SURVEILLANCE

CONVERSION OF INDICATORS TO SUMMARY RATINGS

After rating and assigning a score to each indicator, the COR will total the points an divide that by the number of indicators to arrive at an average score (up to two decimal places). This score will be converted to a summary rating based on the following point values:

Average score will be calculated up to 2 (two) decimal places. This numerical score will then be converted to a summary rating, as follows:

Indicator Ratings Points Assigned Level 4: Achieved Exceptional Results (E) 3.50 to 4.00 Level 3: Achieved Fully successful Results (FS) 2.60 to 3.49 Level 2: Achieved Minimally Successful Results (MS) 2.00 to 2.59 Level 1: Achieved Unacceptable Results (U) 1.00 to 1.99

Analysis of Results Contractor’s Performance Measurement Average Score:___________________________

Contractor’s Performance Measurement Rate: ________________%___________

Indicator Ratings Points Assigned Contractor’s Performance Check Level 4: Achieved Exceptional Results (E) 3.50 to 4.00 Meets Requirements Level 3: Achieved Fully successful Results (FS) 2.60 to 3.49 Meets Requirements Level 2: Achieved Minimally Successful Results (MS) 2.00 to 2.59 Does Not Meets Requirements Level 1: Achieved Unacceptable Results (U) 1.00 to 1.99 Does Not Meets Requirements

Contractor’s Performance (Check): □ Meets requirements □ Does Not Meet Requirements

COR’s Narrative of Performance during Appraisal Period (Optional):

Total Point Value:

Divide by Number of Indicators:

= Average Score:

VALIDATION

□ This form is hereby validated by the COR and signed indicating the contractor meets the requirements of the contract.

□ This form is hereby validated by the COR and signed indicating the contractor the contractor does not meet the requirements of the contract.

COR SIGNATURE:__________________________________________ DATE: _____________________