Attachment A - PWS OR Scrub Tech Nursing Services.pdf

Attachment A – Performance Work Statement

PERFORMANCE WORK STATEMENT (PWS)

NON-PERSONAL SERVICE – Operating Room (OR) Scrub Technician Services

Table of Contents

Page

1.0 General 2

1.1 Background 2

2.0 Scope 2-3

3.0 Applicable Documents 3-4

4.0 Definitions 4-6

5.0 Government Furnished Information, Property & Services 6

6.0 Contractor Furnished Equipment 6-7

7.0 Performance-Work Statement (PWS) Requirements 7-9

7.1 Scrub Technician Duties

7.2 Work Schedule

7.3 Leave Requests

7.4 Timesheets

7.5 Ethics & Conduct

7.6 Performance Evaluation

7.7 Identification of Contractor

7.8 Management of Medical Information

7.9 IHS Information Technology Systems

8.0 Contractor Qualification Requirements 9-10

8.1 Experience

8.2 License/Registration Certifications

8.3 Motor Vehicle Operator’s License

8.4 Certifications

8.5 Health Requirements/Conditions of Employment

8.6 Immunization

8.7 Language Requirement and Cultural Awareness

8.8 Information Technology Skills

8.9 Orientation

8.10 Background Checks

9.0 Technical Direction 10-11

10.0 List of Attachments and Exhibits 11

Performance Work Statement (PWS) – Requirements Summary 12

1. General: This performance work statement describes the requirements for a Non-Personal Service Contract

Operating Room (OR) Scrub Technician Services to support the mission of the Indian Health Service (IHS) at the Northern Navajo Medical Center (NNMC) and associated Navajo Area facilities, as applicable.

1.1. 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.

There is a nationwide shortage of Scrub Technicians, a condition that is further amplified in the remote and rural areas served by the Indian Health Service (IHS). This Performance Work Statement (PWS) defines the requirements for the Navajo Area and Shiprock Service Unit, which includes Northern Navajo

Medical Center (NNMC), Dzilth-Na-O-Dith-Hle Health Center (DZHC), and Four Corners Regional Health

Center (FCRHC).

The positions to be filled under this PWS include Operating Room (OR) Scrub Technicians to provide comprehensive scrub technician services in both the Operating Room (OR) and Endoscopy Room settings.

1.2. The Operating Room (OR) service supports a full range of perioperative services, including endoscopy procedures, dental surgeries, general surgeries, obstetrics and gynecology (OB/GYN) procedures, minor oral and facial surgeries, and podiatry cases. Orthopedic procedures are infrequent. Northern Navajo

Medical Center (NNMC) does not perform urology, neurosurgery, or total joint replacement procedures.

Pediatric patients are primarily treated for general surgical and dental procedures. The maximum daily surgical volume is approximately fifteen (15) cases per day, including endoscopy procedures, with up to three (3) surgical cases scheduled to begin at 8:00 a.m.

2. Scope: The Contractor shall provide surgical scrub technician services in accordance with section 8.0, performance work statement requirements.

2.1. Overview of deliverables may encompass working the surgical team by working closely with the surgeon and other members of the surgical team. Scrub Technicians play a vital role in ensuring the safety and success of surgical procedures.

2.1.1. Operating Room (OR)

2.1.1.1. Perform scrub duties for scheduled and add-on surgical cases, functioning as a sterile member of the surgical team within demonstrated competency and training.

2.1.1.2. Prepare, set up, and maintain the sterile field, including selection and arrangement of surgical instruments, supplies, and equipment required for each procedure.

2.1.1.3. Adhere to infection prevention and control standards; maintain sterile technique throughout all surgical procedures; and support compliance with correct-site, correct-side, and correct-procedure verification, including participation in surgical time-outs per facility policy.

2.1.1.4. Anticipate the needs of the surgeon and surgical team by passing instruments, sutures, and supplies in a timely and safe manner during procedures.

2.1.1.5. Perform surgical counts (sponges, needles, instruments) in accordance with facility policy and assist with specimen handling and labeling as required.

2.1.1.6. Provide scrub support for the facility’s surgical case mix, including endoscopy, dental, general surgery, obstetrics and gynecology (OB/GYN), minor oral and facial procedures, and podiatry cases. Pediatric patients may be present primarily for general surgery or dental procedures.

2.1.2. Endoscopy Room

2.1.2.1. Perform scrub technician duties for endoscopic procedures, including preparation of the sterile field, assistance during procedures, handling of instruments and specimens, and support of room turnover in accordance with facility policies and procedures.

2.2. Place of Performance: Services are to be performed at hospitals, clinics and other healthcare facilities within the Shiprock Service Unit.

Primary Location: Northern Navajo Medical Center, US Hwy 491 North, Shiprock, NM 87420

2.3. Department: Operating Room Department.

2.4. Period of Performance: Shall be 1 Base Period + 4 Option Periods. Each contract period of performance shall contain a 6-month period of performance.

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

3.1. The Joint Commission (TJC) http://www.jointcommission.org

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

3.3. Accreditation Association for Ambulatory Health Care(AAAHC) https://www.aaahc.org

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

http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf

3.5. Section 4087 of Public Law 101-630, the Indian Child and Family Violence Act http://www.icctc.org/IHS-BIA%20CPT%Handbook/PL%201101-630.pdf

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

http://www.cms.gov/HIPAAGeninfo/

3.7. Privacy Act of 1974. http://www.justice.gov/opcl.privacyact1974.htm

3.8. Code of Ethics: Association of Surgical Technologists (AST) https://www.ast.org

3.9. IHS Service Unit and Health Center Policies, Procedures and Protocols. (See section 11.0 for a list of attachments and exhibits)

3.10. Computer Security Act of 1980 http://security.ihs.gov/index.cfm

3.11. Federal Code of Conduct: Contractor Code of Business Ethics and Conduct http://www.jointcommission.org/ http://www.cms.hhs.gov/ http://www.aaahc.org/ http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf http://www.icctc.org/IHS-BIA%20CPT%25Handbook/PL%201101-630.pdf http://www.cms.gov/HIPAAGeninfo/ http://www.justice.gov/opcl.privacyact1974.htm https://www.ast.org/ http://security.ihs.gov/index.cfm eCFR :: 48 CFR 52.203-13 -- Contractor Code of Business Ethics and Conduct. (FAR 52.203-13)

3.12. IHS General Directives http://www.ihs.gov/index.cfm?module=AtoZ&option=index

3.13. IHS Computer Security Directives: http://security.ihs.gov/index.cfm

4. Definitions

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

4.2. 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.

4.3. Area: A defined geographical region for Indian Health Service administrative purposes. Each Area Office may administer several Service Units.

4.4. Code of Ethics: Association of Surgical Technologists (AST)

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

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

4.7. Contracting Officer's Representative (COR): 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. COR- contracting Officer's Representative or GTR-Government Technical Representative,).

4.8. Contractor Performance Assessment Report: A report that assesses a contractor's performance and provides a record, both positive and negative, on a given contract for specific period of time.

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

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

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

4.12. 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.

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

https://www.ecfr.gov/current/title-48/chapter-1/subchapter-H/part-52/subpart-52.2/section-52.203-13 http://www.ihs.gov/index.cfm?module=AtoZ&option=index http://security.ihs.gov/index.cfm

4.14. 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.

4.15. 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.

4.16. Health Insurance Portability and Accountability Act (HIPAA): A US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

4.17. Non-Personal Service Contracts: means a contract under which the personnel rendering the services are not subject, either by the contract's terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees as defined in FAR 37.

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

4.19. 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.

4.20. Patient Outcome: End result of nursing care.

4.21. Performance Work Statement Matrix: lists the services to be monitored and the standards to be applied.

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

4.23. Service Unit: The local administrative unit of IHS.

4.24. Standards of Practice and Standards of Care: Authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable. The standards provide direction for professional nursing practice and a framework for the evaluation of practice. The standards of professional nursing practice may pertain to general or specialty practice.

4.25. Technical Direction: A directive to the Contractor that approves approaches, solutions, designs, or refinements; fills in details or otherwise completes the general description of work or documentation items; shifts emphasis among work areas or tasks; or furnishes similar instruction to the Contractor.

Technical direction includes requiring studies and pursuit of certain lines of inquiry regarding matters within the general tasks and requirements in Section 5 of this contract.

4.26. Tour of Duty: The time of day the technician is scheduled to perform scrub duties; also considered the shift of the day (8–10-hour Tour of Duty, Nurses/Scrub Technicians work 40 hours per week, Monday through Friday. They are also on call during weekends, holidays, nights, and evenings after regular work hours, typically for 4 on-call shifts per month. Weekend/Holiday coverage is rotated among nurses).

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

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

5. Government Furnished Information, Property and Services

5.1. 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.

5.2. Joint Use by the Government and the Contractor: 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.

5.2.1. Government Vehicle: If required by the position, authorization shall be in accordance with IHS

Manual, Chapter 9, Part 1 - Motor Vehicle Safety.

5.3. Contractor Exclusive Use:

5.3.1. Personal Protective Equipment (PPE). The Government will furnish the Contractor with appropriate PPE other than specified in section 7 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.

5.3.2. The Government will provide facility specific contractor identification badges for each contractor. A minimum fee of $20.00 will be charged for lost or destroyed badges.

5.4. Training: Facility specific training necessary for the Contractor to perform the required duties, e.g., IHS information technology (IT) systems and operational procedures. Training will be provided ONLY if the subject matter is necessary to improve or enhance the quality of nursing and surgical scrub services or includes mandates made by the service unit while the nurse is working under this contract. Training will not be provided for the purpose of continuing education, career development or individual development.

6. Contractor Furnished Property

6.1. Except for the property specified in section 5.0 as government furnished, the Contractor shall provide all uniforms and other personal medical instruments subject to the following:

6.1.1. Uniforms and Lab Coats: Uniforms and Lab Coats shall conform to the requirements of the Indian

Health Service Manual, Part 3, Chapter 6, and meet the approval of the SCN within the Shiprock

Service Unit or Northern Navajo Medical Center.

6.1.2. Other personal medical instruments: "Other personal medical instruments" are defined as

Contractor owned items may include but not limited to stethoscope, 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 Supervisory Clinical Nurse (SCN) prior to use by the Contractor. The Government reserves the right to prohibit the use of any materials, supplies, or equipment.

7. Performance Work Statement (PWS) Requirements.

7.1. Scrub Technician Duties:

7.1.1. The Contractor shall perform Scrub Technician duties and support patient care needs as described in this Performance Work Statement (PWS), and in accordance with technical direction provided by

Northern Navajo Medical Center’s (NNMC) Clinical Nursing Supervisor, also referred to herein as the Supervisory Clinical Nurse (SCN).

7.1.2. The Contractor shall be flexible and willing to support patient care needs by rotating to other departments as required, which may include serving as a patient sitter, assisting with patient transports, or providing support in other departments, as appropriate and within scope of practice.

7.1.3. The Contractor shall perform in accordance with the following competency standards:

7.1.3.1. Written Competency Standards

7.1.3.1.1. Confidentiality/HIPAA/Patient's Rights

7.1.3.1.2. EMTALA Compliance Exam, 2004

7.1.3.1.3. Age Specific Competency Verification

7.1.3.1.4. RN Medication Administration Competency Examination

7.1.3.1.5. RN Medication Administration Competency Verification

7.1.3.1.6. Intravenous Therapy Exam

7.1.3.1.7. Venipuncture Procedure Skills Competency Verification

7.1.3.1.8. Pain Management Competency Verification

7.1.3.1.9. Restraints

7.1.3.1.10. Soft Restraint Application Competency

7.1.3.2. Contract Nurse Orientation Check List I Health Stream

7.1.3.3. Contract Nurse Orientation Competency Verification Instructions

7.1.3.4. Contract Nurse Billing Information

7.1.3.5. Standard Emergency Codes

7.1.3.6. Confidentiality: Legal and Ethical Concerns in Healthcare

7.1.3.7. EMTALA- Emergency Medical Treatment and Labor Act

7.1.3.8. What are Age-Specific Competencies?

7.1.3.9. An Introduction to the Navajo Culture

7.1.3.10. Verbal and Telephone Orders

7.1.3.11. Medication Administration

7.1.3.12. Pain Management

7.1.3.13. Latex Allergy

7.1.3.14. Charting

7.1.3.15. Patient Restraints

7.1.3.16. Charge Nurse Duties: Responsibility and Expectation

7.1.3.17. Nursing Standards

7.1.3.18. Standards of Nursing Practice

7.2. Work Schedule:

7.2.1. Hours of Work: Scrub Techs should expect to work 8 – 10 hours dependent on patient needs.

Hours may include regular hours, call-back, or on-call as needed.

7.2.1.1. Regular hours are from 7:00 AM to 3:30 PM, Monday through Friday, plus on-call shifts as assigned.

7.2.1.2. Call-back hours occur outside regular schedule, including after hours, weekends, and holidays.

7.2.1.3. On-call hours occur outside regular schedule, on weekends, and on holidays. RN is required to respond within 15 minutes of notification. A sleep room shall be provided for on-call RNs, located adjacent to the hospital housing, for use only during on-call periods.

7.2.2. The Supervisory Clinical Nurse (SCN) for each department will provide technical direction on the specific tour of duty the contract nurse will work.

7.3. Leave Requests

7.3.1. The Contractor is responsible for establishing and administering its own leave policies and procedures. The Contractor shall be solely responsible for managing leave, absences, and scheduling of its personnel. This includes establishing internal procedures for requesting, approving, and coordinating leave.

7.3.2. The Contractor shall coordinate leave in a manner that ensures continuity of services and always maintains adequate staffing levels. Contractor personnel availability shall be managed so that performance requirements are consistently met, and services are delivered without disruption.

7.3.3. The Contractor is responsible for ensuring that leave or absences do not adversely impact the quality, timeliness, or effectiveness of services, including maintaining appropriate coverage to support patient care requirements.

7.3.4. The Contractor shall ensure that staffing levels remain sufficient to meet all contract requirements and performance standards, regardless of individual personnel availability. Any internal staffing adjustments necessary to maintain performance are the responsibility of the Contractor.

7.3.5. Leave must be contingent upon availability of adequate staffing.

7.3.6. The key personnel must notify their Supervisor, the Contractor and COR for any leave requests.

7.4. Timesheets: The contractor shall track timesheets and ensure accurate tracking of hours worked to allow for correct billing. The government shall provide a blank timesheet template for use to track hours for billing. The contractor shall use blank template or provide the contractor with a blank timesheet copy for accurate tracking.

7.4.1. Timesheets shall be verified by SCN each week for correct billing purposes.

7.5. Ethics & Conduct: The Contractor shall meet standards as listed in the Federal Code of Conduct:

Contractor Code of Business Ethics and Conduct.

7.5.1. The Government reserves the right to examine and or re-examine any Contractor who meets the criteria of unplanned absences and does not meet performance standards as listed herein this PWS.

7.6. Performance Evaluations:

7.6.1. The Contractor's performance will be evaluated in accordance with the standards set forth in the contract and Performance Work Statement Requirements Summary.

7.6.2. 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.

7.7. Identification of Contractor:

7.7.1. The Contractor shall wear a government issued contractor identification badge during performance of duty. The identification badge, any other assigned keys or badges that are given upon starting the contract must be returned to the supervisor upon completion of contract or service end date.

7.8. Management of Medical Information: The Contractor shall manage all patient information in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards, Privacy Act, and IHS Service

Unit and/or Health Center specific policies and protocols.

7.8.1. 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.

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

7.9. IHS Information Technology Systems:

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

7.9.2. 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.

8. Contractor Qualification Requirements:

10.0 The Contractor shall have a minimum of two (2) years of Operating Room experience, as required by this contract.

8.1. Certifications:

8.1.1. Current Basic Life Support (BLS) is mandatory with the American Heart Association

8.1.2. The contractor shall ensure that the contract nurse's certifications remain valid throughout the term of this contract.

8.2. Health Requirements/Conditions of Employment:

8.2.1. Medical Evaluation. The Contractor shall provide a fitness for duty certificate issued by a licensed physician to perform the proposed job without significant risk to personal health or the health and safety of others.

8.3. Immunization. The Contractor shall also provide the following documentation prior to RN Candidate selection:

8.3.1. Immunity to Rubella, Mumps, and Rubeola (Measles);

8.3.2. Proof of Hep B vaccination x3 OR positive titer OR a signed declination of the Hep B vaccinations will also be accepted;

8.3.3. Documented history of chicken pox OR varicella vaccination x2 OR positive varicella titer;

8.3.4. History of Tdap vaccination, with subsequent Td vaccination if older than 10 years;

8.3.5. Documentation of Tuberculosis testing (TB skin test or IGRA) within the past 12 months with documentation of chest x-ray and follow-up for a positive history;

8.3.6. 12 months with documentation of follow-up for a positive test.

8.3.7. Proof of influenza vaccination from October -1 thru March 31, per IHS Mandatory Influenza

Vaccination Policy.

8.4. 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.

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

8.6. Orientation. All nurses providing service under this contract shall attend mandatory orientations and training specified by the government.

8.7. Background Checks: As directed by the Contracting Officer, the Contractor shall provide all requested information necessary to perform background checks. The Contractor 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.

9. Technical Direction:

9.1. Performance of work under this contract shall be carried out in accordance with the terms and conditions of the contract. The Government may provide clarifications, interpretations, or administrative guidance related to the contract requirements through the SCN.

9.2. The SCN is not authorized to alter the terms and conditions of the contract. Accordingly, any communication from the SCN shall not be construed as:

9.2.1. An assignment of work outside the Performance Work Statement;

9.2.2. A contract change as defined under the Changes clause;

9.2.3. Direction that would result in an increase or decrease in contract cost, fixed fee (if any), or performance schedule;

9.2.4. A modification of any contract terms, conditions, or specifications.

9.3. The Contractor remains solely responsible for determining the manner and means of performing the work required under this contract. If the Contractor believes that any communication from the SCN is inconsistent with the contract requirements, the Contractor shall notify the Contracting Officer in writing within five (5) working days and request clarification. The Contracting Officer will review the matter and, as appropriate, provide written clarification or issue a formal contract modification.

9.4. If the Contractor and Contracting Officer do not reach agreement regarding whether a matter constitutes a contract change or the appropriate course of action, the issue shall be resolved in accordance with the

Disputes clause of the contract.

9.5. Only the Contracting Officer has authority to modify the terms of the contract. The Contractor shall not rely on any communication from individuals other than the Contracting Officer as authorization to change contract requirements.

10. Attachments:

A. Operating Room (OR) Department - Scrub Technicians

1. Department specific competencies

2. Blank timesheet template

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Northern Navajo Medical Center: PeriOperative – Surgical Tech Orientation Competency

Employee Name/Title: ________________________________________ Date: _______________ Dept: ___________________

Permanent: __________ Contract: __________

Please consult provided Competency Book or PDF File to view/review each competency listed.

SELF EVALUATION HOW COMPETENCY/SKILL IS VALIDATED EXPERIENCE LEVEL

1. Have not experienced before

2. Know principle, but have not performed

3. Have performed but not recently, need review

4. Feel comfortable and competent in activity/skill

Competency will be validated by:

Direct observation (D) Simulation (S) Return Demonstration (RD) Test (T) Class (C ) Verbalize (V)

Use the appropriate letter in the column “How Validated”

1. Acquired some experience (may require practice, assistance) = Fail

2. Competent and/or can perform independently = Pass

3. Competent, performs independently, and is able to teach and/or assess the competency of others = Pass

Use the appropriate number in the column “Experience Level”

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

Equipment Competencies

1. 4K Wolf Laparoscopic tower

2. Arthrex Arthroscopy Pump

3. Berkeley Vacuum Curettage System

4. C-arm & Mini c-arm

5. Drill power (MicroAire direct power console)

6. Electrical Surgical Unit – Valley Lab

7. Olympus CV-200 Endo camera

8. Myosure Fluent Fluid Management System

9. Medtronic Situate Detection System

10. GE Panda Warmer

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11. Stryker Neptune

12. Conmed Buffalo Filter

13. SchureMed Candy Cane & YelloFin Stirrups

14. Skytron OR Table 3503 EZ Slide and 6300 Elite

15. Zimmer A.T.S. 4000TS Tourniquet

16. EndoDry Cabinet

17. Air transfer mat

18. Blanket Warmer

Skills & Procedures

19. Endoscopes – Precleaning at Point of Use

20. Instruments – Precleaning at Point of Use

21. Surgical hand scrubbing

22. Time-Outs

23. Counts – Sponges/Needles/Sharps/Instruments

24. Patient positioning (surgical position, safety)

25. Sterile field/Sterile Technique

26. Sterile gowning and gloving

27. Surgical Tech Core competency

Infection Control

28. Hand hygiene

29. PPE – Basic and COVID

Communication & Safety

30. Overhead Paging with Plain Language

Validating Initials & Signatures:

Initials Signature Initials Signature

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Acknowledgement:

By signing this competency validation, I attest that I take responsibility for the contents therein. I have to the best of my knowledge and skills, verbalized and or demonstrated my competency for all topics and skills listed above. I will actively seek out resources for review of skills, as needed, in regular clinical practice.

Printed Name:___________________________________________ Signature: _________________________________________ Date: ___________

Clinical Coach Signature: _____________________________________ Date: _____________________

Supervisor Signature: (only required if multiple failed attempts) ______________________________________ Date: ___________________

Quizzes/tests can be added here and graded in addition to skill assessment. Duplicate as needed.

Comments:

Knowledge Assessment

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Northern Navajo Medical Center: PeriOperative – Surgical Tech Annual Competency

Employee Name/Title: ________________________________________ Date: _______________ Dept: ___________________

Permanent: __________ Contract: __________

Please consult provided Competency Book or PDF File to view/review each competency listed.

SELF EVALUATION HOW COMPETENCY/SKILL IS VALIDATED EXPERIENCE LEVEL

1. Have not experienced before

2. Know principle, but have not performed

3. Have performed but not recently, need review

4. Feel comfortable and competent in activity/skill

Competency will be validated by:

Direct observation (D) Simulation (S) Return Demonstration (RD) Test (T) Class (C ) Verbalize (V)

Use the appropriate letter in the column “How Validated”

1. Acquired some experience (may require practice, assistance) = Fail

2. Competent and/or can perform independently = Pass

3. Competent, performs independently, and is able to teach and/or assess the competency of others = Pass

Use the appropriate number in the column “Experience Level”

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

Equipment Competencies

1. Arthrex Arthroscopy Pump

2. Myosure Fluent Fluid Management System

3. Medtronic Situate Detection System

4. Stryker Neptune

Skills & Procedures

5. Endoscopes – Precleaning at Point of Use

6. Instruments – Precleaning at Point of Use

7. Transporting Instruments to and from SPD

8. Count – Sponges/Needles/Sharps/Instruments

Infection Control

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9. Hand hygiene

10. PPE – Basic and COVID

Validating Initials & Signatures:

Initials Signature Initials Signature

Acknowledgement:

By signing this competency validation, I attest that I take responsibility for the contents therein. I have to the best of my knowledge and skills, verbalized and or demonstrated my competency for all topics and skills listed above. I will actively seek out resources for review of skills, as needed, in regular clinical practice.

Printed Name:___________________________________________ Signature: _________________________________________ Date: ___________

Clinical Coach Signature: _____________________________________ Date: _____________________

Supervisor Signature: (only required if multiple failed attempts) ______________________________________ Date: ___________________

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Quizzes/tests can be added here and graded in addition to skill assessment. Duplicate as needed.

Comments:

Knowledge Assessment

WEEKLY NURSING TIMESHEET

WEEK OF:

FACILITY NAME:

NORTHERN NAVAJO MEDICAL CENTER

EMPLOYEE NAME: CONTACT INFO:

PO NUMBER: PCN #:

DEPARTMENT: SUPERVISOR:

REGULAR HOURS

DATE DAY

START

TIME

LUNCH

(mins)

END

TIME

TOTAL

HOURS NOTES

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

WEEKLY

TOTALS

EMPLOYEE: I CERTIFY THAT THE HOURS SHOWN ABOVE REPRESENT MY TOTAL HOURS

WORKED AND THAT THEY ARE PROPERLY VERIFIED.

EMPLOYEE SIGNATURE: DATE:

SUPERVISOR SIGNATURE: DATE:

COMPANY NAME

Use increments of .25

Use increments of .25

BILL TO LINE:

PERFORMANCE WORK STATEMENT (PWS) MATRIX

IDENTIFICATION OF REQUIRED PERFORMANCE STANDARD/QUALITY LEVELS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Government shall use these standards to determine contractor performance.

TASK ID INDICATOR STANDARD ACCEPTABLE

QUALITY LEVEL

METHOD OF

SURVEILLANCE

INCENTIVE

The Contractor shall provide Scrub Technicians for the delivery of patient care in accordance with this Performance Work Statement (PWS) within the Operating Room (OR) Department at Northern Navajo Medical Center (NNMC), Shiprock, New Mexico.

A Care for Sterile Surgical Field/Surgical Patient

Scrub Technicians shall provide patient care support as a sterile member of the surgical team in accordance with this Performance Work Statement (PWS), facility policies, and established standards of practice.

A rating or “Fully

Successfully or

“Exceptional” must be attain on the Peer Review

NAO Provider Exit Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract price for satisfactory service.

Favorable CPAR report

B Compliance No reprimands or disciplinary actions or violations of published Policies;

Procedures; Standards of Care or

Hospital Protocols

No reprimands or disciplinary actions

Periodic inspection, 100% inspection and an analysis of contractor’s progress reports

Payment of

C Culturally Sensitivity

Contractors were compassionate culturally sensitive

A rating or “Fully

Successful” or

“Exceptional” must be attain on the Peer Review NAO Provider Exit

Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of

D Documentation Contractors completed require documentation in clear and legible form in a timely manner. (Element 6)

A rating or “Fully

Successful” or

“Exceptional” must be attain on the Peer Review

NAO Provider Exit

Profile Form.

Periodic inspection, 100% inspection and an analysis of contractor’s progress reports

Payment of

E Professionalis m

Contractors presented in professional appearance demonstrated exceptional ethical conduct with effective communication, and exhibited exemplary attitude by being flexible and being adaptable. (Element 4, Element 5

Element 8)

A rating or “Fully

Successful” or

“Exceptional” must be attain on the Peer Review

NAO Provider Exit

Profile Form.

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of