Attachment A - PWS Tour Coordinator Nursing Services.pdf

PERFORMANCE WORK STATEMENT (PWS)

NON-PERSONAL SERVICE – Tour Coordinator Nursing 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 6-7

6.0 Contractor Furnished Equipment 7

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

7.1 Nursing 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 10-11

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 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 for Registered Nurse (RN) Tour Coordinator nursing 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.

1.2. There is a nationwide shortage of nurses which is amplified by the remote and rural areas served by the Indian Health Service. This performance work statement covers 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 position(s) to be filled include Registered Nurse (RN) for the provision of Tour Coordinator services.

1.3. NNMC requires tour coordinators within the nursing department to help manage the flow of patients, staff, and resources across shifts in a complex hospital environment. Ongoing nursing staffing pressures and high patient volumes make real-time coordination essential, especially during peak hours, admissions, and emergencies. Tour coordinators ensure appropriate staffing coverage, facilitate communication between units, and help resolve operational issues as they arise.

1.4. This role is important because it supports patient safety, reduces delays in care, and improves overall efficiency. By maintaining situational awareness across the hospital, tour coordinators help prevent bottlenecks, support clinical teams, and ensure that patients receive timely, well-coordinated care.

2. Scope: Scope: The Contractor shall provide Tour Coordinator duties in accordance with the performance work statement requirements.

2.1. Overview of deliverables may encompass Tour Coordinator services overseeing hospital operations, ensuring quality patient care, managing staff, and handling administrative tasks.

2.1.1. Patient Care Oversight:

2.1.1.1. Ensures patient care is delivered effectively and efficiently across all departments.

2.1.1.2. Address patient needs and concerns, collaborating with healthcare professionals and facilities to resolve issues, including transports.

2.1.2. Staff Management:

2.1.2.1. Supervise Nursing staff, coordinating with Supervisors ensuring adequate staffing levels each shift.

2.1.3. Administrative duties:

2.1.3.1. Handle various administrative tasks, documenting incidents, ensuring compliance with healthcare regulations, and reporting issues to senior management.

2.1.4. Crisis Management:

2.1.4.1. Address any emergencies or unexpected situation that arise during shift, ensuring appropriate actions are taken considering patient care, compliance, and life safety.

2.1.5. Communication:

2.1.5.1. Acts as a liaison between patients, families, and healthcare providers, facilitating communication to ensure that all parties are informed and involved in care decisions.

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: Nursing

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. Revised American Nurses Association Code of Ethics and Standards of Practice and Care (1996) http://www.nursingworld.org

3.9. State Nurse Practice Act for the Contractor's licensing state. http://www.medi-smart.com/

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

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

3.12. Federal Code of Conduct: Contractor Code of Business Ethics and Conduct eCFR :: 48 CFR 52.203-13 -- Contractor Code of Business Ethics and Conduct. (FAR 52.203-13)

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

3.14. 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: The Revised American Nurses Association Code of Ethics and Standards of Practice and Care, published in 1996 by the American Nurses Association which makes explicit primary goals, values and obligations of the nursing profession.

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.

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 Tour Coordinator 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 Requirements summary: 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 Coordinator: The official title of the position in IHS is Tour Coordinator. A Tour Coordinator is one who coordinates hospital operations during assigned shifts, ensuring safe, efficient patient care and compliance with policies and regulatory standards. Coordinate staffing, patient transport, respond to emergencies, and serve as the primary point of contact for clinical and administrative issues across departments.

4.27. Tour of Duty: The time of day the Tour Coordinator is scheduled to perform duties; also considered the shift of the day (8-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).

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

4.29. 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 6. 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 services or includes mandates made by the service unit while the Tour Coordinator 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 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. Nursing Duties:

7.1.1. The Contractor shall perform Tour Coordinator patient care coordination duties to meet the standard for safe patient care delivery in the hospital (outpatient and inpatient) in accordance with technical direction provided by NNMC's Patient Care Coordinator Supervisor Nurse or designee.

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

7.1.2.1. Written Competency Standards

7.1.2.1.1. Confidentiality/HIPAA/Patient's Rights

7.1.2.1.2. Association of Perioperative Registered Nurses (AORN)

7.1.2.1.3. American Society of PeriAnesthesia Nurses (ASPAN)

7.1.2.1.4. Association for the Advancement of Medical Instrumentation (AAMI)

7.1.2.1.5. EMTALA Compliance Exam, 2004

7.1.2.1.6. Age Specific Competency Verification

7.1.2.1.7. RN Medication Administration Competency Examination

7.1.2.1.8. RN Medication Administration Competency Verification

7.1.2.1.9. Intravenous Therapy Exam

7.1.2.1.10. Venipuncture Procedure Skills Competency Verification

7.1.2.1.11. Pain Management Competency Verification

7.1.2.1.12. Restraints

7.1.2.1.13. Soft Restraint Application Competency

7.1.2.2. Contract Nurse Orientation Check List I Health Stream

7.1.2.3. Contract Nurse Orientation Competency Verification Instructions

7.1.2.4. Contract Nurse Billing Information

7.1.2.5. Standard Emergency Codes

7.1.2.6. Confidentiality: Legal and Ethical Concerns in Healthcare

7.1.2.7. EMTALA- Emergency Medical Treatment and Labor Act

7.1.2.8. What are Age-Specific Competencies?

7.1.2.9. An Introduction to the Navajo Culture

7.1.2.10. Verbal and Telephone Orders

7.1.2.11. Medication Administration

7.1.2.12. Pain Management

7.1.2.13. Latex Allergy

7.1.2.14. Charting

7.1.2.15. Patient Restraints

7.1.2.16. Charge Nurse Duties: Responsibility and Expectation

7.1.2.17. Nursing Standards

7.1.2.18. Standards of Nursing Practice

7.2. Deliverables:

7.2.1. Collaborates with departments to coordinate bed assignment and patient care activities and support activities to ensure a smooth hospital operation during the assigned shift.

7.2.2. Coordinates admissions, discharges, and transfers (intra-and, interfacility) of patients and documents disposition in shift reports. Shift reports are then sent to Nursing Administration and Executive Leadership via email through Secure Data Transfer (SDS).

7.2.3. Utilizes the Electronic Health Record and Patient Classification System to document patient disposition or to determine patient needs.

7.2.4. Coordinates callback for support departments, i.e. Facilities, Bio-Med, Laboratory, Radiology, Operating Room staff, Motor Vehicle Operators, and Medical Staff.

7.2.5. Makes nursing rounds on the units during the shift to evaluate patient care needs, staffing, environmental, and safety aspects and calls in required resources if needed.

7.2.6. Assists with patient care in emergency situations utilizing the nursing process and observes patients for conditions that may require emergency measures and exercises sound judgment in interpreting observations to the physician.

7.3. Work Schedule:

7.3.1. The Patient Care Coordinator Supervisor Nurse or designee will provide technical direction on the specific tour of duty the Tour Coordination will work. The hours for this position are a rotating shift of days, evenings, nights and weekends including Holidays.

7.4. Leave Requests

7.4.1. The Contractor shall establish, implement, and administer its own leave policies and procedures.

The Contractor is solely responsible for managing leave, absences, and scheduling of its personnel, including the development of internal processes for requesting, approving, and coordinating leave.

7.4.2. The Contractor shall coordinate all leave in a manner that ensures continuity of services and maintains adequate staffing levels at all times. Personnel availability shall be managed to consistently meet all performance requirements without disruption to services.

7.4.3. 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.

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

7.4.5. Approval of leave shall be contingent upon the Contractor’s ability to maintain adequate staffing levels and uninterrupted service delivery.

7.4.6. The Contractor shall ensure that all key personnel provide timely notification of leave requests and coordinate such requests with the Supervisor and the Contracting Officer’s Representative (COR) in advance, in accordance with established procedures, to ensure proper coverage and continuity of services.

7.5. 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 nursing contractor with a blank timesheet copies for accurate tracking.

7.5.1. Timesheets shall be verified by Patient Care Coordinator Supervisor Nurse or designee each week for correct billing purposes.

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

Contractor Code of Business Ethics and Conduct.

7.6.1. 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.

7.7. Performance Evaluations:

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

7.7.2. 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.

7.8. Identification of Contractor:

7.8.1. 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.

7.9. 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.

7.9.1. 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.

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

7.10. IHS Information Technology Systems:

7.10.1. 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.

7.10.2. 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:

8.1. Experience: The Tour Coordinator shall have thirty-six (36) months of nursing experience, with a minimum of two (2) years in the Tour Coordinator environment. Experience must include performance improvement projects and measures, applying evidence-based practice, and data collection and analysis.

8.2. License/Registration: All Tour Coordinators shall possess a current, valid, unrestricted nursing license in a state, the District of Columbia, the Commonwealth of Puerto Rico, or a Territory of the United States, throughout the term of this contract.

8.2.1. Bachelor of Science in Nursing (BSN) required

8.3. Certifications:

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

8.3.2. Advanced Cardiac Life Support (ACLS) with the American Heart Association is required

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

8.4. Health Requirements/Conditions of Employment:

8.4.1. 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.

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

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

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

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

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

8.5.5. 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;

8.5.6. 12 months with documentation of follow-up for a positive test.

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

Vaccination Policy.

8.6. 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.

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

8.8. Orientation. The Tour Coordinator under this contract shall attend mandatory orientations and training specified by the government.

8.9. 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 subject to the technical direction of the Patient Care Coordinator Supervisor Nurse or designee. The Tour Coordinator shall receive and act upon such direction as it relates to coordination of patient care activities and day-to-day operational support within the scope of the Performance Work Statement (PWS).

8.2 The Patient Care Coordinator Supervisor Nurse or designee is not authorized to, and shall not, issue any direction that:

9.2.1. Requires performance 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 Patient Care Coordinator Supervisor Nurse or designee 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. Tour Coordinator

1. Role specific competencies

2. Blank timesheet template

P a g e

N or th er n N av aj o M ed ic al C en te r:

To ur C oo rd in at or O rie nt at io n Co m pe te nc y

E m pl oy ee N am e/

T it le

D at e:

ep t:

P er m an en t:

C on tr ac t:

P le as e co ns ul t pr ov id ed

C om pe te nc y

B oo k or

P D

F Fi le t o vi ew /r ev ie w e ac h co m pe te nc y lis te d.

SE

LF

E

VA

LU

AT

IO

N

HO

W

C O

M

PE

TE

N

CY

/S

KI

LL

IS

V

AL

ID

AT

ED

EX

PE

RI

EN

CE

LE

VE

L 1.

Ha ve n ot e xp er ie nc ed b ef or

2.

Kn ow p rin cip le , b ut h av e no t pe rfo rm ed

3.

p er fo rm ed b ut n ot re ce nt ly ne ed re vi ew

4.

Fe el co m fo rt ab le a nd co m pe te nt in ac tiv ity /s ki ll

Co pe te nc y w ill b e va lid at ed b y:

Di re ct o bs er va tio n (D

Si ul at io n

(S

Re tu rn

D em on st ra tio n (R

D)

Te st (T

Cl as s (

Ve rb al ize

(V

Us e th e ap pr op ria te le tt er in th e co lu m n “H ow V al id at ed

Ac qu ire d so m e ex pe rie nc e

(m ay ire p ra ct ice

, a ss ist an ce

F ai l

C o pe te nt a nd

/o r c an p er fo de pe nd en tly

P as s pe te nt , p er fo rm s i nd ep en de nt ly an d is ab le to te ac h an d/ or a ss es s t he co pe te nc y of o th er s =

P as s Us e th e ap pr op ria te n um be r i n th e co lu m n “E xp er ie nc e Le l” pe te nc y

Se lf

Ev al

Va lid at io n

Ty pe

Ex rie nc e

Le ve l Va lid at

In iti al s Da

Eq ui pm en t C om pe te nc ie

AE

( A ut om at ed e xt er na l d ef ib ril la to r)

De fib ril la to r

Cr h ca rt

M ito rs

(N ih on K oh n)

5.

Nu rs e

Ca ll-

Lig ht

S ys

6.

Tr an sp t

Sk ill s & P ro ce du

7.

Ch ap er

8.

ca l L ab

N ot ifi ca tio n

9.

sp os ab le in st ru m en ts

P a th er n N av aj o M ed ic al C en te r:

To ur C oo rd in at or O rie nt at io n Co m pe te

. I ns tr um en t C le an in g So lu

. S itt er

. M al ig na nt

H yp er th er m ia (M

H)

. R es tr ai nt s ( be ha vi or al a nd v io le

. F al l P re ve nt io

. P O

C w ith cl ea ni ng

. B ac k up

P O

C w ith cl ea ni ng pe te nc y Se lf at io n rie nc e Le ve l

Va lid at al s ic at io n

Ad m in ist ra

CM

A ed ica tio n Ad m in ist ra tio n-

Ba sic

. A na ph yl ax is yx is

IV

s, P hl eb ot om y, B lo od

A dm in ist ra lo od

A dm in ist ra lo od

C ul tu re

C ol le ct io

TP

fe ct io n Co nt ro

. H an d

Hy gi en oi nt o f u se cl ea ni ng fo r r eu sa bl e m ed ica l d ev ice m un ic at io n

S af et

. E

HR

-B as ic Us

. H an do ff-

SB

AR

. O ve rh ea d

Pa gi ng /P la in

La ng ua ge

To ur

C oo rd in at or sp ec ifi c ro vi de s a nd m ai nt ai ns le ad er sh ip th ro ug ho ut th e fa cil ity

. C on du ct s R ou nd s t o ev al ua te p at ie nt ca re

, s ta ffi ng

, e nv iro nm en ta l an d sa fe ty a sp ec ts in fa cil ity

. C oo rd in at es p at ie nt a dm iss io ns

, d isc ha rg ed , a nd tr an sf s.

P a th er n N av aj o M ed ic al C en te r:

To ur C oo rd in at or O rie nt at io n Co m pe te rr an ge fo r i nt ra /in te r f ac ili ty tr an sp ts ev ie w s p ol ici es , p ro ce du re s, an d st an da rd s, un io n ag re em en ts an d em er ge nc y co de s t o en su re sm oo th a nd e ffi cie nt h os pi ta l f lo w

. I s k no w le dg ea bl e fo r E m er ge nc y co de s a nd re sp on ds to e h.

ss ist st af f i n ad he re nc e to re st ra in t p ol icy a nd p ro ce du ep or ts a ll pa tie nt d ea th s t o

NM

D on or

S er vi ce s w ith in m in ut es of ti m e of d ea th

. U nd er st an ds a nd u til ize s c al l-b ac k lis t f or a fte r h ou rs a n ne ed

O ffi ce sk

Na va jo In te rp re r

Tr an sf er

P k

Up da te d by V

J 3 /1

0/ at in g In iti al s & S ig na tu s:

al s

S ig na al s

Si gn at kn ow le dg em en t:

By si gn in g th is co m pe te nc y va lid at io n, I at te st th at I ta ke re sp on sib ili ty fo r t he co nt en ts th er ei n.

I h av e to th e be st o f m y kn ow le dg e an d sk ill s, ve rb al ize d an d or d em on st ra te d m y co m pe te nc y fo r a ll to pi cs a nd sk ill s l ist ed a bo ve

. I w ill a ct iv el y se ek o ut re so ur ce s f or re vi ew o f s ki lls , a s ne ed ed

, i n re gu la r c lin ica l p ra ct ice

Pr in te d

N am e:

S ig na tu re ic al

C oa ch S ig na tu re

P a th er n N av aj o M ed ic al C en te r:

To ur C oo rd in at or A nn ua l C om pe te

E pl oy ee N am e/

T it le at e:

ep t:

P er m an en t:

tr ac t:

P le as e co ns ul t pr ov id ed

C om pe te nc y

B oo k or

P D

F Fi le t o vi ew /r ev ie w e ac h co m pe te nc y lis d.

SE

LF

E

VA

LU

AT

IO

N

HO

W

C O

M

PE

TE

N

CY

/S

KI

LL

IS

V

AL

ID

AT

ED

EX

RI

EN

CE

LE

VE

L n ot e xp er ie nc ed b ef or

Kn ow p rin cip le , b ut h av e no t p er fo p er fo rm ed b ut n ot re ce nt ly

, n ee d re ew

Fe el co m fo rt ab le a nd co m pe te tiv ity /s ki pe te nc y w ill b e va lid at ed b y:

ct o bs er va tio n (D

Si ul at io n

(S rn

D em on st ra tio n (R

D)

Te

(T s (

Ve rb al ize

(V

Us e th e ap pr op ria te le tt er in th e co lu m n “H ow V al id at ed ire d so m e ex pe rie nc e

(m ay ire p ra ct ice

, a ss ist an ce

F ai pe te nt a nd

/o r c an p er fo pe nd en tly

P as pe te nt , p er fo rm s i nd ep en de nt ly an d is ab le to te ac h an d/ or a ss es s t he co pe te nc y of o th er s =

P as s Us e th e ap pr op ria te n um be r i n th e co lu m n “E xp er ie nc e Le ve l”

Co m pe te nc y

Se lf at io n rie nc e

Le ve l Va lid at al s

Eq ui pm en t C om pe te nc ie h ca rt

Sk ill s &

P ro ce du ig na nt

H yp er th er m ia (M

H) ra in ts

(b eh av io ra l a nd v io le

Fa

Pr ev en pe te nc y Se lf at io n rie nc e Le ve l

Va lid at al s ic at io n

Ad m in ist ra

5.

An ap hy la xis

IV

s, P hl eb ot om y, B lo od

A dm in ist ra

6.

TP

fe ct io n Co nt ro m un ic at io n

S af et

To

C oo rd in at or sp ec ifi c

P a th er n N av aj o M ed ic al C en te r:

To ur C oo rd in at or A nn ua l C om pe te

7.

ew s p ol ici es , p ro ce du re s, an d st an da rd s, un io n ag re em en ts an d em er ge nc y co de s t o en su re sm oo th a nd e ffi cie nt h os pi ta l f lo w

8.

po rt s a ll pa tie nt d ea th s t o

NM

D on or S er vi ce s w ith in m in ut es of ti m e of d ea th

9.

Un rs ta nd s a nd u til ize s c al l-b ac k lis t f or a fte r h ou rs a n ne ed

O ffi ce sk

Up da te d by V

J 5 /2

5/ at in g In iti al s & S ig na tu s:

al s

S ig na al s

Si gn at kn ow le dg em en t:

By si gn in g th is co m pe te nc y va lid at io n, I at te st th at I ta ke re sp on sib ili ty fo r t he co nt en ts th er ei n.

I h av e to th e be st o f m y kn ow le dg e an d sk ill s, ve rb al ize d an d or d em on st ra te d m y co m pe te nc y fo r a ll to pi cs a nd sk ill s l ist ed a bo ve

. I w ill a ct iv el y se ek o ut re so ur ce s f or re vi ew o f s ki lls , a s ne ed ed

, i n re gu la r c lin ica l p ra ct ice

Pr in te d

N am e:

S ig na tu re ic al

C oa ch S ig na tu re

Su rv iso r S ig na tu re on ly re qu ire d if m ul tip le fa ile d at te m pt s)

WEEKLY TIMESHEET

WEEK OF:

FACILITY NAME:

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

PERFORMANCE WORK STATEMENT (PWS)

REQUIREMENTS SUMMARY

2. 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

Contractor shall provide Tour Coordinator services for the delivery of patient care in accordance with this PWS in the Nursing department at the Northern Navajo Medical Center, Shiprock, NM.

A Patient Care Oversight

Ensures patient care is delivered effectively and efficiently across all departments.

No reports of breached safety or other procedures that may have adversely affect patient outcomes.

A rating or “Fully Successfully or “Exceptional”

No reports of breached safety

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

Payment of contract price for satisfactory service.

Favorable CPAR report

B Staff Management

Ensuring adequate staffing levels.

No reprimands or disciplinary actions or violations of published Policies;

Procedures; Standards of Care or Hospital Protocols

A rating or “Fully Successful” or

No reprimands or disciplinary actions

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

Payment of

C Administrative Duties

Handle various administrative tasks, documenting incidents, ensuring compliance with healthcare regulations, and reporting issues to senior management.

No reprimands or disciplinary actions or violations of published Policies;

Procedures; Standards of Care or Hospital Protocols

A rating or “Fully Successful” or

No reprimands or disciplinary actions

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

Payment of

D Communication Acts as a liaison between patients, families, and healthcare providers, facilitating communication to ensure that all parties are informed and involved in care decisions

A rating or “Fully Successful” or “Exceptional”

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

Payment of

E Crisis Management

Address any emergencies or unexpected situation that arise during shift, ensuring appropriate actions are taken considering patient care, compliance, and life safety.

A rating or “Fully Successful” or “Exceptional”.

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

Payment of