CCSQ-393-2018-0292_SOW.docx

Post-Acute Care (PAC) Quality Reporting Program (QRP) Support QMVIG 83

SECTION C – STATEMENT OF WORK 08/09/18

Section 1: Background and Purpose

1. A. Background

The Centers for Medicare & Medicaid Services (CMS) strive to ensure that the American public receives the highest quality of health care. In the quest for optimal high-quality care, the current health care system must be continuously evaluated to address performance gaps, identify and incentivize opportunities for improvement, and reduce unintended consequences that may arise with treating a large health care population. Recognizing performance gaps and the opportunities available for improvement and acting on those opportunities can improve the quality of care provided to the beneficiaries we serve.

Large gaps exist between the goal of high-quality care for every patient, during every episode of care, and the actual delivery of care in our health care system. CMS has many important opportunities to help health professionals, patients, and all of the stakeholders in our health care system turn promising new ideas into action, helping to close the existing gaps in the delivery of quality care.

This project supports the administration of the Quality Improvement Organization (QIO) Program. The Social Security Act, as set forth in Part B of Title XI - Section 1862(g), established the Utilization and Quality Control Peer Review Organization Program, now known as the QIO Program. The statutory mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.

Further, this statement of work (SOW) is intended to fulfill the stipulations and mandates as set forth in section 1899B of Title XVIII of the Social Security Act (SSA), as added by Section 2(a) of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). Specifically, this contract will support the standardized patient/resident assessment data requirements under subsection 2(a) that must be submitted by long-term care hospitals (LTCH), inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF) and home health agencies (HHA).

1. B. Purpose and Scope:

The purpose of this Contract is to obtain services to provide support for the IMPACT Act of 2014, to include:

· develop modifications of patient assessment domains and achieve standardized data across the assessment instruments in post-acute care (PAC) settings;

· support and advise policy development related to the implementation of new standardized data;

· support the development and/or updates necessary to the various assessment manuals to ensure consistency across such manuals;

· provide support activities associated with the testing required to achieve standardized data as required and support the national training required for testing and development;

· provide help desk support for PAC quality reporting programs (QRP) to LTCH, IRF, SNF and HHAs;

· provide subject matter expertise (SME) and oversight related to the content of the CMS assessment data element library (e.g., related to relational mappings, and identification of gaps in health it standards);

· provide advice on strengths and weaknesses of implementing certain technical standards; and

· work with standards development organizations.

Section 2: General Personnel Requirements

2. A. Subject Matter Expertise (SME)

The Post-Acute Care (PAC) Quality Reporting Program (QRP) Support Contractor shall:

· Provide expert clinical, research and academic experience relevant to post-acute care quality reporting program policies, patient/resident assessments, the IMPACT Act, reporting requirements and patient assessment data for the following quality reporting programs: LTCH, IRF, SNF and HHA.

· Utilize their understanding and expertise in interoperability requirements, health information technology and informatics, and in-depth knowledge of PAC assessment information to support the Division of Chronic and Post-Acute Care (DCPAC) as needed.

· Provide/maintain security of data used to complete tasks under this contract. Some tasks required in this contract involve sensitive information and require security and confidentiality of data, analyses, rulemaking, and program support. The Contractor shall not share information with any entity outside the scope of this contract, unless the CMS Contracting officer (CO), and Contracting Officer Representative (COR), have provided written consent.

· Participate in meetings, conference calls and Technical Evaluation Panels (TEPs), as needed, to provide subject matter expertise, specifically including measures, help desk, training, manual, data library and contractor calls.

· Write, review and edit documents as assigned, related to standardized patient assessment data elements; technical requirements for quality measures; training and other manuals, presentations and help desk questions and answers.

· Ensure that all written and electronic deliverables under this contract are 508 compliant, IAW the standards, policies, and procedures of the Rehabilitation Act, Section 508 Accessibility Standards. This includes the consideration of the time needed for 508 preparation of all documents when setting timelines related to due dates of contract deliverables.

· Provide timely support by phone or email, on a daily basis to answer questions or provide updates as needed.

Deliverable 1: Participation in meetings, conference calls and TEPs Deliverable 2: Document preparation, review and editing, to include

· Manual reviews to ensure clinical soundness, consistency with policy and other manuals, etc.

· Assessment instrument reviews ensure clinical soundness, consistency with policy and other manuals, etc.

· Submission data specification review, etc.

· QM requirements for reports/payment penalties

· Quality Measure (QM) or other reviews as needed

· Training and education material review for same reasons Deliverable 3: Monthly Progress Reports

2.B. Ad Hoc Requests from CMS

The Contractor shall perform ad hoc requests under this contract pertaining to additional analysis and reports. The ad hoc requests are for those activities and deliverables that were unanticipated.

Deliverable 4: Ad hoc deliverables are negotiable and are due within a negotiated time frame.

Section 3: Additional Requirements

Contract Closeout and Transition

Should termination occur, CMS may require transition services beginning at the earliest mutually agreeable date. During this period, the Contractor shall work with the successor contractor, CMS staff, and other identified CMS contractors to ensure continued research efforts.

Transition Plan

Should termination or non-renewal of an option year occur, CMS may request a Transition Plan and its execution. As required by the COR, the Contractor shall provide a Transition Plan that provides adequate coverage to ensure progress on the data analysis tasks within this contract. The contractor shall demonstrate effective and efficient administration of the transition within a reasonable timeframe. At a minimum, the Transition Plan shall provide detailed methods to ensure a smooth transition from the incumbent contractor’s operation to sole operation by the successor contractor. At a minimum, the Contractor shall deliver and implement a Transition Plan that provides for the following:

· A Milestone Chart detailing the time lines and stages of transition from the effective date of contract performance until the successor contractor assumes sole responsibility.

· An Organizational Chart that displays internal and external organizational relationships.

· The organizational chart shall identify the individuals (at all levels) responsible for the transition and their respective roles; detail the lines of communication and how the Contractor will interface with CMS during this phase of contract performance.

· Plans to communicate and cooperate with the current incumbent contractor.

· Transition services shall include transfer of any completed or in-progress artifacts, code, materials, models, Government Furnished Property (GFP), e.g., hardware (HW), software (SW), and records/data, from the incumbent contractor to the successor contractor, or to CMS or another CMS contractor.

Deliverable 5: Detailed and executed Transition Plan

Deliverable Requirements

The Contractor shall provide the deliverables listed under the Schedule of Deliverables.

The Contractor shall submit documents formatted ready to print, in Times New Roman 12 point font. Except for drafts of letters, all files shall include header information with a succinct description of the file’s content, including the applicable program name fully spelled out the first time it is used, with the acronym in parentheses. File headers must also include a description of data presented, including the data source and the data time period (the time period must be specific to type of time period, i.e., encounter/discharge period, deadline, payment determination, etc.). Documents shall include footer information with the page number (out of total pages); contact information including a phone number for questions, and the date content was updated.

Contractor must use good grammar, clear writing, and order of ideas. This includes spelling out acronyms the first time they are used, writing in active voice, writing in plain language whenever possible, and clearly identifying time periods (e.g. discharge period, payment period, deadline, etc.). This also includes fully articulating the range of months and years in a quarterly period. (For example, a reference to Q1 – Q3, 2016 must also additionally provide parentheses to explain that this indicates the time period January 1, 2016 through September 30, 2016). All reports and analysis shall include a cover page with a brief description of the content, any relevant history that preceded the report and a full description of the methodology utilized to collect/analyze data. The methodology description shall be a dedicated section/paragraph of the cover letter and shall include such items as: all data sources, specific data elements (as appropriate), inclusion criteria, exclusion criteria, etc.

When using a CMS template, the Contractor shall ensure that it is using the most up to date version of the template.

Documents shall not include Contractor logos or business names and be in 508/504 compliant format. In education and outreach materials, the Contractor shall refer to itself by role, e.g. “IRF, LTCH or Hospice Support Contract” or another working title as approved by CMS.

Information Security Requirements

As mandated by the Federal Information Security Management Act of 2002 (Public Law 107-347) (FISMA), all Federal agencies, as well as the Contractors and Subcontractors supporting those agencies, must develop, document, and implement an Information Security (IS) program to safeguard information and information systems. FISMA applies to any organization which has physical or electronic access to a Federal agency’s computer systems, networks, or Information Technology (IT) infrastructure; or use information systems to generate, store, process, or exchange data with, or on behalf of a Federal agency. This includes the external third-party/outsourced and cloud hosting of agency information or information systems.

The Contractor and all of its respective Subcontractors shall hereby agree to follow and remain compliant at all times with all CMS and Federal IT Security and Privacy standards, policies, statutes and reporting requirements, as well as all National Institute of Standards and Technology (NIST) standards and guidelines, other Government-wide laws and regulations for the protection and security of Government Information.

Security Policy and Regulation

The CMS IT Security program was developed in accordance with applicable Federal mandates and CMS requirements for the handling and processing of CMS’ information and information systems.

The CMS IS Web site at http://www.cms.gov/InformationSecurity provides an overview of CMS security policies and procedures across the program.

A list of the CMS Information Security requirements is detailed within the most recent version of the CMS Information Security Contract Clause/Provision.

Contractors and subcontractors will also adhere to the guidance and requirements provided within the CMS Information Systems Security and Privacy Policy (IS2P2). This policy supersedes the CMS Policy for Information Security and Privacy, dated April 11, 2013, the CMS Policy for the Information Security Program, dated August 31, 2010, the CMS Master Security Plan, version 6.00, dated June 25, 2010, and the CMS Policy for Privacy Act Implementation & Breach Notification, dated July 23, 2007. This policy consolidates existing information security and privacy policy documents into a single volume and directly integrates the enforcement of information security and privacy through the CMS Chief Information Officer, Chief Information Security Officer, and Senior Official for Privacy.

These documents can be obtained from the CMS IS Library, located at the following URL:

http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html

The Contractor shall visit the CMS security website and information security library at minimum every 30 calendar days for updates.

Contract Types and Security Roles

The CMS IS Contract Clause/Provision, listed above, is an all-encompassing document which encapsulates all CMS IS requirements. However, the specific security responsibilities of the Contractor are dependent upon the contractor’s access and role(s) in supporting CMS requirements.

IT Hardware/Software Procurement

Unless otherwise directed by CMS, the Contractor shall adhere to the most current version of the policies and procedures outlined and posted on any of the CMS websites. Please note that name changes can/will occur so specifics can be provided upon contract award. The Contractor shall comply with all present and future statutes as well as Federal, Department of Health and Human Services (DHHS), and CMS regulations and program instructions relating to providing a secure computer operations environment. Additional policies, procedures, updates in documents may be released, requiring the Contractor to comply.

The Contractor shall not develop software products for use by other contractors, partners, etc. without written prior approval from CMS. In addition, no funds from this contract shall be used for data collection activities not specified in this contract without prior approval from the COR and in accordance with other CMS administrative guidance. The Contractor shall maintain all necessary documentation as identified by CMS.

Hardware/Software

The Contractor shall provide the funding to support the IT needs to meet the contract requirements. This includes, but is not limited to, a file/print server, a domain controller, a database server, network/telecomm equipment, workstations and/or laptop for each employee. The servers, workstations, and laptops shall be equipped with a standard operating system and a software suite following the approved CMS Federal Desktop Core Configuration (FDCC) standard which is also referred to as the United States Government Configuration Baseline (USGCB). Please note that this listing in not an all-inclusive list and should be used to identify basic IT needs and current associated costs for an office. The list and pricing identified should be used for budgeting purposes only as they are subject to change. All HW/SW required will be procured as GFE via CMS compliant processes and systems (where applicable). The amount of hardware & software provided will be dependent on the agreement between CMS and the Contractor based on the work identified. Any additional resources required, such as printers, faxes, etc., the Contractor will be responsible for funding the procurement of the equipment.

The Contractor must receive approval from their CMS COR prior to submitting a purchase request. No additional hardware peripherals or non-approved software may be connected or installed to any GFE without prior written approval by CMS and the COR.

The Contractor maintain the necessary documentation ensure proper asset management and tracking of all GFE.

If the Contractor determines they would like to use the Health Care Quality Information Systems (HCQIS) VDI Solution, they will be responsible for providing the HW and Circuit for connecting. SW used to connect to the VDI Solution will be provided by the infrastructure contractor.

The HCQIS Contractor shall utilize their corporate Local Area Network (LAN) infrastructure and/or personal home office infrastructure to fulfill the contractual requirements. Corporate and/or personal data lines and PCs will be utilized by the users to access the HCQIS VDI environment. It will be the HCQIS Contractor’s responsibility to size the data line correctly in order to obtain acceptable bandwidth so users can perform the contractual requirements.

In addition, it is the responsibility of the HCQIS Contractor to maintain the Operating System (OS), the latest security patches, and latest virus definitions in accordance with the CMS Information Security Acceptable Risk Safeguards (ARS)

Transition of Equipment

In the event that CMS requires transition services from an incumbent Contractor to a successor Contractor, the incumbent will be responsible for funding the cost of transfers, which includes, but is not limited to, the packing, shipping and so forth of any GFE.

The Contractor is responsible for adhering to the CMS HHS-565 and HHS-22 processes (including any associated deliverables) which focuses on asset management and transition of equipment (transfers, disposals, donations, etc.).

At the end of a contract period, the Contractor must follow CMS contractor transition procedures to Shut down and Startup Operations process to ensure that proper transition of all GFE is done in timely manner.

References

CMS XLC Framework and information about CMS XLC is available at:

(http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/XLC/index.html)

DHHS Earned Value Management (EVM) Procedures: https://www.hhs.gov/ocio/policy/policydocs/20050004p.doc

Federal Enterprise Architecture Consolidated Reference Model, http://www.whitehouse.gov/sites/default/files/omb/assets/fea_docs/FEA_CRM_v23_Final_Oct_2007_Revised.pdf

A Practical Guide to Federal Service Oriented Architecture: http://www.whitehouse.gov/omb/E-Gov/pgfsoaIEEE Std 829-1998

IEEE Standard for Software Test Documentation: https://standards.ieee.org/findstds/standard/829-2008.html

The CMS TRA and Supplements are in process of being updated to provide developer guidelines for agile and cloud development.

Government Property

Independently and not as an agent of the Government, the Contractor shall furnish all the necessary services, qualified personnel, materials, equipment and facilities, not otherwise provided by the Government, as needed to perform the requirements of this. Intellectual property developed for CMS as part of this contract must remain within the control and ownership of CMS in accordance with Technical Considerations.

Quality Assurance

CMS shall review and approve all work products and deliverables submitted by the Contractor. Progress meetings shall be held between the Contractor and the COR monthly. Identified below are basic performance standards that will be used to determine how well the Contractor is fulfilling the core functions presented in this SOW. The Contractor shall successfully perform the specific requirements defined by this SOW. The Contractor shall provide, in a timely manner, complete and accurate information, as requested in order for its performance to be evaluated.

CMS will use the performance indicators below, at a minimum, in evaluating Contractor performance and the acceptance of Contractor deliverables as appropriate:

Cooperation/Coordination (Level of interaction between the Contractor, CMS and stakeholder(s))

The Contractor shall cooperate and coordinate with CMS, other CMS Contractors, using the following measures and activities:

· Demonstration of timely and successful ongoing communications and cooperation of all types with CMS

· Feedback from other persons and entities with which the Contractor has had to work; and

· Number and type of issues that arise and indicate communication, or a lack of communication, between appropriate entities and the Contractor.

Quality/Quality of Product or Service (Appropriateness, completeness and error free nature of all activities conducted by the Contractor)

The Contractor shall maintain the highest degree of quality for all activities performed throughout the period of performance of the contract. CMS will evaluate the Contractor’s performance using measures related to completeness, accuracy, and number of revisions to deliverables to address reports and data analysis needed by CMS to inform quality, payment and other uses of the research.

Timeliness of Performance (Ability to meet established time lines)

The Contractor shall submit all deliverables to CMS in order that they are received on or before the due dates specified. Some examples of how the Contractor performance shall be evaluated include Demonstration by the Contractor performed tasks in accordance with the schedule set forth in this contract.

Satisfaction/Business Relations (Ability of the Contractor to meet and manage customer expectations)

The Contractor shall provide, at a minimum, professional and courteous service to the different stakeholders involved with this contract.

Cost Control

The Contractor shall manage the costs within CMS specified budget requirements.

Further, Quality assurance by CMS may include inspection of deliverables; review and approval of interim or draft reports; progress meetings; and/or review and approval of progress at prescribed points before authorization to continue to be given to the Contractor. Contract evaluation criteria and monitoring are described below.

A. Performance Evaluation Criteria

As specified by CMS, assessment of the Contractor’s performance in this contract will be used as past performance information for future award considerations.

Elements that may be included in this performance assessment include:

· Completion of specific tasks (deliverables) required in the contract;

· Financials;

· Appropriateness of the Contractor’s staffing, including both number of staff as well as their skill sets;

· Performance in meeting the needs of the quality of activities to improve performance;

· Participation in other improvement activities;

· Efforts to address issues/barriers identified; and

· Achievement of specified levels of performance (e.g., timeliness, quality, usability, effectiveness, scientific merit).

The COR will conduct performance assessment.

B. Contract Monitoring

The COR will conduct periodic monitoring of the Contractor’s progress in the ongoing efforts related to data analysis and application of such analysis. The frequency and nature of this monitoring is to be determined by the COR, but is anticipated to occur monthly on the regularly scheduled COR monitoring calls; and via written progress reports to the COR. The Contractor will participate in these monitoring activities, including the provision of a brief summary of activities, internal quality improvement efforts, barriers and efforts to address those barriers, and other pertinent information, as directed by the COR.