CCSQ-393-2018-0532_SOW.docx

Attachment A

STATEMENT OF WORK

Production and Implementation of Registry-Based Hospital Surgical Outcome Measures 8/08/18

I. Background The Centers for Medicare & Medicaid Services (CMS) publicly reports performance measures and results for beneficiaries, providers, and other stakeholders. CMS and Quality Innovation Network-Quality Improve Organizations QINs/QIOs) work together to report this performance information on the CMS Hospital Compare website as a method to inform beneficiaries and drive efforts to improve the quality of care.

Furthermore, this project supports the administration of the Quality Improvement Organizations Program (QIO). The Social Security Act established the Utilization and Quality Control Peer Review Organization Program, now known as the Quality Innovation Network-Quality Improvement Organizations Program. The statutory mission of the program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. This project will help reach goals of improving the quality of patient care by supporting transparency and sharing hospital performance for patients.

Moreover, the work under this contract/TO aligns with the work and mission under Section 3015 section 399JJ b of Health Care Reform H.R. 3590 titled DATA COLLECTION, PUBLIC REPORTING.

To support CMS and QIN/QIO efforts to improve the quality of care for Medicare beneficiaries through public reporting of performance information, CMS will continue public reporting of outcome measures. CMS and QIN/QIOs support the selection of measures that help inform beneficiaries and stakeholders of clinical health outcomes. Due to the limited number of outcome measures available for public reporting, it is especially important for CMS to partner with entities collecting and calculating health outcomes.

CMS previously contracted for the production and voluntary public reporting of surgical outcome measures for the CMS Hospital Compare website. Prior work involved the collection and production of performance information on surgical outcomes which assisted in the transparency of provider performance for beneficiaries and limited the reporting burden for providers through voluntary reporting of performance measures. CMS will continue to partner with entities that collect and calculate performance information for voluntary public reporting of outcome measures that address high-priority gaps within clinically important topic areas to support CMS and QIN/QIO duties to improve quality of care for beneficiaries.

A. Purpose The purpose is to produce and implement three surgical outcome measures. The measure data is voluntarily publicly reported on the CMS Hospital Compare website to improve transparency for consumers, limit reporting burden for providers, and leverage existing, cost-effective quality measurement and reporting efforts.

II. Requirements

A. General Requirements The Contractor shall furnish the necessary services and qualified personnel, facilities, equipment, materials, and supplies not otherwise provided by the government as needed to perform the requirements set forth in this Statement of Work (SOW). The Contractor shall provide CMS with complete and accurate information on all actions upon request and perform requirements, as defined in this SOW, in accordance with applicable Medicare laws, Medicare regulations, Medicare manuals, the Federal Managers’ Financial Integrity Act (FMFIA), Government Auditing Standards (GAS), the Chief Financial Officer (CFO) Act of 1990, Office of Management and Budget (OMB)/Paper Work Reduction Act (PRA), and others as may be identified herein.

The Contractor shall regularly evaluate the effectiveness of all actions and deliverables as described in this SOW. The Contractor shall meet all deliverable requirements and deadlines in accordance with the deliverables schedule.

The Contractor must perform all tasks for the production and implementation of the following three performance measures:

· Risk Adjusted Lower Extremity Bypass (LEB) Surgery Outcomes developed jointly by CMS and the American College of Surgeons (ACS);

· Risk Adjusted Case Mix Adjusted Elderly Surgery Outcomes developed by ACS; and

· Risk Adjusted Case Mix Adjusted Colorectal Surgery Outcomes developed by ACS.

The Contractor must independently collect and calculate performance data for each measure. The term independently requires that the Contractor must have an existing infrastructure and process for collecting data from hospitals and calculating the performance for each measure. CMS is seeking the production of the three outcome measures and services for implementation on the CMS Hospital Compare website.

B. Tasks to be Performed

1. Operational IT Infrastructure Upon contract award, the Contractor shall have in place data abstraction and reporting tools to independently collect data for the three performance measures identified in Section II.A of this action.

The Contractor shall have tools that can be easily adopted and used by hospitals, such as rural hospitals, that may have less developed infrastructures to conduct data abstraction and transmission. The Contractor must have an established calculation and validation system to validate that the data collected and calculated is accurate and meaningful. The Contractor will not conduct any system and infrastructure development under this contract.

2. Outreach and Education The Contractor shall establish and implement a process for hospital education and outreach regarding the registry reporting process, the voluntary participation of hospitals, and the public reporting of information on the CMS Hospital Compare website.

The Contractor shall communicate with stakeholders to recruit hospitals for voluntary participation and in support of the public reporting of measures on the CMS Hospital Compare website.

The Contractor must produce and submit to the Contracting Officer’s Representative (COR) a final communication and outreach plan for the period of performance of this action (Deliverable 1).

3. Production of Performance Measure Data The Contractor shall use the most recent months of data submitted by voluntary participating hospitals to independently calculate the performance measures. In addition, the Contractor shall provide the COR with written documentation that all participating hospitals have volunteered to participate in public reporting of the data.

Following independent calculation of performance measures, the test and production files for all three measures are due to the COR quarterly, at specified times according to the Public Reporting Timeline, for CMS Hospital Compare public reporting CMS and its contractors will provide the required timelines for file delivery (Deliverable 2).

4. Implementation on Hospital Compare The Contractor shall prepare and submit, in accordance with CMS policies and approval by the COR, documentation for how the measures will be displayed to the public on the CMS Hospital Compare website. The Contractor must clearly state that participating hospitals voluntarily reported the performance measure information for public reporting on the CMS Hospital Compare website. The Contractor shall also update and submit measure methodology reports, fact sheets, and Question and Answer (Q&A) documents for each public release of information. The Contractor shall work with the COR and the CMS Hospital Compare Support Contractor, to publicly report all information on all applicable CMS websites.

Draft documentation for how measures will be publicly displayed on CMS Hospital Compare, updated measure methodology reports, updated fact sheets, and updated Question and Answer (Q&A) documents are due quarterly per the release timeline. (Deliverable 3). Final documentation for how measures will be publicly displayed on Hospital Compare, measure methodology reports, fact sheets, and Q&A documents are also due quarterly per the release schedule to be provided by another CMS contractor. (Deliverable 4).

The Contractor, in collaboration with the COR, and the CMS Hospital Compare Support Contractor, will preview the CMS Hospital Compare display information to ensure performance measure production file information is accurately captured for public release. The Contractor will identify any inconsistencies and inaccurately displayed information for correction on a quarterly basis (Deliverables 5).

5. Hospital Compare Public Reporting Review The Contractor shall check the CMS Hospital Compare website at each quarterly public release and refresh to ensure information is accurately displayed. The Contractor must review Hospital Compare website displays at the quarterly (October, December, April, and July) releases and refreshes. The Contractor must provide a written list to the COR of any inconsistencies and inaccuracies that may be displayed online (Deliverable 6).

6. Project Management

a. Kickoff Meeting The Contractor must hold a contract Kickoff Meeting with the COR (Deliverable 7). The Contractor shall present to the COR the agenda and associated materials that will contain their established data collection, calculation, and validation process and systems, a process and timeline for production and implementation, and draft hospital outreach and education plan.

b. Project Management Plan and Key Personnel Communication Plan The Contractor shall submit to the COR a project management work plan that describes milestones, deliverables, and deliverable dates in Microsoft Project, or an agreed upon alternative. The Project Management Plan shall also contain the Key Personnel Communication Plan that identifies key personnel and contact information (Deliverable 8).

c. Monthly Status Reports The Contractor shall submit monthly status reports to the COR (Deliverable 9). The monthly status report must describe the prior month’s activities, including:

i. Issues requiring CMS input or support;

ii. Status of all deliverables and activities;

iii. List of unresolved issues;

iv. Prior month’s accomplishments; and

v. Identification of risks and risk management.

d. Management Call The Contractor shall facilitate a monthly management call with the COR. The Contractor shall update the COR on the Project Management Plan and identify any key risks and issues. The Contractor must prepare and disseminate necessary materials, agenda, and the prior meeting’s minutes (Deliverable 10).

e. Final Report The Contractor shall submit a final report summarizing all activities conducted under the period of performance of the contract (Deliverable 11). The body of the report shall not exceed twenty (20) pages, with an executive summary of no more than two (2) pages. The final report must meet CMS 508 compliance requirements.

C. Quality Assurance Performance evaluation and monitoring will be conducted, as outlined in the Statement of Work. The COR will conduct monthly monitoring of the Contractor’s progress toward completion of deliverables. Monthly monitoring calls with the COR will be used for review of the performance and progress of the deliverables. Monthly progress reports will be submitted to the COR. Following the completion of all deliverables under the SOW, the COR will assess the Contractor’s performance.

D. References Not applicable

E. Government Property Not applicable

F. SECTION 508 - ACCESSIBILITY OF ELECTRONIC AND INFORMATION TECHNOLOGY

(a) This SOW, PWS, or TO is subject to Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. 794d) as amended by the workforce Investment Act of 1998 (P.L. 105-220). Specifically, subsection 508(a)(1) requires that when the Federal Government procures Electronic and Information Technology (EIT), the EIT must allow Federal employees and individuals of the public with disabilities comparable access to and use of information and data that is provided to Federal employees and individuals of the public without disabilities.

(b) The EIT accessibility standards at 36 CFR Part 1194 were developed by the Architectural and Transportation Barriers Compliance Board ("Access Board") and apply to contracts and task/delivery orders, awarded under indefinite quantity contracts on or after June 25, 2001.

(c) Each Electronic and Information Technology (EIT) product or service furnished under this contract shall comply with the Electronic and Information Technology Accessibility Standards (36 CFR 1194), as specified in the contract, as a minimum. If the Contracting Officer determines any furnished product or service is not in compliance with the contract, the Contracting Officer will promptly inform the Contractor in writing. The Contractor shall, without charge to the Government, repair or replace the non-compliant products or services within the period of time to be specified by the Government in writing. If such repair or replacement is not completed within the time specified, the Government shall have the following recourses:

1. Cancellation of the contract, delivery or task order, purchase or line item without termination liabilities; or

2. In the case of custom Electronic and Information Technology (EIT) being developed by a contractor for the Government, the Government shall have the right to have any necessary changes made or repairs performed by itself or by another firm for the noncompliant EIT, with the contractor liable for reimbursement to the Government for any expenses incurred thereby.

(d) The contractor must ensure that all EIT products that are less than fully compliant with the accessibility standards are provided pursuant to extensive market research and are the most current compliant products or services available to satisfy the contract requirements.

(e) For every EIT product or service accepted under this contact by the Government that does not comply with 36 CFR 1194, the contractor shall, at the discretion of the Government, make every effort to replace or upgrade it with a compliant equivalent product or service, if commercially available and cost neutral, on either a contract specified refresh cycle for the product or service, or on a contract effective option/renewal date; whichever shall occur first.

Section 508 Compliance for Communications The Contractor shall comply with the standards, policies, and procedures below. In the event of conflicts between the referenced documents and this SOW, PWS, or TO, the SOW, PWS, or TO shall take precedence.

Rehabilitation Act, Section 508 Accessibility Standards

1. 29 U.S.C. 794d (Rehabilitation Act as amended)

2. 36 CFR 1194 (508 Standards)

3. www.access-board.gov/sec508/508standards.htm (508 standards)

4. FAR 39.2 (Section 508)

5. CMS/HHS Standards, policies and procedures (Section 508) In addition, all contract deliverables are subject to these 508 standards as applicable.

Regardless of format, all Web content or communications materials produced, including text, audio or video - must conform to applicable Section 508 standards to allow federal employees and members of the public with disabilities to access information that is comparable to information provided to persons without disabilities. All contractors (including subcontractors) or consultants responsible for preparing or posting content must comply with applicable Section 508 accessibility standards, and where applicable, those set forth in the referenced policy or standards documents above. Remediation of any materials that do not comply with the applicable provisions of 36 CFR Part 1194 as set forth in the SOW, PWS, or TO, shall be the responsibility of the contractor or consultant.

The following Section 508 provisions apply to the content or communications material identified in this SOW, PWS, or TO:

36 CFR Part 1194.21 a - l 36 CFR Part 1194.22 a - p 36 CFR Part 1194.31 a - f 36 CFR Part 1194.41 a – c The contractor shall provide a completed Section 508 Product Assessment Template and the contractor shall state exactly how proposed EIT deliverable(s) meet or does not meet the applicable standards.

The following Section 508 provisions apply for software development material identified in this SOW, PWS, or TO:

For software development, the Contractor/Developer/Vendor shall comply with the standards, policies, and procedures below:

Rehabilitation Act, Section 508, Accessibility Standards

(1) 29 U.S.C. 794d (Rehabilitation Act as amended)

(2) 36 CFR 1194 (508 Standards)

(3) www.access-board.gov/sec508/508standards.htm (508 Standards)

(4) FAR 39.2 (Section 508)

(5) CMS/HHS/HHS Standards, policies and procedures (Section 508)

For web-based applications, the Contractor shall comply with the standards, policies, and procedures below:

Rehabilitation Act, Section 508, Accessibility Standards

(1) 29 U.S.C. 794d (Rehabilitation Act as amended)

(2) 36 CFR 1194 (508 Standards)

(3) www.access-board.gov/sec508/508standards.htm (508 Standards)

(4) FAR 39.2 (Section 508)

(5) CMS/HHS Standards, policies and procedures (Section 508)

C.4. HCQIS 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 or HealthCare Quality Information Systems (HCQIS) websites (e.g. QIONET, QualityNet). These include, but are not limited to, the QualityNet System Security Policy and the QualityNet Incident Response Procedures. 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 C.4.A. Hardware/Software

The contractor shall provide the funding to support the IT needs to meet the contract requirements. This includes but 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 refer to attachment (HCQIS Setup Costs) as it provides a standard list of basic IT HW/SW and the associated pricing that is used within the HCQIS environment. 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 via the HCQIS Remedy Purchase System/Engineering Review Board process which is used to help track and maintain all GFE. 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, including, but not limited to, printers, faxes, etc… the contractor will be responsible for funding the procurement of the equipment.

The contractor must receive approval from their CMS Contractor Officer Representative (COR) prior to submitting a purchase request via the HCQIS procurement process, currently identified as the Remedy Purchase Request/Engineering Review Board (ERB) to be procured (QNET ERB User Guide). No additional hardware peripherals or non-approved software may be connected or installed to any Government Furnished Equipment (GFE) or on the QualityNet infrastructure without prior written approval by CMS. If there are items that are not listed in attachment (HCQIS Setup Costs) in which the contractor would like to use in support of their network contract, a request will have to be submitted thru their CMS COR to begin the approval process.

The contractor shall update Remedy inventory for all procured GFE and maintain the necessary documentation such as HHS-565 and HHS-22’s located in the Remedy Purchase System to ensure proper asset management and tracking of all GFE.

C.4.B.1 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 not limited to, the packing, shipping and so forth of any Government Furnished Equipment (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…).

1. At the end of a contract period, the contractor must follow the QualityNet Contractor Transition Procedures to Shutdown and Startup Operations process to ensure that proper transition of all GFE is done in timely manner.