2_SectionFFinal.doc

SECTION F - SCHEDULE OF DELIVERABLES

F.1.

PERIOD OF PERFORMANCE

The period of performance for the 9th SOW QIO contracts is August 1, 2008 through July 31, 2011.

All work and deliverables required under this contract shall be completed by the expiration date of the period of performance.

For Section F – QIO Schedule of Deliverables, unless otherwise specified all deliverable due dates required monthly, quarterly, or annually are defined as due 10 days after the given time period based on the start date of the period of performance.

For example: If the contract period of performance begins on August 1, then a deliverable due date of “quarterly” would be due on the 10th day following the end of each quarter (i.e., November 10 for the period of August 1 – October 31; February 10 for the period of November 1 – January 31; etc.).

F.2.

ITEMS TO BE FURNISHED AND DELIVERY SCHEDULE

The QIO shall furnish the reports and deliverables required under this contract in accordance with the Delivery Schedule and Reporting Instructions as set forth below:

Deliveries or Performance Reports/Items to be Furnished and Delivery Schedule

Section F – QIO Schedule of Deliverables

Notes Evaluation Criteria

C.4. GENERAL REQUIREMENTS

C.4.1 Infrastructure Operations Support and Data Management

(C.4.1.)

QIO Project Officer (PO)

Standard Data Processing System (SDPS) Government Task Leader (GTL) November 30, 2008

Update when staff changes SDPS Application

NA

SDPS GTL

November 30, 2008

11:59 PM Eastern

Annually thereafter on November 30

(Tape Backup Rotation Schedule and Logs)

(C.4.1.)

QIO PO

SDPS GTL

Upon Request

Kept locally at site

NA

(Offsite Storage Logs)

(C.4.1.)

QIO PO

SDPS GTL

NA

(C.4.1.)

QIO PO

SDPS GTL

November 28, 2008, Annually thereafter on November 30

Update when staff changes SDPS Application

NA

(C.4.1.)

QIO PO

SDPS GTL

If required, include any documentation with ticket to validate completion

NA

(C.4.1.)

QIO PO

SDPS GTL

(C.4.3.)

application

Annually thereafter

(C.4.3.)

CMS QualityNet Information System Security Officer

November 30, 2008

11:59 PM Eastern

Annually thereafter on November 30 Mail hard copy of Signed Compliance Form Letter to CMS QualityNet Information System Security Officer

NA

(C.4.3.)

NA

(C.4.1.)

QIO Security POC

PO or CMS GTL upon request

NA

(C.4.1.)

CMS QualityNet Information System Security Officer

PO or CMS GTL upon request

NA

(C.4.1.)

Maintain and follow HHS-22 process within Remedy

QIO PO

SDPS GTL

NA

(C.4.1.)

CMS Property Officer

Annually on

November 30

11:59 PM Eastern or upon request Mail hard copy printout of HHS-565 to CMS Property and Contract Officer

NA

(C.4.1.)

Update record in Remedy Inventory Module

NA

(C.6.B.8.)

PO

Communications GTL

Region Office Communications Specialist working through Communications GTL August 31, 2008 11

:59 PM Eastern

Every 6 months thereafter

Available upon request

(C.4.10.)

11:59 PM Eastern

Update Project Officer during regular subtask discussions or as otherwise requested by the Project Officer SDPS Application and as directed by the Project Officer

NA

C.6.1. Beneficiary Protection

a. Review Activities (includes Sub-tasks 1, 3, 4, and 7)

All case review information will be entered into the case review information system within three days of completion of:

1. initial review

2. reconsideration or reopening review

3. other review activity

PO/

Protection GTL/

SDPS/

Theme Lead

1. initial review

2. reconsideration or reopening review

3. other review activity

Task 2

Report on Quality Improvement Activity as a result of case review data analysis

PO/

Protection GTL/

SDPS/

Theme Lead

Provide an outline of QIA identification, development and evaluation process.

The QIOs will submit a write-up of all QIA implementation that focus on systems change, including an explanation of the nature of the issue/system change, interventions, intended and actual outcomes associated with the change, and the QIO’s efforts related to adoption of the systems change by other providers.

Task 5

Report of completed Physician Acknowledgement Monitoring

Task 6

Report of Documented Collaboration with QIO Beneficiary Satisfaction Survey Contractor, State Survey Agencies, FIs, MACs, Qualified Independent Contractors (QICs), the OIG.

PO/GTL/

Theme Lead/

SDPS

Task 7

No less than annual posting of QIO CR information on both QIO websites

PO/GTL/

Theme Lead

Task 8

Quality Data Reporting

PO/GTL/

Theme Lead

Task 9 Quality Data Reporting

PO/GTL/

Annually by August 31

C.6.2. Patient Safety

Theme Lead

Cultural leadership survey-AHRQ Patient Safety Survey or HLQAT Survey

Re-administer or collect leadership or safety cultural assessment and submit results by month 35.

PO/GTL/

Theme Lead January 31, 2009

And

June 30, 2011

http://www.ahrq.gov/qual/hospculture/ Hospital Leadership Quality Assessment Tool (HLQAT) available:

http://www.ofmq.com/hospital-leadership-collaborative

In this deliverable, CMS is looking for QIOs to ensure that each provider takes a baseline survey and subsequent survey by month 35 to track interventions. QIOs to provide technical assistance based on survey results.

The APSS consists of 42 items that measure 12 areas or composites of patient safety culture. Detailed instructions on how to measure improvement using the survey are on AHRQ’s web site. A provider will be considered passing if they have an “acceptable” score (see website) at remeasurement.

The HLQAT consists of 72 questions that cover five domains. Since this tool is still in the developmental stages, CMS is in the process of determining what an acceptable score will be. Field testing is occurring in August and September, 2007 which will refine the tool and the scoring system.

Survey participants on training effectiveness

Training feedback survey

PO/GTL/

Theme Lead

Theme Lead

The QIO shall obtain individual provider data on applicable measures. As necessary, the QIO shall obtain authorization to receive and review data where applicable.

PO/GTL/

Theme Lead

CMS MDS

NHSN Interface

Data for pressure ulcers and restraints in nursing homes come from the Minimum Data Set (MDS) and is available quarterly as well.

MRSA data are collected by CDC’s National Healthcare Safety Network (NHSN). CDC will make this data available to the QIO on at least a quarterly basis.

These goals can be found in the 9th SoW in the Evaluation Tables of the Patient Safety Text. There are goals beyond the 18th month, as spelled out in the SoW, however the first 18 months requires monitoring.

If any provider is not reaching their stated goal at any of the month markers, the PO must alert the GTL who must alert the Theme Lead.

Within a time frame specified by CMS, the QIO shall provide to CMS the names of the physician(s) and nurse(s) who successfully completed the TeamStepps Training.

PO/GTL/

Theme Lead

Stepps trainers

CMS or a CMS contractor will announce when the training is to be held.

CMS is coordinating with AHRQ to provide QIOs with TeamSTEPPS training. AHRQ will provide a contractor to train all QIO trainers (a team including a physician and nurse). Once training or trainings are completed, QIOs will need to document completion by submitting names of two staff members who have become certified trainers. Any QIO that does not participate in the training will not be able to engage in the MRSA sub-task.

Theme Lead

Exchange

And/or electronically as directed by CMS

QIO should prepare a brief summary of each session with provider participant feedback and QIO “lessons learned.” This should be submitted to the PO and GTL. This summary should be less than 5 pages long; contain a description of the provider group for which the training was held; include the provider feedback; and any lessons learned the QIO gleaned from its experience.

If the QIO does not submit reports with any constructive suggestions for QIO improvement on training, the PO should intervene by either participating via teleconference on the next provider training evaluation/survey session or making it very clear that CMS expects the QIO to be continually assessing its opportunities for improvement.

C.6.3 Prevention

34.

Recruitment of participating practices (PPs)

PO/GTL/

Monthly, through Quarter 6

ST1

Marketing plan clearly defines how recruitment will occur throughout contract, including marketing strategies.

PPs meet enrollment criteria:

Currently implementing Certification Commission of Health Information Technology (CCHIT)-certified electronic health records (EHRs)

Evidence of agreement to implement care management processes using their EHR that include breast cancer and CRC screening and influenza and pneumococcal vaccination for at least 75% of their patients or patient encounters.

Evidence of agreement to report their practice results for the preventive measures as outlined in the SoW. Implemented processes for disease management for at least one of the targeted chronic conditions outlined in the SoW Implemented care management processes in at least one of the clinical topics outlined in the SoW Meets definition of Solo Practice and Group Practice as specified in SoW. Meets definition of Practice Site specified in SoW: Submission of a practice site readiness assessment form and a signed consent form that meet CMS requirements for these forms. Recruitment of at least 80% of the PP target by the end of Quarter 2.

Reports monthly through Quarter 2 the number of successfully-recruited practices, attrition of practice sites and the reason for loss, e.g., practice site closed or moved out of state; no longer provides preventive care services.

Meets the characteristics outlined in the SoW and these characteristics are clearly listed for each state/territory.

Submission of characteristic list to the support contractor by the end of quarter 2 of the contract.

Evidence of completion of the Office System Survey (OSS).

Theme Lead End of 2nd Quarter

ST2

Marketing plan clearly defines how recruitment will occur throughout contract, including marketing strategies.

NPs meet enrollment criteria:

NPs must have E.H.R. capability.

The size of this pool shall not be less than 50% of the number of PPs nor more than 125% of the number of PPs.

Meets the characteristics outlined in the SoW and these characteristics are clearly listed for each state/territory.

Submission of characteristic list to the support contractor by the end of quarter 2 of the contract.

Theme Lead Monthly

ST3

SDPS

Application CMS to provide Office Systems Survey

Defined approach to providing technical directions on the EHR redesign and/or implementation of care management and patient self-management for preventive service needs.

Education and outreach plan include use of EHR capabilities and Doctor’s Office Quality Information Technology - University.

Monthly submission to CMS the number of practices who have received at least 2 hours of post-recruitment education (in-person or by telephone).

Completion of initial education of all Intervention Group Practices (PPs) by end of the 7th month.

80% of the responding PPs will report tracking of each preventive service for at least 75% of their patients or patient encounters by 18th month.

Theme Lead End of 3rd Quarter

ST4

SDPS

Application

Results of this Assessment are reported to CMS by the end of Quarter 3.

B-weekly

ST5

Data is corrected, cleaned, and aggregated (if submitting aggregate data) before submission to CMS.

PP use their EHR to report breast cancer and colorectal cancer screening and flu and pneumococcal immunization data directly to the CMS clinical data warehouse or generated electronic reports from their EHR and transmit through CMS approved method.

PP report quarterly the number of ordered and number of performed screens and immunizations for the defined populations for each quarter.

PPs collect and report at the beginning of Quarter 3 and continue quarterly thereafter screens and immunizations performed in both of their practice sites and in other venues such as in the community.

Bi-weekly beginning Quarter 3, the QIO reports to CMS the number of PPs that are reporting data via each method, and the actual rates each PP reports.

Data is extracted from the practices EHR, or in the case of practices without this functionality, by a CMS defined data abstraction tool.

Theme Lead Quarterly

ST6

Rates to be provided by support contractor

Performance measure rates will be analyzed and reported quarterly by the support contractor. In addition, the support contractor will aggregate data, track progress, and compare measures for the PPs and the comparison groups.

Report quarterly the numerators, denominators, and disparity rates for mammograms, CRC screening, flu immunizations, and pneumococcal pneumonia

End of 16th Month

ST7

90% of PPs and 65% of NPs have completed the OSS

Annually, 12th, 24th, 36th month

ST8

Report annually the baseline and rates for PPs and the statewide trends on each measure.

Annual report includes a self-assessment, barriers to performance, and corrective action plans.

The PO and GTL to analyze data to review trends and patterns for identification of potential failure and take actions as outlined in protocols

Theme Lead 18th month

ST9

SDPS

Application

Submission of plans to optimize performance based on experience to date by 18th months.

C.7.1 Prevention Disparities

Theme Lead Weekly, through 2nd Qtr

ST1

SDPS Application

Must achieve 80% recruitment by end of 2nd quarter

Weekly, through 2nd Quarter

ST2

Theme Lead 2nd Quarter

ST3

Deliverable only.

Theme Lead Monthly

ST4

Theme Lead Weekly

ST5

Theme Lead Quarterly

ST6

SDPS Application

Deliverable only. However, QIO is expected to indicate other efforts to improve diabetes disparity at statewide level

Theme Lead Quarterly

ST7

12th, 24th, 36th month

ST8

SDPS Application

12th, 18th month

ST9

Application

C.7.2. Patient Pathways (Care Transitions)

Theme Lead

Theme Lead

Theme Lead

Theme Lead 18 months following contract award (Interim)

28 months following contract award (Final) SDPS Application, hardcopy and/or electronic report as agreed by CMS

Theme Lead/QIOs

Theme Lead

Theme Lead

tiality requirements Necessary for performance monitoring.

The written, quarterly reports that the QIO submits to CMS shall be in accordance with Section F – QIO Schedule of Deliverables and work requirements set forth in the SoW.

CMS and/or the CMS contractor will supply the QIO with a template, guidance, and/or guidelines related to the report requirements.

The report must describe QIOs progress in carrying out the work plan, report progress on IQC activities that related to the Patient Pathways (Care Transitions) Theme, and identify any areas in which adjustments to the work plan and IQC measures are needed. In addition, the QIO shall discuss progress on the 3 interim measures and 4 outcome measures listed in the SoW, and, if that progress falls below the quarterly milestones laid out in the work plan, the QIO shall describe the corrective actions that it has or will take along with the timeframe for these actions and for expected results.

Theme Lead/CMS contractor

CMS or CMS contractors will supply the QIO with guidance and/or guidelines related to the interim measures.

Theme Lead/CMS contractor

CMS or CMS contractors will supply the QIO with guidance and/or guidelines related to the interim measures.

C.7.3. Chronic Kidney Disease

a. Work plan

b. Revisions to the initial work plan

c. Re-evaluate and update the work plan

PO/ GTL/

Theme Lead

a. 1-month after contract signed

b. 1 ½ months prior after contract effective date

c. 18 months after contract effective date

Concise

Clear explanation of all required elements (as defined in template), including timelines, benchmarks, monitoring strategy consistent with evaluation timelines.

Revision –

Concise and in accordance to timeline.

Clear explanation and justification for required change, including why change is necessary and what will be achieved as a result of change. Change must include benchmarks, timelines, and monitoring strategy.

Quarterly and at week 4

CMS or CMS contractor to provide system and format for reporting.

Evidence of full participation as demonstrated through signed letters of commitment upon PO request.

40% requirement must be maintained, and increased in subsequent months. Elements for the letter of commitment will include confidentiality requirements and participation in the QIO projects.

Providers should be aware of, and agree to, all requirements of participation (data submittal, data sharing, completion of surveys, etc.)

Retention of original practices is expected unless extenuating circumstances such as change in ownership. Turnover greater than 4% must be justified to PO or corrective action plan and/or other contract action may be undertaken.

Theme Lead

CMS or CMS contractor to provide template for reporting and the protocol to be used in determining a system change & TA to be provided.

Information is clear and concise and only includes system change (e.g. changes in practices, policies, procedures) that was a direct result of QIO activity. Determination of what is a system change is in accordance with the protocol provided by CMS, or CMS contractor, as determined by the PO. If it is verified CMS, or CMS contractor, that there is a high degree (40% or greater) error in reporting (e.g. not in accordance to protocol), PO may require a corrective action plan and/or other contract action.

Theme Lead

CMS, or CMS contractor to provide template for reporting, and the protocol to be used in determining a system change and the TA that should be reported.

See information provided under deliverable for CKD work plan. And information provided for subtask 1a.

CMS, or CMS contractor, to provide TA on effective collaboration and coalition building.

See information provided under deliverable for CKD work plan.

Theme Lead

CMS, or CMS contractor, to provide TA on what is a system level change.

See information provided under deliverable for CKD subtask 1a and 1b.

Theme Lead

CMS or CMS contractor to provide system and format for reporting.

See information provided under deliverable for recruitment of 40% practices.

Theme Lead

CMS or CMS contractor to provide system and format for reporting.

See information provided under deliverable for recruitment of 40% practices.

Theme Lead

CMS, or CMS contractor, to provide template for reporting & TA on determining what a system change that should be reported is.

See information provided under deliverable for CKD work plan and information provided for subtask 1a and 1b.

Theme Lead

Additionally, it is expected that an acceptable corrective action plan (e.g. approved by PO) is implemented if there is a negative impact on disparities.

Theme Lead

PO may impose corrective action if there is not an 80% response rate when the survey was given to providers that signed a letter of commitment. (100% response rate is expected from those providers)

Theme Lead

Theme Lead

Theme Lead

Providers should be aware, and commit to participation in surveys at the time or recruitment.

Theme Lead

CMS provide system for reporting, and TA and support on system use.

See information as it relates to reporting.

Information is entered into the system accurately, in accordance to the required timeline and format.

Support for CMS Quality Initiatives (PQRI)

Health Information Technology

Reduction in Disparities

PO/GTL/

Quarterly reports The deliverables for the optional tasks will be tailored to the specific sub task that the QIO elects.

See information for CKD work plan regarding expectations for reports.

G. Contract Administration

H. Special Contract Requirements

* Any changes to the Deliverable due dates for all tasks of this contract not exceeding 60 days and do not have a cost impact on the contract may be authorized in writing by the Project Officer. However, due dates must not exceed the period of performance of this contract.

A.

Project Officer (PO):

As assigned

B.

Contracting Officer (CO):

Centers for Medicare & Medicaid Services

OAGM/MCG/DQC

Attn: Naomi Haney-Ceresa

7500 Security Boulevard, MS C2-21-15

Baltimore, MD 21244-1850

C.

Contract Specialist (CS):

OAGM/MCG/DQC

Attn: (To be completed upon award)

D.

SDPS Government Task Leader (GTL):

Office of Clinical Standards and Quality

Attn: Gary Schultheis

7500 Security Boulevard, MS S3-02-01

E.

OCSQ CMS Property Officer:

Attn: Michael Reinhold

F.

SDPS Contractor:

Iowa Foundation for Medical Care (IFMC) Attn: Thane Peterson

6000 Westown Parkway, Suite 350E

West Des Moines, IA 50266

G.

Theme 6.1: Donna Williamson, R.N., GTL

Attn: Donna Williamson

H.

Theme 6.2: Jade Perdue, GTL

Attn: Jade Perdue

I.

Theme 6.3: Linda Smith, R.N., Prevention GTL

Attn: Linda Smith

Baltimore, MD 21244-1850I.

J.

Theme 7.1: Linda Smith, R.N., Prevention: Disparities GTL

K.

Theme 7.2: Douglas Brown, Patient Pathways (Care Transitions) GTL

Attn: Douglas Brown

L.

Theme 7.3: Linda Smith, R.N., Prevention: Chronic Kidney Disease GTL

M.

CMS Small Business Specialist

Office of Operations Management

Attn: Alice Roache

N.

CMS Property Administrator

Centers for Medicare & Medicaid Services

OICS, Administrative Services Group

Division of Property and Space Management

7500 Security Boulevard, MS SLL-14-06

Baltimore, Maryland 21244-1850

O.

CMS QualityNet Information System Security Officer

Attn: Michael Blake

P. Communications GTL Centers for Medicare & Medicaid Services

Office of Clinical Standards and Quality

Attn: Richard McNaney

7500 Security Boulevard, MS S3-02-01

Baltimore, MD 21244-1850

F.3. 52.252-2 CLAUSES INCORPORATED BY REFERENCE. (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this address:

http://www.arnet.gov/far/fac.html

52.242-15 Stop Work Order, Alt.1 (APR 1984)

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