AmendedRFPSection F.doc
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- 9th SOW Quality Improvement Contracts Federal contract opportunity
- Solicitation number
- CMS-2007-QIO9thSOW-NAHC
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Amended RFP Section F
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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 “calendar” days after the given time period. If a due date falls on a weekend or holiday, the due date shall be the very next business day.
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).
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
| No. |
| Task Description |
| Recipient |
| Due Date(s) |
| Reporting Mechanism |
| Contract Requirement Emphasis/ |
Notes Evaluation Criteria
C.4. GENERAL REQUIREMENTS
C.4.1 Infrastructure Operations Support and Data Management
| 1. |
| Provide list of assigned disaster recover individuals with specified responsibilities and actions [Point of Contact (POC) list] |
(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
| 2. |
| Provide a written Contingency Plan that details the roles, responsibilities, and process for recovering data and that documents procedures for making and safeguarding backup copies of software, operating data, and user data (C.4.1.) |
| QIO PO |
SDPS GTL
November 30, 2008
11:59 PM Eastern
Annually thereafter on November 30
| SDPS Application |
| Template will be provided by CMS |
| NA |
| 3. |
| Record daily iterative and weekly full tape backup |
(Tape Backup Rotation Schedule and Logs)
(C.4.1.)
QIO PO
SDPS GTL
Upon Request
Kept locally at site
NA
| 4. |
| Record offsite storage of backups and rotation |
(Offsite Storage Logs)
(C.4.1.)
QIO PO
SDPS GTL
| Upon Request |
| Kept locally at site |
NA
| 5. |
| Provide list of assigned QIO Information Technology (IT) Representatives with contact information (i.e., name; position; phone numbers; email addresses) |
(C.4.1.)
QIO PO
SDPS GTL
November 28, 2008, Annually thereafter on November 30
Update when staff changes SDPS Application
NA
| 6. |
| Complete Remedy ticket assignments within the designated timeframe |
(C.4.1.)
QIO PO
SDPS GTL
| As assigned to QIO IT Representative through Remedy Action Request (AR) System |
| Remedy AR System |
| Perform task and close ticket in Remedy AR System |
If required, include any documentation with ticket to validate completion
NA
| 7. |
| Maintain systems and software to be in compliance with current standard configuration |
(C.4.1.)
QIO PO
SDPS GTL
| As Released |
| Memorandums or Remedy AR System |
| Perform task as assigned through Memorandums or Remedy AR System and maintain as required |
| NA |
| 8. |
| QNet System Security Policies (SSP) Training |
(C.4.3.)
| QIO Security POC |
| Before QIO employee receives a User Account to access a QNet system/ |
application
Annually thereafter
| Maintain a log locally onsite with the attached user certificate |
| Train QIO employees on QNet Security Policies and maintain a log locally onsite with Security POC of QIO employee signatures confirming receipt of the QNet SSP Training |
| NA |
| 9. |
| QNet Security POC Site Compliance Letter |
(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
| 10. |
| Sign in log for visitors |
(C.4.3.)
| QIO Security POC |
| As required when visited by external personnel |
| Maintain Visitors Log (current and historical) locally onsite |
NA
| 11. |
| Information Security Plan (ISP) |
| QIO Security POC |
| Within 1-month after contract award |
| SDPS Application |
| The QIO will provide a 1-pager high level ISP on how it will control access and security of its system. |
| 12. |
| List of current Active users accounts with access roles and privileges identified and a log of deactivated users |
(C.4.1.)
QIO Security POC
PO or CMS GTL upon request
| As required when establishing or changing user access and when user leaves the organization |
| User account and permission logs maintained locally onsite |
NA
| 13. |
| Records of incident response |
(C.4.1.)
CMS QualityNet Information System Security Officer
PO or CMS GTL upon request
| As required when a security incident occurs |
| Incident report maintained in Remedy AR and a hard copy (and/or electronic copy depending on the sensitivity of the incident) of incident reports sent to CMS QualityNet Information System Security Officer via the Remedy Tracking System as outlined in the most current QualityNet Incident Response Procedure (http://qionet.sdps.org/training_resources/IncidentResponse.pdf) |
NA
| 14. |
| Update Remedy inventory for all procured and received IT equipment (hardware and software) |
(C.4.1.)
Maintain and follow HHS-22 process within Remedy
QIO PO
SDPS GTL
| As required when hardware or software equipment received |
| Update record in Remedy Inventory Module |
NA
| 15. |
| List of all purchased and leased equipment in HHS-565 submission |
(C.4.1.)
Final Report (G.12.E) CMS Property Officer
Annually on
October 31, 11:59 PM Eastern or upon request July 31, 2011 Mail hard copy printout of HHS-565 to CMS Property and Contract Officer
NA
| 16. |
| HHS-22 submission |
(C.4.1.)
| CMS Property Officer |
| When hardware or software equipment is transferred and/or retired or disposed |
| Submit HHS-22 for approval via Remedy to CMS Property Officer |
Update record in Remedy Inventory Module
NA
| 17. |
| Corrective Action Plans |
| CMS Security Lead and FISMA Audit Team |
| Once findings are identified; quarterly submitted until closed |
| Submit via QualityNet Exchange to audit team accounts and CMS/QualityNet/ISSO |
| Templates to be provided by CMS |
| 18. |
| Partnership and Communications Plan |
(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
| SDPS Application electronically by request as directed by the Communications GTL |
| Template provided by the Communications GTL |
| NA |
| 19. |
| Internal Quality Control (IQC) Plan which includes each subtask and major activity |
(C.4.10.)
| PO |
| September 30, 2008 |
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
| 20. |
| C.6.1. |
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
| Ongoing |
| SDPS Application |
| The QIOs will enter data related to case reviews and their associated activity (as applicable) as directed per the SDPS user’s guide. |
| 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
| 21. |
| C.6.1. a. B. Sub- |
Task 2 and 7 Report on Quality Improvement Activity as a result of case review data analysis
PO/
Protection GTL/
SDPS/
Theme Lead
| Annually |
| SDPS Application and emailed reports to support contractor |
| The QIOs will identify the methods in which they determine the presence of quality of care issues, QIA development, implementation and follow-up. |
The QIOs shall submit the annual report within 30 days of the anniversary date of the contract award date. For year 3, the report shall be submitted no later than July 1, 2011. The report shall contain information on all aspects detailed in Task 2 and 7.3 (a-d).
Data shall be provided regarding all QIA activity to the support contractor on a regular recurring basis. Specific information related to system wide QIAs shall be provided to both the support contractor and CMS.
System-wide change QIA information shall contain 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.
| 22. |
| C.6.1. a. E. Sub- |
Task 5
Report of completed Physician Acknowledgement Monitoring
| SDPS |
| Annually, in accordance with TOPs Memo 2006-02 |
| SDPS Application |
| Provide data to demonstrate the required sample size (per CMS instructions) and validation is being met. |
| Provide data to demonstrate the required sample size and validation is being met. |
| 23a. |
| C.6.1. a. F. Sub- |
Task 6
Report of Documented Collaboration with the QIO Beneficiary Satisfaction Survey Contractor, FIs, MACs, RACs, Qualified Independent Contractors (QICs), the OIG.
PO/GTL/
Theme Lead/
SDPS
| Quarterly |
| SDPS Application |
| At a minimum, the QIO will collaborate with these entities on an as needed basis to discuss information exchange and areas relating to QIO contract performance. |
| The QIO will provide an update to CMS regarding the level of contact and coordination with the QIO Beneficiary Satisfaction Survey Contractor, FIs, MACs, RACs, Qualified Independent Contractors (QICs), the OIG. |
| 23b. |
| C.6.1. a. F. Sub- |
Task 6
Report of Documented Collaboration with State Survey Agencies (SSAs).
PO/GTL/
Theme Lead/
SDPS
| Annually |
| SDPS Application |
| At a minimum, the QIO shall meet with the SSA annually to discuss information exchange and areas relating to QIO contract performance. |
| The QIO will provide an update to CMS regarding the level of contact and coordination with the SSAs. A summary of the annual meeting with the SSA will also be required. This should include topics discussed, level of collaboration, applicable actions and follow-up items. |
| 24. |
| C.6.1. a. G. Sub- |
Task 7
No less than annual posting of QIO CR information on the QIO website.
PO/GTL/
Theme Lead
| Annually |
| SDPS Application |
| The template is part of an SDPS application. As such, it will guide the QIO as well as automatically populate the required data. |
| Via an SDPS application, the QIO will utilize the Annual Medical Services Review template to populate all of the applicable fields related to specific review types and their outcome. To be posted on the individual QIO website. |
| 25. |
| C.6.1. a. H. Sub- |
Task 8
Quality Data Reporting
PO/GTL/
Theme Lead
| Quarterly |
| SDPS Application |
| Update the Program Resource System (PRS) on a quarterly basis by keeping the data on the status of hospitals up-to-date, including open/closed status, information on the CEO, hospital mailing address, and e-mail and telephone contact information. |
| 26. |
| C.6.1. a. H. Sub- |
Task 8
Quality Data Reporting
PO/GTL/
Annually by August 31
| SDPS Application |
| Provide CMS with a diary of contacts between the QIO and all hospitals participating in the RHQDAPU program. This diary’s purpose is to document technical assistance provided by each QIO to the hospitals, and it is necessary for the RHQDAPU reconsideration process. The diary shall include a list of contacts, dates, and summarized information about each contact. This deliverable is due to CMS Hospital Reporting Program contractor annually by August 31. |
C.6.2. Patient Safety
| 27. |
| Recruit up to a specified maximum number of providers from a state pool defined by CMS. |
(PrU, PR, SCIP/HF) Corresponds to Required Activity # 1.
| Support Contractor |
| September 30, 2008 |
| Directly to Support Contractor |
| Maximum number of providers for each subtask is specified in Table A. NOTE: There is no minimum number of providers. |
| Complete and submitted by due date. |
| 28. |
| Provide Quarterly Reports on Effectiveness of existing tools and tools to be developed. Corresponds to Activity #2 |
| PO/GTL |
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
| This task is integral to building an all teach all learn community. QIOs are expected to share successful interventions and tools. |
| Submission of timely and complete reports. |
| 29. |
| Provide quarterly reports on provider requests from non-directly recruited providers for assistance related to quality improvement. Corresponds to Activity #2. |
| PO/GTL |
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
| Reports should include numbers of requests, nature of requests, staff time and budgetary information. |
| Submission of timely and complete reports. |
| 30. |
| Administer and collect baseline survey tools: HLQAT/AHRQ Patient Safety Hospital Survey, Patient Safety Nursing Home Survey |
Re-administer and collect in months 18-35. Corresponds to Activity #3.
PO/GTL/
Theme Lead January 31, 2009
And
June 30, 2011
| SDPS Application |
| In this deliverable, CMS is looking for QIOs to ensure that each provider takes a baseline survey and subsequent survey by month 35 to assist in determining what areas need to be focused on and track interventions being tested. QIOs to provide technical assistance based on survey results. |
AHRQ Patient Safety Survey (APSS) available:
http://www.ahrq.gov/qual/hospculture/ AHRQ Nursing Homes survey will be available before beginning of contract.
Hospital Leadership Quality Assessment Tool (HLQAT) available:
http://www.ofmq.com/hospital-leadership-collaborative
Successful completion and reporting of related tasks.
| 31. |
| Provide names and contact info for National Quality Improvement Leader(s). 2-3 From each QIO |
| PO/GTL/ |
Theme Lead
| August 30, 2008 |
| SDPS Application |
| 32. |
| Training/Meeting Summary Report. Corresponds to Activity #4. |
| PO/GTL/ |
Theme Lead
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
| Template to be provided by CMS, or CMS contractor |
| Successful completion and reporting of related tasks. |
| 33. |
| Obtain executive agreement and notify support contractor. Corresponds to Activity #5. |
| Support Contractor |
| September 30, 2008 |
| SDPS Application |
Successful completion and reporting of related tasks.
| 34. |
| Provide quarterly report on provider data on applicable measure. Corresponds to Activity #6. |
| PO/GTL/ |
Theme Lead
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
| Assures the QIO will have provider data to work with and improve upon. All measures, except MRSA, have CMS sponsored or endorsed data collection tools and ware-housing MRSA data will be collected per standards NHSN protocol and the hospital will agree to share/ provide the data to CMS/QIO |
| Submission of timely and complete reports. |
| 35. |
| Document meetings/trainings of Provider Staff. Corresponds to Activity #7. |
| PO/GTL/ |
Theme Lead
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
Submission of timely and complete reports.
| 36. |
| Provide Quarterly Reports that summarize activities related to Local Quality Improvement Communities. Corresponds to Activity #8. |
| PO/GTL/ |
Theme Lead
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
| Community refers to providers, associations, patients, or any entity that have an interest in Patient Safety and can assist QIOs in advancing the Patient Safety goals. |
| Submission of timely and complete reports. |
| 37. |
| Provide Quarterly Reports that summarize effectiveness of QIO interventions. Corresponds to Activity #9. |
| PO/GTL/ |
Theme Lead
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
| QIOs are expected to track their own approaches to quality improvement and assess their effectiveness in each patient Safety Component. |
| Submission of timely and complete reports. |
| 38. |
| Establish an agreement with hospitals participating in NHSN and report names/provider numbers (both previously reporting hospitals and those recruited by QIO) Corresponds to Activity #11 |
| CMS Support Contractor |
| September 30, 2008 |
| SDPS Application |
| It is expected that QIOs will conduct outreach activities to hospitals currently reporting on NHSN as well as recruit additional hospitals to the NHSN System. The report must identify which hospital were recruited, and which had been existing participants. |
| Successful completion and reporting of related tasks. |
| 39. |
| Document Course completion and names of two Master TeamSTEPPS trainers from the QIO staff. Corresponds to Activity #11 |
| PO/GTL/ |
Theme lead
| January 31, 2009 |
| SDPS Application |
| QIOs are expected to provide full contact info for Master Trainers. |
| Successful completion and reporting of related tasks. |
| 40. |
| Quarterly Report on amount of Technical Assistance and Associated Successful Practices related to Drug Safety. This corresponds to Activity #12. |
| PO/GTL/ |
Theme Lead
| October 31, 2008 and Quarterly thereafter |
| SDPS Application |
Submission of Timely and Complete Reports
| 41. |
| Progress Report on Activity Related to Achieving Evaluation Goals related to Drug Safety. This corresponds to Activity #12. |
| PO/GTL/ |
Theme Lead
| January 31, 2010 (18 months after start of contract) |
| SDPS Application |
| QIOs are expected to report on progress towards achieving 28 month target criteria with corresponding plan to address any identified obstacles. |
| Submission of Timely and Complete Report |
| 42. |
| Provide periodic progress reports as requested by CMS. Corresponds to Activity #13. |
| PO/GTL/ Theme Lead |
| TBD |
| SDPS Application |
| These reports should include the RCA and the Action Plan developed by the QIO. Additional information may be requested by CMS. |
| Submission of Complete Reports |
| 43. |
| Provide report on Healthcare Disparities of Nursing Home Residents. Corresponds to Activity # 14. |
| PO/GTL/ |
Theme Lead
| January 31, 2009. Every 6 months thereafter. |
| SDPS Application |
Submission of Timely and Complete Reports
C.6.3 Prevention
44.
| Recruitment of participating practices (PPs) – including eligibility criteria outlined in the SOW |
| PO/GTL/ |
Monthly
| SDPS Application |
| CMS to provide template and consent form |
The QIO shall submit an excel worksheet with each practice name, practice identifier, and eligibility criteria. 80% of PPs shall be recruited by February 1, 2009.
The QIO shall submit monthly reports of the number of successfully recruited practices and any attrition of practices. The report shall include the reasons for attrition, e.g. practices closed or moved out of state; or no longer provide preventive care services.
| 45. |
| Identification of a pool of non-participating practices (NPs) – including eligibility criteria |
| PO/GTL/ |
Theme Lead/support contractor
| Monthly through the end of Quarter 2 |
| SDPS Application |
| CMS to provide template and consent form |
The QIO shall submit an excel worksheet with each practice name, practice identifier, and eligibility criteria.
The size of the NP pool shall not be less than 50% of the number of PPs nor more than 125% of the number of PPs.
| 46. |
| Promote Care Management Processes for Preventive Services using EHR – PPs receiving educational session |
| PO/GTL/ |
Theme Lead Monthly through end of quarter 2 70% of PPs using EHR to report tracking of each preventive service for at least 75% of their patient encounters by Month 18 from the start of the contract.
SDPS
Application
Each PP shall receive at least 2 hours of post-recruitment education on care management processes and QIO interventions to improve rates. The QIO shall submit the number of PPs that have received the educational sessions monthly.
| 47. |
| Assessment of Care Processes and Reporting – PPs and NPs |
| PO/GTL/ |
Theme Lead Baseline assessment report due March 31, 2009
Monthly reports of PPs and NPs
SDPS
Application
| CMS to provide outline of care processes and progress toward reporting that QIOs will assess and report on. |
| The QIO will report monthly each PP and NPs use of care processes and progress towards reporting of EHR-derived data. |
| 48. |
| Participating Practice (PP) and Non-participating practice Data Submission |
| CMS Management Information System/QIO/Support contractor |
| Quarterly |
Beginning quarter 3, monthly
| CMS Management Information System, electronic report of EHR-derived data, or other method required by CMS. |
| CMS to specify approved standards and methods for data submission |
| PPs and NPs EHR CCHIT certified by October 31, 2008. |
The QIO shall capture the number of ordered and the number of performed screens and vaccinations.
The QIO shall report the number of PPs reporting data, the method of reporting, and the actual rates for each measure.
| 49. |
| QIO Monitoring of statewide rates and disparities – report |
| PO/GTL/ |
Theme Lead Quarterly report
| SDPS Application |
| Breast and colorectal cancer screening rates will be prepared annually from fee-for-service claims data by a support contractor and distributed to the QIOs. CAHPS will provide immunization rates each year; these rates will be distributed to the QIOs. Racial/ethnic breakdowns will also be provided. |
| The report identifies actual or potential disparities, QIO interventions, and recommendations. |
| 50. |
| Annual Report |
| PO/GTL/ |
Annually (July 31, 2009 -2011)
| SDPS Application |
| CMS contractor to provide template |
Report includes PPs baseline rates, quarterly rates, QIO successful interventions, QIO unsuccessful interventions, barriers to performance, and corrective action plans
| 51. |
| QIO Plan for optimization of performance |
| PO/GTL/ |
Theme Lead
| February 1, 2009 and them monthly |
| SDPS |
Application
The QIO shall submit an optimization plan by month seven of the contract. The QIO shall submit monthly reports of activities to improve and sustain performance.
C.7.1 Prevention Disparities
| 52. |
| Recruitment of Participating Practices (PP) |
| PO/GTL/ |
Theme Lead Weekly, through 2nd Qtr
ST1
SDPS Application
Must achieve 80% recruitment by end of 2nd quarter
| 53. |
| Submission of intervention participants QIO attempted to recruit |
| PO/GTL/ |
Weekly, through 2nd Quarter
ST2
| SDPS Application |
| CMS Template TBD |
| Deliverable only. |
| 54. |
| Identification of Matched Control Groups |
| PO/GTL/ |
Theme Lead 2nd Quarter
ST3
| SDPS Application |
| CMS Template TBD; |
Deliverable only.
| 55. |
| Submission of Monthly Completion Report |
| PO/GTL/ |
Theme Lead Monthly
ST4
| SDPS Application |
| CMS Template TBD |
| Must meet threshold listed in SoW by 12th , 18th and 28th month |
| 56. |
| Submission of list of PQRI-reporting PPs |
| PO/GTL/ |
Theme Lead Weekly
ST5
| SDPS Application |
| CMS Template TBD |
| Deliverable only |
| 57. |
| QIO monitoring of statewide diabetes rates |
| PO/GTL/ |
Theme Lead Quarterly
ST6
SDPS Application
Deliverable only. However, QIO is expected to indicate other efforts to improve diabetes disparity at statewide level
| 58. |
| QIO monitoring of other diabetes education activities in the state |
| PO/GTL/ |
Theme Lead Quarterly
ST7
| SDPS Application |
| CMS Template TBD |
| Deliverable only. |
| 59. |
| Annual report of statewide trends |
| PO/GTL/ |
12th, 24th, 36th month
ST8
SDPS Application
| CMS Template TBD |
| Deliverable only. This should tie into deliverable #94, and provide an annual summary based on what is reported quarterly within #94. |
| 60. |
| QIO plan for optimization of performance |
| PO/GTL/ |
12th, 18th month
ST9
| SDPS Application |
| CMS Template TBD |
| Deliverable only. PO approval required. |
| 61. |
| QIO Sub-task experience report |
| PO/GTL/ |
| 28th month |
| SDPS |
Application
| CMS Template TBD |
| Deliverable Only. PO approval required. |
C.7.2. Care Transitions
| 62. |
| Initial Report Characterizing the Selected Community |
| PO/ GTL/ |
Theme Lead
| Within 1 month after contract award |
| SDPS Application |
| The Site Selection Report shall be an update of the plan submitted in response to the Request for Proposal (RFP). |
| Must address the areas specified in Task 1. |
| 63. |
| Report Characterizing the Selected Community 18-Month Update |
| PO/GTL/ |
Theme Lead
| 18 months after contract award |
| SDPS Application |
| Describes and analyzes the impact that QIO efforts have had on the origins and drivers (root causes) of observed patterns of unreliable, inappropriate or wasteful services affecting re-hospitalization rates within the target community, relative to deliverable 53. |
| Must address the areas specified in Task 1. |
| 64. |
| Report Characterizing the Selected Community 28-Month Update |
| PO/GTL/ |
Theme Lead
| 28 months after contract award |
| SDPS Application |
| Describes and analyzes the impact that QIO efforts have had on the origins and drivers (root causes) of observed patterns of unreliable, inappropriate, or wasteful services affecting re-hospitalization rates within the target community, relative to deliverable 53. |
| Must address the areas specified in Task 1. |
| 65. |
| Narrative Report of Project Progress |
| PO/GTL/ |
Theme Lead 18 months following contract award (Interim)
28 months following contract award (Evaluation) 34 months following contract award (Final) SDPS Application, hardcopy and/or electronic report as agreed by CMS
| 66. |
| Conference Calls, Meetings |
| PO/GTL/ |
Theme Lead/QIOs
| At least monthly or as directed by CMS |
| SDPS Application, hardcopy and/or electronic report as agreed by CMS |
| The QIO shall participate in regular conference calls with CMS, other QIOs, and CMS contractors that are engaged in the Care Transitions Theme and contribute findings, tools, and other information that is of potential use to other QIOs. The QIIO shall also participate in project meetings, in-person or by teleconference as scheduled by CMS or the support contractor. |
| Evidence of calls, documented by the contractor’s monthly reports and meeting minutes to be provided within 3 working days following each meeting. |
| 67. |
| Intervention Plan |
| PO/GTL/ |
Theme Lead
| Within 1 month after contract award, and quarterly updates |
| SDPS Application, hardcopy and/or electronic report as agreed by CMS |
| The QIO shall collaborate with organizations to set priorities and to generate the commitment to test and adapt interventions aimed to improve patient transitions from hospitals and between other health care providers. The plan will be updated on the basis of experience. The QIO will report annotated time series for all interventions as part of O-3. |
| Must address the areas specified in Task 2. |
| 68. |
| Reporting Requirements |
| PO/GTL/ |
Theme Lead
| Quarterly and/or as directed by CMS |
| SDPS Application, hardcopy via U.S. mail and/or e-mail (if not prohibited by confidentiality 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 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 interim measures and 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.
| 69. |
| Interim Measures |
| PO/GTL/ |
Theme Lead/CMS contractor
| Report quarterly and/or as requested by CMS |
| SDPS Application |
| The QIO shall report data monthly as needed to calculate all of the interim measures. |
CMS or CMS contractors will supply the QIO with guidance and/or guidelines related to the interim measures.
| 70. |
| Outcome Measures |
| PO/GTL/ |
Theme Lead/CMS contractor
| Report quarterly and/or as requested by CMS |
| SDPS Application |
| The QIO shall report data associated with all outcome measures |
O-3 and O-6 as specified in the SoW.
CMS or CMS contractors will supply the QIO with guidance and/or guidelines related to the interim measures.
C.7.3. Chronic Kidney Disease
| 71. |
| CKD: |
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 after contract effective date
c. 18 months after contract effective date
| SDPS application or other system specified by CMS. |
| Template to be provided by CMS, or CMS contractor. |
| Initial Work Plan – |
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.
| 72. |
| CKD: Number of providers recruited for each subtask 1.a., 1.b., and 1.c. |
| PO/GTL/ |
Theme Lead Quarterly and at 1 month
| SDPS application or other system specified by CMS. |
| Report the percent of practices recruited for each subtask. CMS or a CMS contractor will provide a template for the letter of commitment and the satisfaction of service survey. |
CMS or CMS contractor to provide system and format for reporting.
50% of targeted providers shall be recruited by the end of quarter 2.
Evidence of full participation as demonstrated through signed letters of commitment upon PO request.
Number of CKD participating providers 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.
| 73. |
| CKD: subtask 1a. Report on activities that led to system change to increase the number of individuals with diabetes who are tested yearly for microalbumin |
| PO/GTL/ |
Theme Lead
| Quarterly in the progress and status report |
| SDPS application or other system specified by CMS. |
| Emphasis on change as a result of activity. Address the four continuous evaluation questions in the report. |
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.
| 74. |
| CKD: subtask 1b. Report on activities that led to system change to increase the use of ACE and/or ARBs in CKD patients with hypertension |
| PO/GTL/ |
Theme Lead
| Quarterly in the progress and status report |
| SDPS application or other system specified by CMS. |
| Emphasis on change as a result of activity. Address the four continuous evaluation questions in the report. |
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.
| 75. |
| List of Community Partners in Collaborative |
| PO/GTL/ |
| End of Quarter 1 |
| SDPS application or other system specified by CMS. |
| Participation secured. |
CMS, or CMS contractor, to provide TA on effective collaboration and coalition building.
See information provided under deliverable for CKD work plan.
| 76 |
| CKD: Summary report of system level change(s) as a direct result of collaborative activities. |
| PO/GTL/ |
Theme Lead
| 18 months after signing contract |
| SDPS application or other system specified by CMS. |
| Minimally one system level change. |
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.
| 77. |
| CKD: Number of providers recruited for each subtask 1.a., b., & c. |
| PO/GTL/ |
Theme Lead
| End of Quarter 3 |
| SDPS application or other system specified by CMS. |
| 75% of practices recruited. |
CMS or CMS contractor to provide system and format for reporting.
See information provided under deliverable for recruitment of 50% practices.
| 78. |
| CKD: Number of providers recruited for each subtask 1.a., b., & c. |
| PO/GTL/ |
Theme Lead
| End of Quarter 4 |
| SDPS application or other system specified by CMS. |
| 100% of targeted practices recruited. |
CMS or CMS contractor to provide system and format for reporting.
See information provided under deliverable for recruitment of 50% practices.
| 79. |
| CKD: subtask 1.c. Report on activities conducted in support of the AV fistula placement and maturation as a part of timely renal replacement |
| PO/GTL/ |
Theme Lead
| Quarterly in the progress and status report |
| SDPS application or other system specified by CMS. |
| Emphasis on change as a result of activity. Address the four continuous evaluation questions in the report. |
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.
| 80. |
| Report on impact quality interventions had on disparity, including corrective actions planned and/or undertaken. |
| PO/GTL/ |
Theme Lead
| Quarterly in the progress and status report |
| SDPS application or other system specified by CMS. |
| Report impact on disparities in all clinical areas, as well as the specific disparity intervention |
| See information provided under deliverable for CKD work plan. |
Additionally, it is expected that an acceptable corrective action plan (e.g. approved by PO) is developed and implemented if there is a negative impact on disparities.
| 81. |
| Baseline survey to partners and providers to determine QIO effectiveness in driving change |
| PO/GTL/ |
Theme Lead
| End of month 2 |
| SDPS application or other system specified by CMS. |
| The standard survey will be provided by CMS or CMS contractor and will also provide specific information on “which” providers to send survey (e.g., all, random selection, specified, etc.). A CMS contractor will administer the survey. |
| Distributed in a timely manner, in accordance to the instructions provided by CMS, or CMS contractor, and in a manner that ensures a high response rate. |
PO may impose corrective action if there is not an acceptable response rate when the survey was given to providers that signed a letter of commitment.
| 82. |
| Mid-course survey to partners and providers |
| PO/GTL/ |
Theme Lead
| 16 months after contract signing |
| SDPS application or other system specified by CMS. |
| Standard survey to be provided by CMS, or CMS contractor. CMS, or CMS contractor, to provide specific information on “which” providers to send survey (e.g., all, random selection, specified, etc.). A CMS contractor will administer the survey. QIO must use survey for CQI purposes. |
| See information for initial survey. |
| 83. |
| Final survey to partners and providers |
| PO/GTL/ |
Theme Lead
| 26 months after contract signing |
| SDPS application or other system specified by CMS. |
| Standard survey to be provided by CMS, or CMS contractor. CMS or CMS contractor to provide specific information on “which” providers to send survey (e.g., all, random selection, specified, etc.). A CMS contractor will administer the survey. QIO must use survey for CQI purposes. |
| See information for initial survey. |
| 84. |
| Results of baseline, mid-course and final survey. |
| PO/GTL/ |
Theme Lead
| Due one month after the established deadline for partners’ and providers’ response |
| SDPS application or other system specified by CMS. |
| Results reported to CMS, or CMS contractor as instructed by CO, GTL, or PO, in the manner specified (e.g., aggregate, each survey de-identified). |
| Follow-up is required until response rate is in-line with what is specified in instructions provided by CMS, or CMS contractor. |
Providers should be aware, and commit to participation in surveys at the time or recruitment.
| 85. |
| Report of system change that occurred as a result of QIO intervention or action, with description of the QIO activity that caused (directly or indirectly) the change to occur. |
| PO/GTL/ |
Theme Lead
| Monthly |
| SDPS Application or Other System specified by CMS |
| As close to real time data entry as possible, with record of effective date of change, including the activity (and date) that drove change, and other required data elements |
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.
G. Contract Administration
| 86. |
| Electronic submission of voucher in FIVS (G.2.A.2.) |
| PO |
| Monthly |
| Electronic |
| 87. |
| Notice request for provisional rates from DCAA (G.3.D.) |
| CO |
| Ongoing Annually |
| Hardcopy |
| 87a. |
| Indirect Cost Rate Proposal (G.3.D.) |
| DCAA |
| Ongoing Annually |
| Hardcopy |
| 88. |
| Annual Incurrent Cost Proposal (G.3.E.) |
| CO and |
DCAA
| 6 months after the close of the QIO’s fiscal year |
| Hardcopy |
| 88a. |
| SF 294 ISR |
| CO |
| Oct 1 thru Mar 31 (G.14.C.) |
| eSRS, due date Apr 30th |
| 88b. |
| SF 294 ISR |
| CO |
| Apr 1 thru Sep 30th (G.14.C.) |
| eSRS, due date Oct 30th |
| 88c. |
| SF 295 SSR |
| CO |
| Oct 1 thru Sep 30th (G.14.C.) |
| eSRS, due date Oct 30th |
| 88d. |
| Severance Plan (H.13) |
| CO |
| Within 60 days of the effective date of the contract |
| Hard Copy |
H. Special Contract Requirements
| 89. |
| Organizational Conflict of Interest Certificate |
| CO, PO, OCI Specialist |
| Per section H.11.D.2 |
| Hard Copy to CO |
Electronic or Hard Copy to PO/OCI Specialist Per section H.11.D.1
| 90. |
| Organizational Conflict of Interest (H.11.C.2(f) – Notification of an Outside Contract or Agreement under the 5/20% rule |
| CO, PO, OCI Specialist |
| Annual submission due on February 28th each year and may be included with deliverable #88, listing ownership interests |
| Hard Copy to CO |
List all contractor(s) name, address, start date, duration, dollar amount, auto renewal provisions for contracts falling under the 5% and the 20% thresholds. It will be for notification purposes only.
| 91. |
| Organizational Conflict of Interest (H.11.C.2(d) – Request for Approval Outside Contracts and Agreements - |
| CO, PO, OCI Specialist |
| At least 30 days prior to the start date of the proposed agreement |
| Hard Copy to CO |
Copy of contract or agreement
| 92. |
| Organizational Conflict of Interest (H.11.D.1.) – Outside Contracts and Agreements |
| CO, PO, OCI Specialist |
| Every six (6) months from start of 9th SoW |
| Hard Copy to CO |
Electronic or Hard Copy to PO/OCI Specialist (6 column landscape format with numbering) Name, address, line(s) of business or if governmental start date, duration, dollar amount
| 93. |
| Organizational Conflict of Interest (H.11.C.3) – Sub-Contracts to the QIO Contract |
| CO, PO, OCI Specialist |
| At least 30 days prior to the start date of the proposed agreement |
| Hard Copy to CO |
Name, address, line(s) of business or if governmental start date, duration, dollar amount
| 94. |
| Organizational Conflict of Interest (H.11.F) – Key Personnel Appointments |
| CO, PO, OCI Specialist |
| At least 30 days prior to the start date of the proposed appointment |
| Hard Copy to CO |
Electronic or Hard Copy CV or Resume, including other board positions or ownership interests in healthcare entities
| 95. |
| Organizational Conflict of Interest (H.11.G) – Proposed subsidiary start-up |
| CO, PO, OCI Specialist |
| At least 60 days prior to the start date of the proposed subsidiary |
| Hard Copy to CO |
Description of the structure of the subsidiary, line(s) of business, physical location, any support services from the parent, source of funding, composition of the Board of Directors
| 96. |
| Organizational Conflict of Interest (H.11.D.) |
| CO |
| Every February 28 |
| Hard Copy Only |
| Per Section H.11.D.1.&2. |
* 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):
Centers for Medicare & Medicaid Services
Attn:(To be completed upon award) 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: Susan Fleck, RN, MMHS, Prevention: Disparities GTL
Centers for Medicare & Medicaid Services
Division of Quality Improvement
Attn: Susan Fleck
CMS
JFK Federal Building, Rm. 2350
Government Center
Boston, MA 02203
K.
Theme 7.2: Douglas Brown, Patient Pathways (Care Transitions) GTL
Attn: Douglas Brown
Baltimore, MD 21244-1850I.
L.
Theme 7.3: Teresa Casey, Prevention: Chronic Kidney Disease GTL
Attn: Teresa Casey
Baltimore, MD 21244-1850I.
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: Kelly Anderson 7500 Security Boulevard, MS S3-02-01
Baltimore, MD 21244-1850 Q.
Conflict of Interest and Governance Specialist
Centers for Medicare & Medicaid Services
Office of Clinical Standards and Quality
Attn: Don Forgione
7500 Security Boulevard, Mail Stop S3-02-01
Baltimore, Maryland 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)
PAGE
File details come from the government source that posted it. Updated .