J.24-C_NCC_SOD.pdf

Attachment J.24 – C September 29, 2015

ESRD NCC SOD

Schedule of Deliverables (SOD) ESRD National Coordinating Center

December 1, 2015- November 30, 2016

The ESRD NCC contractor shall submit all required reports and Deliverables in accordance with the following schedule unless otherwise specified by CMS. This Schedule of Deliverables is for December 1, 2015–November 30, 2016. All days are calendar days unless otherwise specified.

All reports and deliverables submitted under this contract shall be in accordance with the Statement of Work titled “National Coordinating Center, HHSM-500-2015-NW00XC.”

Definitions of Abbreviations:

CO = Contracting Officer COR = Contracting Officer’s Representative CS = Contract Specialist ELT = Electronic Copy ISG BA = Information System Group Business Analyst HC = Hard Copy PCU SME = Patient Contact Utility Subject Matter Expert

Table of Deliverables

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Task 1. Support for Clinical AIM 1 Subtask 1.A. Foster Patient and Family Engagement at the National Level Subtask 1.A.1. Develop and Recruit Members for the National Patient and Family Engagement LAN (NPFE-LAN) 1 Develop an innovative marketing plan to recruit initially at least 40 patient, family, or caregiver SMEs from the Network-selected pool of candidates

1 ELT to COR

December 31st, for Base Contract Year and December 31st for each subsequent Option Year

2 Maintain a national Patient and Family Engagement LAN (NPFE-LAN); hold meetings with patient participation at least quarterly during Base Contract Year and Option Years 1–4;

maintain 100%

1 ELT to COR

1 ELT to members of

NPFE-LAN

Select NPFE-LAN members within 90 calendar days PCA and maintain 100% membership with 60% attendance at required meetings in the Base Contract Year and continuing through Option Year

NCC SOD Version 3.0

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) membership with 60% attending each required meeting or activity throughout the course of the contract; recruit to replace lost members as applicable

4, evaluating the effectiveness of meetings and, at CMS direction, changing structure as needed; report SME names within 90 calendar days PCA and with NPFE-LAN meeting minutes

3 Organize and facilitate an annual NPFE-LAN kick-off meeting to outline the group’s objectives and membership and set goals/objectives and arrange and facilitate meetings every three months through Option Year 4

1 ELT to COR

1 ELT to members of

NPFE-LAN

February 28th of Base Contract Year then every 3 months of the Base Contract Year and each subsequent Option Year

Subtask 1.A.2. Enhance and Sustain the NPFE-LAN 4 Support the development and launch of 4 Affinity Groups: 3 focused on the mandatory QIAs and 1 focused on a patient-selected topic

1 ELT to COR

1 ELT to members of

NPFE-LAN

Beginning no later than March 31st of the Base Contract Year and each subsequent Option Year

5 Support the development of at least four QIAs through the Affinity Groups on Grievance Process, ICH CAHPS, and HAI and a patient-recommended topic, providing best practices, tools, and resources

1 ELT to COR

1 ELT to members of

NPFE-LAN

Beginning no later than June 30th of Base Contract Year and each subsequent Option Year for the 3 mandatory QIAs

Beginning no later than September 30th of the Base contract year and each subsequent Option Year for the patient-selected topic

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

6 Support the distribution of tools and resources supporting best practices to the wider ESRD community through the resource hub on the ESRD NCC website

1 ELT to COR

1 ELT to members of

NPFE-LAN

No later than November 30th of and updated monthly

7 Provide summary meeting minutes inclusive of action items, responsible individuals, and list of participants after each NPFE-LAN and Affinity Group meeting

1 ELT to COR

1 ELT to Networks

1 ELT to other invitees

Provide summary meeting minutes within 7 business days after meeting

8 Establish mailing and/or e-mail list for participants; send letters/e-mails/listserv messages as approved by COR

Update March and August of Base Contract Year and each subsequent Option Year

Subtask 1.A.3. Spread the Work of the NPFE-LAN and Affinity Groups 9 Develop a NPFE-LAN strategic plan 1 ELT to COR No later than

September 30th for the Base Contract Year and each subsequent Option Year

10 Create a method to test tools and resources on the specific outcomes relative to each Affinity Group’s outcome goal utilizing pilot zones

1 ELT to COR No later than November 30th for the Base Contract Year and each subsequent Option Year

11 Implement pilot zone testing as requested by

CMS

1 ELT to COR

1 ELT to applicable Network(s)

As requested by

CMS

Subtask 1.B. Improved Grievant Experience of Care and Evaluation and Resolution of Grievances 12 Monitor the timely receipt of PCU data from each Network and provide a cumulative

1 ELT to COR Within 10 business days of the receipt of the data monthly beginning 60

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) report calendar days PCA Subtask 1.B.1. ESRD Grievant Satisfaction Survey Subtask 1.B.2. Administration of the Grievant Satisfaction Survey 13 Subcontract with an independent third party administrator and provide subcontractor name to the COR

1 ELT to COR 60 calendar days

PCA

Subtask 1.B.3. Process for the Administration of the Grievant Satisfaction Survey Subtask 1.B.3.1 Initial Preparation for Survey Administration 14 Ensure that the independent third party administrator subcontractor completes the preparation activities described in the ESRD NCC SOW; report completion to the COR

Preparation activities to be completed in 2 stages 5 business days after the start of the independent third party administrator’s contract and 30 calendar days after the start of the independent third party administrator’s contract each stage reported to the COR within 10 business days of completion

15 Ensures the independent third party administrator subcontractor hires and trains staff as described in the ESRD NCC SOW; report verification to the COR

1 ELT to COR Within 30 calendar days and prior to the start of survey administration reported to COR within 10 business days of completion

Subtask 1.B.3. Survey Administration 16 Receive and securely transmit monthly PCU extract of patient authorizations to the survey administration subcontractor

1 ELT to COR

Report progress in the Monthly Status and Progress Report

Within 30 calendar days of receiving OMB (Office of Management and Budget) and CMS approval

Obtain and transmit data by the 12th calendar day of each month to the

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) independent third party administrator subcontractor during the Base Contract Year and each subsequent Option Year; report monthly to COR

17 Ensure that the independent third party administrator subcontractor completes the activities as described in the ESRD NCC SOW to prepare and distribute pre-notification letter mailings; report activities to the COR

1 ELT to COR

Report progress in the

Within 4 business days of independent third party administrator subcontractor receipt of data; report monthly to COR

18 Oversee implementation of survey administration and performance of the independent third party administrator subcontractor; report monthly to COR

1 ELT to COR

Report progress in the

Provide monthly reports of findings to CMS within 15 calendar days of the end of the previous month during the Base Contract Year and each subsequent Option Year

Subtask 1.B.4. Analysis of National Grievance Data 19 Receive raw survey data files as well as summary and trending reports of the survey results from the independent third party administrator subcontractor

1 ELT to COR

Report progress in the

Obtain data by the 5th business day after the close of the monthly survey administration period during the Base Contract Year and each subsequent Option Year

20 Provide summary and trending reports of information collected from the PCU as described in the SOW

1 ELT to COR

1 ELT to Network

Provide report findings beginning September 30th then every 3 months through the Base Contract Year and

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) each subsequent Option Year

Subtask 1.B.5. Development of Grievance-Related CMS Publications 21 Support the development/revision of grievance-related CMS publications

1 ELT to COR As requested by

CMS

Subtask 1.B.6. Patient Contact Utility 22 Secure and maintain

Web-based Portal for Patient Care Utility

COR, PCU SME First year of contract, if feasible, and/or approved by CMS-

ISG

23 Provide Orientation and Training of any PCU to All Networks to include any future updates within the contract period

COR, PCU SME If an update occurs, Coordinate with SME and COR on orientation and training.

24 Provide updates to the Manual for PCU as future enhancements are implemented

COR, PCU SME If an update occurs, Coordinate with SME and COR.

25 Quarter monitoring of PCU use of all Networks to ensure uniformity nationally.

1 ELT to COR, PCU SME Quarterly Report, along with Monthly COR Calls

26 Quarterly National Grievance Data

1 ELT to COR, PCU SME Quarterly Report, along with Monthly COR Calls

27 Monitor and track the number of calls from the Network regarding PCU performance issues and actions taken to resolve issues.

1 ELT to COR, PCU SME Monthly Report and Monthly COR Call

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

28 Provide monthly updates to CMS of schedule maintenance and any updates or enhancements to the

PCU

1 ELT to COR, PCU SME Monthly Report and Monthly COR Call

29 Provide monthly updates to CMS of SME activities

1 ELT to COR, PCU SME Monthly Report and Monthly COR Call

30 Secure and maintain Web-based Portal for Patient Care Utility

COR, PCU SME First year of contract, if feasible, and/or approved by CMS-

ISG

Subtask 1.C. ICH CAHPS 31 Obtain DUA with ICH

CAHPS data owner for access to ICH CAHPS data

1 ELT to COR No later than February 28th, for the Base Contract Year and renewed no later than February 28th of each subsequent Option Year

32 Design and develop reports for release to the Networks days of receipt of the semiannual survey data for the Base Contract Year and reviewed/revised as needed in each subsequent Option Year

33 Deliver reports and releases to the Networks

1 ELT to Networks days of receipt of the semiannual survey data for the Base Contract Year and each subsequent Option Year

Subtask 1.C.1. Data Support for ICH CAHPS 34 Establish data file 1 ELT to COR No later than

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) formats for transfer of data and request technical documentation, including data dictionary and requirements from the ICH CAHPS contractor

February 28th for Base Contract Year and updated as needed throughout 2016 and throughout each subsequent Option Year

35 Identify additional reporting needs through the ESRD Data Committee days of ICH CAPHS data becoming available to the

ESRD NCC

36 Provide trending reports to the Networks to interpret data available from ICH CAHPS including disparity data

As requested and directed by CMS

Subtask 1.C.2. Clinical Support for ICH CAHPS 37 Host a LAN event with

Network representatives to report promising practices in QIAs that the Networks are executing

1 ELT to COR

1 ELT to Networks

As requested and directed by CMS

38 Compile Network ICH CAHPS QIA report and submit to CMS for review

1 ELT to COR Within 30 calendar days of LAN event

39 Utilize reports that track/trend outcome measures through ICH CAHPS data system to determine success of individual Network QIAs

1 ELT to COR September 30th for the Base Contract Year and February 28th and September 30th for each subsequent Option Year

40 Promote QIAs that showcase greatest improvement through creation of central national repository of tools and resources

1 ELT to COR As requested and directed by CMS

Subtask 1.D. Supporting Facility Vascular Access Reporting; Spread of Best Practices; and Provision of Technical Support

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Subtask 1.D.1. Fistula First Catheter Last Workgroup Coalition 41 Maintain FFCL

Workgroup Coalition including Network Quality Improvement Directors representing the Regional Office areas

1 ELT to COR

Report progress in the

Review and evaluate process, purpose, and value monthly

42 Convene the FFCL Focus Feedback teams to identify tools and resources to support FFCL initiatives

As needed to support

AIM 1 FFCL

initiatives

43 Distribute FFCL tools and resources supporting best practices to the wider ESRD community

1 ELT to COR

Report progress in the

Beginning no later than February 28th for the Base Contract Year and continuing monthly throughout 2016 and throughout each subsequent Option Year

44 Provide summary meeting minutes inclusive of action items and responsible individuals after each FFCL Workgroup meeting

1 ELT to COR

1 ELT to Networks

1 ELT to other invitees

Provide summary meeting minutes

Subtask 1.D.2. Data Support for the Increased Use of AVFs and Decreased Use of Catheters 45 Maintain FFCL Data

Committee including Network Quality Improvement Directors and Data Managers representing the Regional Office areas

1 ELT to COR

Report progress in the

Review and evaluate process, purpose, and value monthly

46 Convene the FFCL Data Committee to provide input on data needs to support FFCL initiatives

1 ELT to COR

Report progress in the

As needed on an ongoing basis to support AIM 1 FFCL initiatives for the Base Contract Year and subsequent Option Years

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

47 Provide summary meeting minutes inclusive of action items and responsible individuals after each FFCL Data Committee meeting

1 ELT to COR

1 ELT to members of FFCL Data Committee

Provide summary meeting minutes

48 Provide summary of FFCL Data Committee recommendations for data requirements, development of production report examples to CMS for review and approval for national implementation

As need with each planned CROWNWeb release

49 Fistula First Catheter Last Dashboard

ESRD Networks

As directed by CMS based on the CROWNWeb Clinical Closure Schedule

50 Fistula First Catheter Last Reports

ESRD Networks As directed by CMS based on the CROWNWeb Clinical Closure Schedule

51 Establish a routine schedule for providing reports to ESRD Network community or posting reports to ESRD NCC website

ESRD Networks

Provide schedule for delivery of reports following each CMS-announced closure of clinical period by February 28th of the Base Year

Deliver reports per the established schedule

52 Provide support to the ESRD Networks to improve the completeness and accuracy of CROWNWeb data needed to achieve CMS

1 ELT to COR

Report progress in the

Ongoing Summary of activities by February 28th of the Base Year then every three months continuing throughout the Base

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) goals Contract Year and subsequent Option Years

Subtask 1.E. Reduce HAIs Subtask 1.E.1. Establish National HAI LAN 53 Establish the HAI LAN with focus and activities to support the Network community in the BSI/Sepsis and Vaccination initiatives

1 ELT to COR

Report progress in the

Beginning by May 31st for the Base Contract Year and continuing to meet at a minimum every 3 months throughout 2016 and throughout each subsequent Option Year

54 Based on assessment of the ESRD Networks’ HAI evolution, Chapter 6 in the HHS Roadmap to Elimination, and at CMS direction, maintain the HAI LAN workgroup to discuss best practices, tools, and resources that can be effective at a national level

1 ELT to COR

Report progress in the than May 31st for the Base Contract Year and continuing monthly, as needed, throughout 2016 and throughout each subsequent Option Year

55 Provide summary meeting minutes inclusive of action items and responsible individuals after each National HAI LAN

1 ELT to COR

1 ELT to members of LAN

Provide summary meeting minutes within 7 business days after meeting

56 Distribute HAI tools and resources supporting best practices as well as HAI LAN events to the wider ESRD community on the ESRD NCC website

1 ELT to COR

Report progress in the than September 30th for the Base Contract Year and continuing monthly, as needed, throughout 2016 and throughout each subsequent Option Year

Subtask 1.E.2. Data Support for HAI Vaccination QIA 57 Support the Networks’

HAI Vaccination QIAs

By February 28th for the Base Contract

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) by assisting in defining available data in CROWNWeb and obtaining data from CROWNWeb and developing standard performance measurement reports

1 ELT to Network Year and with CROWNWeb closures throughout 2016 and throughout each subsequent Option Year

Task 2. Support for Clinical AIM 2 Subtask 2.A. Network Population Health Focused Pilot Project Data Support 58 Assist Networks in defining available data in CROWNWeb and obtaining it from CROWNWeb and developing standard performance measurement reports

1 ELT to COR

1 ELT to Network

By February 28th for the Base Contract Year and continuing throughout 2016 and throughout each subsequent Option Year

59 Support and facilitate a workgroup for each of the projects to include representation from Networks that have selected that specific project to identify data needs to support trending

1 ELT to COR

Report progress in the

Establish no later than May 31st for the Base Contract Year and continuing every three months throughout 2016 and throughout each subsequent Option Year

60 Provide summary of requirements for each Focused Project to support data needs including a level-of-effort assesssment and timeline requirements

Provide level-of-effort assessment and timeline requirements to the COR by May 31st of the Base Contract Year and annually for each subsequent Option Year

Continuously evaluate and respond to Network data needs in Base Contract Year 2016 and throughout each subsequent Option

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Year 61 Establish a routine schedule for providing reports to ESRD Network community or posting reports to ESRD NCC website

1 ELT to COR Provide schedule for delivery of reports by February 28th of the Base Year

Deliver reports per the established schedule

62 Provide support to the ESRD Networks to improve the completeness and accuracy of CROWNWeb data needed to achieve CMS goals

1 ELT to COR

Report progress in the

Ongoing than February 28th and reported monthly for the Base Year and throughout each subsequent Option Year

Subtask 2.B. Network Population Health Focused Pilot Project Clinical Support 63 Provide a central library cataloguing Focused Project resources and LAN event educational materials

1 ELT to COR Ongoing

Beginning no later than September 30th and at a minimum every 3 months during the Base Year and throughout each subsequent Option Year

Task 3. Support for Clinical AIM 3 Subtask 3.A. Support for the ESRD QIP, Dialysis Facility Compare, Star Ratings, and Dialysis Facility Reports for Performance Improvement 64 Establish a DUA with the ESRD QIP contractor to receive ESRD QIP data into the NCC data warehouse

No later than February 28th for the Base Contract Year and each subsequent Option Year

65 Provide data analysis and reports as directed by CMS to support Network QIAs for AIM

1 ELT to COR

1 ELT to Networks

No later than February 28th for the Base Contract Year and continuing monthly throughout 2016 and throughout each subsequent

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Option Year 66 Convene national

Affinity Group to increase the level of understanding of patients, family members, and caregivers of the ESRD QIP, Dialysis Facility Compare (DFC), and Star Ratings

Beginning 90 calendar days PCA then every 3 months throughout the Base Contract Year and continuing every three months throughout each subsequent Option Year

67 Support and facilitate a Community of Practice call focusing on the Networks’ QIA projects with their 10 dialysis facilities

1 ELT to COR

1 ELT to Network

No later than May 31st for the Base Contract Year and continuing every three months throughout 2016 and throughout each subsequent Option Year

68 Create data extractions, file specifications, or other technical documentation to support the collection and exchange of data

69 Provide a summary of each Network’s requirements to support data needs including a level-of-effort assessment and timeline

1 ELT to COR Provide level-of-effort assessment and timeline requirements to the COR by May 31st of the Base Contract Year and annually for each subsequent Option Year

Continuously evaluate and respond to Network data needs in Base Contract Year 2016 and throughout each subsequent Option Year

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Subtask 3.B. Clinical Support for ESRD QIP Projects 70 Provide a central library cataloguing QIP Project resources and CoP event educational materials

1 ELT to COR

Report progress in the than September 30th for the Base Contract Year 2016 and continuing monthly throughout the Base Year and throughout each subsequent Option Year provide a summary of activities

Task 4. Maintenance, Enhancement, Security of the ESRD Network Program Data Warehouse Subtask 4.A. Data Warehouse 71 Establish a DUA between the ESRD NCC contractor and CMS that is consistent with the contract Period of Performance

1 ELT to COR Upon contract award

72 Request for data access to CROWNWeb 24-hour “snapshots”

1 ELT to COR Within 5 business days after contract award

73 Attend data center maintenance weekend planning calls

1 ELT to COR Ongoing monitoring;

report any impact to COR as necessary

Subtask 4.B. Support for CROWNWeb 74 Test upcoming releases of CROWNWeb for impacts to current or existing ESRD NCC reporting. Summarize any other impacts to Networks or data completeness and accuracy with expert recommendations as applicable

With each release beginning 1st Quarter of calendar 2016 for the Base Contract Year and continuing as frequently as quarterly throughout 2016 and through each subsequent Option Year

75 Establish an ESRD Data Committee including Network Data Managers than February 28th for the Base Contract

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) representing the Regional Office areas

Year and continuing every three months throughout 2016 and throughout each subsequent Option Year

76 Convene the ESRD Data Committee to provide input on data needs to Network SOW activities

1 ELT to COR

1 ELT to members of ESRD Data Committee

Beginning no later than February 28th for the Base Contract Year, meet at least monthly initially and then as needed to support core contract AIMs and/or other core contract SOW activities throughout 2016 and each subsequent Option Year

77 Provide summary meeting minutes inclusive of action items and progress after each Data Committee meeting

1 ELT to COR

1 ELT to members of ESRD Data Committee

Provide summary meeting minutes

78 Convene the Batch/Network Collaborative Meeting group to provide input to workflows and data needs

1 ELT to COR

1 ELT to members of ESRD Data Committee

No later than February 28th for the Base Contract Year, meet at least monthly initially and then as needed to support workflow and data needs throughout 2016 and throughout each subsequent Option Year

79 Provide summary meeting minutes inclusive of action items and progress after each Batch/Network Collaborative Meeting

1 ELT to COR

1 ELT to members of ESRD Data Committee

Provide summary meeting minutes within 7 business days after meeting

80 Provide summary of ESRD Data Committee

Ongoing as defined and prioritized by

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) recommendations of data requirements and development of production report examples to CMS for review and approval for national implementation

CROWNWeb Data Committee for Base Contract Year 2016 and throughout each subsequent Option Year

81 Establish a routine schedule for providing reports to ESRD Network community or posting reports to ESRD NCC website

1 ELT to COR

1 ELT to ESRD Data Committee

Ongoing as defined and prioritized by the CROWNWeb Data Committee for Base Contract Year 2016 and throughout each subsequent Option Year

82 Provide support to the ESRD Networks to improve the completeness and accuracy of CROWNWeb data needed to achieve CMS goals

1 ELT to COR

Report progress in the than February 28th for the Base Contract Year 2016 and continuing at least every three months throughout the Base Year and throughout each subsequent Option Year provide a summary of activities

Subtask 4.C. Participation in CROWNWeb User Group (CWUG) Meetings 83 Coordinate and participate in meetings of CWUG via phone

1 ELT to COR

1 ELT to members of ESRD Data Committee

Beginning no later than February 28th for the Base Contract Year and then monthly throughout 2016 and throughout each subsequent Option Year

84 Provide summary meeting minutes inclusive of action items and progress after each CWUG meeting

1 ELT to COR

1 ELT to members of ESRD Data Committee

Provide summary meeting minutes within 7 business days after meeting

85 Coordinate, participate, 1 ELT to COR No later than May

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) and, if necessary, travel to CWUG in-person meetings

1 ELT to members of

31st for the Base Contract Year then every three months or as CMS directs throughout 2016 and throughout each subsequent Option Year

86 Provide summary meeting minutes inclusive of action items and progress after each CWUG in-person meeting

1 ELT to COR

1 ELT to members of ESRD Data Committee

Provide summary meeting minutes within a month of the in-person meeting

Subtask 4.D. ESRD Network Dashboard Data Support 87 Discuss the ESRD

Network Dashboard at ESRD Data Committee Meetings, as appropriate and directed by CMS

1 ELT to COR No later than February 28th for the Base Contract Year, then every three months or as CMS directs throughout 2016 and throughout each subsequent Option Year

88 Provide summary meeting minutes inclusive of action items and progress after each meeting regarding Network Dashboard Input Form

1 ELT to COR

1 ELT to members of ESRD Data Committee

Provide summary meeting minutes

89 Provide summary of data requirements and development of production report examples to CMS for review and approval for provision to the Networks

90 Establish a routine schedule for providing reports to ESRD Network community or posting reports to ESRD

Provide schedule for delivery of reports by February 28th of the Base Year

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

NCC website 91 Deliver reports to ESRD

Network community 1 ELT to COR

1 ELT to members of

1 ELT to Network

Deliver reports per the established schedule as defined and prioritized by the Data Committee for Base Contract Year 2016 and throughout each subsequent Option Year

Subtask 4.E. Support for Clinical AIM Data Analysis 92 Develop a prioritization process and intervention strategies for performing Root Cause Analysis and utilizing change methodologies to promote rapid cycle testing for continuous quality improvement

1 ELT to COR

1 ELT to members of ESRD Data Committee

Ongoing and as directed by CMS, identify, monitor, and assess quality improvement efforts no later than June 30th of the Base Contract Year and continuing throughout Base Contract Year 2016 and each subsequent Option Year

Subtask 4.F. Clinical AIMs Data Extract, Reporting Business Requirements, and Development 93 Create and maintain technical documentation for each data extract available in the Data Warehouse

Available upon request by CMS

94 Create and maintain logic used to create data extracts available in the Data Warehouse

95 Create and maintain User Guides or Training Materials for each produced report

Subtask 4.G. Support for Change Management 96 Develop a Work

Request Log tracking

Maintain tracking systems beginning

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) new data extractions and changes to existing data extractions no later than February 28th of the Base Contract Year and enhance as needed throughout 2016 and throughout each subsequent Option Year

97 Provide a summary of data requests to CMS for review and prioritization

1 ELT to COR Beginning no later than February 28th, then every three months throughout Base Contract Year and throughout each subsequent Option Year

Subtask 4.H. Infrastructure Operations Support Subtask 4.I. ESRD Security Compliance Subtask 4.I.1. Certification by Information System Security Officer (ISSO) for Compliance with CMS Systems Security Requirements Subtask 4.I.2. Administer Security Program 98 Establish, maintain, and implement Business Continuity and Contingency Plan

(BCCP)

1 ELT to COR

1 ELT to ISSO

Beginning no later than March 31st establish a BCCP for the Base Contract Year and reviewed and revised annually for each subsequent Option Year

Maintain and implement BCCP ongoing for remainder of performance period, as directed by CMS

99 Document compliance with CMS security requirements in Network System Security Plan (SSP) and Information Security Risk Assessment (RA)

1 ELT to COR

1 ELT to ISSO

Beginning no later than March 31st document compliance in SSP and RA for the Base Contract Year and annually for each subsequent Option

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Year

Maintain documentation of compliance with CMS security requirements ongoing for remainder of performance period, as directed by CMS

Subtask 4.I.3. Correct Deficiencies Subtask 4.I.4. Security Review and Verification 100 Provide annual certification in accordance with SA&A methodology

1 ELT to COR

1 ELT to ISSO

Within 30 calendar days of start of the Base Contract Year and annually for each subsequent Option Year

Task 5. ESRD NCC Project Management and Communications Subtask 5.A. Strategic Plan 101 Submit a Strategic Plan encompassing the components outlined in the ESRD NCC SOW

45 calendar days after PCA and update as necessary but no less than each subsequent Option Year

Subtask 5.B. Internal Quality Improvement Program 102 Maintain a detailed IQC

Plan 1 ELT to COR Submit to the COR for review no later than 45 calendar days PCA for the Base Contract Year and update as necessary throughout the Base Contract Year

Submit at minimum annually and update as necessary throughout each subsequent Option

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Year Subtask 5.C. Comprehensive Progress and Status Report 103 Utilize the Monthly

Status and Progress Report Template in Appendix A to communicate to CMS the overall health of the NCC’s performance as well as specific challenges and barriers

1 ELT to COR Beginning 45 calendar days PCA for the Base Contract Year, then monthly throughout the Base Contract Year and throughout each

Subtask 5.D. Change of Key Personnel 104 Written notification of changes in key contract and/or subcontract personnel

1 ELT to Contracting Officer

1 ELT to COR

At least 30 calendar days prior to diverting/replacing any of the specified individuals

105 Qualifications of any new key personnel provided to the Contracting Officer and COR for approval

1 ELT to Contracting Officer

1 ELT to COR

At least 30 calendar days prior to replacing any of the specified individuals

Task 6. End of Contract Transition Task 7. National Coordinating Role for the ESRD Network Program Subtask 7.A. Plan, Facilitate, Participate in National/Regional/Local Meetings 106 Plan, facilitate, participate in national/regional/local meetings at the request of CMS

Discuss with COR during monthly progress calls

Report as directed by CMS during monthly progress calls

Subtask 7.B. Lead ESRD Program Planner/Organizer for the CMS Annual QualityNet Conference 107 Plan, manage, facilitate, and participate in the ESRD track of the QualityNet Conference provide work plan and conference theme, logistics, agenda;

identification and recruitment of speakers;

development of conference evaluation

Submit work plan 6 months prior to scheduled conference date

Submit conference theme, logistics, agenda;

identification and recruitment of speakers;

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) tools development of conference evaluation tools when developed

Report as directed by CMS during monthly progress calls

108 Hold QualityNet Planning Committee calls; invite SMEs to present on and discuss clinical AIMs–related topics; provide agenda prior to call

1 ELT to COR

1 ELT to Networks

1 ELT to other invitees

Submit agendas to COR at least 5 business days prior to call; provide to invitees after CMS acceptance

109 Provide summary meeting minutes inclusive of action items and responsible person after each conference call

1 ELT to COR

1 ELT to Networks

1 ELT to other invitees

Submit meeting minutes to COR 7 business days after call; provide to invitees after CMS approval

Subtask 7.C. Actively Participate in and/or Attend National and Regional Meetings 110 Plan, facilitate, participate in national/regional/local meetings at the request of CMS

Discuss with COR during monthly progress calls

Report as directed by CMS during monthly calls

Subtask 7.D. Support ESRD Network Refresh of Standard Computer Hardware and Software 111 Canvass ESRD

Networks to inventory current computer hardware and software and replace with updated equipment, as directed by CMS

As needed

Report as directed by CMS during monthly calls, if refresh is required

Subtask 7.E. Clinical AIM Resource Library—Facilitate Exchange of ESRD Network and Patient Information, Tools, Resources, and Other Materials 112 Develop and coordinate a centralized location to link to resource information that supports the activities of the Networks and

Review with COR Beginning no later than February 28th for the Base Contract Year, then maintained no less than monthly

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

LANs; review with CMS prior to release throughout the Base Contract Year and throughout each subsequent Option Year

113 Develop a written process that allows for posting of tools, resources, lessons learned, articles, and other information in the Clinical AIMs Resource Library

1 ELT to COR

Report progress in the

February 28th for the Base Contract Year, then review and revise annually each subsequent Option Year

Submit progress monthly

114 Conduct an environmental scan of relevant literature and available educational events on a monthly basis; distribute information to the ESRD community

ESRD NCC

Communication Exchange

Beginning no later than February 28th, then monthly throughout the Base Contract Year and monthly throughout each subsequent Option Year

Subtask 7.F. Clinical AIMs Marketing and Social Media Responsibilities 115 Support all LAN and workgroup activities and goals by developing marketing campaigns and materials to promote tools and resources

Provide status update in Monthly Status and Progress Report

Task 8. Development, Lead Authorship, Limited Printing, and Distribution of the Directory of ESRD Network Organizations Subtask 8.A. Collection of Information for Directory of ESRD Network Organizations 116 Notify Network

Executive Directors and CMS contact persons to update information for the annual Directory;

provide detailed instruction on use of online utility

Notification to COR

Notification to CMS contact persons

Notification to Network Executive Directors

No later than May 31st for the Base Contract Year and no later than May 31st for each subsequent Option Year

117 Complete collection of information for annual Directory

Notification to COR No later than May 31st for the Base Contract Year and no

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) later than May 31st for each subsequent Option Year

Subtask 8.B. Organization, Editing, Design of Directory of ESRD Network Organizations 118 Submit draft of annual

Directory to COR for review

June 30th for the Base Contract Year and June 30th for each subsequent Option Year

119 Submit final draft of annual Directory to COR and CMS Editor

CMS Editor

August 31st for the and August 31st for each subsequent Option Year

120 Submit final version to

COR

October 31st for the and October 31st for each subsequent Option Year

121 Submit final version for OCSQ clearance once approved by COR and CMS Editor

As directed by COR Submit as directed by COR

Subtask 8.C. Limited Printing and Distribution of Directory of ESRD Network Organizations 122 Submit list of those receiving hard copies of the annual Directory;

submit projected cost of photocopying and mailing with cost comparison to previous year

1 ELT to COR By end of second calendar week of October in the Base Contract Year and

123 Submit draft cover letters to COR and CMS Editor for review

1 ELT to COR

ELT to CMS Editor

By end of second calendar week of October in the Base Contract Year and each subsequent Option Year

124 Distribute hard copies of annual Directory and post electronic version to ESRD NCC website with notification e-mails

Notification to COR

Notification to CMS Editor

Notification to Networks

No later than November 30th in the Base Contract Year and no later than November 30th for

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) to 18 Networks and

CMS

Notification to other CMS staff as directed by COR

Task 9. Development, Lead Authorship, Printing, and Distribution of the End Stage Renal Disease Network Organization Program Summary Annual Report Subtask 9.A. Project Initiation, Designation of NCC Lead Author, Collecting Data for Summary Annual Report 125 Designate a Lead Author who will work in concert with designated NCC staff and the CMS COR to prepare the Summary Annual Report

Notification to COR No later than February 28th for the Base Contract Year and each subsequent Option Year

126 Compile Annual Reports from the 18 Networks and make available to Lead Author

1 ELT to Lead Author

Notification to COR

Within 10 business days of receiving Network Annual Reports for the Base Contract Year and each subsequent Option Year

127 Initiate contact with external contractor(s) as required to obtain access to required data

Notification to COR Within 10 business days of receipt of Network Annual Reports in the Base Contract Year and each subsequent Option Year

128 Complete draft of data tables and provide to the Lead Author

1 ELT to Lead Author

Notification to COR

Within 15 business days of receiving data extractions in the Base Contract Year and each subsequent Option Year

129 Distribute a request for additional information to Network Executive Director(s)

1 ELT to Networks

1 ELT to COR

Within 15 business days of receipt and review of all Network Annual Reports, request additional information as necessary from the Executive Directors in the Base Contract

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

Year and each subsequent Option Year

130 Provide any requested forms/information to the Lead Author

1 ELT to Lead Author

Notification to COR

Within 5 business days of receipt of any completed form/information from Network Executive Director(s) for the Base Contract Year and each subsequent Option Year

Subtask 9.B. Preparation of Final Draft of Summary Annual Report 131 Submit a draft of the

Summary Annual Report to the COR and CMS Editor

1 ELT to COR

1 ELT to CMS Editor

August 15th of the Base Contract Year and each subsequent Option Year

132 Work with the Lead Author to revise the draft of the Summary Annual Report to include any COR-requested revisions

1 ELT to COR 10 business days after initial COR/CMS Editor comments received for the Base Contract Year and each subsequent Option Year

133 Following final approval by the COR, submit a draft of the Summary Annual Report via e-mail to the Network Executive Directors for comment

1 ELT to Networks

Notification to COR

Notification to Lead Author

September 15th for the Base Contract Year and each

134 Review and address all Network comments and prepare a final draft for CMS leadership review in conjunction with the Lead Author; print 2 hard copies of the final draft and submit them to the COR to begin the clearance process through CMS

1 ELT and 1 HC to COR

1 ELT to Lead Author

October 15th of the Base Contract Year and each subsequent

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

135 Incorporate CMS leadership comments and edits and submit to

COR

1 ELT to COR

1 ELT to CMS Editor

Within 5 business days of receipt of CMS leadership comments for the Base Contract Year and each subsequent Option Year

Subtask 9.C. Photocopying and Distribution of Summary Annual Report 136 Submit list of those to receive hard copies of the Summary Annual Report; submit projected cost of photocopying and mailing with cost comparison to previous year

1 ELT to COR No later than September 30th the SAR for the Base Contract Year and each subsequent Option Year

137 Submit draft cover letters to COR and CMS Editor for review

1 ELT to CMS Editor

September 30th for the Base Contract Year and each subsequent Option Year

138 Distribute hard copies of Summary Annual Report and post electronic version on ESRD NCC website;

notify18 Networks and CMS by e-mail of website posting

Notification to COR

Notification to CMS Editor

Notification to Networks

Notification to other CMS staff as directed by the

COR

Within 10 business days of CMS final approval for the Base Contract Year and each subsequent Option Year

Task 10. Maintenance and Ongoing Development/Enhancement of a Centralized Website for the ESRD Network Program, Including All ESRD-Related Special Projects Subtask 10.A. Maintain a Centralized Website for the ESRD Network Program, Including All Special Projects 139 Report establishment and/or maintenance of a centralized website for the ESRD Network community

Notification to COR

Notification to Networks

Report progress, problems, and issues in Monthly Status and Progress Report due 15 calendar days after end of previous calendar month for the Base Contract Year and each

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) subsequent Option Year

Subtask 10.B. Update the Website 140 Enhance the website as necessary and report website updates monthly

Notification to COR Report on website updates in the Monthly Status and Progress Report due 15 calendar days after the close of each calendar month for the Base Contract Year and each subsequent Option Year

Task 11. Maintain a System for the Identification of all New Dialysis Patients and Distribute New ESRD Patient Orientation Packets (NEPOPs) Monthly to New Patients 141 Support the monthly

NEPOP mailing process and report monthly progress

1 ELT to COR Report progress, problems, and/or issues in Monthly Status and Progress Report due 15 calendar days after the close of the previous month for the Base Contract Year and each subsequent Option Year

Subtask 11.A. Maintain a System for the Identification of All New Dialysis Patients 142 Perform activities to identify all new ESRD patients and obtain correct mailing addresses

1 ELT to COR Report progress, problems, and/or issues in Monthly Status and Progress Report due 15 calendar days after the close of the previous month for the Base Contract Year and each subsequent Option Year

Subtask 11.A.1 Data Support to Monitor and Evaluate New Patient Mailing Datasets 143 Produce New Patient

Extract 1 ELT to COR Monthly for the Base

Contract Year and

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) each subsequent Option Year

144 Build upon data extract query specifications as needed for monthly management of NEPOP mailing

1 ELT to COR As needed; report any activity in this area in the Monthly Status and Progress Report due 15 calendar days after the end of the previous calendar month for the Base Contract Year and each subsequent Option Year

Subtask 11.B. Maintain a System for the Monthly Distribution of NEPOPs 145 Distribute NEPOPs monthly 1 ELT to COR as part of Monthly Status and Progress Report

Provide mailing dataset to mailing processor by the 15th calendar day of each month for the Base Contract Year and each subsequent Option Year

Report progress, problems, and issues in Monthly Status and Progress Report due 15 calendar days after the end of previous calendar month for the Base Contract Year and each subsequent Option Year

Subtask 11.C. Maintain a System for Tracking and Trending Sent and Returned Packets and Reasons for Return 146 Maintain a system for tracking and trending of sent and returned NEPOPs and reasons for returns

1 ELT to COR as part of Monthly Status and Progress Report

Report progress, problems, and issues in Monthly Status and Progress Report due 15 calendar days after end of previous calendar month for

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) the Base Contract Year and each subsequent Option Year

Subtask 11.D. Provide Ongoing Education to Network Staff on the NEPOP and NEMO Systems 147 Provide update on the

NEPOP and NEMO systems by WebEx

Notification to COR

Notification to Networks

As requested by Network or as necessary due to staff changes at the Network(s) for Base Contract Year and for each subsequent Option Year

148 Review and update NEMO User Guide;

submit for review to CMS Editor and COR prior to publication; post NEMO User Guide to ESRD NCC website

1 ELT to CMS Editor

1 ELT to COR

Submit for review by October 15th, or as directed by CMS for Base Contract Year and annually for each subsequent Option Year

Complete and publish by November 15th, or as directed by CMS for Base Contract Year and annually for each subsequent Option Year

Subtask 11.E. Evaluation and Performance Review of NEPOP Mailing Subcontractor 149 Develop comprehensive reporting structure and internal quality control plan for NEPOP Mailing Subcontractor

1 ELT to COR

1 ELT to NEPOP Mailing Subcontractor

Ongoing; report progress on a monthly basis to CMS or as directed for Base Contract Year and for each subsequent Option Year

Subtask 11.E.1. Monthly Evaluation Process Specific to NEPOP Mailing Subcontractor 150 Evaluate potential subcontractor ability to meet criteria in Mail Distribution Center

1 ELT to COR

1 ELT to NEPOP Mailing Subcontractor

Ongoing; report progress on a monthly basis to CMS or as directed

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s)

SOW for Base Contract Year and for each subsequent Option Year

151 Oversee NEPOP distribution; monitor and assess subcontractor performance against evaluation criteria in Mail Distribution Center

SOW

1 ELT to COR

1 ELT to NEPOP Mailing Subcontractor

Ongoing; report progress on a monthly basis to CMS or as directed for Base Contract Year and for each subsequent Option Year

Subtask 11.E.2. Annual On-Site Visit of NEPOP Mailing Subcontractor 152 Annual audit of mailing service provider In Person

1 ELT to COR

Annually no later than October 31st for the Base Contract Year and annually for each subsequent Option Year

Report to COR within 10 business days of in- person audit for the Base Contract Year and each subsequent Option Year

Subtask 11.F. Develop, Implement, and Evaluate a Pilot Program to Test an Alternate Method for Distributing New Patient Orientation Material 153 Convene a workgroup of

4 Networks designated by CMS to participate in the NEPOP Pilot including patient SMEs from these Networks;

provide names to COR

1 ELT to COR Within 45 calendar days PCA for Base Contract Year

154 Develop and distribute to new ESRD patients in the 4 Network areas a postcard to request NEPOP information

February 28th of the Base Contract Year for COR approval

155 Develop and implement a model for evaluation of the success of this

Submit 90 calendar days PCA for the Base Contract Year

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) process for COR approval 156 If requested by CMS, convene a Workgroup to review and update the existing NEPOP materials and to assist in the development of at least one additional CMS publication

Report progress in the Monthly Status and Progress Report to COR as directed for Base Contract Year and for each subsequent Option Year

Task 12. Provide Administrative Support to CMS as Requested Subtask 12.A. Provide Administrative Support to CMS “Executive Office Hours” Series 157 Distribute CMS

Executive Office Hours meeting agenda

1 ELT to COR

1 ELT to Participants

3 business days prior to each meeting as requested for the Base Contract Year and each subsequent Option Year

158 Provide detailed minutes of Executive Office Hours meeting

1 ELT to Participants

Distribute COR-approved summary within 10 business days after each meeting for the Base Contract Year and each subsequent Option Year

Subtask 12.B. Provide Administrative Support to AIM SMEs for Community of Practice (CoP) Meetings for AIMs 1, 2 and 3 of the ESRD Network Core Contract SOW 159 Distribute agendas for

AIM 1, 2, and 3 CoP Meetings

1 ELT to COR

1 ELT to Participants

2 business days prior to each meeting as requested for the Base Contract Year and each subsequent Option Year

160 Provide detailed summary for each AIM 1, 2, and 3 CoP Meeting

1 ELT to Participants

Distribute COR-approved summary within 10 business days after to each meeting for the Base Contract Year and each subsequent Option Year

Subtask 12.C. Provide Additional Administrative Support to CMS ESRD Network Program Director and the ESRD NCC COR as Requested 161 Coordination and 1 ELT to COR As directed by CMS

Deliverable # Deliverable Description

Recipient and Reporting Mechanism Due Date(s) dissemination of communication between CMS and the ESRD Networks, as directed by CMS leadership

Subtask 12.D. Develop Documents at CMS’ Request 162 Provide and/or assist with white papers, position papers, presentations, and…