DRAFT PWS IHS Hospital Accreditation DEC 25.pdf

DRAFT PERFORMANCE WORK STATEMENT (PWS)

Hospital Accreditation Compliance Assessments and Leadership Support

December 4, 2025

1. General Information

1.1 Purpose

This Performance Work Statement (PWS) establishes the requirements for consultation and professional support services to federal Indian Health Service (IHS) healthcare facilities, with an emphasis on healthcare leadership, accreditation, and operational and financial management support. The Government shall not supervise or control contractor personnel performing these services; such personnel are accountable solely to the Contractor, who, in turn, is responsible to the Government.

1.2 Description of Services / Introduction

The Contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to perform the services described herein, except for those items specified as Government-furnished property or services. The Contractor shall perform to the standards and quality of work defined in this PWS.

1.3 Background

The IHS provides comprehensive primary health care and disease prevention services to approximately 2.8 million American Indian and Alaska Native (AI/AN) people in 574 federally recognized tribes through a network of more than 605 hospitals, clinics, and health stations on or near Indian reservations. IHS facilities are located across 12 Areas and serve populations in rural and urban locations in 37 states. IHS healthcare facilities are accredited and Centers for Medicare & Medicaid Services (CMS) certified to ensure high-quality, safe, evidence-based care and to support third-party billing for eligible AI/AN patients.

Historically, some IHS facilities have experienced challenges maintaining accreditation and CMS certification, resulting in actual or threatened loss of accreditation/certification. To address these issues, IHS has implemented site-specific contract support and a range of strategies to assist facility leadership in meeting the IHS mission. Comprehensive and proactive service support initiated before CMS certification or accreditation issues arise, has been identified as essential to effectively address problems and sustaining the highest standards of medical services.

1.4 Locations

Support services must be available, upon request, for all IHS federal facilities in multiple locations that need leadership and management support services. Individual task orders will be issued for each Service Unit.

1.5 Objectives

1. Guide, mentor, develop, and coach IHS facility executive leadership, nursing, and medical staff to maintain compliance with CMS Conditions of Participation (CoPs) and accrediting-body requirements, including credentialing and privileging functions.

2. Establish functional, sustainable programs addressing compliance issues; quality assessment; performance improvement; patient safety and risk management; environment of care; documentation and clinical processes; infection prevention and control;

sterilization; patient-centered collaboration; team building; and medical and nursing leadership operations.

3. Develop skills that foster mutual respect, effective communication, and mission-oriented collaboration.

4. Equip IHS facilities’ executive leadership and departmental managers with tools and knowledge to effectively lead teams and perform technical leadership functions.

1.6 Scope

Consultative services shall be provided for IHS facilities, upon request, to include:

1.6.1 Gap Analysis and Corrective Action Plan (CAP)

Conduct a gap analysis measuring an IHS facility’s performance against CMS CoPs, applicable accreditation standards, and EMTALA. Develop a Corrective Action Plan (CAP) explaining results and addressing compliance issues and process improvements. Special emphasis will be placed on:

• Governance and Leadership (excluding cases managed by Human Resources Employee Relations/Labor Relations (ER/LR)).

• Patient Safety, including the facility-wide culture of safety.

• Nursing leadership and nursing programs.

• Measurement and improvement of patient satisfaction and employee value/satisfaction scores.

• Infection Prevention and Control, including sterilization processes.

• Facility building management, including Environment of Care and Life Safety standards.

• Accreditation compliance and readiness.

• Collaboration between medical staff and nursing staff in the operation of services.

• Quality Assessment and Performance Improvement (QAPI), including quality-metrics management.

• Dental leadership, including dental sterilization.

• Laboratory leadership and sustainable resolution of gaps to open or maintain all laboratory services and prevent closures.

• Project management, planning, leading meetings, and prioritization of work.

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support December 4, 2025

• Relationship building, improved communications, effective use of delegation, and clarity of roles, responsibilities, and accountability.

1.6.2 Gap Analysis Method

The gap analysis shall assess and document existing performance, processes, and conditions through physical, on-site inspection and observation; review of policies, procedures, and plans;

analysis of executive-leadership processes (including medical staff leadership) and individual leadership performance; and other relevant documentation pursuant to Section 1.5. Executive leadership includes the Chief Executive Officer, Deputy Chief Executive Officer, Chief Operating Officer, Chief Nursing Officer, Chief Quality Management Officer, Chief Financial Officer, and Chief Medical Officer.

1.6.3 Gap Analysis and CAP Timelines

• The gap analysis report shall be completed within five (5) business days of the on-site gap analysis and provided to the facility’s executive leadership and the COR.

• Within ten (10) business days after completion of the on-site gap analysis, the Contractor shall develop the CAP addressing compliance issues and process improvements and submit to the COR and/or relative Task Order Contracting Officer Representative (TOCOR).

1.6.4 CAP Content

The CAP shall address noncompliance issues identified in the gap analysis report against CMS CoPs and accreditation standards. It shall describe actions required to bring the facility into compliance and outline actions to address Executive Leadership development needs (education;

process/procedure management; change and crisis management). The CAP shall include specific corrective steps, start and completion dates, responsibilities, and oversight assignments. Facility staff are responsible for action oversight and completion; the Contractor is responsible for insuring oversight, implementation and execution of the CAP.

1.6.5 CAP Presentation

Within ten (10) business days of submitting the gap analysis, the Contractor shall present the CAP to the facility’s Executive Leadership (and others designated by the facility and the Contractor) and to IHS personnel designated by the COR and the COR. During this period, the Contractor may interview leadership to obtain additional information needed to finalize the CAP.

1.6.6 CAP Implementation Oversight and Review Cadence

Upon COR approval, the Contractor shall oversee CAP execution daily. Facility Executive Leadership, IHS Area leadership, the COR, and other designated IHS personnel shall review the CAP weekly.

1.6.7 CAP Implementation Approach

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

As approved, the CAP shall be implemented on Day 1 per each action item. The Contractor shall be actively involved with facility staff at the level needed to complete action items while equipping staff with the skills to sustain processes and manage independently long-term.

1.6.8 Completion

The Contractor shall ensure all CAP steps are completed by the specific completion dates established in the approved plan.

1.6.9 Monthly Progress Reporting

Written monthly progress reports shall describe progress on CAP completion; risks, issues, challenges, and concerns; consulting activities; and training/mentoring topics provided in the prior month. Reports shall be provided electronically to facility executive leadership, IHS Area leadership, and the COR.

1.6.10 Monthly Meetings & Financial Reporting

The Contractor shall participate in virtual monthly meetings and provide feedback on CAP performance via progress reports. The Contractor shall also provide written data and verbal presentations regarding the project’s financial status, challenges to completing the CAP, and remediation activities. Requested data shall be provided electronically to the requestor and the

COR.

1.6.11 Period of Performance

The Period of Performance consists of a Base Period plus four (4) option years.

2. Administrative and Security Requirements

2.1 Quality Control Plan (QCP)

The Contractor shall develop a QCP to ensure all tasks and deliverables meet acceptable quality and performance standards.

2.2 Quality Assurance

The Government shall evaluate performance under the Quality Assurance Surveillance Plan (QASP), which defines how performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rates.

2.3 Federal Holidays

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

Recognized Federal holidays (per OPM) include: New Year’s Day; Birthday of Martin Luther King Jr.; Washington’s Birthday; Memorial Day; Juneteenth; Independence Day; Labor Day;

Columbus Day; Veterans Day; Thanksgiving Day; and Christmas Day.

2.4 Hours of Operation

The Contractor shall conduct business on-site between 8:00 a.m. and 4:30 p.m., Monday– Friday, except Federal holidays or Government-directed closures. The Contractor shall not be reimbursed when the Government facility is closed for such reasons. The Contractor shall maintain adequate staffing for uninterrupted performance when the facility is open. Stability and continuity of assigned personnel are required.

2.5 Place of Performance

Work shall be performed at any IHS healthcare facility and as identified in a Task Order.

2.6 Security Requirements

Contractor personnel must complete all security requirements as outlined by the Government at award and maintain the required level of security throughout the contract.

2.7 Physical Security

The Contractor shall safeguard all Government equipment, information, and property.

Government facilities, equipment, and materials shall be secured at the close of each work period.

2.8 Key Control

The Contractor shall implement methods to ensure that all keys/key cards issued by the Government are not lost, misplaced, or used by unauthorized persons. Keys shall not be duplicated. Key-control procedures (including turn-in) shall be included in the QCP. Lost or duplicated keys/key cards shall be reported immediately to the Contracting Officer (CO).

2.8.1 Lost/Duplicated Keys

If keys other than master keys are lost or duplicated, the Contractor shall re-key/replace affected locks upon CO direction. Alternatively, the Government may do so and deduct the cost from the Contractor’s monthly payment. If a master key is lost or duplicated, the Government will replace the system and deduct the total cost from the Contractor’s monthly payment.

2.8.2 Prohibited Use

The Contractor shall prohibit the use of Government-issued keys/key cards by any person other than Contractor employees. Contractor employees shall not open locked areas to permit entrance of persons other than authorized Contractor employees or personnel authorized by the CO.

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

2.8.3 Lock Combinations (if applicable)

The Contractor shall ensure lock combinations are not disclosed to unauthorized persons and are changed when personnel with access no longer require it. Procedures shall be included in the

QCP.

2.9 Special Qualifications

2.9.1 Certifications

The Contractor shall ensure all subject-matter experts (SMEs) assigned are qualified to advise licensed healthcare professionals in their subject areas. The Contractor shall submit a QCP ensuring all tasks are performed by qualified individuals.

2.9.2 Experience

The Contractor shall demonstrate experience performing the work requested in Section 1.6. The Contractor must have documented experience of similar size, scope and complexity in relation to the PWS, , including cultural sensitivity in this unique workplace, and an ability to work effectively with diverse groups in challenging and austere conditions.

2.10 Post-Award Conference / Periodic Progress Meetings

The Contractor shall attend any post-award conference convened under FAR Subpart 42.5. The CO, COR, and other Government personnel may meet periodically with the Contractor to review performance, communicate assessments, and resolve issues. These meetings shall be at no additional cost to the Government.

2.11 Contracting Officer’s Representative (COR)

The IDIQ COR is designated as: INSERT NAME and will be designated in the COR designation letter. The COR monitors technical aspects of the contract and assists in administration, including ensuring performance of technical requirements; necessary inspections; technical communications; interpretations of technical requirements; monitoring performance and reporting deficiencies; coordinating Government-furnished property; and providing site entry for Contractor personnel. The COR is not authorized to change any terms or conditions.

A Task Order Contracting Officer’s Representative (TOCOR) has the same responsibilities as noted for the IDIQ COR but has cognizance over a specific Task Order.

2.12 Key Personnel and Staff

The Government considers the project manager to be Key Personnel. The Contractor shall designate a Key Personnel deemed qualified to manage the work.

Project Manager Responsibilities:

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

• Provide overall leadership, direction, and oversight for the IHS Hospital Accreditation IDIQ contract tasks, ensuring alignment with IHS strategic goals, accreditation standards, and federal requirements.

• Serve as primary point of contact for IHS leadership, federal partners, subcontractors, and accreditation bodies.

• Oversee task order planning, execution, tracking, and reporting.

• Ensure timely delivery of all contract deliverables, reports, and documentation in compliance with federal acquisition and accreditation-related guidelines.

• Coordinate and manage multidisciplinary teams to support hospital accreditation activities, survey readiness, performance improvement, and timely execution of corrective action plans.

• Manage and oversee all SME’s and SME consultants.

• Manage budget execution, financial tracking, resource allocation, subcontractor oversight, and IDIQ task order lifecycle management.

• Monitor contract performance and compliance, identifying and resolving issues proactively.

• Lead regular project meetings, briefings, and progress reviews with leadership and stakeholders.

• Prepare and deliver high-quality written and oral reports, analyses, and presentations.

Required Qualifications:

• Bachelor’s degree in healthcare administration, public health, business, project management, or a related field.

• 7 - 10 years of progressively responsible project or program management experience in healthcare, hospital operations, or related field or program management.

• Proven experience managing large-scale or multi-site projects, healthcare accreditation or regulatory compliance projects including deliverable management, and performance tracking.

• Strong understanding of hospital accreditation standards (e.g., TJC, CMS CoPs) and healthcare quality requirements.

• Excellent leadership, communication, problem-solving, stakeholder engagement, and team-management skills.

• Proficiency in project management tools, scheduling, and reporting systems.

• Ability to manage budgets, timelines, competing priorities, and cross-functional teams.

Preferred Qualifications

• Master’s degree in a related field (MPH, MHA, MBA, etc.).

• Project Management Professional (PMP) or equivalent certification.

• Experience working within health agencies or tribal health systems.

• Experience coordinating accreditation readiness efforts directly with hospitals or health systems.

• Knowledge of federal acquisition regulations (FAR) and federal program oversight.

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

Other Staff

A minimum of three (3) consistent SME key personnel shall be present at each site at all times.

While not key, the contractor must demonstrate that each SME retains the necessary credentials and experience to serve as a SME for any particular site. The contractor must provide resumes for all SMEs at the government’s request.

2.12.1 Project Manager Availability

The Contractor shall provide a contract manager with full authority to act on behalf of the Contractor in all matters related to daily operations. An alternate shall be designated in writing to the CO. The contract manager or alternate shall be available between 8:00 a.m. and 4:30 p.m., Monday–Friday, except Federal holidays or Government-directed closures.

2.12.2 Replacement of Key Personnel

Before removing, replacing, or diverting specified individuals, the Contractor shall notify the CO in writing, reasonably in advance, and submit justification (including proposed substitutions) with sufficient detail to permit evaluation of the impact on the contract. No diversion shall occur without the CO’s written consent; see HHSAR 352.237-75 Key Personnel.

2.13 Identification of Contractor Employees

Contract personnel attending meetings, answering Government telephones, or working in situations where status is not apparent shall identify themselves as Contractor personnel.

Documents and reports shall be marked to disclose contractor authorship or participation.

Contract personnel shall wear badges identifying them as on-site consultant contractors.

2.14 Contractor Travel

During performance, the Contractor will be required to travel to IHS facilities nationwide, as identified in each Task Order, to provide on-site services in collaboration with facility staff.

Depending on availability, lodging may be within 50 miles or more of the facility.

2.15 Data Rights

The Government retains unlimited rights to all documents and materials produced under this contract, including the source code of any software. All such materials are Government-owned and may not be used or sold by the Contractor without the CO’s written permission. This right does not abrogate any other Government rights.

2.16 Organizational Conflicts of Interest (OCI)

Contractors currently providing staffing services at any of the specified facilities shall not be considered for award due to potential impaired objectivity. Contractor/subcontractor personnel

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support may receive or access proprietary or source selection information (e.g., cost/pricing data, budget analyses, specifications/work statements).

The Contractor shall notify the CO immediately upon becoming aware of any actual or potential OCI and promptly submit an avoidance/mitigation plan for CO review. Acceptance of any plan is at the CO’s sole discretion. If the CO determines an OCI cannot be satisfactorily avoided or mitigated, the CO may impose remedies, including prohibiting participation in subsequent requirements affected by the OCI.

3. Government-Furnished Property, Equipment, and Services

3.1 Services

The Government will provide personnel support for administrative functions required for Contractor onboarding and orientation at IHS facilities.

3.2 Facilities

The Government will provide on-site workspace for Contractor personnel, including desks or workstations, telephones, mobile phones, computers, and other items necessary to maintain an office environment for up to three individuals. Facility access control cards and PIV cards will be provided, as appropriate.

3.3 Utilities

The Government will provide internet and telephone utilities at IHS facilities. The Contractor shall instruct staff in utility-conservation practices and operate in a manner that precludes waste (e.g., turning off water faucets/valves after use).

3.4 Equipment

The Government will provide access to a printer located in or near the Contractor’s workspace within IHS facilities.

3.5 Materials

The Government and IHS facilities will provide paper supplies and requested Governmental and facility-specific documents (policies, procedures, plans, etc.).

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

4. Contractor-Furnished Items and Services

4.1 General

The Contractor shall furnish all supplies, equipment, facilities, and services required to perform this PWS that are not Government-furnished under Section 3. The Contractor shall complete all mandatory training and orientation requirements before work (list to be provided upon award) and shall support personnel security and employee-health clearance processes to facilitate expedient onboarding.

5. Specific Tasks

5.1 Basic Services

The Contractor shall guide, mentor, develop, and coach executive, medical, and managerial staff to ensure compliance with CMS CoPs and accrediting-body requirements. The Contractor shall establish functional QAPI programs and patient safety programs that drive compliance.

Activities include, but are not limited to, accreditation support, education, executive-leadership mentoring, and skill-set enhancement at the IHS facilities, with focus on:

• Governance and Leadership (excluding ER/LR cases managed by HR).

• Patient Safety and culture of safety.

• Nursing leadership and nursing programs.

• Measurement and improvement of patient satisfaction and employee value/satisfaction scores.

• Risk Management.

• Environment of Care and Life Safety.

• Infection Prevention and Control (including sterilization processes).

• Pharmacy (USP 797/800; compounding sterile preparations; order management).

• Optimizing Dental Services (including dental sterilization).

• Clinical Transformation and optimization of medical staff services.

• Information Technology transformation for integration into healthcare delivery.

• Emotional Intelligence and Executive Presence for leadership effectiveness.

• Financial Management and transformation.

• Medical Staff OPPE/FPPE metrics.

• Water Management Plans.

• Nutrition (Dietary Services).

• Accreditation, compliance, and readiness.

• Medical and nursing staff collaboration in service operations.

• QAPI functionality, including quality-metrics management.

• Laboratory leadership and sustainable gap resolution to open/maintain all services.

• Project management, planning, meeting leadership, and prioritization of work.

• Relationship building, communications, effective delegation, and role clarity.

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

5.2 Facility-Specific Tasks

5.2.1 Comprehensive Gap Analysis

Conduct a facility-wide gap analysis of current operations against applicable CMS CoPs and accreditation standards:

1. Review governance, leadership (including medical and nursing leadership), and culture to ensure sustained compliance.

2. Review Environment of Care (physical environment), including analysis against the National Fire Protection Association (NFPA) Life Safety Code, to ensure patient safety and quality of care.

3. Review clinical and operational processes of care in all settings and services against CMS CoPs, accreditation requirements, and nationally recognized guidelines (e.g., CDC, ACOG, AWHONN, AORN, AAMI, ISMP). This includes analysis of policies, plans, and other guiding documents.

4. Review QAPI, patient safety, and risk-management processes to ensure mechanisms exist to address and sustain patient safety and quality.

5. Analyze governance, leadership, and management educational/mentoring needs for effective operations and oversight.

6. Analyze nursing leadership and nursing programs.

5.2.2 Corrective Action Plan (CAP)

Complete a comprehensive CAP outlining sub-actions to correct non-compliance identified in the gap analysis, structured to achieve/sustain compliance with CMS CoPs and accreditation standards. The CAP shall include:

1. Actions to correct identified deficiencies in each service/function area.

2. Description of recommended actions; action start/stop dates; responsible facility individual(s); oversight Contractor personnel; implementation steps; and progress tracking.

3. Detailed milestones, including completion dates, related to each action.

5.2.3 CAP Implementation and Stabilization

Provide information on, and oversight of, CAP implementation and stabilization via:

1. Establishment of leadership and facility-wide communication and change-management processes.

2. Establishment of leadership collaboration between medical and nursing leadership with effective communication and change-management processes.

3. Establishment of QAPI and patient-safety programs with simple, implementable tools that support regulatory compliance and ensure quality and safety throughout the facility.

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support o 5.2.3.3.1 Develop QAPI/patient-safety mechanisms (e.g., root, apparent, and common-cause analysis) to rapidly identify challenges and embed processes to consistently, quickly, and durably remediate them.

o 5.2.3.3.2 Establish program oversight of medical and nursing practices (e.g., peer review, collaborative practices, facility-wide and department-specific practices).

o 5.2.3.3.3 Establish quality and safety metrics to evaluate services and functions (e.g., infection prevention, medication management, safety of the physical environment, nursing services, and other clinical/operational processes).

5.2.4 Building and Life Safety Oversight

Establish oversight mechanisms required for optimal building and Life Safety management.

5.2.5 Education and Training Program

Provide leadership and staff development/education programs on-site and virtually in various formats. Topics include, but are not limited to, accreditation and compliance standards for governance; executive, medical, quality, life safety, and nursing leadership. Training may be delivered to departmental managers, clinical leaders, and other staff. Education shall include curriculum, strategies, tools, and other materials needed to achieve educational goals. Content shall be based on the gap analysis and priorities identified in the CAP.

• 5.2.5.1 Education shall be prioritized and tailored to meet facility needs as identified through the gap analysis; necessary process changes shall be reflected in the CAP to sustain compliance.

• 5.2.5.2 Establish sustainable programs to meet facility needs, which may include policies, procedures, competencies, and data analysis.

• 5.2.5.3 Establish a standard agency-wide competency and training program for IHS federal healthcare facility leadership and management.

5.2.6 Executive Leadership Development

Provide Executive Leadership Development with mentorship and guidance tailored to the leadership team’s specific skill sets and needs.

5.2.7 Group and Individual Mentoring

Provide group and individual mentoring in areas identified or requested, including CMS/accreditation compliance, credentialing and privileging, infection prevention, QAPI, communication and change management, and meeting-management accountability.

5.2.8 Communication Structure

Establish an effective communication structure that teaches leaders successful crisis navigation and fosters change management.3

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

5.3 Travel Line Items

5.3.1 Allowability

The Contractor shall be reimbursed for travel costs in accordance with FAR 31.205-46.

5.3.2 Non-Local Travel

If non-local travel is required, the Government will reimburse costs via the appropriate contract line item.

6. Performance Requirements Summary (PRS) The Contractor shall meet the following performance objectives, standards, thresholds, and surveillance methods.

Performance Objective Performance Standard Performance Threshold Method of

Surveillance

PRS #1 –

Accreditation Support:

Provision of accreditation support enabling facilities to meet complex high-risk regulatory challenges.

Detailed CAP outlining steps and strategy to move the facility from current to future state.

100% acceptable upon COR and facility/Area Office leadership review, with receipt of CAP within 10 business days of Contractor being provided with accreditation survey findings.

Validated CAP received by

COR.

Ongoing dialogue with facility leadership and staff to achieve compliance with accreditation and CMS CoPs.

≥90% of actions met under the approved CAP by defined due dates and deliverables;

overall compliance with CMS CoPs and accreditation standards facility-wide.

Weekly review through 100% inspection of CAP progress and adherence to due dates;

validated monthly progress reports received by COR.

Continuity of SMEs:

Continuity, stability, and

SMEs are available as scheduled; advice is accurate, relevant, and actionable.

COR reviews staffing rosters and facility/Area/HQ feedback; Contractor limits

COR monitoring of rosters and feedback channels.

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support reliability of a core team of three (3) primary SMEs at each facility.

turnover and retains assigned SMEs/Key Personnel.

PRS #2a – Education for Executive & Departmental Leaders

Development of custom educational curriculum meeting needs identified in survey reports and through interviews/observations.

100% acceptable upon COR and facility/Area Office leadership review, with receipt of tailored curriculum within 15 business days of approved CAP.

Weekly review of CAP progress;

validated monthly progress reports received by COR.

Application of learned skills resulting in improved job and leadership performance.

≥90% of leaders demonstrate application of new/improved skills consistent with job descriptions/assignments.

Weekly CAP inspection;

monthly progress reports; pre/post knowledge checks;

evaluation via direct observation and written/verbal performance evaluations (including JCR tracers, as applicable).

PRS #2b – Education for Staff

Delivery of training/education to staff in accordance with gap analysis and CAP.

≥90% of staff demonstrate application of new/improved skills consistent with job descriptions/assignments.

Weekly CAP inspection;

monthly progress reports; pre/post knowledge checks;

departmental evaluations via direct observation and performance evaluations (including JCR tracers, as applicable).

PRS #3 –

Leadership & Management Capacity

Leadership-skill development for operations;

process/policy design and management; change/crisis

Acceptable when the facility attains ≥90% compliance with accreditation standards, including, if applicable, TJC

Weekly CAP inspection;

monthly progress reports; Area

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support management; facility-wide quality and safety (as identified in survey reports and leadership interviews/observations).

Leadership chapter and CMS Governance Condition (reflecting strategic planning, alignment, and adherence to leadership intent).

leadership direct observation;

written/verbal evaluations.

PRS #4 –

Executive (C-Suite) Mentoring

Mentoring of the executive team (CEO, CMO, CNO, COO, CQMO, and DPS) in organizational accreditation and regulatory compliance.

Acceptable when the facility attains ≥90% compliance with accreditation standards and CMS CoPs, including (if applicable) TJC Leadership and Medical Staff chapters and CMS Governance/Medical Staff CoPs.

Weekly CAP inspection;

monthly progress reports.

7. Attachments / Technical Exhibits

7.1 Attachment 1 – (Reserved)

7.2 Attachment 2 / Technical Exhibit 2 – Deliverables Schedule (per Facility)

Deliverable Frequency Quantity Medium/Format Submit To

Conduct a mock survey/gap analysis measuring performance against CMS CoPs, accreditation standards, and EMTALA (per Sections 1.6.1–1.6.3).

Once per facility

1 per facility

Electronic (secure method) and PDF

COR;

Facility and Area Office leadership;

HQ/OQ

Gap analysis report completed within 5 business days of on-site gap analysis (Section 1.6.3).

Once per facility

1 per facility

Electronic (secure method) and PDF

COR;

Facility and Area Office leadership;

HQ/OQ

Draft CAP: Develop the CAP addressing compliance issues and process improvements (due 10 business days from completion of Sections 1.6.1–1.6.3).

Once per facility

1 per facility

Electronic (secure method) and PDF

COR;

Facility and Area Office leadership

Final CAP incorporating Government input (due 5 business days after receipt of Government input).

Once per facility

1 per facility

Electronic (secure method) and PDF

COR;

Facility and Area Office leadership

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

CAP presentation within 10 business days of submitting the gap analysis (Section 1.6.5).

Once per facility

1 per facility

Electronic MS PowerPoint

COR;

Facility and Area Office leadership

On-site support: minimum of three

(3) SMEs per facility each business day, providing hands-on services to achieve performance objectives (Accreditation Support, Education, Leadership/Management Development). SMEs must demonstrate expertise in CMS CoPs and Joint Commission/AAAHC accreditation across Quality/Patient Safety; Facility/Environment of Care;

and Leadership domains.

Daily N/A N/A

Facility Executive Leadership and staff, as appropriate

Custom educational curriculum for executives and department leaders (per Section 5.2.5).

Once per facility

1 per facility

Electronic (secure method) and MS Excel or MS Word

COR;

Facility and Area Office leadership

Education/training slides, materials, and tools provided or developed specifically for covered facilities.

As defined by gap analysis and

CAP

As defined Various media

COR;

Facility and Area Office leadership

CAP updates (progress on action items and adherence to due dates), starting Week 1 after CAP approval.

Weekly Minimum of 26

Electronic (secure method)

COR;

Facility and Area Office leadership

Project Status Reviews: report prior month’s activities (including risks/issues/concerns and mitigation) and projected next-month activities.

Monthly Minimum of 6

Virtual presentation and

PDF

COR;

Facility;

Area Office;

HQ

leadership

Program Management Reviews:

financial status (projected vs.

incurred costs; anticipated overages identified in advance), risks/issues/concerns, and mitigations.

Monthly Minimum of 6

Virtual presentation;

electronic (secure method); and PDF

COR

Roster of SMEs and Key Personnel assigned to each facility (name, position, email, phone, responsibilities); submit updates per COR/CO direction; submit staffing-change revisions per

Once per facility (with updates as directed)

1 per facility

Electronic (secure method) and MS Excel or MS Word

COR;

Facility and Area Office leadership;

HQ/OQ

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

COR/CO timeline and investigation level guidance.

Quality Control Plan. Once per facility

1 per facility

Electronic (secure method) and PDF

COR;

Facility and Area Office leadership;

HQ/OQ

8. References

• FAR Subpart 42.5 (Post-Award Orientation).

• FAR 31.205-46 (Travel Costs).

• HHSAR 352.237-75 (Key Personnel).

• Applicable CMS Conditions of Participation.

• Applicable accreditation standards (e.g., The Joint Commission (TJC), AAAHC).

• NFPA Life Safety Code.

• CDC, ACOG, AWHONN, AORN, AAMI, ISMP guidelines, as applicable.

• OPM Federal Holidays list.

Acronyms

• AAAHC – Accreditation Association for Ambulatory Health Care

• AAMI – Association for the Advancement of Medical Instrumentation

• ACOG – American College of Obstetricians and Gynecologists

• AORN – Association of periOperative Registered Nurses

• AWHONN – Association of Women’s Health, Obstetric and Neonatal Nurses

• CAP – Corrective Action Plan

• CDC – Centers for Disease Control and Prevention

• CMS – Centers for Medicare & Medicaid Services

• CO – Contracting Officer

• COR – Contracting Officer’s Representative

• CoPs – Conditions of Participation

• CQMO – Chief Quality Management Officer

• DPS – Director of Patient Safety (or equivalent)

• EMTALA – Emergency Medical Treatment and Labor Act

• ER/LR – Employee Relations / Labor Relations

• HQ/OQ – Headquarters / Office of Quality

• IHS – Indian Health Service

• NFPA – National Fire Protection Association

• OPPE/FPPE – Ongoing/Focused Professional Practice Evaluation

• OPM – Office of Personnel Management

• PIV – Personal Identity Verification

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support

• PRS – Performance Requirements Summary

• QAPI – Quality Assessment and Performance Improvement

• QASP – Quality Assurance Surveillance Plan

• QCP – Quality Control Plan

• SME – Subject-Matter Expert

• TJC – The Joint Commission

DRAFT PWS - Hospital Accreditation Compliance Assessments & Leadership Support