External Accreditiation_PWS_2024 10 15.docx

PERFORMANCE WORK STATEMENT (PWS)

USCG Clinic External Accreditation

Vision Statement

97% of the United States Coast Guard (USCG) clinics are fully externally accredited per federal and civilian standards of practice. The lack of external accreditation can impede the delivery of high-quality health care and erode confidence in the healthcare system among stakeholders. The USCG desires to have all (100%) USCG clinics receive full external accreditation resulting in three (3) year Medical and Dental Home certification for each site.

1 Introduction/Background

Under the direction of Health, Safety, and Work-Life Service Center (HSWL SC), the USCG ambulatory health care clinics are responsible for achieving external accreditation through a civilian accreditation agency with current national and state recognition. The USCG operates ambulatory health care clinics throughout the contiguous United States, as well as Alaska, Hawaii, and Puerto Rico, offering outpatient medical, dental, and vision care, as well as pharmacy, radiology and laboratory services. Specifically, the type of care provided includes outpatient medicine utilizing the patient centered wellness home model, and can include aviation medicine, preventive medicine, physical therapy, optometry, dentistry, occupational medicine, dental anesthesiology, pharmacy, behavioral healthcare and telehealth.

The number of medical professionals (e.g., doctors, dentists, pharmacists, optometrists, physician assistants, nurse practitioners, registered nurses) providing care and services at each clinic site ranges from 1 to 30, with an average of 5 credentialed and/or privileged personnel at each location. The USCG operates one site that provides overnight outpatient in a bed service at Training Center Cape May, New Jersey, which includes a 25-bed ward for the recruits with mild to moderate illnesses requiring overnight housing.

1.1 Mission

In accordance with the Defense Health Agency (DHA) and the Department of Defense (DoD) Directives, health care clinics that provide care to Department of Defense (DoD) beneficiaries are required to be accredited. Additionally, to ensure continued participation in TRICARE, USCG clinics must be externally accredited. USCG Headquarters is responsible for maintaining a central repository for all credentials and privileges for USCG health care personnel. The HSWL SC is responsible for maintaining a central repository for all USCG health care facility accreditations.

1.2 Scope

The purpose of this requirement is to obtain external accreditation services for all ambulatory health care clinics located across the USCG enterprise in the United States and applicable territories.

2 General Requirements

The USCG requires Contractor employees and surveyors be familiar with current Coast Guard Medical Manual (current version COMDTINST M6000.1F), HSWLSCTD 2016-008: Patient Event Reporting Template (PERT), and all other instructions relating to credentialing and privileging, the peer review process, etc. as carried out per USCG established policy and HSWL SC Technical Directives (HSWLSCTD).

2.1 Non-Personal Services

This is not a personal services requirement as described in FAR 37.104. The Government shall neither supervise Contractor employees nor control the method by which the Contractor performs the required tasks. Under no circumstances shall the Government assign tasks to, or prepare work schedules for, individual Contractor employees. It shall be the responsibility of the Contractor to manage its employees and to guard against any actions that are of the nature of personal services or give the perception of personal services. If the Contractor believes that any actions constitute, or are perceived to constitute personal services, it shall be the Contractor's responsibility to notify the Contracting Officer’s Representative (COR) and/or Contracting Officer (KO) immediately.

2.2 Business Relations

The Contractor shall successfully integrate and coordinate all activities needed to execute the requirement. The HSWL SC will be the primary point of contact for the Contractor. Meetings will take place between 0900-1600 ET. Survey schedules are to be arranged with the HSWL SC and validated by the clinics through the HSWL SC at the start of the performance period and within a month following the approval of each period of performance. This is a necessary step due to the size and scope of healthcare operations within the CG. The applications for surveys will be the responsibility of the individual clinics; however, the HSWL SC POC shall have complete access to the application and survey as program sponsors and technical authority.

Should the clinic not complete the required application one month prior to survey, the HSWL SC shall be notified. The Contractor shall manage the timeliness, completeness, and quality of survey. Should there be a concern; a grievance policy shall be available. All survey results will be remitted to the HSWL SC and clinics for review. Certificates shall be mailed directly to clinics for posting. Current and future handbooks are to be made available in both digital and print form for all clinic sites as well as to the HSWL SC Clinic Quality program within Operational Medicine/Clinical Services Product Line. The Contractor shall seek to ensure customer satisfaction and the professional and ethical behavior of all Contractor personnel.

2.3 Administration and Management

The USCG requires Contractor support/Key Personnel to complete the accreditation process. To remain current in standards, the USCG requires the Contractor to provide the current and future Accreditation Handbooks to be distributed to each clinic, and the HSWL SC and annual virtual webinars or an optional (at CG’s discretion) in person training to ensure that clinics are successful in maintaining the standards which the Contractor uses to measure the clinics in the survey process.

The USCG requires Contractor employees and surveyors become familiar with current USCG policy, instructions, Technical Directives (TD), and other requirements pertaining to medical care, credentialing and privileging, peer review process, etc. Current USCG policies and instructions can be reviewed on the following link: https://www.dcms.uscg.mil/Our-Organization/Assistant-Commandant-for-C4IT-CG- 6/The-Office-of-Information-Management-CG-61/About-CG-Directives-System/Commandant- Instruction-Manuals/. Technical directives can be provided upon award.

2.3.1 Survey Management

The Contractor shall provide technical advice and feedback during and after each survey to assist the USCG in continuously improving health care for USCG personnel. The Contractor, however, has no authority to alter the current USCG policy, instructions, and directives.

2.3.2 Requirements Administration

The Contractor shall establish processes and assign appropriate resources to effectively administer the requirement. The Contractor shall respond to Government requests for contractual actions in a timely fashion. The Contractor shall have a single point of contact between the Government and Contractor personnel assigned to support this Contract. The Contractor shall assign work effort of the personnel assigned to work on the requirement.

2.3.3 Personnel Administration

The Contractor shall provide the following support as required. The Contractor shall not conduct surveys during designated Government non-workdays or other periods where Government offices are closed due to weather or security conditions. The Contractor shall maintain the training currency of their employees by providing initial and refresher training on USCG policies and procedures as required to meet the PWS requirements. The Contractor shall make necessary travel arrangements for their employees. The Contractor shall provide the necessary infrastructure to support the Contract tasks and ensure that each surveyor has completed annual Health Insurance Portability and Accountability Act (HIPAA) training.

2.5 Contractor Personnel, Disciplines, and Specialties

The Contractor shall provide qualified personnel to perform all requirements specified under this PWS in accordance with the contracting company's hiring practices for surveyors to include experience in conducting surveys in small government healthcare facilities. The Contractor shall not employ any person who is a current employee of the United States Government ass it would constitute a conflict of interest. Surveyors should be knowledgeable or familiar in accessing USCG websites for documents including the Coast Guard Medical Manual, instructions and technical directives provided by the USCG to its health care facilities in matters related to the survey process. A surveyor webinar will be conducted regarding updates to USCG policies, procedures and program updates as needed with feedback provided by the HSWL SC.

2.6 Location and Hours of Work

The Contractor shall conduct survey activities (e.g., interviews, site surveys) involving clinic staff members between the hours of 0800 and 1600 (local time) Monday through Friday, except Federal holidays or when the clinic is closed due to security or weather concerns. The Contractor shall coordinate all survey activities in advance with designated USCG personnel at each clinic locations.

2.7 Key Personnel

Before replacing any individual designated as Key by the Government, the Contractor shall notify the Contracting Officer in advance, submit written justification for replacement, and provide the name and qualifications of any proposed substitute(s). All proposed substitutes shall possess qualifications equal to or superior to those of the Key person being replaced. The Contractor shall not replace Key Contractor personnel without written consent from the Contracting Officer. The Key Personnel for this requirement are the Program Manager and Surveyors. Refer to Homeland Security Acquisition Regulation (HSAR) 3052.215-70.

3 Performance Requirements

The purpose of this requirement is to obtain external accreditation services for all ambulatory health care clinics located across the USCG enterprise in the United States and applicable territories.

3.1 Provide external accreditations for all USCG clinics.

Performance Standards

a) Standard: There are no gaps in accredited status for each clinic (unless the Government causes the delay or gap; e.g., a clinic fails to achieve accreditation).

b) Acceptable Quality Limit (AQL): No deviation acceptable.

Deliverables A002 - Individualized Survey Report A004 - Accreditation Certificate A007 - Quality Report

3.1.1 The Contractor shall conduct accreditation surveys.

Performance Standards

a) Standard: Clinics due for survey in a given option year are scheduled at the beginning of that option year in coordination with the HSWL SC to allow clinics the ability to ensure mission essential personnel are available during that survey period. The Contractor is expected to complete these surveys on time unless prior approval given by program office or the USCG causes the delay.

b) AQL: Delay allowed if prior approval received from USCG Program Office, and an extension of the current accreditation term is granted with no additional cost to the USCG.

Deliverables A001 - Accreditation Survey

3.1.1.1 The Contractor shall be knowledgeable about the operation of small government run clinics.

Performance Standards

a) Standard: Verifiable via past performance from similarly sized organizations.

b) AQL: No deviation.

3.1.1.2 The Contractor shall provide survey reports to the program office for review within 60 days of the completed survey.

Performance Standards

a) Standard: Provide survey reports to the program office and clinics.

b) AQL: Must be received by the program office within 60 days of the completed survey.

Deliverables A002 - Individualized Survey Report

3.1.2 The Contractor shall provide electronic access and a paper copy of the organization’s handbook to each clinic and the HSWL SC upon contract award and when updated.

Performance Standards

a) Standard: Each clinic and the HSWL SC is to receive a copy of the handbook upon award and when updated. Both electronically and in print due to the transitory nature of the healthcare team.

b) AQL: As long as all clinics have a digital copy of the current handbook, print copies can be mailed to the clinics at the beginning of the clinic’s survey option year. The HSWL SC must have the most current copy of the handbook at all times.

Deliverables A003 - Accreditation Handbook

3.1.2.1 The Contractor shall have a grievance policy/protocol available.

3.1.3 The Contractor shall provide each clinic with an accreditation certificate for display and records upon successful completion of an accreditation survey.

Performance Standards

a) Standard: Timely presentation of certificates for display.

b) AQL: Within 60 days of completion of survey.

Deliverables A004 - Accreditation Certificate

3.2 Provide advice and expertise for USCG clinics during surveys and on an ad hoc basis.

3.2.1 The Contractor shall provide training for clinic personnel to be successful in external accreditation.

3.2.1.1 The Contractor shall conduct three (3) webinars or one live training annually at the discretion of the government.

Performance Standards

a) Standard: Three (3) webinars (or one (1) live training if exercised at beginning of a period of performance) will be arranged to provide training to the entire enterprise annually at the beginning of the option year. The webinar topics will require prior approval from the Contracting Officer's Representative (COR)/Program Office and should be designed to ensure clinics have the latest information on topics designed to lead to successful accreditation.

b) AQL: Webinars must include topics relevant to the USCG and aid in successful outcomes. Recordings of webinars should be available for on demand review by CG healthcare personnel during the course of the option year.

Deliverables A005 – Webinar with recording A006 - In-person training

3.2.2 The Contractor shall be available for communication with the government between the hours of 0800-1630 ET.

3.3 Compose and deliver quarterly quality reports on USCG clinics for program office.

Performance Standards

a) Standard: Provide quarterly quality reports to the program office.

b) AQL: Must be received by the program office within 60 days of the close of the quarter.

Deliverables A007 - Quality Report

3.3.1 The fourth quarter quality report shall be a consolidated annual report to the program office.

Performance Standards

a) Standard: Provide annual quality reports to the program office. This shall be a combination of the 4th quarter report along with the annual review.

b) AQL: Must be received by the program office within 90 days of the close of the performance period.

Deliverables A008 - Annual Quality Report

4.1 Security and Safety

Contractor access to classified information is not currently required under this performance work statement. Therefore, at this time, Contractor employees are not required to have a Secret Clearance. However, the Contractor shall be knowledgeable on HIPAA Rules and Regulations and their employees (surveyors) are required to have completed all necessary training required under the HIPAA Rules and Regulations. Additionally, the Contractor shall not have unescorted or unaccompanied access into locked files or files requiring CAC or password access. Information review by the Contractor in these files shall not be shared with other than the Government, specifically the USCG HSWL SC.

4.2 Government Furnished Materials

The Government will make available the materials, office space, communications capability and information to complete the accreditation survey during the survey process for each clinic for use by the Contractor in the performance of this Contract.

4.3 Quality

This section describes the Quality Control components for this effort. The following sub-sections provide details of various considerations on this effort.

4.3.1 Quality Control

The Contractor shall develop a Quality Control Program (QCP) to maintain an effective quality control standard to ensure services are performed in accordance with this PWS. The Contractor's QCP is the means by which they assure the Government that their work complies with the requirements.

The finalized QCP will be accepted by the Government prior to the period of performance start date. The Contracting Officer may notify the Contractor of required modifications to the plan during the period of performance. The Contractor then shall coordinate suggested modifications and obtain acceptance of the plan by the Contracting Officer. Any modifications to the program during the period of performance shall be provided to the Contracting Officer for review no later than ten (10) working days prior to effective date of the change. The QCP shall be subject to the Government's review and approval. The Government may find the QCP "unacceptable" whenever the Contractor's procedures do not accomplish quality control objective(s). The Contractor shall revise the QCP within ten (10) working days from receipt of notice that QCP is found "unacceptable."

5 Deliverables

The Contractor shall provide the following deliverables specified by the government. Format and delivery schedule for the deliverables shall be outlined in the Contract Data Requirements List below.

Survey of USCG clinics {see clinic roster Appendix A} for accreditation.

{all clinics}

Additional 2 copies to the Health, Safety and Work-Life Service Center

Certification for display and one for records

Instead of annual webinar training at government's request.

Annual {as requested} 1 per performance period

6 Related Documents

The following documents are related to this requirement.

Appendix A - 2024 Clinic Verification - (attached)

Appendix B - COMDINST M6000.1F (AUG 2014): Coast Guard Medical Manual- (due to file size document attached)

Appendix C - HSWLSCTD 2018-008: Patient Event Reporting Template (PERT) - (due to file size document attached)

Appendix D - HSWLSCTD 2018-013: Quality Improvement Focus Group (QIFG) - (due to file size document attached)

Appendix E – HSWLSCTD 2021-004: MHS Gensis Procedural Guidance (due to file size, document attached)

Appendix F – HSWLSCTD 2024-001: Peer Review for Medical, Dental, Pharmacy and Regional Behavioral Health Providers (due to file size, document attached)

Appendix G – HSWLSCTD 2024-006: Pharmacy & Therapeutics Committee – (due to file size, document attached)

7 Performance Requirement Summary (PRS)

AQL: No deviation acceptable.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

option year are scheduled at the beginning of that option year in coordination with the HSWL SC who coordinates with the clinics to allow clinics the ability to ensure mission essential personnel are available during that survey period.

The Contractor is expected to complete these surveys on time unless prior approval given by program office or the USCG causes the delay.

AQL: Delay allowed if prior approval received from USCG Program Office, and an extension of the current accreditation term is granted with no additional cost to the USCG and negative ramifications on the clinic.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

3.1.1.1 The Contractor shall be knowledgeable

about the operation of small government run clinics.

a) Verifiable via past performance from similarly sized organizations.

AQL: No deviation.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

AQL: Must be received by the program office within 60 days of the completed survey.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

3.1.2 The Contractor shall provide access (both electronic and paper copy) to the organization's handbook to each clinic annually or as the handbook is updated.

a) Each clinic is to receive a digital and print copy of the handbook annually or as the handbook is updated.

AQL: The print copy of the handbook can be provided at the beginning of the option year to the clinics that are pending survey during that option year provided they have a digital copy. The HSWL SC should have the most current copy of the handbook at all times.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

3.1.3 The Contractor shall provide each clinic

with an accreditation certificate for display and records upon successful completion of an accreditation survey.

a) Timely presentation of certificates for display.

AQL: Within 90 days of completion of survey.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

3.2.1.1 The Contractor shall conduct three (3)

webinars or one live training annually as the discretion of the government.

a) Three webinars (or one live training if exercised at beginning of option year) will be arranged to provide training to the entire enterprise annually at the beginning of the option year. The webinar topics will require prior approval from the COR/Program Office and should be designed to ensure clinics have the latest information on topics designed to lead to successful accreditation.

AQL: Webinars must include topics relevant to the USCG and aid in successful outcomes.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

AQL: Must be received by the program office within 60 days of the close of the quarter.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

3.3.1 The fourth quarter

quality report shall be a consolidated annual report to the program office.

a) Provide annual quality reports to the program office. This shall be a combination of the 4th quarter report along with the annual review.

AQL: Must be received by the program office within 90 days of the close of the performance period.

Feedback through the Contractor Performance Assessment Reporting System (CPARS).

DRAFT External Accreditation date 10-15-2024

Appendix A – 2024 Clinic Locations