PWS_Gen_Surg_(17_July_14).pdf

PERFORMANCE WORK STATEMENT

FOR

Services

(NON-PERSONAL SERVICE)

17 July 2014

39th Medical Support Squadron

PERFORMANCE WORK STATEMENT

FOR

NON-PERSONAL GENERAL SURGEON SERVICES

AT

MEDICAL TREATMENT FACILITY

39th MEDICAL SQUADRON

TABLE OF CONTENTS

SECTION TITLE PAGE

C-1 DESCRIPTION OF SERVICES 3

C-2 QUALITY ASSURANCE/SURVEILLANCE 14

C-3 GOVERNMENT FURNISHED PROPERTY AND SERVICES 16

C-4 GENERAL INFORMATION 17

C-5 RECORDS/DOCUMENTS REQUIREMENTS 19

C-6 PATIENT PRIVACY REQUIREMENTS 20

C-7 MISCELLANEOUS REQUIREMENTS 21

C-8 APPENDICES 22

SECTION C-1

1. DESCRIPTION OF SERVICES

1.1 DESCRIPTION. The general surgeon shall provide all services and labor required in accomplishing the performance of duties as specified, in strict accordance with all terms, conditions, general and special provisions, specifications, attachments, etc., contained herein or incorporated by reference. The Government requires availability as outlined in the Performance Work Statement (PWS) Section B.2. The contract shall be performed at the 39th Medical Group (39 MDG), also referred to as the "medical treatment facility" (MTF). The general surgeon provided under this contract is a non-personal service as described in Federal Acquisition Regulation 37. Performance shall be according to the requirements contained in this Performance Work Statement (PWS) and professional standards of The Joint Commission (TJC), Health Services Inspection (HSI) and the Accreditation Association for Ambulatory Health Care (AAAHC). The general surgeon shall perform services in accordance with the ethical, professional, and technical standards of the Air Force Medical Service as outlined in DoD Instruction 1332.38.

1.2. GENERAL DEFINITIONS. As used throughout this PWS, the following terms shall have the meaning set forth below:

1.2.1. ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE (AAAHC).

Civilian accreditation program for ambulatory healthcare organizations.

1.2.2. ADVERSE ACTION. IAW AFI 44-119. A clinical adverse action is an action invoked against a healthcare provider (privileged or non-privileged), where the authority to practice healthcare for the Air Force Medical Service is adversely affected. This action is taken in response to a threat to patient safety or to the integrity (bring discredit or unfavorable scrutiny) of the Medical Treatment Facility (MTF) as related to clinical incompetence, professional misconduct, or impairment.”

1.2.3. CLINICAL PRIVILEGES. Those inpatient and ambulatory clinical activities that are permitted to the general surgeon the by the granting MTF after evaluation by the credentials function and approved by the MTF Commander.

1.2.4. COMPOSITE HEALTH CARE SYSTEM (CHCS), ARMED FORCES HEALTH

LONGITUDINAL TECHNOLOGY APPLICATION (AHLTA). Computer system, which stores clinical and administrative data. This system provides on-line communication for users in any supported location.

1.2.5. CONTRACTING OFFICER (CO). A duly appointed person with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings on behalf of the Government.

1.2.6. CONTRACTING OFFICER REPRESENTATIVE (COR). An individual, including a contracting officer’s technical representative (COTR), designated and authorized in writing by the contracting officer to perform specific technical or administrative functions.

1.2.7. CREDENTIALS. Documents providing, evidence of education, training, licensure, experience, board certification and expertise of a health care provider.

1.2.8. CREDENTIALS COMMITTEE. The professional body set up to review credentials, make recommendation on clinical privileges for providers, and to promote quality control practice.

1.2.9. DEFECTIVE SERVICE. A service output that does not meet the standard of performance specified in the contract for that service. The method of surveillance for each performance objective is listed in the Services Summary. Defective services will be determined by either customer complaint or periodic inspection. A validated defect may be either an unsatisfactory inspection report or a customer complaint which addresses unacceptable turn-around times or errors in reports.

1.2.10. EXPOSURE-PRONE PROCEDURE. Examples of certain invasive surgical and dental procedures that have been implicated in the transmission of the hepatitis B virus from an infected health care worker to a patient include certain oral, cardiothoracic colorectal and obstetric/gynecological procedures. Characteristics of exposure-prone procedures include the following: Surgical procedures or object in a poorly visualized or highly confined anatomic site.

1.2.11. FREEDOM of INFORMATION ACT (FOIA) REQUEST. A written request for DoD records made by any person, including a member of the public, an organization, or a business that either explicitly or implicitly involves the FOIA, DoD Directive 5400.7.

1.2.12. FUNCTIONAL COMMANDER. The MTF Commander will appoint the Functional Commander who will be the liaison between the COR and the CO.

1.2.13. GOVERNMENT. The federal government of the Unites States of America.

1.2.14. HEALTH CARE PROVIDER. Any care professional whom, under regulations of a Military Department is granted clinical practice privileges in a military MTF or Dental Treatment Facility or who is licensed or certified to perform health care services by a Government board or Agency or professional health care society or organization.

1.2.15. HEALTH SERVICES INSPECTION (HSI). Air Force-specific health care inspection.

1.2.16. INVASIVE MEDICAL PROCEDURE. Is any procedure that involves a puncture or incision of the skin, the insertion of an instrument or foreign material into the body, or breaking the mucosa lining of the body.

1.2.17. THE JOINT COMMISSION. An independent, not-for-profit group in the United States that administers accreditation programs for hospitals and other healthcare organizations.

1.2.18. MEDICAL TREATMENT FACILITY (MTF). Air Force hospitals or clinics, including all activities providing outpatient and inpatient health care services for authorized personnel.

1.2.19. ON CALL. General surgeon shall be available for emergency consultations via telephone or cellular telephone.

1.2.20. PERFORMANCE WORK STATEMENT (PWS). A document that accurately describes a service in the terms of the output requirements and the required quality level or a standard of acceptable performance of those outputs.

1.2.21. PERSONNEL RELIABILITY PROGRAM. (PRP). Program that maintains reliable individuals to perform duties associated with nuclear weapons.

1.2.22. PRACTITIONER. Any medically qualified individual providing direct patient care.

1.2.23. PREPRIVILEGING. The application of screening process whereby prospective DoD health care providers, required to be privileged to provide patient care within MTFs, have their education, retraining, and past performance evaluated preliminary to their being considered for a contractual relationship.

1.2.24. PRIVACY ACT REQUEST. A written request from the subject of the records or a request with the subject’s written consent.

1.2.25. PRIVILEGING. Frequently referred to as credentialing. The process whereby the MTF Commander or the Major Command Surgeon General, upon recommendations from the MTF credentials function, grants to individual health care providers the privileges and responsibility of providing specific medical and dental care within the MTF.

1.2.26. VALID LICENSE. A grant of permission by an official agency of the Republic of Turkey to provide care independently as a health care professional. Licenses must be current.

1.2.27. QUALITY ASSURANCE/RISK MANAGEMENT (QA/RM). A committee comprised of medical professionals appointed by the MTF to provide QA and RM oversight.

1.3. GENERAL and SPECIFIC TASKS

1.3.1. GENERAL. The general surgeon shall perform the professional general surgery services required for patients’ healthcare needs as stated in Technical Exhibit 2. The quality of medical practice shall meet or exceed standards of professional practice for general surgery healthcare as determined by the same authority that governs military medical professionals in general surgery.

A percentage of all medical records will be reviewed through a peer review process per AFI 44- 119 and 39 MDG policies.

1.3.2 SPECIFIC PROCEDURES FOR WHICH THE CONTRACTOR SHALL BE

RESPONSIBLE.

1.3.3. TYPE of WORK. The duties will be performed in accordance within MTF established procedures and protocols, within the scope of practice. Duties include but are not limited to the following:

1.3.4. PROCEDURE GUIDANCE. General surgeon shall perform procedures in accordance within the MTF’s operating capacity and equipment. Medical procedures/services other than those included in Technical Exhibit 2 shall not be introduced by the general surgeon without prior approval of the MTF Commander or delegated authority.

1.3.5. SUPPORT SERVICES. The general surgeon may be required to perform procedures as assigned by the Chief of Medical Services to provide support in other sections/departments of the MTF commensurate with their experience. General surgeon shall serve as a liaison between the MTF and local host nation hospitals as designated by the Chief of Medical Staff (SGH). The general surgeon will also act as a medical liaison between the local Turkish Host Nation providers and the 39 MDG.

1.3.6. COMMUNICATION. The general surgeon shall ensure they maintain open and professional communication with patients and members of the MTF. Complaints validated by the COR, shall be reported in writing, in turn to the CO/Administrator and the Contractor for action.

1.3.7. MEDICAL MALPRACTICE LIABILITY INSURANCE. This contract is a non-personal services contract and the general surgeon shall provide and maintain adequate medical malpractice liability insurance in accordance with the (FAR) 52.237-7. The general surgeon is required to provide copies of all supporting documents at start of contract performance to the COTR. The minimum amount of this insurance shall be not less than $500,000.00 U.S. dollars.

1.3.8. CLINIC SUPPORT AND OUTPATIENT SURGERY. The general surgeon shall provide outpatient services for patients as scheduled by the MTF. This shall include but not be limited to examinations, diagnosis, and treatment of by surgical and other means, injuries and disorders consistent with injuries and disorders in the field of general surgery. This shall include initial visits as well as follow up visits.

1.3.8.1. The general surgeon shall provide MTF outpatient clinic visits at an average of four patients each duty hour. This shall include initial visits as well as follow up visits.

1.3.8.2. Patient scheduling will be at the determination of the MTF.

1.3.8.3. The general surgeon shall maintain proficiency in all types of major and minor surgeries to include multiple traumas. The general surgeon will maintain a log of surgeries done outside the MTF as proof of surgical proficiency. The log shall be provided to the COR upon request for peer review and proficiency purposes.

1.3.9. TYPES OF MAJOR AND MINOR SURGERY. General surgeon outpatient procedures shall be performed during regular duty hours when possible.

1.3.9.1. Examples of Minor Surgery include but not limited to:

Breast Biopsy

Colonoscopy

Hernia

Upper Gastrointestinal Endoscopy

Lipoma Removal

Scar Revision

Hemorrhoidectomy

Wound Exploration

1.3.9.2. Examples of Major Surgery include but not limited to:

Gallbladder

Appendectomy

Wound Exploration

* May be required to render assistance for Obstetrics/Gynecology Surgery, Orthopedic Surgery and ENT surgery during emergent situations to include Cesarean Sections.

1.3.10. DOCUMENTATION. The general surgeon shall prepare all documentation to meet established standards of the MTF and AFI 41-210 to include, but not limited to: timeliness, legibility, accuracy, content, and signature. Note: only MTF and Air Force approved abbreviations can be used to document patient care in the health care record. MTF staff practitioners will note defects, omission, agenda, etc. in/on the general surgeon’s medical documentation. If errors or discrepancies exist, the MTF staff will notify the COR.

1.3.10.1. Indicate responsibility for the content and correctness of all prepared and transcribed reports by affixing the general surgeon’s printed name and signature to the documents and validating their contents.

1.3.10.2. The general surgeon shall prepare and provide to the MTF appropriate narrative summaries, document recommendations for medical boards, profile changes, and job retraining recommendations within the MTF required time frame.

1.3.10.3. The general surgeon shall write patient progress note at appropriate intervals as determined by the MTF. Ensure postoperative note and discharge summaries are prepared and signed within the MTF required time frame.

1.3.10.4. The general surgeon shall provide and document appropriate history, physical examination, required laboratory and x-ray examination, provisional diagnosis and preoperative diagnosis, as required. The general surgeon shall complete these procedures prior to the performance of any treatment.

1.3.10.5. The general surgeon shall ensure complete patient identifying information is on all documentation that is Chronological Record of Medical Care; SF 513, Medical Record – Consultation Sheet and AF Form 781, Multiple Item Prescription shall be stamped with a rubber stamp, which shall include the following information: name, Turkish Citizenship (T.C.) number, and professional degree (M.D., D.O.).

1.3.10.6. Documentation of patient visits shall be completed in the Composite Health Care System (CHCS) and/or Armed Forces Health Longitudinal Technology Application (AHLTA) or as required by the MTF.

1.3.10.7. The general surgeon shall be trained on and required to use Composite Health Care System (CHCS) and/or AHLTA.

1.3.11. MEDICAL CODING OF PROCEDURES/OFFICE VISITS. The general surgeon shall be required to accurately and timely code all medical encounters in the Ambulatory Data Module (ADM) of CHCS or AHLTA. Coding must meet the documentation in the medical records for procedures and services performed. Coding must be completed within 24 hours.

1.3.12. REFERRALS AND CONSULTS. The general surgeon shall follow DoD, Air Force and MTF regulations and policies when arranging for a referral or consult. The general surgeon shall inform patients of the required referral or consult by indicating the medical/surgical discipline required. The general surgeon shall not recommend to the patient that he/she should consult a specific practitioner or use a specific practice in the local civilian community. The general surgeon may not refer patients for consult to him/herself outside of this MTF without prior approval from the MTF. TRICARE/ISOS reimbursement will not be pursued or granted under this contract.

1.3.13. PRESCRIPTIONS. The general surgeon shall use and be guided by the MTF formulary and enter all prescriptions into CHCS and/or AHLTA. The MTF must approve drugs not listed on the formulary

1.3.14. ATTENDANCE AT MEETINGS. The general surgeon shall attend and participate in meetings, professional staff conferences, and other appropriate professional activities within the

MTF.

1.3.15. RECORDS. The general surgeon shall be responsible for creating, maintaining and disposing of only those government required records that are specifically cited in the PWS or as required by the provisions of a mandatory directive listed in Section C-4 of this PWS. If requested by the MTF, the general surgeon shall provide the original record or a reproducible copy of any such records within five working days of the request.

1.3.16. PATIENT LISTS. Patient lists, no matter how developed, shall be treated as privileged information. Lists and/or names of patients shall not be disclosed to or revealed in any way for use outside the MTF without prior approval from the MTF.

1.3.17. PATIENT SENSITIVITY. The general surgeon shall respect and maintain the basic rights of patients, demonstrating concern for personal dignity and human relationships in accordance with MDG patient rights, responsibilities, and MDG policies.

1.3.18. RELEASE OF MEDICAL INFORMATION. The general surgeon shall only release medical information obtained during the course of this contract to other MTF staff and host nation providers involved in the care and treatment of that individual patient and in accordance with Health Insurance Portability Accountability Act (HIPAA).

1.3.19. HIPAA. The general surgeon shall be briefed and trained on HIPAA and the requirements for protecting patient information and confidentiality, along with release of information. The general surgeon will assist the MTF in ensuring all network providers or local providers comply with HIPAA to the maximum extent practicable. The general surgeon will assist with ensuring all local providers have on file a signed acknowledgement of all HIPAA requirements. The general surgeon will assist in resolving disputes in the healthcare arena for the MTF.

1.3.20. EMERGENCY RESPONSE. The general surgeon will be required to respond to patient emergencies in accordance with MTF guidelines occurring in the MTF while the provider is physically present.

1.3.21. PERSONAL RELIABILITY PROGRAM (PRP). The general surgeon shall be responsible for knowing and adhering to the regulations and guidelines under the PRP program as outlined in AFI 36-2104.

1.3.22. OPERATIONAL SECURITY (OPSEC) TRAINING. In accordance with AFI 10-701:

5.2.4. : OPSEC PMs/SMO/SMNCOs/Coordinators will provide OPSEC training or training materials to the general surgeon within 90 days of employees’ initial assignment to the contract.

The general surgeon attached to the 39 MDG must complete OPSEC training.

1.4. PERSONNEL REQUIREMENTS.

1.4.1. LANGUAGE REQUIREMENT. The general surgeon must be able to read, write, speak and understand English and Turkish. Languages shall be spoken with sufficient proficiency, accuracy and vocabulary to participate effectively in most formal and informal conversations on practical and professional topics to include medical specific terminology without the assistance of an interpreter.

1.4.2. CRIMINAL BACKGROUND CHECK REQUIREMENT. Provider checks will be conducted by the MTF by means of written professional reference and screening of all prior and existing lawsuits and their outcomes. The general surgeon shall provide copies of all documents held by the Turkish Health Department. Requests may be submitted to the address listed below:

Saglik Mudurlugu Stadyom Giris Kapisi Karsisi Hifzisihha Mlid Bitsigi Adana

1.4.2.1 Concurrent with the consent of the MTF, the general surgeon may provide contract services prior to completion of background checks. However, at all times while children are in the care of that individual, the general surgeon shall be within sight and continuous supervision of an MTF staff person whose background check has been completed, a chaperone, or parent/guardian.

1.4.2.2. The general surgeon has the right to obtain a copy of any background check pertaining to them and to challenge the accuracy and completeness of the information contained in the report.

1.4.2.3. In the event of a break in U.S. Government service, a complete background check must be re-accomplished.

1.4.3. UNIFORMS/PERSONAL APPEARANCE. The general surgeon shall present a neat appearance and be easily recognized as a MTF employee.

1.4.3.1. Clothing should present a professional, modest appearance in keeping with the normally accepted community standards of dress for the work being performed. In all cases, clothing shall be neat and clean. This includes being free from visible dirt, stains, strong cologne, and offensive odors. When required and supplied by the MTF, personnel shall wear special protective clothing and shoe covers. These items shall remain the property of the Government and shall not be removed from the MTF. Special protective clothing shall be turned in or destroyed after use as directed by the MTF.

1.4.3.2. The general surgeon shall wear identification issued by the MTF. Identification shall be a controlled item to be returned at the completion of the contract performance.

1.4.3.3. Facial hair including beards, mustaches, and sideburns shall be controlled (restrained) or trimmed to have a professional appearance and to maintain safe work practices. When duties will be performed in specified areas, a disposable protective hood shall be worn to ensure infection control standards are met.

1.4.4. OFFICE/WORK AREA APPEARANCE. The general surgeon shall ensure work areas are tidy and decorations present a professional and modest appearance in keeping with acceptable MTF standards.

1.4.5. CONFLICT OF INTEREST. The Contractor shall not employ any person who is an employee of the United States Government, as the employment of that person would create a conflict of interest. The Contractor shall not employ any person who is an employee of the Department of the Air Force, either military or civilian, unless such person seeks and receives approval in accordance with DoD Directive 5500.7 and Air Force policy.

1.5 PRIVILEGING REQUIREMENTS. (ALL SUBMISSIONS MUST BE TRANSLATED

INTO ENGLISH)

1.5.1. PRIVILEGING. The credentials of all providers shall be reviewed and privileges granted as outlined in AFI 44-119. The Contractor is responsible to ensure that proposed staff possesses the requisite credentials enabling the granting of privileges by the applicable MTF sufficient to allow for performance of this PWS. The must be privileged to provide services in the MTF and approved local host nation hospital facilities which provide services to the 39 MDG, with which the MTF, or TRICARE/ISOS, has a Memorandum of Understanding (MoU).

1.5.1.1. The MTF shall initiate the pre-privileging process upon award. The general surgeon shall be required to provide credential’s action history, malpractice history, and completed copies of the below listed documents with their proposal.

• Copy of all medical licenses and board certifications/eligibility.

• Provider education and training.

• Current Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), and

Advanced Cardiac Life Support (ACLS) certification.

• Current certification in Neonatal Resuscitation Program (NRP), if applicable.

• A signed consent for release of information.

• A copy of the proposed’ s professional resume, accompanied by that individual’s sworn affidavit of the truthfulness of same, indicating experience, training, and technical expertise in the type of car to be rendered.

• Standard Form 86 (Questionnaire for National Security Positions)

• A list of all places in which current holds or has held a license to practice related services.

• A certification of current physical examination for each employee. The certification shall contain a signed statement by the examining physician stating that the employee is free of any contagious diseases. Physical examination must be current and within the 12 months prior to the application for privileges.

• Proof of immunization from the following diseases according to Centers of Disease Control and Prevention (CDC) guidelines: Hepatitis B, measles, mumps, rubella, vermicelli, and influenza. The general surgeon shall also provide proof of a negative TB skin test within 12 months (if positive, proof of negative chest X-ray within 12 months) to be considered for award.

1.5.1.2 Clinical privilege actions will be based on review in accordance with AFI 44-119.

Reappointment shall occur not less than every two years, in accordance with AFI 44-119.

1.5.1.3. Applications for clinical privileges for replacement s shall be submitted to the MTF through the COR where services are to be provided not later than 30 calendar days prior to the provider assuming duty. The credentials requirements delineated in AFI 44-119.

1.5.1.4. The general surgeon is required to begin full performance of the contract requirements within 5 days after contract award.

1.5.1.5. The Contractor will submit applications for only those who can reasonably be anticipated to render the actual, substantial performance on the contract.

1.5.2. DENIAL/TERMINATION OF PRIVILEGES.

1.5.2.1 Actions to limit, suspend, or revoke clinical privileges shall be in accordance with the procedures outlined in AFI 44-119.

1.5.2.2. The COR shall notify the CO as soon as possible when the necessity to exercise such authority becomes apparent. The COR will also provide the CO with copies of documentation initiating the revocation process if such actions become apparent.

1.6 EDUCATION AND TRAINING REQUIREMENTS.

1.6.1. FORMAL EDUCATION. The general surgeon must have graduated from an approved school of medicine or completed a residency or fellowship acceptable to the U.S. Air Force Surgeon General and Turkish Doctor’s Chambers, Division of General Surgery.

1.6.2. LICENSE/REGISTRATION. The general surgeon shall possess a valid, unrestricted license to practice General Surgery in the Republic of Turkey.

1.6.3. BOARD CERTIFICATION. The general surgeon shall be board certified or board eligible by the Turkish Doctor’s Chambers, Division of General Surgery. Membership in United States, International, or National Professional Organization commensurate with medical specialty, is required.

1.6.4. EXPERIENCE. The general surgeon shall be actively practicing General Surgery and shall have a minimum of five years’ experience.

1.6.5. OTHER CERTIFICATIONS. The general surgeon must maintain current training in CHCS, AAAHC, BLS, ACLS, and PALS In the event the required certifications expire during the term of this contract the general surgeon shall complete required coursework successfully.

Certification courses will be offered by the 39 MDG.

1.7. GOVERNMENT ORIENTATION/TRAINING.

1.7.1. INITIAL ORIENTATION. The general surgeon shall attend MTF provided initial training for the procedures and use of MTF equipment, supplies, forms, safety, infection control, QA procedures and policies, personnel reliability program.

1.7.2. CONTINUING ORIENTATION. The general surgeon shall participate in orientations for new equipment, procedures, etc. as determined by the MTF.

1.7.3. CONTINUING MEDICAL EDUCATION (CME) REQUIREMENTS. Health care providers registered or certified by national/medical associations shall continue to meet the minimum standards for CME to remain current as prescribed in AFI 41-117. CME shall be obtained at no additional cost to the Government and shall be reported to the MTF annually.

Periodic CME may be conducted at the MTF and will be available, at no cost, to any healthcare provider desiring to attend. The CME must be approved Category I CME or a satisfactory equivalent as approved by the MTF.

1.7.4. ANNUAL TRAINING REQUIREMENTS. All contract employees must complete annual training requirements IAW local MDG policies.

1.7.5. PATIENT SENSITIVITY TRAINING. Training may include attendance at a customer college and/or computer based customer sensitivity training. Participation in the training class shall be at no cost to the MTF.

1.7.6. ADDITIONAL TRAINING REQUIREMENTS. The general surgeon may be required to attend additional training not listed in this PWS on an as needed basis

1.7.7. CREDENTIALING. The general surgeon shall be subject to the credential verification requirements of AFI 44-119.

1.8 SUSPENSIONS/REVOCATIONS/TERMINATION OF CREDENTIALS.

1.8.1. Clinical privileges as well as the right or opportunity to prescribe medications may be limited, suspended, or revoked in the event of substandard performance. Actions to limit, suspend, or revoke clinical privileges/prescribing rights shall be IAW the procedures outlined in AFI 44-119 regarding adverse clinical, administrative actions related to the provision of healthcare and related professional staff issues.

1.8.2. In the event of an adverse action (whether it be clinical or administrative), the CO and the Contractor, shall be notified by the COR in coordination with the FC as soon as possible when the necessity to exercise such authority becomes apparent. The COR will also provide the CO and the Contractor with a written statement, advising the Contractor of an adverse action involving the general surgeon, a brief statement of the basis for the action to provide the Contractor sufficient information in order to make employment/substitution decisions as necessary, and if required, the final outcome of the adverse action process. The written notice(s) will be marked by the government as covered by 10 USC.

SECTION C-2

2. QUALITY ASSURANCE/SURVEILLANCE

2.1. QUALITY ASSURANCE. The COR will periodically evaluate the general surgeon’s performance and patient satisfaction surveys to ensure services are satisfactorily received. The COR will also receive and investigate complaints from various customers located on the installation. The COR will give the general surgeon a written copy of the complaint. The general surgeon shall reply in writing to the COR on the complaint within 10 calendar days from the date of notice of the complaint. The COR will evaluate the general surgeon’s performance through random inspections and receipt of complaints from customers. The COR shall be responsible for validating customer complaints.

2.2. PEER REVIEWS. Reviews will be completed by the general surgeon by contacting another military surgeon (i.e. ENT surgeon at Lakenheath AB, England) on a monthly basis, assistance will be provided by the COR.

2.2.1 SERVICE DELIVERY SUMMARY.

SDS Performance Objective

PWS

Para.

Performance Measure Surveillance Method

Frequency

1 Regular Clinical Services

Appendix B.2.

General surgeon available for duty, Ensure maximum compliance with contract hours for clinic and surgery cases performed monthly

95% Inspection

Monthly

2 Completes CHCS, AAAHC, or job specific data training as required.

1.6.5. Mandatory to initial or

maintaining job performance

Random As Needed

3 On-Call/After Duty Response Time

Appendix B.3

Within 60 minutes of notification for routine on-call consultation and 30 minutes for emergency requirement

95% inspection

Monthly

4 Documentation Accuracy/Timeliness

1.3.10. General surgeon shall

follow DoD, Air Force and MTF regulations and policies when documenting pharmacy interventions when required

95% inspection

Monthly

5 Patient Sensitivity 1.7.5. General surgeon shall respect the basic rights of patients, demonstrating

95% inspection

Monthly concern for personal dignity

6 Referrals and Consults

1.3.12. General surgeon shall

follow DoD, Air Force and MTF regulations and policies when arranging for a referral or consult

95% Inspection

Monthly

7 Medical Coding of Procedures/Office Visits

1.3.11. General surgeon must

accurately and timely code medical encounters

95% inspection

Monthly

8 Maintains patient privacy/ HIPAA compliance

6.4. General surgeon will have

zero breaches of privacy

100% Inspection

Monthly

2.3. CONTRACT COMPLIANCE. If the general surgeon fails to maintain compliance within the performance measure, a monthly surveillance report will be sent to him/her annotating the discrepancy. If performance measures are not met each month, this may lead to a disciplinary proceeding.

SECTION C-3

3. ACCESS TO GOVERNMENT PROPERTY AND SERVICES

The Government will allow access to the following equipment, supplies, and services listed below:

3.1. IDENTIFICATION CREDENTIALS. The MTF will provide all required identification media.

3.2. EQUIPMENT. Contract personnel shall have use of all available equipment for performing services required by this contract only, including a computer for use while in the MTF.

3.3. PERSONAL PROTECTIVE EQUIPMENT (PPE). The MTF will make available appropriate PPE. This does not include any type of uniform or laboratory coat.

3.4. SUPPLIES. The MTF will make available medical and non-medical supplies commonly used in the facility for the care and management of patients.

3.5. COMPUTER EQUIPMENT. The MTF will make available access to computer equipment required to schedule, document, and maintain appropriate electronic medical information that support the hard copy medical record. The MTF will provide required training for these systems.

The health care workers will be required to use the computer systems that are standard for the support of health care delivery at the MTF.

3.6. UTILITIES. For the purpose of this contract, the government will make available all required utilities (such as water, local telephone, electricity, etc.) to the general surgeon. The general surgeon shall participate in government energy conservation programs.

3.7. EMERGENCY HEALTH CARE. The MTF will provide emergency health care for the general surgeon for injuries incurred while on duty in the MTF.

3.8. SUPPORT SERVICES.

3.8.1. ADMINISTRATIVE SUPPORT. The general surgeon will be authorized to use selected administrative support available to MTF employees.

3.8.2. MTF ORIENTATION/TRAINING. The MTF will provide training as required.

3.8.3. PATIENT SCHEDULING. MTF personnel shall arrange patient scheduling. Complete administrative control of the patient shall remain with the MTF.

3.8.4. RECORDS, FILES, DOCUMENTS, AND WORK PAPERS. All records, files, document, and work papers remain confidential and property of the MTF (per current HIPAA guidelines). The COR will provide guidance for general surgeon who shall maintain and dispose of these records, files, documents and work papers.

SECTION C-4

4. GENERAL INFORMATION

4.1. IMMUNIZATION. In accordance with AFI 48-105, the general surgeon shall follow the methods for controlling and preventing disease as described in the American Public Health Association publication, Control of Communicable Diseases Manual, and the Centers for Disease Control and Prevention (CDC) publication, Morbidity and Mortality Weekly Report (MMWR), and its supplements. Where applicable, the most recent guidelines from these publications are utilized as the standard.

4.1.1. The general surgeon must be immunized annually with the influenza vaccine. This vaccine will be provided by the MTF. Although this vaccine may be provided by the MTF, it may be obtained at other facilities with the cost being borne by the general surgeon. Unless vaccinated by the MTF, the general surgeon shall be required to show proof of the vaccination.

4.2. OSHA requires that all contract personnel who will have occupational exposure to blood or body fluids, or other potentially infectious materials, shall receive Hepatitis B vaccine, sign a voluntary declination, or have documented proof of immunity to Hepatitis B infection.

Personnel who sign declinations may change their minds at anytime and receive the Hepatitis B vaccine without penalty.

4.3. LIFE SUPPORT CERTIFICATION. At a minimum, the general surgeon must maintain current certification in either the American Heart Association Basic Life Support (BLS) with AED, (Course C), American Red Cross CPR/BLS Course or Turkish equivalent.

4.4. PREGNANT EMPLOYEES. The general surgeon should report their pregnancy to the Contractor and COR. The MTF Employee Health or Public Health Office will provide information concerning any work hazards in her work area inherent to gestational females. The MTF is to notify the pregnant health care worker of any work hazards. It will be the MTF, Contractor, and health care worker’s joint decision whether she continues work in the environment or if temporary accommodations need to be implemented.

4.5. PREVENTATIVE, PROPHYLACTIC, AND FOLLOW-UP PROCEDURES. The Contractor shall ensure that his/her employees are in compliance with preventive, prophylactic and follow-up procedures, as well as infection control and employee health program procedures, as established by the MTF. Required preventive, prophylactic and follow-up procedures will be provided by the MTF to contract employees in the military MTF. If care is received elsewhere, the Contractor shall provide written verification of treatment.

4.6. SECURITY REQUIREMENTS

4.6.1. AUTOMATED DATA PROCESSING (ADP) III SECURITY REQUIREMENTS. Since the general surgeon under this contract have access to and/or process information requiring protection under the Privacy Act of 1974, these positions are considered “ADP III” positions.

Compliance with DoD Directive 8500.1, DoD Directive 5200.2, and AFI 31-501 is mandatory for ADP III positions. Therefore, a National Agency Check with Inquiries (NACI) is required for each health care worker under this contract.

4.6.2.. The Contractor shall fully adhere with the provisions of referenced publications by having each of their employees who are performing under this contract make an appointment (through the COR) with the appropriate security organization at the installation where service is provided. The contractor shall advise their employees that a positive report is needed as a condition of employment under this contract.

4.6.3. Requests for a NACI for personnel hired subsequent to the contract start date shall be submitted to the Government not later than five (5) workdays from the employee’s first duty day.

The government will submit requests for investigations on AF Form 2583, “Request for Personnel Security Action”, at no additional cost to the general surgeon. Each individual will be fingerprinted and required to complete the appropriate forms as part of the process.

4.6.4. The contractor understands that, while the MTF commander may allow the general surgeon to temporarily occupy non-critical sensitive positions pending NACI, the general surgeon will be immediately removed from the position if at any time the NACI receives unfavorable adjudication, or if other unfavorable information that would affect the NACI becomes known. The general surgeon shall comply with the requirements of DoD 5200.2-R, Personnel Security Program, and AFI 33-119, Electronic Mail (E-Mail) Management and Use.

4.6.5. The general surgeon shall comply with the requirements of Volume 1, AFI 71-101, Criminal Investigations and Volume 2, Protective Service Matters. The general surgeon shall report any information or circumstances of which they are aware that may pose a threat to the security of DoD personnel, contractor personnel, resources, and classified or unclassified defense information to the Chief, Pharmacology Services. The general surgeon shall notify the COR of any negative information that may affect security clearances or contract performance.

4.7. PHYSICAL SECURITY. The general surgeon shall safeguard all MTF property, including controlled forms provided for contractor use. At the close of each work period, government equipment, facilities, and other valuable materials shall be secured.

4.8. ENTRY PROCEDURES TO MTF CONTROLLED/RESTRICTED AREAS. The general surgeon shall adhere to local base procedures for entry to Air Force controlled/restricted areas.

4.9. OPERATIONS SECURITY. In the performance of contract terms and conditions, contractors performing work on Incirlik Air Base may witness or hear of activities, which provide them insight into present or future military activities. Each contractor is responsible to ensure its employees and/or subcontractors understand this type of information shall not be discussed and/or spread to any other sources.

SECTION C-5

5. RECORDS/DOCUMENTS REQUIREMENTS.

5.1. DOD FREEDOM OF INFORMATION ACT (FOIA) PROGRAM. The general surgeon shall comply with the requirements of DoD Regulation 5400.7/Air Force Supplement, DoD Freedom of Information Act Program. The regulation sets policy and procedures for the disclosure of records to the public and for marking, handling, transmitting, and safeguarding For Official Use Only (FOUO) material. If the general surgeon receives a FOIA request, the general surgeon will refer the task to a MTF official who, as the authorized official, will make the decision on releasing of records.

5.2. FOR OFFICIAL USE ONLY (FOUO). The general surgeon shall create and maintain FOUO material IAW DoD 5400-7R, DoD Freedom of Information Act Program, Chapter 4; AFI 33-129, Transmission of Information via the Internet, paragraphs 7.4, 8.2.3, 16 and 17; and AFI 33-201, Communications Security (COMSEC), Table 1. Mark all documents meeting the requirements identified in DoD Regulation 5400-7/Air Force Supplement, paragraphs C3.2.1.2 thru 3.2.1.9 as “For Official Use Only” IAW instructions identified in paragraph C4.2.1.

Safeguard all sensitive data IAW DoD Regulation 5400.7/Air Force Supplement, paragraph C4.4.

SECTION C-6

6. PATIENT PRIVACY REQUIREMENTS.

6.1. PRIVACY ACT PROGRAM. The general surgeon shall create and maintain Privacy Act data IAW AFI 33-129, Transmission of Information Via the Internet, paragraphs 7.4, 8.2.3, 16, and 17, and supplements; AFI 33-201, Communications Security (COMSEC), table 1; AFI 33- 322, Air Force Privacy Act Program, paragraphs 1.4.7, 1.4.8, 3.3.3, Chapters 7, 9 and 10, and supplements; and, Privacy Act systems of records notice(s) (http://www.defenselink.mil/privacy/notices/usaf). The general surgeon shall not create or maintain a Privacy Act system of records prior to public notice. If the general surgeon receives a Privacy Act request, the general surgeon shall be responsible for searching for the records and providing those records to a Government official who, as the authorized official, will make the decision on releasing of records.

6.2. PATIENT LISTS. Patient lists, no matter how developed, shall be treated as privileged information. Add the following to the bottom of all patient lists: “FOR OFFICIAL USE ONLY.

This document contains information exempt from mandatory disclosure under the Freedom of Information Act (FOIA), Title 5 U.S.C. 552(b)(2) High and (b)(6) apply.” Lists and/or names of patients shall not be disclosed or revealed in any way for any use outside the MTF without prior written permission by the FAC.

6.3. PATIENT SENSITIVITY. The general surgeon shall respect and maintain the basic rights of patients, demonstrating concern for personal dignity and human relationships IAW DoD 6025.18-R. Complaints validated by the COR and FAC shall be subject to counseling and, depending on the nature and severity of the complaint, separation from performing services under this contract.

6.4. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF

1996: All individuals performing services at an Air Force MTF are required to complete initial and annual refresher HIPAA Privacy and Security Rule training as provided by the MTF for its personnel and will be held accountable for complying with health information privacy and security policies and procedures.

http://www.defenselink.mil/privacy/notices/usaf

SECTION C-7

7. MISCELLANEOUS REQUIREMENTS

7.1. MTF REQUIREMENTS. The general surgeon shall complete all base and MTF-specified orientation program(s), initial and annual training requirements, and comply with all MTF policies, procedures, productivity standards, and instructions as provided by the MTF.

7.2. TOBACCO USAGE IN USAFE FACILITIES. The general surgeon is advised that the Commander has placed restrictions on the use of tobacco products in USAFE facilities. The general surgeon and visitors are subject to the same restrictions as government personnel.

Tobacco usage is permitted only in designated tobacco usage areas.

SECTION C-8

APPENDIX A

APPLICABLE PUBLICATIONS AND FORMS

A.1. Publications and forms applicable to the performance work statement (PWS) are listed below. The general surgeon is obligated to follow those publications. These publications are available in the MTF and maintained by the Government. Supplements or amendments to listed publications from any organizational level may be issued during the life of the contract. The general surgeon shall immediately implement those changes in publications. Publications and forms applicable to the PWS include 41-series, 44-series and 48-series Air Force Instructions.

A.2. Publications and forms are also available electronically through the internet. For example, http://www.e-publishing.af.mil/ is the Air Force’s e-Publishing site and one way to obtain Air Force Instructions. DoD Directives can be found at http://west.dtic.mil/whs/directives/.

Regulations are followed by a “-R” (e.g., DoD 6025.18-R) and can be located on the website by clicking on “Publications” instead of “Directives.”

PUB NO. TITLE

DEPARTMENT OF DEFENSE (DoD) REGULATIONS/MANUALS

INSTRUCTIONS/DIRECTIVES

DoDD 5200.2 Personnel Security Program DoD 1402.5 Criminal History Background Checks on Individuals in Child Care

Services DoD 5400-70 DoD Freedom of Information Act Program DoD 5500.7 Standards of Conduct DoD 6000.14 Patient Bill of Rights DoD 6025.18-R Health Information Privacy DoDD 8500.1 Information Assurance DoDI 3020.37 Continuation of Essential DoD Contractor Services During Crisis DoDI 1332.38 Physical Disability Evaluation

PUB NO. TITLE

AIR FORCE INSTRUCTIONS/MANUALS

AFI 31-501 Personal Security Program Management AFI 33-119 Electronic Mail (E-mail) Management and Use AFI 33-129 Web Management and Internet Use AFI 33-201V1 Communications Security (COMSEC) AFI 33-322 Records Management Program AFI 33-332 Air Force Privacy Act Program AFI 33-364 Records Disposition—Procedures and Responsibilities, and Electronic Records AFI 40-102 Tobacco Use in the USAF http://www.e-publishing.af.mil/ http://west.dtic.mil/whs/directives/

AFI 41-117 Medical Service Officer Education AFI 41-210 TRICARE Operations and Patient Administration Functions AFI 44-102 Community Health Management AFI 44-119 Medical Service Clinical Performance Improvement AFI 48-123_AFGM4 Medical Examinations and Standards Memorandum AFI 48-105 Surveillance, Prevention, and Control of Diseases and Conditions of

Public health or Military Significance AFI 71-101V1 Criminal Investigations

PUB NO. TITLE

MEDICAL GROUP INSTRUCTIONS

MDGI 41-101 Sexual Assault

MDGI 41-135 HIPAA

MDGI 41-217 Health Information Security MDGI 41-121 Line of Duty MDGI 44-112 Customer Relations MDGI 44-115 Education and Training MDGI 91-101 Safety

PUB NO. TITLE

OFFICE INSTRUCTIONS and MFRS (MEMOS FOR RECORD) AF Physical Disability Department

FORM NO. TITLE

DD Form 602 Patient Evacuation DD Form 689 Individual Sick Slip DD Form 1172 Application for Uniformed Services Identification Card DD Form 2005 Privacy Act Statement, Health Care Records DD Form 2161 Referral for Civilian Medical Care Standard Form 86 Questionnaire for National Security Positions Standard Form 502 Medical Record – Narrative Summary (Clinical Resume) Standard Form 504 Clinical Record – History Part 1 Standard Form 505 Clinical Record – History Part 2 and 3 Standard Form 506 Clinical Record Physical Examination Standard Form 507 Clinical Record Report on-or continuation of SF __506__ Standard Form 509 Medical Record – Progress Notes Standard Form 513 Medical Record – Continuation Sheet Standard Form 515 Medical Record – Tissue Examination Standard Form 516 Clinical Record – Operation Report Standard Form 517 Clinical Record – Anesthesia Standard Form 518 Medical Record – Blood of Blood Component Transfusion

Standard Form 519 A/B Radiology Report Standard Form 522 Medical Record – Request for Administration of Anesthesia and for

Performance Operational and other Procedures Standard Form 536 Clinical Record – Pediatric Notes Standard Form 539 Medical Record – Abbreviated Medical Record (short form) Standard Form 544 Clinical Record – Statement of Patient’s Treatment Standard Form 546 Chemistry I Standard Form 547 Chemistry II Standard Form 548 Chemistry III Standard Form 549 Hematology Standard Form 550 Urinalysis Standard Form 551 Serology Standard Form 552 Parasitology Standard Form 553 Microbiology I FD Form 258 FBI US Department of Justice Fingerprint Card AF Form 55 Employee Safety and Health Record AF Form 222 Patient Effects/Clothing Storage Tag AF Form 250 Health Record Charge Out Request AF Form 348 Line of Duty AF Form 422 Physical Profile Serial Report AF Form 555 Patient Visit Register AF Form 560 Admission Authorization and Treatment Statement AF Form 565 Record of Inpatient Treatment AF Form 569 Patient’s Absence Record AF Form 570 Notification of Patient’s Medical Status AF Form 618 Medical Board Report AF Form 735 Sensitive Duties Program Record Identifier AF Form 765 Hospital Incident Statement AF Form781 Multiple Item Prescription AF Form 1480 Summary of Care AF Form 1535 Physical Therapy Consultation AF Form 3066 Doctor’s Orders AF Form 3078 Weekly Personnel Time and Salary Distribution Worksheet VBA 21-686C Declaration of Status of Dependents VBA 21-0819 VA/DoD Joint Disability Evaluation Board Claim

APPENDIX B

WORKLOAD ESTIMATE FOR CONTRACT PERSONNEL

B.1. POINT OF CONTACT. The Contractor shall provide a point of contact that shall be responsible for the performance of the work. The point of contact shall have full authority to act for the Contractor on all matters relating to the daily operation of this contract. The Contractor shall designate this individual, in writing, to the Contract Officer Representative (COR) before the contract start date.

B.2. REGULAR CLINICAL SERVICES. Contractor shall perform outpatient/APU, emergency, and clinical services in the MTF and designated local civilian hospitals, which have active Preferred Provider Agreements with the 39 MDG, with which the MTF, or TRICARE/International SOS (ISOS), has a Memorandum of Understanding (MOU). The contractor may not see patients at a private office unless care is coordinated with the 39 MDG staff. Regular Clinical Services and consultation shall be provided for a minimum of 25 hours per week, which includes a combination of clinical, surgical and administrative liaison time as the representative to host nation facilities Major and minor outpatient procedures shall be performed during regular clinical services and consultations inclusive of a maximum of 120 hours per month during open MTF clinic days according to a schedule that is mutually agreed upon between the 39 MDG and the contractor. Contractor must be available for call 24 hours a day seven days a week. Emergency consultations shall be performed as needed.

B.3. ON-CALL/AFTER DUTY RESPONSE TIME REQUIREMENTS. On-call telephone standby shall be provided on a…