131216-FINAL-QIOPPCDeck.pptx

Welcome!

Quality Improvement Organization (QIO) Program Pre-proposal Conference December 16, 2013 | Baltimore, Maryland

Please note that today’s session is being recorded.

Ground Rules and Housekeeping

Kimberly Brown | Facilitator and Quality Improvement Advisor

Brian Hebbel | Director, Division of Quality Contracts

Remarks from Acquisition Leadership

Daniel Kane | Director, Office of Acquisitions & Grants Management

Welcome Successful program for 30 years.

A lot of changes in CMS.

Changes in QIO Program resulting from the Trade Bill.

Welcome Trade Bill impacts contract awards.

Competitive contracts.

New contracting environment.

Big impact to current contractors.

A challenge to industry to implement.

A challenge to CMS to implement.

Changes:

5-year contracts.

Separation of case review & quality improvement.

Unique solicitation provisions.

Additional support contracts.

Anticipate success in the future.

Welcome your participation in this process.

Framing Our Work

Jade Perdue-Puli | Lead, Learning & Action Networks

“Every system is perfectly designed to achieve the results it gets.”

--Dr. Donald Berwick

Video example of reframing.

Program Overview & Vision for Our Future: Reflect, Reframe, Revise and Refocus

Jean Moody-Williams, RN | Director, Quality Improvement Group

Preparing for the QIO 11th SOW

Reflect…….

Think deeply or carefully about QIO program dates back to the 1970s with the creation of the Professional Standards Review Organization (PSRO) program.

PSROs performed utilization reviews and special studies to improve the quality of care, primarily for Medicare and Medicaid.

In 1982, as part of the Tax Equity and Fiscal Responsibility Act, Congress replaced the PSRO program with the Utilization and Quality Control PRO.

Reflect…PROs Assembled and analyzed data on services provided to Medicare beneficiaries, and Intervened when services had been provided unnecessarily, inappropriately, or with inadequate quality.

Required to randomly sample a percentage of hospital records for case review, including:

inadequate discharge planning, medical instability of the patient at discharge, deaths, nosocomial infection, unscheduled return to surgery, trauma suffered in the hospital, and medication or treatment changes within 24 hours of discharge without adequate observation.

Reflect….

If a hospital had too many deficiencies within sampled records, the PROs could do an intensified review (100%).

Physicians with persistent quality problems faced harsh penalties, including payment denial and recommended exclusion from participation in the Medicare program.

Reflect In 1992, role of PROs changed with implementation of Health Care Quality Improvement Initiative (HCQII).

HCQII shifted focus from individual case reviews to reporting patterns of care delivered to beneficiaries.

PROs were to:

Examine practice patterns at the institutional, regional, and national level, rather than uncover individual physician lapses in quality for punitive purposes.

Evaluate quality of care using national, disease-specific guidelines, rather than local criteria.

Work collaboratively with hospitals as partners in the development and implementation of hospital quality improvement initiatives (instead of merely collecting data).

Consistent with the new collaborative style and broadening scope of the PRO program, it was officially renamed the QIO Program in 2001.

Reframe...

Frame or express a concept differently

Reframe… Frame or express a concept differently

Revise.

Revise...

Section 261 - Amends the SSA to:

(1) rename a utilization and quality control peer review organization a quality improvement organization (QIO), and

(2) revise requirements for contracts with Medicare QIOs with respect to the quality of care furnished to beneficiaries under SSA title XVIII (Medicare).

Requires the Secretary to establish throughout the United States local, state, regional, national, or other geographic areas with respect to QIO contracts.

Extends the term of QIO contracts from three years to five years.

Authorizes the Secretary to consider a variety of factors in selecting QIO contractors that would provide for the most efficient and effective administration, such as geographic location, size, and prior experience in health care quality improvement.

Revise...

Section 261 - Implements FAR requirements for QIOs and repeals requirement that Secretary provide a QIO with opportunity to provide performance information before terminating contract.

Requires QIO contracting with Secretary to perform all specified activities, except:

to the extent otherwise negotiated with Secretary pursuant to contract, or for a function Secretary determines is not appropriate for QIO to perform, such as a function that could cause a conflict of interest with another function.

Requires QIO to perform quality improvement activities Secretary determines necessary for improving quality of care furnished Medicare beneficiaries.

Refocus...

Focus attention or resources in something new or different

Source: Congressional Budget Office projections.

30-Day, All-Condition Medicare Readmission Rates

2007 2008 2009 2010 2011 2012 2013 YTD 0.18960650059396839 0.19009901307965751 0.1913894253020911 0.1906787374437299 0.18973508401853578 0.18475144825587919 0.17888918534147091

Continued Evolution Review for Premature Discharges (70s and 80s)

Public Reporting of Readmission Rates (90s)

Community Care Transitions (early 2000s)

Value Based Purchasing and Care Integration (early 2000s)

Population Care Management and Health Care Transformation

A Message from the Field Support Beneficiaries and their families so that they can fully participate in their health and wellness decisions.

Facilitate the organization of local communities and build momentum for change within the community.

Support the development of learning communities.

Measure and review often, while responding quickly to data.

Use principles of idealized design, constantly questioning and testing assumptions.

Conduct and apply operations research principles and reducing waste using Lean techniques.

Support advance quality improvement and value activities such as value stream mapping, health system economics, using continuous improvement tools.

Serve as a facilitator and coach in transformation activities.

Help with “sense making” in a growingly complex health care market place.

The QIO Program’s Approach to Clinical Quality

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Formula for the 11th SOW Development Keeping the Patient at the Center + CMS and HHS Priorities + Statutory Requirements + Evidence and Input from National and Local Leaders in the Field + Experience and Data from 10th SOW and Previous Contracts = QIO 11th Statement of Work Example of Inputs Considered: Secretary’s Priorities (e.g. National Quality Strategy, Million Hearts, Partnership for Patients, HAI High Priority Goal)-National Action Plan to Prevent Health-care Associated Infections-National Prevention Strategy -HHS Action Plan to Reduce Racial and Ethnic Health Disparities-Federal Health IT Strategic Plan-AHRQ Comprehensive Unit Based Safety Program-HRSA Consultation in Rural Health and Adverse Drug Events-IOM Reports: Medicare QIO Program and Better Care at Lower Costs – GAO and OIG Reports –Focused Groups with Patients, Families and Providers of Care

What Is Our End Goal….

Support a continuously evolving network of dedicated and committed experts in quality improvement, working together in partnership with multiple entities, patients and families to improve health care, support the creation of healthy people in healthy communities and lowering costs through improvement.

“To change a nation……..”

BREAK

Please send questions to:

BFCCmailbox@cms.hhs.gov or QINmailbox@cms.hhs.gov; or

Index card box in lobby.

Friendly reminder: this session is being recorded.

QIO Program Contracting Overview

Pamela Collins | Director, Acquisition Support Group

11th SOW Overview 11th SoW Contract Structure Eight (8) Separate Procurement Pieces

Staggered Awards Stage 1 Awards: May 2014 (BFCC-QIO, BFCC NCC, PCC, VIQRCs)

Stage 2 Awards: July 2014 (QIN-QIO, QIN NCC)

Stage 3 Awards: December 2014 (IEC)

Stage 4 Awards: January 2015 (BFCC ORC)

QIO AREAS TBD

# and distribution of awards based on results of full-and-open competition Program Collaboration Center

Independent Evaluation Center

QIN NCC

BFCC NCC

Program Contract Structure as of 8/1/2014 BFCC = Beneficiary and Family Centered Care M&E = Monitoring and Evaluation NCC = National Coordinating Center O&E Hospital Inpatient-Psych-Cancer BFCC Oversight & Review Center BFCC-QIO Area 1 BFCC – QIOs

BFCC-QIO Area 2 BFCC-QIO Area 5 BFCC-QIO Area 3 BFCC-QIO Area 4 QIN - QIOs O&E = Outreach and Education QIN = Quality Innovation Network Value Incentives and Quality Reporting Centers O&E ASC and Outpatient M&E /Analytics Validation Support Appeals

Eight Procurement Segments Stage 1: Award in May 2014

BFCC-QIO – Beneficiary & Family Centered Care-QIO Full & Open (F&O) Competition Anticipate 5 Separate contract awards w/ CPFF pricing arrangement

BFCC NCC – BFCC National Coordinating Center F&O Competition Single contract award w/ CPFF pricing arrangement

Stage 1: Award in May 2014 (continued)

PCC – Program Collaboration Center Acquisition Strategy – TBD

VIQRCs – Value Incentives and Quality Reporting Centers Anticipate competing five (5) tasks under the current Measure Instrument Development Support (MIDS) IDIQ

Stage 2: Awards in July 2014

QIN-QIO – Quality Innovation Network – Quality Improvement Organization Full & Open Competition Estimate award of between 12 to 17 IDIQ holders with 53 initial task order awards CPFF pricing arrangement

QIN NCC – QIN National Coordinating Center Anticipate Full & Open Competition Single contract award w/ CPFF pricing arrangement

Stage 3: Award in December 2014

IEC – Independent Evaluation Center Acquisition Strategy: TBD

Stage 4: Award in January 2015

BFCC-ORC – Beneficiary & Family Centered Care Oversight & Review Center Acquisition Strategy TBD

High-level Timeline

July 2014 – QIN-QIO & QIN NCC

December 2014 – IEC

January 2015 – BFCC ORC

Today’s Pre-Proposal Conference Two pieces of the work will be discussed in more detail today:

BFCC-QIO RFP

QIN-QIO RFP

RFP Provisions Contract Award Limitations/Conflict of Interest

Waiver of Government Accountability Office (GAO) and Court of Federal Claims (COFC) Bid Protests

Contract Award Limitations BFCC-QIO & QIN-QIO procurements awarded within two months of each other.

You may propose on both the BFCC- and QIN-QIO but you can not win both.

BFCC will be awarded 1st. If you win a BFCC and you proposed on the QIN, you will be removed from the QIN competition(s).

Contract Award Limitations See your RFP for the Contract Limitation Chart.

Contractors need to consider “big picture” business strategy before proposing, as winning one contract can exclude you from other competitions.

The limitations apply to prime, subcontractors and corporate affiliates.

Conflict of Interest (not limited to the chart in RFP).

Waiver Authority Section 1153(e)(1) of the Social Security Act provides:

Except as provided in paragraph (2), contracting authority of the Secretary under this section may be carried out without regard to any provision of law relating to the making, performance, amendment, or modification of contracts of the United States as the Secretary may determine to be inconsistent with the purposes of this part…

This authority has been delegated by the Administrator to the Deputy Director, Center for Clinical Standards & Quality (CCSQ).

RFP Provisions – Waiver of Bid Protests (both GAO & COFC) The contracting authority for the QIO Program may be carried out without regard to:

31 U.S.C §§3551-3557 (GAO Bid Protests) including its implementing FAR subpart 33.1 & HHSAR subpart 333.1 regulations.

28 U.S.C. §1491(b) (COFC Bid Protests) and the implementing regulations at FAR Subpart 33.1 & HHSAR Subpart 333.1.

Stay of Provisions for an Agency-level protest – FAR §33.103(f).

Rationale for Protest Waiver…

QIO AREAS TBD

# and distribution of awards based on results of full-and-open competition Program Collaboration Center

Independent Evaluation Center

QIN NCC

BFCC NCC

Program Contract Structure as of 8/1/2014 BFCC = Beneficiary and Family Centered Care M&E = Monitoring and Evaluation NCC = National Coordinating Center O&E Hospital Inpatient-Psych-Cancer BFCC Oversight & Review Center BFCC-QIO Area 1 BFCC – QIOs

BFCC-QIO Area 2 BFCC-QIO Area 5 BFCC-QIO Area 3 BFCC-QIO Area 4 QIN - QIOs O&E = Outreach and Education QIN = Quality Innovation Network Value Incentives and Quality Reporting Centers O&E ASC and Outpatient M&E /Analytics Validation Support Appeals

Rationale for Protest Waiver Failure to continue the critical requirements of the QIO program will result in failure to comply w/ P.L. 112-40 and will not protect the rights of millions of Medicare beneficiaries.

Delay of the start of the 11th SOW QIO will adversely affect every aspect of the QIO work.

Protest Waiver covers all 11th SOW contracts to be awarded over the next two years.

Protest Rights Agency Protests will be allowed and handled in accordance with the agency-level bid protest process described in FAR §33.103 and HHSAR §333.103.

No Stay of Performance under agency protests.

Agency Protests will be determined by impartial CMS authority/individual.

Accounting Systems

Mark Werder | Director, Division of Audit, Compliance & Close- Out

Remarks from Quality Program Leadership

Wes Perich | Deputy Director, Center for Clinical Standards & Quality

QIO Eligibility Requirements Jeneen Iwugo, MPA | Director, Division of Beneficiary Healthcare Improvement and Safety

Expansion of QIO Eligibility Requirements Requirements Finalized via OPPS November 25, 2013; 42 CFR 475.

QIO Area Geographic area such as the state(s), region(s) or community(ies) in which the CMS contract directs the QIO to perform.

Must have the ability to perform QIO functions with objectivity and impartiality in a fair and neutral manner.

Not required to be physician-sponsored or physician-access organizations.

Requirements for QIOs that Perform Case Review Peer Review – Must have access to multiple levels and disciplines of clinicians and locally licensed physicians who:

Specialize as appropriate for care under review.

Understand the geographic factors that may influence care.

Consider evidence-based national guidelines and standards.

Physicians will still review physician-level care.

Involve beneficiaries and consumers in their work.

Includes the ability to effectively communicate with beneficiaries about the quality of their care and the QIO’s review findings.

Must have access to qualified IT resources.

Requirements for QIOs that Perform Quality Improvement Set or implement acceptable, quantifiable performance objectives to improve quality efficiently and effectively.

Engage multiple levels and disciplines of clinicians.

Includes physicians, nurses and other healthcare professionals.

Clinicians must have expertise appropriate to the care being improved.

Employ experts in quality improvement methods, who can:

Support aim achievement and plan quality improvement activities, Implement and/or support interventions to drive change, Use measurement strategies to study improvement, Support and conduct data analysis, and Advise others to make systems-level improvement and efficiencies.

Must have access to qualified IT resources.

BFCC-QIO Procurement Timeline

Questions Due to CMS December 18, 2013

Amendment Responses Due December 27, 2013

Proposals Due January 15, 2014

Negotiations Begin March 2014

Final Award May 2014

BFCC-QIO Discussion: Technical Aspects Cheryl Lehane | Government Task Lead, BFCC-QIO Program

Beneficiary and Family Centered Care (BFCC)

BFCC-QIO SOW

10th to the 11th 10th SOW contract (August 1, 2011 – July 31, 2014).

11th SOW contract (August 1, 2014 – July 31, 2019).

Anticipate award of BFCC-QIO contracts May 2014 Allows for almost 3 months for contractors to prepare and set up for transition.

11th SOW activities begin August 1, 2014.

Must be ready to handle all BFCC functions and activities on August 1, 2014

Beneficiary and Family Centered Care (BFCC) Changes in BFCC-QIO SOW

Five CMS-defined areas Each required to maintain local presence.

Business hours: 7 days a week Staffing to cover the following times in each time zone within the QIO area:

Mon-Fri 9am-5pm.

Weekends/holidays 11am-3pm.

Local presence: Access to local physician/peer reviewers and local stakeholder relationships

In the 10th SOW and previously, there have been certain beneficiary appeals that require QIOs to process the appeal reviews 7 days a week. The appeal volume varies and some QIOs have staff on-call during weekends and holidays to accommodate that requirement. Beginning with the 11th SOW, BFCC-QIOs will be required to staff operations 7 days.

Beneficiary and Family Centered Care (BFCC) Changes in BFCC-QIO SOW (continued)

Quality Improvement Initiatives (QIIs) BFCC-QIOs will not conduct technical assistance with QII.

QIIs have also been known as “Quality Improvement Activities (QIAs).”

BFCC-QIOs will refer providers/practitioners to appropriate QIN- QIOs for technical assistance with QII.

Currently and in previous statements of work, from confirmed quality of care concerns in case review work, QIOs identified areas of improvement and worked with providers/practitioners to assist them with quality improvement activities within the BFCC/case review area. Beginning with the 11th SOW, BFCC-QIOs will refer QIIs to the QIN-QIOs for technical assistance. More to come during QIN-QIO discussion.

Beneficiary and Family Centered Care (BFCC) BFCC-QIOs will utilize two case review systems:

Quality Management and Review System (QMARS) New system

Case Review Information System (CRIS) Current system

Quality Management and Review System (QMARS) New system developed Currently undergoing testing To include beneficiary complaints and quality reviews for first release Will integrate other reviews in future Case Review Information System (CRIS) Currently being utilized by QIOs for all reviews This system will be used for reviews other than beneficiary complaints and quality reviews

BFCC Tasks Task 1: Quality of Care Reviews Beneficiary Complaints Immediate Advocacy General Quality of Care Referrals

Review System = QMARS

BFCC Tasks, continued Task 2: Reviews of Beneficiary Appeals of Provider Discharges/Service Terminations and Denials of Hospital Admissions Termination of services in home health, skilled nursing facility, hospice, and comprehensive outpatient rehabilitation facility Discharge decisions in the hospital setting Hospital Requested Reviews Hospital Issued Notices of Non-Coverage

Review System = CRIS

Task 3: Medical Necessity Reviews Reasonable and medically necessary Appropriateness of setting Medical necessity review shall be conducted on all cases reviewed by the QIO for any purpose, unless otherwise directed

Task 4: Higher Weighted Diagnostic Related Group (DRG) Reviews Selected by CMS 100% of cases that hospitals request a higher DRG payment

Task 5: Readmission Reviews Medicare FFS: include quality of care, medical necessity and appropriateness of setting reviews Medicare Advantage: include quality of care

Review System = CRIS/QMARS

Task 6: Focused Reviews CMS may direct the QIO to perform any of the reviews in the SOW as part of a focused review Some examples:

In response to concerns identified in beneficiary appeal review In response to a trend identified in case review

Review System = CRIS/QMARS

Task 7: Emergency Medical Treatment and Labor Act (EMTALA) Reviews Requested by the CMS Survey and Certification Group Regional Office 5-day review 60-day review

Task 8: Sanction Activities To be carried out if QIO identifies care that is either:

Gross and flagrant, or Fails in a substantial number of cases to comply with any obligation in Section 1156(a) of the Act Coordination with Office of Inspector General

Task 9: Recommendations for Quality Improvement Initiatives (QIIs) and Technical Assistance BFCC to make recommendations to QIN-QIOs for QIIs associated with quality of care concerns QIIs may be the result of any BFCC function and could include system-wide and non-system wide change QIIs.

QII system under development

Task 10: General Tasks Collaboration with CMS contractors and other entities Transparency: Annual Medical Services Review Report To include state level data and regional level data Beneficiary Helpline: toll free beneficiary helpline 7 days a week; intake of cases shall occur 7 days per week Monitoring of Physician Acknowledgement Statements

Task 11: Patient and Family Engagement Will be phased in during second year Anticipate activities will be built from past successes

Task 12: Discrimination Referrals Referral of cases for investigation to Office of Civil Rights Suspicion of delay or denial of care due to discrimination on basis of race, color, national origin, age, disability, religion, or sex

BFCC Talking Points Local Presence

Customer Service

Inter-Rater Reliability

Local presence: We will look to QIOs to use expertise in determining most appropriate physician/peer reviewer. However, it is a requirement that QIOs build and maintain local presence with healthcare stakeholders.

Customer service/beneficiary and family centered approach is critical. With the changes in structure, it is critical that we ensure beneficiaries and their families are able to access QIO and have a positive experience. QIOs will be required to monitor their responsiveness to callers. A new deliverable in the 11th SOW is helpline data to report call wait times, number of answered calls, abandoned calls, etc.

QIOs will be required to participate in IRR.

BFCC-QIO Discussion: Business Review Aspects Clarissa Whatley | Financial Management Specialist, Business Operations Group

BFCC-QIO Discussion:

Sections L and M Christina Heller | Contracting Officer, Division of Quality Contracts

Introduction OAGM BFCC Team Christina Heller Contracting Officer

Kelley Williams-Vollmer and Brendan Doherty Contract Specialists

For the BFCC-QIO and BFCC NCC contracts.

Procurement Timeline

Type of Contract Anticipate five (5) CPFF contracts One (1) in each BFCC-QIO Area.

Separate proposals are required for each proposed BFCC-QIO Area.

Solicitation Questions Submitted electronically to BFCCmailbox@cms.hhs.gov.

Questions submitted by telephone, fax or verbally will not be honored.

Template for questions:

Section & Title (example: C.1 Background):

Page #:

Question:

Closing Date: 1pm EST on December 18, 2013 Responses on or about December 27, 2013 through solicitation amendment.

Small Business Subcontracting Plan/Goals Required for these contracts.

Sample Provided as Attachment J-15.

Plan covers the entire contract Period of Performance.

Goals: Total dollars subcontracted:

33% should be awarded to Small Businesses

System Award Management (SAM) Offerors must be registered, prior to award.

Responsible for accuracy and completeness of the data.

Failure to register in SAM will prohibit CMS from making an award to your organization.

Eligibility Requirements

42 CFR 475.101

Governing body that includes:

At least one (1) individual who is a representative of health care providers; and

At least one (1) individual who is a representative of consumers.

All other eligibility requirements should be met through submission of an acceptable proposal.

BFCC-QIO

Proposal Organization Volume 1: Technical Proposal Volume 2: Business Proposal Volume 3: Conflict of Interest, Compliance and Governance

Page limitations:

Volume 1 – 80 pages single sided (40 double sided) Volume 2 and 3 – no page limitation

BFCC-QIO

Proposal Delivery Due: 2pm EST January 15, 2014

Hand Delivery Appointments must be scheduled at least 24 hours in advance with the CO.

All packages must be clearly labeled with the RFP #.

Evaluation for Award(s) “Best Value” and “Tradeoff Process”

Order of Importance for Technical Evaluation:

Technical Approach

Experience

Management Plan and Quality Assurance

Staffing Plan and Key Personnel

Transition Plan and Privacy and Confidentiality Regulations

Evaluation for Award(s) Business Evaluation:

Cost Realism Analysis

Price Analysis

Limited Cost Analysis, if necessary

Conflict of Interest, Compliance and Governance:

OCI/PCI Disclosure submission

Reasonable opportunity to respond

Preclusion from consideration for award(s)

Best interest award(s)

BFCC-QIO Award(s) Offerors may receive no more than four (4) BFCC-QIO Area contract awards.

If an Offeror is determined to be the Best Value in all five (5) areas, CMS reserves the right to select which area(s) is (are) awarded to each offeror.

Conclusion Thank you for attending the Pre-Proposal Conference today.

I look forward to the new QIO program structure and the next 5 years.

LUNCH

Please send questions to:

BFCCmailbox@cms.hhs.gov or QINmailbox@cms.hhs.gov; or

Quality Innovation Network (QIN)-QIO Discussion Various Members of the CMS Team

Better Health Better Care Lower Costs through Improvement

Getting Results!

QIN-QIO Agenda Technical Panel Discussion

Business Proposal Clarissa Whatley, Financial Management Specialist

Proposal Instructions and Evaluation Criteria Kimberly Tatum, Contracting Officer

QIN Task Order Framework A B C D E QIN Essential Functions

Results-Oriented Quality Improvement Activities

2. Community Learning and Action Networks

3. Technical Assistance (i.e., Quality Improvement Experts)

4. Integrated Communications

QIN NCC

Technical Support

Excellence in Operations

Better Health

Lower Costs

B1. Improving cardiac health & reducing cardiac disparities

B2. Reducing disparities in diabetes care

B3. Coordinating care through Immunization Information Systems

Better Care

B4. Coordinating prevention through Health Information Technology

C1. Reducing care-associated infections

C2. Reducing care-acquired conditions

C3. Coordinating care to reduce readmits & adverse drug events

D1. Quality Improvement through Physician Value Modifier

D2. Local QIO Projects

Technical Assistance

BFCC-QIO, et al – Quality Improvement Initiatives

Value-Based Purchasing

QIN Statement of Work Section C Teresa Titus-Howard Four key roles of the QIO permeate all QIN work:

Results-Oriented: A Multi-State and Local Change-Agent Champion Data driven Active engagement of patients and other partners Proactive, intentional innovation spread that improves and “sticks”

Learning and Action Networks: A Facilitator of Learning and Action Implement an “all teach, all learn” approach to share clinical QI expertise Placing impetus for improvement at the bedside level

Technical Assistance: A Teacher and Advisor Consultation and education in QI science and process improvement Knowledge management so learning is never lost

Communication: A Highly Effective Communicator and Trusted Partner Optimal learning, patient activation, and sustained behavior change The “Go To” for healthcare transformation

This is for visualization purposes only.

HCQIP – Health Care Quality Improvement Program LAN – Learning and Action Network MBPP – Medicare Beneficiary Protection Program QIO – Quality Improvement Organization Quality Innovation Network QIO Plans Better Health, Better Care, Lower Cost

LAN – Learning and Action Network MBPP – Medicare Beneficiary Protection Program QIO – Quality Improvement Organization

LAN – Learning and Action Network MBPP – Medicare Beneficiary Protection Program QIO – Quality Improvement Organization

LAN – Learning and Action Network MBPP – Medicare Beneficiary Protection Program QIO – Quality Improvement Organization

QIN Task Order Task GTLs/SMEs Panel Presenters Task B.1. Cynthia Pamon

Task B.2. Sue Fleck (by phone)

Task B.3. Michael W. Scott (by phone)

Task B.4. Indira Jevaji

Task C.1. Annese Higgs

Task C.2. Carmen Winston

Task C.3. Traci Archibald

Task D.1. Chisara Asomugha (by phone)

Task D.2. Bob Kambic

Task E.1. Cheryl Lehane (by phone)

QIN Task Order Panel Discussion Focus Areas For Panel Remarks:

Getting Results/ Achieving Goals

Recruitment

Beneficiary and/or Family/Advocate Engagement

Public Websites Task B.1. – Improving Cardiac Health and Reducing Cardiac Healthcare Disparities

Task B.2. – Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts

Task B.4. – Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with Regional Extension Centers (Disparities in Critical Access Hospitals) www.cms.gov/Outreach and-Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/CritAccessHospfctsht.pdf

Task C.1. – Reducing Healthcare Associated Infections in Hospitals

Task C.3. – Coordination of Care (Care Transitions Toolkit) www.cfmc.org/integratingcare

Task D.1. - Quality Improvement through Physician Value-Based Modifier and the Physician Feedback Reporting Program (Physician Value Modifier/Feedback Reports) www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/

QIN-QIO Discussion: Business Review Aspects Clarissa Whatley | Financial Management Specialist, Business Operations Group

QIN-QIO Business Proposal Instructions J-15 (Template) & J-15(a) (Instructions) QIN and Information Services 5-year costs (exclusion of QIO Staffing worksheet)

Supporting Information/Documentation

Travel Detail Worksheet

QIN-QIO Discussion:

Sections L and M Kimberly Tatum | Contracting Officer, Division of Quality Contracts

QIN-QIO Team

Indefinite Delivery Indefinite Quantity Contract (IDIQ)

Appropriate when a recurring need for an item or service exists and is impossible to determine precise quantities and timing of requirements.

Full and Open Competition All vendors, large and small, are eligible to compete for the IDIQ.

Multiple awards

Period of performance: 5-year contract

Task Orders Multiple task order pricing arrangements Firm, Fixed Price Cost-Plus-Fixed-Fee

Task Order 001: Excellence in Operations and Quality Improvement To be awarded at the same time as the IDIQ contract

Level of effort

Additional task order awards

Structure Overview Objective: Establish regions rather than individual states to perform SOW

Proposal: Minimum three (3) states, maximum of six (6) states proposal If fewer than 3 states proposed, proposal will not be evaluated and not considered for award.

States without a proposal will result in amendment of solicitation to provide an opportunity for offerors that did not submit the maximum number of proposals to include the state as part of their proposal.

Award: Intent to award no fewer than three states per contract CMS reserves the right to award fewer than 3 states to one contractor and reserves the right to make a single-state award.

Each IDIQ contract award may not cover more than 25% of Medicare Beneficiary population. Government intends to award no more than 25% of total Medicare beneficiary population to one offeror.

Evaluation Phase I: Multi-state

“Go/No-Go”: Proposal evaluated against the evaluation factors to determine if the proposal is technically acceptable.

The government does not place any qualitative value on the proposal, such as the proposal is “excellent,” “fair,” etc.

If the proposal is technically acceptable, it will move into the Phase II evaluation process.

Eligibility Requirements 42 CFR 475.101(a), 475.103. 475.105

Governing body that includes (Section L.14):

At least one (1) individual who is a representative of health care providers; and At least one (1) individual who is a representative of consumers.

Access to relevant professionals with appropriate quality improvement methodologies and practices.

Access to qualified information technology expertise.

Other eligibility requirements are part of the proposal (Section B).

Evaluation (cont.)

Phase II: Individual States (Task Order) Technical proposal, business proposal, past performance, organizational conflict of interest.

Primary consideration given to the technical quality of the proposals in the evaluation process.

Past performance, business, and organizational conflict of interest proposals will not be scored using adjectival ratings, but will be reviewed in accordance with M.3, M.4, M.5, and M.6 of the solicitation.

Technical Evaluation Criteria - On a per-state basis All technical evaluation factors are technically equal.

All technical evaluation factors, when combined, are significantly more important than cost.

Technical Evaluation Factors:

Technical Approach Key Personnel and Other Recommended Staff Management Plan Management Plan, Corporate Capacity, and Internal Oversight and Monitoring

Past Performance – Past performance history Similar in nature, scope, and complexity.

Organizational Conflict of Interest Contractor eligibility: Contractor must be free, to the greatest extent possible, of all conflicts of interest for each Task Order.

Business Proposal Price analysis Cost Realism analysis Cost analysis (limited, if necessary)

Phase III: Source Selection

Placement of the most highly ranked proposal under individual state.

Consider the minimum (3) and maximum (6) state requirements to develop service area.

Preference given to offerors with at least three highly ranked proposals.

Government reserves the right to award less than three state task orders under any single IDIQ contract.

Additional Information

LOE for each state to be provided in amendment.

Questions submitted electronically to QINmailbox@cms.hhs.gov.

Procurement Timeline RFP Release Date Dec 05, 2013 Question Due Date Dec 19, 2013 Amendment and Answers Jan 08, 2014 Intent to Submit Proposal Jan 15, 2014*

Contact Information Primary Point of Contact:

Kimberly Belli Tatum, Contracting Officer QINmailbox@cms.hhs.gov

Contracting Office Address:

7500 Security Blvd.

C2-21-15 Baltimore, Maryland 21244-1850 Secondary Point of Contact:

Holly Lynn Supinski, Contracting Officer QINmailbox@cms.hhs.gov

BREAK

Please send questions to:

BFCCmailbox@cms.hhs.gov or QINmailbox@cms.hhs.gov; or

Security and Information Technology Support for 11th SOW QIO Contractors

Debbra Hattery | Director, Information Systems Group

Security and Information Technology Support for 11th SOW QIO Contents

Security Policies

Security Responsibilities

Security Controls Assessments, and Corrective Actions

Incident Response

IT Operations Support

Engineering Review Board

Help Desk

Data Access

11th SOW QIO Security Policies

All CMS Contractors shall comply with Federal and CMS security policies:

Federal Information Security Management Act of 2002 (FISMA) National Institute of Standards and Technology (NIST) standards and guidelines CMS Policy for Information Security (PIS) CMS Policy for the Information Security Program (PISP) CMS Acceptable Risk Safeguards (ARS) CMS Risk Management Handbook (RMH), Security Standards and Procedures www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html

11th SOW QIO Security Responsibilities

Establish senior management level responsibility for information security.

Define key information security roles and responsibilities within their organization.

Appoint a Security Point of Contact (SPOC) to oversee its compliance with the CMS information security requirements.

Complete Information Security and Privacy Awareness training courses prior to performing any work under this contract.

Comply with the HHS Rules of Behavior (RoB).

Document security compliance by providing CMS with a System Security Plan (SSP), IT Systems Contingency Plan Report, Risk Assessment Report, and Security Attestation (https://qionet.sdps.org).

11th SOW QIO Security Controls and Corrective Actions On a periodic basis, the Government reserves the right to evaluate any/all of the security controls implemented by the Contractor.

The Government has the right to perform manual or automated audits, scans, reviews, or other inspections of the Contractor’s IT environment being used to provide or facilitate services for the Government.

The Contractor shall track and correct any applicable information security deficiencies conditions, weaknesses, findings, and gaps identified by audits, reviews, security control assessments, and tests.

All high-risk deficiencies shall be mitigated within 30 days and all moderate-risk deficiencies within 90 days from the date deficiencies are formally identified.

The cost associated with Corrective Actions is the sole responsibility of the contractor.

If the contractor believes that an updated or new security requirement may result in a significant cost impact, the contractor may submit a request for equitable cost adjustment before implementing the change.

11th SOW QIO Incident Response

An information security incident is a violation of information security policy.

All security-related incidents shall be reported to CMS.

An information security incident becomes a privacy incident, when the incident involves the suspected or actual loss of PII. PII incidents shall be reported within one (1) hour of discovery.

11th SOW QIO IT Operations Support The ISG infrastructure contractor will support and maintain all major systems required for the SOW on the QualityNet environment (e.g. email, active directory, file and print).

QIO contractors are required to provide local IT resources/support for tasks. Local servers must be housed in environmentally controlled suitable space within the facility.

HCQIS environment totally separate and isolated from the QIO corporate environment. Cannot interconnect the 2 networks.

CMS provides CORE infrastructure for QIO contractor:

Items include servers/network/telecom/laptops at the start of the contract based upon resource needs identified in proposals.

The QIO will fund all requests for HW/SW not included in the CORE setup, such as SAS, Adobe, Printers, Faxes, etc., and will procure them via the Engineering Review Board (ERB) process.

CMS handles technology refreshes with local-QIO support (swapping out, imaging if needed, etc.)

11th SOW QIO Engineering Review Board (ERB) and Remedy Purchase Process

QIOs can order from the current list of approved hardware/software, located in Remedy system. Off-list items require CMS approval.

On-going review of items occurs in support of technology changes.

QIO generates each ERB request, describing a hardware or software product desired in a Purchase Request form in Remedy.

Purchase request require review/approval by the QIO COR, HCQIS ERB team, OAGM and then ISG prior to order.

ISG infrastructure contractor does all procurements to help maintain consistency.

The ERB team (Infrastructure and CMS) meet and review submitted ERB’s weekly and if/when approved are purchased and shipped to the requestor.

11th Scope QIO QualityNet Help Desk The QualityNet Help Desk serves as a front line resource for the healthcare user communities (QIOs, ESRDs, Inpatient Providers, Physician Offices, Vendors, CMS Central/Regional Offices, CDAC, Nursing Homes, Home Health Agencies) who utilize CMS quality applications and infrastructure. They respond to incidents, concerns, questions, service requests, and problems in a timely manner.

The QualityNet Help Desk’s core functions include, but are not limited to:

Operating (Monday through Friday, 8:00 am to 8:00 pm, Eastern) of toll-free number and email, except some Federal holidays. CMS may direct extended hours as needed; 1-866-288-8912; Qnetsupport@bcssi.sdps.org;

Acting as Tier 1 services;

Being 1st point of contact and coordinator for issues ranging from application, performance, user accounts, security incidents, etc.;

Creating and managing major system events, upon identification of a common problem/resolution;

Creating incident and problem management reports, on a schedule/ad-hoc basis; and Logging, tracking, escalation, resolution of important, urgent and critical incidents/events.

11th SOW QIO Data Access QIOs request Parts A, B, and/or D claims data extractions (with or without beneficiary or reference code data) for the SOW and special studies by creating a Remedy non-pass through ad-hoc request that is received by a CMS contractor (currently the Reports & Analytics contract).

R&A may e-mail the requestor for more information if needed. R&A will do research queries as needed against the production warehouses. Then, the ad-hoc status is changed to “send to CMS for approval.”

After obtaining approval from CMS COR/GTL to work on an ad-hoc request, R&A copies and modifies SAS template programs for the specific needs of the ad-hoc request, and reviews and runs code.

Organizational and Personal Conflict of Interest Greg Gesterling | Contractor Compliance Officer, Office of Acquisitions & Grants - Management

Agenda OCI Introduction

Personal Conflict of Interest

Three Types of Conflict of Interest

What Is Expected of the Contractor

Compliance Program

Governance

Basic Prohibitions

Potential Conflicts

What is an Organizational Conflict of Interest (OCI) FAR 2.101 Definition: Organizational conflict of interest means that because of other activities or relationships with other persons, a person is unable or potentially unable to render impartial assistance or advice to the Government, or the person’s objectivity in performing the contract work is or might be otherwise impaired, or a person has an unfair competitive advantage.

In Other Words...

An OCI arises when work performed on one contract creates an unfair advantage in competing for another, or the contractor cannot perform impartially because of its other interests.

An OCI could exist with respect to existing procurement, or with respect to a future procurement.

FAR 9.502 - Applicability Applies to profit and non-profit organizations and more likely to occur in service contracts.

An OCI may result when factors create an actual or potential conflict of interest on a instant contract or when the nature of the work to be performed on the instant contract creates an actual or potential conflict of interest on a future acquisition.

An OCI must be avoided, neutralized or mitigated.

Each individual contracting situation should be examined on the basis of its particular facts and the nature of the proposed contract.

What Is a Personal Conflict of Interest FAR 3.1101 Definition: Personal conflict of interest means a situation in which a covered employee has a financial interest, personal activity, or relationship that could impair the employee’s ability to act impartially and in the best interest of the Government when performing under a contract (A de minimis interest that would not “impair the employee’s ability to act impartially and in the best interest of the Government” is not covered under this definition).

Note – In FAR 3.1101 the covered employee means an individual who performs an acquisition function closely associated with inherently governmental functions.

Three Forms of OCIs Unequal Access to Information

Biased Ground Rules

Impaired Objectivity

Type of Information We May Look for You to Disclose:

Description of all business or contractual relationships or activities that may be viewed by a prudent business person as a conflict of interest.

Description of methods that will be applied to mitigate any conflicts.

Description of a program to monitor compliance of conflict of interest requirements.

Corporate and organizational structure.

Financial interests in other entities including percentage of ownership in any other entity, income generated from other sources, and a list of current or known future contracts with entities that cause conflict.

Type of Information We May Look for You to Disclose:

The list of current or future known contracts could include:

(1) Identify whether the Offeror is a Prime, Subcontractor, parent company, subsidiary, or other affiliated entity;

(2) Contract Number or Other Identifier;

(3) Period of Performance;

(4) Points of Contact (Project Officer and Contracting Officer);

(5) Cost;

(6) Short Description of Work;

(7) Whether the identified contract, relationship or activity creates any of the following types of OCIs: (1) Unequal Access to Information, (2) Biased Ground Rule, (3) Impaired Objectivity, and/or (4) Other. If a potential organization conflict of interest is identified, the Offeror must submit a mitigation plan.

Compliance Program FAR 3.10 Incorporates Seven Elements for Federal Contracts Exceeding $5M in value and 120 Days of Performance.

Guidance/Recommendations for Establishing an Effective Compliance Program can be found at:

www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative- Contractors/Downloads/compliance.pdf.

All Primes and Subcontractors.

All Large Businesses must have a Compliance Program.

All Small Businesses must have, at the minimum, a Code of Conduct and Written Compliance Policies and Procedures.

Compliance Program Elements Code of Conduct and Written Compliance Policies and Procedures

Compliance Officer and Compliance Committee

Employee Training and Education

Process to Receive Complaints Including the Ability to Report Anonymously

Monitoring and Auditing

Enforcement and Discipline

Investigation and Prevention of Problems and the Development of Policies to Address Sanctioned Persons

Governance Board of Directors 2/3 of which are independent from and not compensated by the QIO Entity.

Compliance Committee Subset of the Board of Directors to handle Conflict of Interest issues.

Compliance Officer Independent personnel that reports to the Compliance Committee on Conflict of Interest issues that warrant resolution.

Basic Prohibitions In accordance with 42 CFR §475.105, Prohibition against contracting with healthcare facilities, affiliates, and payor organizations, the following restrictions apply to awards under these contracts:

2. Subcontracting. A QIO must not subcontract with a healthcare facility to perform any case review activities except for the review of the quality of care.

BFCC-QIO & QIN-QIO

Potential Conflicts Examples:

BFCC having a separate contract with a provider.

A subcontractor performing work on both BFCC-QIO and QIN-QIO contracts.

Financial interests in other entities, including the following:

Questions?

Please submit all questions concerning Conflict of Interest in writing to both the BFCC and QIN mailboxes:

Question Response Panel Cadre of CMS Leadership Representatives

Close Out & Adjourn Brian Hebbel | Director, Division of Quality Contracts

Thank you!

Please send questions to:

BFCCmailbox@cms.hhs.gov or QINmailbox@cms.hhs.gov; or

Index card box in lobby before you leave.

Any new information about these solicitations will be available on FBO.gov.

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