RED_LINED_J.1_QIN-QIO_Task_Order_001.docx

Centers for Medicare & Medicaid Services Center for Clinical Standards & Quality Quality Improvement Group Quality Innovation Network (QIN) Quality Improvement Organization (QIO) Scope of Work (SOW) Task Order No. 001:

Excellence in Operations and Quality Improvement

Contract No. _______________ Attachment J.1- Task Order 001 revised 1/20/14

HHSM-500-2014-RFP-QIN-QIO

Attachment J.1- Task Order 001

HHSM-500-2014-RFP-QIN-QIO

xi

QIN-QIO SOW

Task Order 001:Excellence in Operations and Quality Improvement

Government Task Lead (GTL) Task A.1 – Excellence in Operations A. Primary GTL Name:

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B. Alternate GTL Name:

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Task B.1 – Improving Cardiac Health and Reducing Cardiac Healthcare Disparities C. Primary GTL Name:

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

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Task B.3 – Using Immunization Information Systems to Improve Prevention Coordination

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Task B.4 – Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with Regional Extension Centers

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Task C.1 – Reducing Healthcare Associated Infections in Hospitals

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Task C.2 – Reducing Healthcare Acquired Conditions in Nursing Homes

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Task C.3. Coordination of Care

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Task D.1. Quality Improvement through Physician Value-Based Modifier and the Physician Feedback Reporting Program

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Task D.2. QIN-QIO Proposed Projects That Advance Efforts for Better Care at Lower Cost

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Task E.1. Other Technical Assistance Projects – Quality Improvement Initiatives

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Table of Contents

List of Tables

ii Introduction The Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards and Quality (CCSQ) requires expert healthcare quality improvement services. The contractor performing these services will be referred to as a Quality Innovation Network (QIN) Quality Improvement Organization (QIO) (referenced as QIN-QIO). This Task Order (TO) is issued under the terms and conditions of the QIN Indefinite Delivery/Indefinite Quantity (IDIQ) contract. Independently, and not as an agent of the Government (except if noted herein), the QIN-QIO shall furnish all the necessary services, qualified personnel, material, equipment, and workspace facilities, not otherwise provided by the Government, as needed to perform the requirements of this task order. The Contractor's technical proposal will be made a part of this task order. In the event of any inconsistency between the provisions of this contract/task order and the Contractor's technical proposal, the contract/task order provisions take precedence.

Personnel Requirements The QIN-QIO shall provide personnel for this task order in accordance with Section C.6.3, Personnel Core Requirements of the Base Contract. Qualifications for Key Personnel and Other Recommended Personnel positions are provided in Section C.6.3. of the Base Contract and will not be restated in Task Orders. Recommended positions unique to individual tasks and their corresponding qualifications along with other designated Key Personnel, which are not provided in Section C.6.3. of the Base Contract, will be provided in Task Orders and specified at the Task level.

2.1. Designation of Key Personnel

Certain positions may be designated as “Key Personnel”, within the meaning of Health and Human Services Acquisition Regulation 352.270-5. For this TO, the following position is determined as Key Personnel:

IDIQ Director – Required for the overall contract State Program Director – Required for each State Task Order awarded the overall contract (1 FTE with 100% commitment) Definitions See Attachment J-8 , Glossary of Terms and Acronyms, for definitions of terms and the list of acronyms associated with this contract and all task orders.

Core Requirements Applicable to All Task Orders The following list of task requirements is applicable to all Task Orders. Specific requirements for these tasks can be found in the Base Contract at Section C.67.4, “Execution Requirements for All Task Orders.”

· C.67.4.1 Work Plan

· C.67.4.2 Recruitment Plan

· C.67.4.3 Provider and Practitioner Recruitment

· C.67.4.4 Beneficiary (“Patient”) and Family Engagement (PFE)

· C.67.4.5 Partner and Stakeholder Recruitment and Collaboration

· C.67.4.6 Sustainability Plan

· C.67.4.7 Monitoring and Reporting Requirements

· C.67.4.8 Measurement and Interventions Task Order Requirements Excellence in Operations The QIN-QIO shall perform quality improvement work in the designated area(s) for the specified period of performance. Such quality improvement work shall include requirements as specified in the Base Contract and Tasks pursuant to Task Orders issued during the contract term. In performing its work, the QIN-QIO shall take into account servicing multiple areas and the unique needs and characteristics of the Medicare population and healthcare providers of the QIO’s designated area(s). The Tasks for Excellence in Operations spans ALL contract requirements (Base Contract and Task Orders) over the life of the contract to ensure an overall comprehensive operational framework is established to support CMS objectives, concurrent execution of multiple Quality Improvement Tasks for multiple QIN areas, and overall project management. Task A.1, Excellence in Operations provides the specific tasks..

Quality Improvement Quality improvement initiatives are authorized by the Social Security Act (the Act), in particular §§1862(g) and 1154(a)) (18)). Under § 1862(g) of the Act, the Secretary must enter into contracts with QIOs for a number of reasons, including assisting the Secretary in making determinations about whether services are reasonable and medically necessary, and for the purposes of promoting effective, efficient, and economical delivery of healthcare services and of promoting the quality of services of the type for which payment may be made under Medicare. The Centers for Medicare & Medicaid Services (CMS) has interpreted the term “promoting the quality of services” to involve not only beneficiary case reviews, but also as covering a broad range of innovations designed to promote higher quality. Under § 1154(a)(18) of the Act, a QIO must perform, subject to the terms of its contract with CMS, activities that are not explicitly listed in § 1154(a) but are determined by the Secretary to be necessary for the purposes of improving the quality of care furnished to individuals under Medicare.

Quality Improvement Aims comprises of three high-level Aims, each of which has separate Tasks, and technical assistance projects as follows:

AIM: Healthy People, Healthy Communities: Improving the Health Status of Communities Goal 1: Promote Effective Prevention and Treatment of Chronic Disease Task B.1: Improving Cardiac Health and Reducing Cardiac Healthcare Disparities Task B.2: Reducing Disparities in Diabetes Care: Everyone with Diabetes Counts (EDC) Task B.3: Using Immunization Information Systems to Improve Prevention Coordination Task B.4: Improving Prevention Coordination through Meaningful Use of HIT and Collaborating with Regional Extension Centers NOTE: Task B.3 is reserved.

AIM: Better Healthcare for Communities: Beneficiary-Centered, Reliable, Accessible, and Safe Care Goal 2: Make Care Safer by Reducing Harm Caused in the Delivery of Care Task C.1: Reducing Healthcare-Associated Infections Task C.2: Reducing Healthcare-Acquired Conditions in Nursing Homes Goal 3: Promote Effective Communication and Coordination of Care Task C.3: Coordination of Care AIM: Better Care at Lower Cost Goal 4: Make Care More Affordable Task D.1: Quality Improvement through Physician Value-Based Modifier and the Physician Feedback Reporting Program Task D.2: QIN-QIOproposed Projects that Advance Efforts for Better Care at Lower Cost Other Technical Assistance Projects Task E.1: Quality Improvement Initiatives

Tasks The QIN-QIO shall perform the following tasks as described below.

A. Task A.1: Excellence in Operations The purpose of this task is to provide CMS objectives and requirements for management of the contract inclusive of all administrative activities/functions and overall management of all TOs issued under the QIN-QIO contract. The QIN-QIO shall achieve excellence in operations through managing for results. Overall project management is the key to the success of the QIN-QIO contract, the overall QIO Program, and the improvement in the quality of care and health for Medicare beneficiaries. The SOW requirements are results-oriented including measures and performance goals for contract requirements aligned to many Agency/Department goals and industry standards. Projects of such complexity require a systematic, deliberate, and calculated approach to achieve overall QIO Program goals. The QIN-QIO shall follow a basic project management framework, which includes, but may not be limited to a contract management plan, comprehensive strategic plan, integrated communications plan, and a continuous internal quality improvement program.

A.1.1. QIN-QIO Comprehensive Strategic Plan The QIN-QIO Comprehensive Strategic Plan, hereafter referred to as “Strategic Plan”, shall at a minimum, include the requirements specified in Section C.6.1.1, QIN-QIO Comprehensive Strategic Plan in the Base Contract. The minimum components are:

a. Vision Statement

b. Mission Statement

c. Organization Core Values

d. Implementation Strategy

e. Management Plan

f. Integrated Communications Plan

g. Information Security Plan

h. QIO System Security Plan

i. Emergency Preparedness Plans

i. Continuity of Operations Plan (COOP

ii. Contingency Plan

1. Disaster Recovery Plan

To optimize QIN-QIO internal operations, the QIN-QIO shall provide a comprehensive strategic plan that allows CMS to understand the method(s), modes and actions the QIN-QIO will use over the life of the contract to ensure all requirements are successfully executed and goals met. As with CMS’s goals for the QIO Program, the strategic plan should align the QIN-QIO’s work, methods, modes and actions with the CMS Quality Strategy. The QIN-QIO shall provide the strategies and activities it will use to address the strategic requirements as set forth in Section C.6 of the Base Contract. All individual components of the Strategic Plan shall be identified and discussed in separate sections. Of particular note, it is imperative that the QIN-QIO shall clearly articulate how it will carry out the following activities:

a. Collaborate with other healthcare quality improvement and delivery system reform initiatives within and outside of CMS and avoid duplication of work with other CMS contractors involved in those initiatives. Furthermore, the QIN-QIO shall share the names of recruited participants with other healthcare quality improvement and delivery system reform leaders if the sharing of this information will aid the QIN-QIO in the avoidance of the duplication of work.

b. Integrate and/or coordinate Tasks within and across all Task Orders throughout the life of the contract. CMS requires the QIN-QIO to foster the most efficient use of resources, interventions (including recruitment and quality improvement strategies), personnel and achievement of desired outcomes for quality improvement tasks under this contract. For example, a Task Order with multiple separate tasks presents an opportunity for collaboration and cross-integration between the Care Coordination Task and the following Tasks: Improving Cardiac Health and Reducing Cardiac Disparities, Reducing Disparities in Diabetes Care: Everyone With Diabetes Counts, Healthcare acquired infections in Hospitals, Nursing Home Healthcare Acquired Conditions and/or QIN-QIO Proposed Projects that Advance Efforts for Better Care at Lower Costs.

Another example, although not limited to integration and coordination between Tasks is Improving Prevention Coordination Through Meaningful Use of HIT and Collaborating with Regional Extension Centers and Quality Improvement Through Physician Value-Based Modifier and/or the Physician Feedback Reporting Program and QIN-QIO Proposed Projects that Advance Efforts for Better Care at Lower Costs. The QIN-QIO may identify other opportunities for integration and coordination between Tasks.

c. The QIN-QIO shall use an innovative and iterative cyclic approach to incorporate a data-driven monitoring and communication system for network-based interventions across and within Tasks. “Network interventions” is a relatively new term that describes the process of using network mapping and the resultant network data to guide, accelerate, and measure behavior change, including improvements in organizational performance and capabilities, internally and with cross-sector partnerships. A network intervention approach is ideal for the visualization of community and stakeholder interventions, illuminating both strengths and weaknesses. The visualization of interventions is used as a means to engage and inform communities, partners, stakeholders, teams, and organizations, thus creating shared knowledge for all that can be applied to accelerate cycles of improvement (More information is available at www.sciencemag.org Valente, T.W. 6 July 2012, Network Interventions or Adams, J. 17 December 2010, Exploring Links to Improve Health). A network intervention approach may be used in conjunction with Community Organizing techniques (Organizing for Health, http://www.cfmc.org/integratingcare/files/Organizing%20for%20Health%20-%20Introduction%20to%20Organizing%20-%20Kate%20B%20%20Hilton.pdf ). Enabling utilization of network interventions, another innovative approach is known as Relational Network Optimization (RNO) which is the combination of organizational network analysis and relational coordination to optimize delivery of wellness programs and disease treatment (Houston et al 2013 in preparation, Relational Network Optimization). To illustrate, RNO is intended to support identifying structural gaps and quantify operational weakness in collaborations and coalitions for care coordination, thereby supporting specific network interventions, such as creating new bridges between groups, when needed. Including both a social process and specialized enterprise-scale web technology, RNO dynamically operationalizes measurement between roles of key relational coordination constructs of shared knowledge, shared goals, mutual respect, and effective communication, rapid feedback to all stakeholders, and the ongoing creation of new data, information, and scientific knowledge. With the creation of new scientific knowledge, RNO integrates ongoing cycles of inclusive (of all stakeholders) research with improvements in organizational efficiency and effectiveness. RNO scientifically makes evident opportunities for rapid cycle improvement.

d. Contribute to the creation of a culture of sharing (with CORs, GTLs, and other QIOs) the following information: successful interventions, promising practices, lessons learned and/or other relevant information that has led to significant improvement in health, healthcare and/ or lower costs of healthcare for Medicare beneficiaries.

The Strategic Plan shall be submitted as part of the Task Order proposal and updated within 45 calendar days of Task Order award. The approved plan shall be updated within 5 days of any other change event.

A.1.2. Management Plan The QIN-QIO shall establish and execute a management structure that strongly and seamlessly supports contract operations. A Management Plan shall be provided that is results oriented and, at a minimum, includes effective lines of communication, budget and cost controls, quality assurance reviews, project schedule management, resource management to include staffing matrices by task/subtask, progress reviews and performance monitoring, risk management, change management, timely delivery, and clearly defined roles, responsibilities, lines of authority, and resources appropriately aligned to services and deliverables. Task Orders will involve multiple concurrent tasks and may involve multiple levels of subcontracting. QIN-QIOs shall ensure that all work efforts are integrated and also give attention to cross-cutting tasks. As the prime contractor, the QIN-QIO shall coordinate all subcontracted work to ensure that the efforts of all parties under the contract (management, administrative, and TO staff) are combined into a cohesive whole.

A.1.3. QIN-QIO Integrated Communications Plan To optimize effective communication, the QIN-QIO shall provide for CMS approval a comprehensive and integrated communications plan to ensure access to the right information and services, in the right form, at the right time, to the right people, in the right place. This communication plan will focus the QIN-QIO’s energy such that each policy, action, and decision is made with an educated and strategic consideration of the impacts they have on stakeholders.

The QIN-QIO Integrated Communications Plan shall be developed in accordance with Section C.6.1.2. QIN-QIO Integrated Communications Plan of the Base Contract SOW. The Integrated Communications Plan shall be part of the “QIN-QIO Comprehensive Strategic Plan,” also known as the “Strategic Plan,” as required in Task A.1.1 of this Task Order. The Communications Plan is not a stand-alone document that requires independent submission to CMS as a deliverable. Rather, the Communications Plan shall be a discrete portion of the Strategic Plan that follows a CMS-prescribed template. The Communications Plan shall be a working document, to which the QIN-QIO makes regular edits, and which is available for COR/GTL inspection upon request.

QIN-QIOs shall work with providers and practitioners in underserved communities within its area. The communications plan provided to CMS as required by the contract, must provide details at both state-specific and overall area levels. Additionally, the QIN-QIO must describe the proportionate amount of each plan’s subject (e.g. providers recruited in the recruitment plan, activities in the Task Order Work Plan, etc.) by state compared to the QIN-QIO’s overall area along with the rationale/justification for that proportion. The rationale/justification must demonstrate that no state has been excluded and, if numbers are disproportionate for one state versus another that the reason for disproportionate amounts is to work with providers/practitioners most in need of assistance and/or to maximize the amount of improvement achieved. For example, if a QIN-QIO area covers 5 states, each with an equal number of providers, yet 50% of the worst performers were found in just one of those 5 states, the QIN-QIO could disproportionately recruit and plan activities in that single state in order to work with those providers most in need of assistance and maximize the improvement achieved. Some providers must still be recruited from each of the 5 states with activities also planned for each of the 5 states.

A.1.3.1 Other QIN-QIO Communications Deliverables In addition to the Integrated Communications Plan required per Task A.1.3.1 of this Task Order, the QIO shall submit the following additional materials to CMS as deliverables:

a. Before the QIN-QIO begins to use social media tactics as part of its QIN-QIO projects, the QIN-QIO shall submit a business case to CMS, using a format prescribed by CMS and its coordinating center contractors. The business case shall be responsive to the social media requirements articulated in Section C.6.1.2.3 of the base contract.

b. In accordance with C.6.1.2.4 of the base contract, a proposal to spend contract dollars on either of the following:

1) “Outreach items,” as defined Section J, Attachment J.8, Glossary of Terms and Acronyms of this contract, when the total cost of those items exceeds $1,000. (The $1,000 threshold shall apply to the individual state for which the outreach item is used—items used in multiple states shall have their total costs count towards this threshold in proportion to their usage in the SOW.)

2) “Paid media,” as defined Section J, Attachment J.8, Glossary of Terms and Acronyms of this contract, regardless of the dollar amount or the number of states to which a promotional item may apply.

c. Any QIN-QIO-generated communications material requested by the COR/GTL, whether in draft or final form, within 5 business days of CMS’ request. The QIN-QIO shall discuss with the COR/GTL the most efficient and practical way to deliver the material, which may require transmission electronically or in hard-copy for print publications best viewed in hand. Note that QIN-QIOs are encouraged to share QIN-QIO-generated communications materials with one another through the healthcarecommunities.org portal, as per Section C.4.6 of the base SOW. The submission of a deliverable in accordance with this paragraph does not preclude a QIO from sharing its materials on the portal, though the COR/GTL may direct a QIO to remove erroneous, unprofessional, or otherwise inappropriate material from the portal if necessary.

A.1.4. Information Systems and Emergency Preparedness Plans The QIN-QIO shall develop the Information Security Plan, QIN-QIO System Security Plan, and the Emergency Preparedness Plans in accordance with the requirements in Sections C.4, Technical Considerations and C.5, General Requirements. These plans shall be provided as subsections of the Strategic Plan.

A.1.5. Task Order Work Plan Compendium Quality Improvement Task Orders issued under this contract may contain one or multiple separate quality improvement tasks. Section C.6.4.1, Task Order Work Plan in the Base Contract requires that QIN-QIOs provide a Task Order Work Plan for each Quality Improvement Task Order which encompasses separate work plans for each quality improvement task in the Task Order. The Task Order Work Plan provides essential documentation of objectives, goals, timeframes, and staffing to complete each Task. The QIN-QIO shall create a Task Order Work Plan Compendium (hereafter referred to as “Compendium”) within 905 calendar days of the first Task Order award for quality improvement services. The Compendium shall contain all CMS approved Quality Improvement Task Order Work Plans and shall be maintained throughout the life of the contract.

The Task Order Work Plans shall be identified by Task Order number, title, date, and follow the format specified in Section C.6.4.1 in the Base Contract. Task Order Work Plans are to be added to the Compendium on a real-time basis. This means that Task Order Work Plans shall be added to the Compendium upon Task Order award, updated when Task Order contract modifications are executed, and when any changes are made to approved Task Order Work Plan(s).

A.1.6. Continuous Internal Quality Improvement Program Plan The purpose of the Continuous Internal Quality Improvement Program (CIQIP) Plan is to support and foster an environment of continuous quality improvement within the QIN-QIO. Such an environment helps to assure success of the QIN-QIO in their performance of the contract through ongoing assessment of and improvement when necessary in areas that are critical to organizational success. These include but, are not limited to:

Leadership Human Resources Customer Satisfaction Performance Measures Process Management Task Order Results A.1.6.1. Objectives of the CIQIP The objectives of the CIQIP are to:

Support and foster continuous quality improvement within the QIN-QIO in support of the Health Care Quality Improvement Program (HCQIP), the Medicare Beneficiary Protection Program (MBPP), and other Statement of Work (SOW) activities.

Develop and implement measures and targets that relate to the Contract Management Plan and Strategic Plan that ensure all aspects of QIN-QIO activities run efficiently, comply with the contract, and are consistent with and on track to achieve CMS’s goals and objectives for the HCQIP, MBPP, and the SOW.

Maintain QIN-QIO activities within a permissible range of deviation with minimum effort Ensure the financial integrity of the contract by actively monitoring and staying within the total estimated cost and indirect cost ceilings of the contract;

Create a positive work environment in which opportunities for improvement are sought out and addressed at all levels of the organization Improve the reliability, accuracy, consistency, and timeliness of data processing, data reports Ensure the support, understanding, and participation of all beneficiaries, practitioners, providers, and other constituencies that are affected by QIN-QIO activities Provide contract services that consider and meet the needs of both internal and external customers, and result in high levels of customer satisfaction CMS encourages each QIN-QIO to collaborate with other QIN-QIOs in developing and implementing CIQI programs. The QIN-QIO shall share lessons learned regarding these CIQIP activities with other QIN-QIOs using the available mechanisms, including QIN-QIO conferences, newsletters, and databases.

A.1.6.2. CIQIP Requirements The QIN-QIO shall have a CIQIP that encompasses all quality improvement (QI) requirements, and other major activities including administrative functions such as financial management. As new Task Orders are added to the contract, the CIQIP must be modified to address the new areas of work.

The CIQIP shall include the following elements:

Identify QI components and/or activities that are included;

Based on the Contract Management Plan and Strategic Plan, identify measures/monitors of performance that relate to the elements of those plans, including but not limited to each of the QI components and/or activities.

Include measures that assess critical outcomes or SOW targets, as well as measures that assess processes related to those outcomes (e.g. measures that assess the implementation and effectiveness of activities designed to achieve the outcome);

Develop goals or thresholds for all measures, including goals or targets at various points within the contract period that allow for correction when performance does not appear to be on track to achieve contract goals or targets;

Develop timeframes at which measures are to be assessed against the goals/targets;

At least quarterly, or more often as performance indicates, or as otherwise directed, use measures, results, and other information to assess whether you are likely to meet goals/targets.

Analyze those areas where performance fails to achieve expected targets or thresholds and identify any causes of failure;

Identify changes in the process that address the identified causes of failure and that you believe will improve performance;

Implement selected changes designed to improve your process and performance; and Determine whether improvements were successful, and make further adjustments to the process as needed.

Document all aspects of the CIQIP including but not limited to

· QI Components and major activities included,

· Measures,

· Targets/goals and timeframes at which the targets/goals are to be achieved,

· Results of performance at the specified timeframes,

· Description of the analysis conducted when measures fail to achieve targets/goals and results of the analysis,

· Improvement actions identified and those selected that address the findings of the analysis,

· Critical dates and planning for the implementation of improvement actions, and

· Re-measurement results.

Communication of the CIQIP and its results across the organization as well as to leadership and QIN-QIO Board of Directors.

The QIN-QIO shall make available in accordance with the schedule of deliverables and on request by CMS, documentation of measurements/monitoring, plan, results, and improvement actions for all quality improvement components and major activities.

The QIN-QIO shall submit its draft CIQIP plan for CMS approval within 9045 days of Task Order award. The approved plan shall be updated within 5 days of any other change event.

A.1.7. Reporting Requirements The QIN-QIO shall provide the following reports as described below and in accordance with the Schedule of Deliverables:

a. Monthly Documentation of QIN-QIO Activities – at a minimum, the monthly report shall include a summary of QIN-QIO activities by Task including a separate section on Task A. This report is due to the COR at least 3 days prior to the monthly COR monitoring call. The COR will provided guidance on the format and any additional content.

b. Draft Final QIN-QIO Report for All Tasks – at a minimum,, the draft final report shall include the following:

· A summary of the Excellence in Operations Task and the impact of the various plans required to execute tasks under the overall contract.

· A summary of the QIN-QIO Activities spanning the life of the contract by task.

· A summary of the impact of each task that includes a discussion on measures, targets/goals, and results.

· An overall summary of how Medicare beneficiaries in the QIN-QIO’s area benefitted from QIN-QIO activities which is supported by data analysis. Also, include a discussion on activities that will be sustained by providers, practitioners, communities, and beneficiaries at the conclusion of the QIN-QIO contract.

· A summary of lessons-learned on successful practices and non-productive interventions.

The draft final report is due to the COR/GTL by December 15, 2018 for review and comment. CMS will provide comments no later than January 10, 2019.

c. The Final QIN-QIO Report for All Tasks shall be updated to include CMS comments/changes and submitted to the COR/GTL by February 1, 2019.

A.1.8. General Contract Management

a. The QIN-QIO shall participate in an orientation meeting (s) with the CMS Government Task Leads (GTL) and/COR within 5 calendar days of task order award.

b. Within 21 calendar days of the effective date of the Task Order, the QIN-QIO shall participate in a Contract Kick-Off/Planning Meeting to confer with the GTL and COR by conference call to discuss the award. This will include a discussion of the QIN-QIO’s proposal and CMS’ expectations for project objectives and goals, the project design, expected timeframes, project staff, and the project tasks. The discussion shall also include the transition process from previous SOWs to current SOW, if applicable for the QIN-QIO. For this meeting, the QIN-QIO shall prepare discussion materials for its plan on completing the draft QIN-QIO Integrated Communications Plan and the CIQIP Plan.

c. Within 20 21 calendar days after Task Order award, the QIN-QIO shall submit to COR and GTL with approval by COR in consultation with GTL, the draft QIN-QIO Comprehensive Strategic Plan, which includes:

a. Implementation Strategy

b. Management Plan

c. Integrated Communications Plan

d. Information Systems and Emergency Preparedness Plans QIN-QIO Integrated Communications Plan and the CIQIP Plan along with any changes to the Project Management Plan or Comprehensive Strategic Plan, integrating the decisions reached at the orientation conference call. Within 14 90 calendar days after COR approval of the draft QIN-QIO Integrated Communications Plan and the CIQIP Plan, the QIN-QIO shall submit the final versions of the plans.

d. The QIN-QIO shall establish standing conference calls every month (unless otherwise indicated) with the COR on a mutually agreed upon timeframe which may include the CMS Contracting Officer, Contracting Specialists, GTL and/or others with a vested interest in how the contract is progressing.

e. The QIN-QIO shall assist in previous SOW to current SOW transition process after Task Order award in accordance with Section C of the Base Contract.

f. The QIN-QIO shall cooperate and collaborate with CMS partners, stakeholders and other Federal Agencies involved in similar efforts as applicable to tasks specified in this SOW.

g. Conference Attendance Requests (CARs): When the QIN-QIO plans to have a meeting and/or conference directly related to the performance of the contract, the QIN-QIO shall follow the current HHS and CMS travel and meeting policy.

h. In accordance with Section C.4.3.1 Certification by Security Point of Contact (SPOC) for Compliance with CMS Systems Security Requirements of the Base Contract, the QIN-QIO shall:

1) Appoint a SPOC within 14 90 days of Task Order award.

2) Provide a list of assigned QIN IT staff with the required information.

3) Conduct Security Awareness Training (SAT) for all employees utilizing or accessing CMS data within the HCQIS environment on an annual basis. The training shall be tracked and a log maintained of employees trained. A QNET SAT Certification Letter shall be provided to CMS 90 days after Task Order award in accordance with Task Order 001, Schedule of Deliverables.

4) Visit the CMS security website (www.cms.hhs.gov/informationsecurity) and the QualityNet security website (http://qionet.sdps.org) at least every 30 calendar days for updates. [Note: The QualityNet security website is an Intranet website; thus, access is restricted to only active users within the QualityNet Enterprise.]

5) Submit a Business Continuity and Contingency Plan (BCCP) within 90 days after Task Order award and updates provided 30 days after completion of any serious structural changes. Serious structural changes consist of building relocations or major structural changes to the current infrastructure.

6) Provide upon request, all related artifacts, in the format and method prescribed by CMS, resulting from compliance with CMS, FISMA, OIG, and other relevant audits, reviews, evaluations, tests, and assessments of QIN systems, processes, and facilities as it relates to program security and compliance.

7) Provide a QIN System Security Plan (SSP) and Information Security (IS) Risk Assessment (RA) within 90 days of after task order award, annually thereafter, and updates 30 days after any major changes.

8) Develop, in conjunction with CMS, Corrective Action Plans (CAP) for all identified weaknesses, findings, gaps, or other deficiencies in the IS Program (e.g., those items identified during a FISMA audit or similar activity) in accordance with IOM Pub. 100-17 (BPSSM) or as otherwise directed by CMS. Submit CAPs within 30 days after the audit or finding in accordance with Task Order 001, Schedule of Deliverables.

9) Submit the Plan of Action & Milestones (POA&M) within 15 days of approval of a CAP and monthly thereafter until the CAP is closed.

10) Maintain a list of all purchased and leased equipment in a HHS 565 submission Final Report.

11) Comply with all CMS system and software maintenance procedures. All digital media must be encrypted before physically leaving the QIN. The QIN-QIO shall perform maintenance of systems and software in compliance with applicable configuration requirements. QIN IT staffs are responsible for completion of IT tasks as assigned in Remedy tickets for QIN local systems.

12) Comply with CMS Incident Handling Standards and Procedures (RMH Vol III Standard 7-1 Incident Handling, RMH Vol II Procedure 7-2 Incident Handling Procedure) located at http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/InformationSecurity/Information-Security-Library.html and report suspected security breaches within the designated time periods. The QIN shall assist the CMS ISSO on active investigations and provide requested documentation as needed for all security incidents.

i. In accordance with Section C.4 General Requirements in the Base Contract, the QIN-QIO shall:

1) Adhere to the privacy, confidentiality, and disclosure requirements set forth in Section 1160 of the Act, and in Title 42 of the Code of Federal Regulations (CFR) Part 480, which are incorporated by reference in Attachment J-2 in the Base Contract and be prepared to document adherence to these privacy, confidential and disclosure requirements. http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr480_02.html.

2) Be prepared, if required to provide a copy of training materials developed or used to meet the confidentiality training requirement specified in 42 CFR 480.115. CMS may request documentation that users of the QIO review system have been trained in the proper handling of confidential information prior to being given access to that information and review system.

3) Obtain all Data Use Agreements (DUAs) necessary to comply with contract requirements and to execute required services.

4) Execute a data abstraction subcontract with the Clinical Data Abstraction Centers (CDACs).

5) Copy the COR on all communication between the QIN-QIO and the CDAC related to these subcontracting arrangements.

6) At a minimum, participate annually in collaborative activities that are sponsored by the applicable CMS Regional Office and focus on CMS-identified priority initiatives.

7) Follow the CMS Contractor Website Guidelines as specified in www.cms.hhs.gov/AboutWebsite/13_contractorwebguidlines.asp, which is incorporated into this contract by reference in Attachment J-2 in the Base Contract. The QIN-QIO shall refer to this website at least every 90 days for the current standards and guidelines.

8) Assist CMS’ public health efforts by disseminating information and messages as directed by the CO.

9) Develop and provide to CMS two different plans to address emergency preparedness: (1) a Continuity of Operations Plan (COOP) and (2) Contingency Plan (CP), which includes a Disaster Recovery (DR) Plan.

10) Prepare a “Table Top” test to evaluate the effectiveness of the COOP/CP/DR Plans, annually. At a minimum, this test shall include a structured walk-thru of each Plan with all QIN-QIO and CMS key staff needed for CMS to evaluate each Plan.

11) Fully cooperate with and provide, subject to the QIO confidentiality provisions in Section 1160 of the Social Security Act and 42 CFR Part 480, requested data for any evaluation of the QIO program that the Secretary, or CMS on behalf of the Secretary, chooses to conduct. Such evaluations may be conducted by a CMS contractor.

12) Fully comply with all conflict of interest requirements as outlined in Section H of the QIN Solicitation.

B. AIM: Healthy People, Healthy Communities: Improving the Health Status of Communities Goal 1: Promote Effective Prevention and Treatment of Chronic Disease Task B.1: Improving Cardiac Health and Reducing Cardiac Healthcare Disparities Section A. Overview/Background According to the Centers for Disease Control and Prevention (CDC), heart disease and stroke are the first and fourth leading causes of death, respectively, in the United States for all groups. The CDC also presents morbidity and mortality data that suggest the risk for heart attacks and strokes are far greater for racial and ethnic populations (non-whites) than whites. The CDC’s State Maps on Heart Disease and Strokes at http://apps.nccd.cdc.gov/NCVDSS_DTM/ present data on heart attacks and strokes. It includes a breakdown by race and ethnicity and demonstrates the necessity for supporting the Million Hearts® initiative with an intense focus on the ABCS (Aspirin therapy when appropriate, Blood pressure control, Cholesterol management, and Smoking screening and cessation) for racial and ethnic minorities.

In September 2011, the HHS Secretary launched the Million Hearts® initiative to prevent one million heart attacks and strokes by the year 2017. The initiative focuses on improving the ABCS (Aspirin therapy when appropriate, Blood pressure control, Cholesterol management, and Smoking screening and cessation). This work also supports the National Prevention Strategy and three of its core strategic directions to a) promote clinical and community preventive services that ensure prevention-focused healthcare and community prevention efforts are available, integrated, and mutually reinforcing; b) empower people by supporting healthy choices; and c) elimination of health disparities to improve the quality of life for all Americans.

The Million Hearts® initiative created a priority focus on blood pressure measurement and control. High blood pressure has long been considered a “silent killer” in that many will not demonstrate signs and/or symptoms of the disease. Consequently, blood pressure measurement and control are essential to preventing heart attacks and strokes and decreasing the associated high mortality rates in the nation.

Section B. General Desired Outcomes Under the provisions of this Task, the QIN-QIOs shall work with providers and beneficiaries in collaboration with key partners and stakeholders to implement evidence-based practices to improve cardiovascular health and support the Million Hearts® initiative’s goal in connection with care provided to Medicare beneficiaries to prevent one million heart attacks and strokes by the year 2017.

The specific targets and time periods for these outcomes are listed in the Evaluation Measures Table for this Task.