J.1-A_T0001_Endorsement_SOW_7-05-17.pdf

HHSM-500-2017-00060I

HHSM-500-T0001

7/05/2017

STATEMENT OF WORK

Task Order 1 Consensus-Based Endorsement and Maintenance of Performance Measures

I. Background

Section 183 of the Medicare Improvement for Patients and Providers Act (MIPPA) of 2008 established Section 1890 of the Social Security Act (the Act), which requires the Secretary of the Department of Health and Human Services (HHS) to contract with a consensus-based entity for completion of statutorily required consensus-based duties. Among the duties identified in Section 1890 of the Act, is the requirement for the consensus-based entity to establish, implement, and provide consensus-based processes for the endorsement and maintenance of healthcare performance measures. Section 207 of the Medicare Access and CHIP Re-authorization Act (MACRA) of 2015 authorizes the extension of funding for quality measure endorsement, input, and selection.

Various statutory provisions require the Centers for Medicare & Medicaid Services (CMS) to consider the selection of performance measures endorsed by the consensus-based entity with a contract under Section 1890 for quality reporting, public reporting, and value-based purchasing programs. CMS utilizes the consensus-based endorsement and maintenance processes to ensure the selection of reliable, valid, and high-priority performance measures.

The Task Order resulting from this SOW will awarded under the 2017 Consensus-based Entity (CBE) Indefinite Delivery, Indefinite Quantity (IDIQ) vehicle entitled, “National Consensus Development and Strategic Planning for Healthcare Quality Measurement.” CMS is re-competing the CBE IDIQ. This Task Order falls under the scope of Task Order Domains for the Consensus-based Endorsement and Consensus-based Maintenance found in Section II.A. of the CBE Umbrella IDIQ Contract.

A. Purpose

The purpose of this task order is to conduct consensus-based endorsement and maintenance of performance measures with the consensus-based entity under the CBE IDIQ in accordance with Section 1890 of the Act.

II. Requirements

A. General Requirements

Independently, and not as an agent of the Government, the Contractor shall furnish all the necessary services, qualified personnel, material, equipment and facilities not otherwise provided by the Government, as needed to perform the requirements of this Statement of Work.

All General Requirements, under Section II.A. of this Task Order, must be met for each consensus-based endorsement and maintenance project conducted by the Contractor.

1. Consensus-based Endorsement and Maintenance Process Requirements The Contractor shall conduct consensus-based endorsement and maintenance process for performance measures that are in accordance with Section 1890 of the Act, the National Technology Transfer and Advancement Act (NTTAA) of 1995, and OMB Circular A- 119 requirements for a voluntary consensus standards body and process. In addition, the Contractor must meet all requirements of the Umbrella IDIQ Contract for a consensus-based entity and process.

2. Stakeholder Requirements For purposes of this Task Order, the term stakeholders are defined as individuals with the following expertise and representation:

a. Researchers in health services financing, alternative payment models (e.g.

bundled payment, shared savings, gain-sharing, all-payer models, etc.), population health, and measure methodology;

b. Patients/caregivers or patient advocates;

c. Purchasers (State, Federal, and/or Private);

d. Providers, including primary care providers, specialists, accountable care organizations, hospitals or hospital systems, post-acute/long-term care facilities ;

and

e. Other relevant stakeholders, as agreed upon by the Contractor and CMS IDIQ Contracting Officer Representative (COR) and the Task Order COR.

3. Technical Assistance and Education Requirements The Contractor must provide technical assistance and education for measure developers submitting and updating performance measures for consensus-based endorsement and maintenance projects under this Task Order. This assistance may include coordination with developers, responding to questions, and providing guidance on the endorsement and maintenance processes. The Contractor shall develop a document that explains the endorsement and maintenance process in detailed plain language and a step-by-step manner so that both seasoned and novice submitters will understand the various steps that their submitted measures may go through in the endorsement/maintenance process. The explanation shall include each committee review, possible outcomes, and appeals process. If similar measures or competing measures are submitted for the consensus-based endorsement maintenance process, the Contractor will assist with coordination of submission with the developers. To achieve this work, the Contractor shall conduct no more than eighty-three (83) webinars for the continuation of monthly developer webinars during the Task Order period of performance; twenty-four (24) webinars for special topics (e.g. review of changes to the measure evaluation criteria, updates on ICD-10 conversion, and/or review of guidance for eCQM submission and testing requirements, endorsement/maintenance processes for new developers and those for new developers);

up to two (2) measure developer workshops; and up to one hundred and twenty-five (125) conference calls.

B. Tasks To Be Performed

Task 1 Endorsement/Maintenance

Process. The Contractor shall propose and implement innovative approaches to the consensus-based development process (CDP) that could increase the flexibility of measure submission, and reduce the length of the CDP projects (to less than 11 months) without compromising the quality of the decisions or increasing the cost of submission.

The Contractor shall provide a detailed discussion of the rationale for the proposed CDP approach. This includes i) a detailed discussion on the options for CDP approaches, ii) the benefits and risks for each option, iii) why the proposed approach is superior to the alternatives, and iv) how the risks for the proposed approach can be mitigated. The Contractor is encouraged to provide empirical evidence (if available) to support their arguments.

The CDP must be open and transparent. This means the Contractor shall give the public, CMS, other HHS agencies, and other stakeholders the opportunity to comment on the performance measures and process. This also means the Contractor shall provide measure developers, measure stewards (including CMS and other HHS agencies) advance notifications of other stakeholders’ comments on a measure, the opportunity to prepare a response to these comments, and the opportunity for the standing committee to review and deliberate on the response before voting. For each CMS-developed measure under review, the Contractor shall send the CMS measure lead the same review materials as they send the standing committee. The purpose of this requirement is to enhance the openness and transparency of the CDP process by ensuring that CMS and CMS-funded developers know what information the standing committee refers to in reviewing CMS-developed measures.

The Contractor shall not ask or require committee members to vote on a measure when the meeting they are in does not have quorum. It is fine for the committee members to vote electronically after the meeting. However, if there is no quorum at the beginning of the meeting, and the developers of the measure of interest provide additional information or data about the measure in response to prior inquires by the committee, then even if more committee members join the meeting and the meeting reaches quorum later on, the Contractor still shall not ask or require the committee members to vote on the measure. This requirement is to ensure that each committee member who is asked to vote has access to all the pertinent information about the measure, and to reduce the burden of having to come up with a decision within a limited amount of time.

The Contractor shall implement an appeals process to allow measure developers, stewards, members of the public, and other stakeholders to appeal the decisions for endorsement and maintenance. The Contractor shall notify CMS, the measure developers, and the measure stewards in writing of the decisions of the board/committee responsible for adjudicating appeals. Voting outcomes will be relayed to measure developers and measure stewards expeditiously so that they have the maximum time to prepare for the appeals process, if needed.

The Contractor shall not implement any changes to the CDP process of a project after the call for measures for that project is made public. This requirement aims at minimizing developers’ burden of having to make last-minute or mid-stream changes in their measure submission decisions. The Contractor shall also ensure that a measure is not subject to any changes in the CDP process for a project or measure evaluation criteria as long as that measure remains under the same project and through the end of any appeal against it.

The Contractor shall ensure that the staff who facilitate the committee meetings, webinars, and conference calls have at least three (3) years of experience facilitating meetings of similar sizes and topics. In particular, these staff members should be proficient at ensuring that the committee discussions are focused, and that committee members understand and adhere to the measure evaluation criteria in measure reviews, and be ready to intervene and correct course if necessary. The Contractor shall also ensure that the quality of meeting facilitation and committee members’ adherence to the measure evaluation criteria are consistent across projects.

The Contractor shall coordinate the endorsement maintenance process with the IDIQ and Task Order CORs to ensure timeliness and flexibility to accommodate CMS measure submission. Timelines may be modified in accordance with the IDIQ and Task Order CORs’ acceptance.

Measures. To increase flexibility of measure submission, the Contractor shall accommodate the submission of the following measures types in each project:

i) Measures at varying levels of analysis, such as measures developed and tested at population, facility, plan, accountable care organization (ACO), and individual clinician levels;

ii) Electronic clinical quality measures (eCQMs);

iii) Patient reported outcomes performance measures (PRO-PMs);

iv) Measures up for annual updates, three-year maintenance, or for which an ad-hoc review or a time-limited review is requested/needed; and

v) Measures developed to fulfill specific statutory requirements (e.g.

the Improving Medicare Post-Acute Care Transformation Act of 2014).

CMS may request the Contractor to put these measures in the same project for endorsement review. The Contractor shall accommodate such requests or propose alternatives that may better address CMS’ needs without reducing efficiency.

The Contractor shall give priority to all HHS developed measures and measures that are in CMS programs.

Stakeholders . The Contractor must convene stakeholders with the expertise necessary to review performance measures for each project. Because of the potentially broad arrange of measure topics, the Contractor shall leverage the experience of individuals who have participated in previous or on-going CDP projects on various types of performance measures.

The Contractor shall also take into consideration the potential need for a specific measure to undergo an expedited review, due to appeals, patient safety concerns, or other public health or policy imperatives. Expedited reviews often call for measure reviewers with highly specialized training and clinical knowledge. The Contractor’s ability to identify potential reviewers with the appropriate expertise in a specific clinical topic and knowledge in measure methodology is a key to whether the measure in question would be given a fair hearing. The Contractor shall propose mechanisms to facilitate expedited measure reviews that are open, transparent, informed, and fair.

The Contractor shall also reach out to stakeholders who are not members for feedback on measures submitted for endorsement/maintenance reviews. In particular, the Contractor shall include in its outreach efforts stakeholder organizations that may not be able to afford membership dues. The Contractor shall incorporate these outreach efforts into all the activities involving the general public, including, but are not limited to, the calls for nomination and the announcements of public comment periods. The Contractor shall leverage modern technology to facilitate real-time participation of these stakeholders in the CDP without having to attend meetings in person.

Communication. The Contractor shall notify CMS, measure developers, measure stewards, the public, and other stakeholders of any changes in the CDP process, including the appeal process, in a timely manner and in writing. This includes, but is not limited to, changes to the entity that makes the recommendation or the final decision for measure (re-)endorsement, the entity that adjudicates appeals against endorsement decisions, the length of maintenance and annual review cycles, endorsement status, criteria for attaining specific endorsement status, processes for requesting reconsideration on endorsement recommendations or decisions, etc.

The notifications should also include information on the method and due date for submitting comments, how the submitted comments will be considered, and when and how the final decisions will be announced. As the proposed changes go through various steps of the vetting/review process, the Contractor shall update the IDIQ and the Task Order CORs at the weekly calls (see Task 3.4). The Contractor shall not implement any changes to the CDP process until CMS written approval is obtained.

For all the measures developed by CMS, the Contractor shall propose a communication plan to keep measure developers, CMS measure leads, the IDIQ and the Task Order CORs updated about the status of the measures during the endorsement/maintenance review. This includes sending written notifications to all the parties mentioned above about the project timeline at the beginning of each project, the project committee’s recommendation for each measure, the next step for that measure, opportunities for requesting reconsideration or appeals, and the deadlines for such requests. The Contractor shall also delineate the course of action for a measure submitted for endorsement/maintenance review, including all the possible scenarios related to the endorsement status and provide this information to measure developers and stewards at the beginning of each project.

The Contractor shall discuss their communication plan at the kick-off meeting (see Task 3.1 and Deliverable # 8 in the Schedule of Deliverables).

Education materials for multi-stakeholder committees. The Contractor shall develop, compile, and update 508-compliant education materials on the measures to be reviewed for endorsement and maintenance. These materials may include presentation slide decks, FAQs, methodology briefs, and measure submission forms, etc., and shall be provided to members of the multi-stakeholder committees in advance of upcoming meetings. Education materials shall include the measure endorsement and maintenance processes and shall be developed for both seasoned and novice committee members. For measures developed by CMS or currently used in CMS programs, the Contractor shall also send these materials to the measure developers and the measure stewards for reference. The Contractor shall ensure that all the materials sent to committee members ahead of meetings/discussions are also shared with CMS. This is to ensure that the committee members have access to the most current information about the submitted measures.

Conflict of Interest. The contactor shall enforce the disclosure of conflicts of interest for each member of a CDP project committee as well as their own internal staff. The Contractor shall ensure that internal staff who also work with any measure developers are not involved in any CDP or MAP processes in any capacity, regardless of whether these staff members are financially compensated by the measure developers. In addition, the Contractor shall develop a plan to mitigate any conflicts of interest that may exist. This includes, but is not limited to, encouraging timely reporting of potential conflict of interest of CDP committee members, and providing clear instructions to stakeholders on how to report conflict of interest. The Contractor shall provide evidence on the effectiveness of their proposed plan to mitigate conflict of interest, and how this plan could protect the interest of both CMS, measure developers/stewards, and the Contractor. The Contractor shall discuss their plan to mitigate conflict of interest at the kick-off meeting (see Task 3.1 and Deliverable # 8 in the Schedule of Deliverables).

Task 1.1 Quality of Care Projects

The Contractor shall conduct up to one hundred and twenty (120) Quality of Care CDP projects between the base year and the last option year of this Task Order.

The Contractor shall propose the number of new endorsement/maintenance projects for each quarter for CMS to review and approve before implementing any new projects. The Contractor shall provide the rationale for the proposed number of projects for each quarter, and discuss the factors being considered to come up with the proposed number.

The process for each consensus-based endorsement and maintenance project shall take no more than eleven (11) months from beginning to end to include the appeals process. The initial projects under this sub-task shall begin on the start date of this Task Order and end by a date approved by CMS.

The Contractor shall enable each project to accommodate measures of a wide array of clinical topics (e.g. diabetes care, surgical adverse events, reproductive health, infectious diseases), or topics related to the care delivery process (e.g. care coordination, admissions/readmissions), a segment of the population (e.g. dual eligibles, Medicaid recipients, pediatric patients), or broader public health issues (e.g. population health, patient-centered care, health and well-being).

The Contractor shall convene no more than 25 stakeholders for each Quality of Care consensus-based endorsement and maintenance project under this Task Order. To enhance efficiency in resource use and flexibility of measure submission, the Contractor shall leverage the experience of the individuals who have served in CBE committees that review performance measures of a broad range of topics, as this would allow measures of various topics to be submitted for review as soon as they are ready, which will in turn expedite the measure development process. The Contractor shall also take into consideration the potential need for a specific measure to undergo ‘emergency’ review, due to appeals, patient safety concerns, or other public health imperatives. Such emergency reviews sometimes call for measure reviewers with highly specialized training and clinical knowledge. The Contractor’s ability to identify potential reviewers with the appropriate expertise in a specific clinical topic and knowledge in measure methodology is a key to the success of the CDP process. The Contractor shall propose mechanisms to facilitate emergency measure reviews.

In order to complete the objectives under Section II.B. of this Task Order, the Contractor shall convene up to forty (40) hours of meetings for each project, pending CMS approval. These meetings may be conducted in the formats of in-person, webinar, or conference call. The Contractor is welcome to propose the number of webinars, conference calls, and number and length of in-person meetings and discuss the rationale. If the in-person format is proposed, the Contractor shall provide a strong rationale that justifies the cost. In-person meetings shall take place in the Washington, DC area in a government-owned space or an approved alternative.

Task 1.2 Cost and Resource Use Projects

The Contractor shall conduct up to ten (10) Cost and Resource Use CDP projects between the base year and the last option year of this Task Order. The Contractor shall implement at least one (1) Cost and Resource Use project. Because the review of Cost and Resource Use measures tends to be more resource-intensive and requires expertise in health insurance and health care financing, the Cost and Resource Use Project shall include only the measures related to the topics of spending and payment. The Contractor shall propose the number of Cost and Resource Use projects for each Task Order year and discuss the rationale for the proposed number.

The Contractor shall propose at least 15 stakeholders for each Cost and Resource Use project. The Contractor is welcome to recommend a higher number of stakeholders and provide the rationale for the proposed number. The Contractor shall obtain written approval by the IDIQ and the Task Order CORs before beginning the call for nominees.

To enhance efficiency, the Contractor shall leverage the experience of the individuals who have served in prior or current CBE committees that review Cost and Resource Use measures to serve on the CDP committee for the projects under this sub-task.

In order to complete the objectives under Section II.B. of this Task Order, the Contractor shall convene up to forty-six (46) hours of meetings for each project, pending CMS approval. These meetings may be conducted in the formats of in-person, webinar, or conference call. The Contractor is welcome to propose the number of webinars, conference calls, and number and length of in-person meetings and discuss the rationale. If the in-person format is proposed, the Contractor shall provide a strong rationale that justifies the cost. In-person meetings shall take place in the Washington, DC area in a government-owned space or an approved alternative.

Task 1.3 Project Reports

The Contractor shall produce a written report for each consensus-based endorsement maintenance project under Section II.B. of this Task Order. Each written report must summarize the following:

• The consensus-based endorsement maintenance project and scope of review;

• The performance measures submitted, evaluated, endorsed, and those not recommended for endorsement within the project;

• The measure concepts submitted during the solicitation process for measures;

• The public comments received during the process;

• Identification of potential high-priority gap areas for measure developers to consider for future development; and

• Discussion of any major concerns or methodological issues raised during performance measure evaluation.

The Contractor shall submit a draft version of the final project report to the IDIQ and the Task Order CORs for review. These draft reports should be professionally-formatted and -edited to the extent that they are ready for public dissemination. Each project report shall be professionally edited and formatted to facilitate reading by all types of readers. Details are to be included in appendices.

Each project report shall include an executive summary of no more than two (2) pages. The language of each project final report should be concise, objective, factual, and evidence-based and use plain language. The project final reports also should avoid the use of adverbs and adjectives that represent self-appraisal or appraisal of issues not included in the contract scope of work, and exclude subjective statements or assessments by the Contractor about the success or other valuations of the deliverables produced through this IDIQ. Any tables and figures must convey content clearly and accurately, be self-explanatory, clearly delineated from each other, 508 compliant, and referenced in the report. The number of complex tables and figures should be kept to the minimum. There is no page limit to the project final reports. Each project final report should be a stand-alone document that includes all the necessary background and details to enable readers with little prior knowledge of the Contractor’s work to understand the content. The Contractor shall obtain the written approval by the IDIQ and the Task Order CORs before publicly disseminating the finalized project reports.

Task 2: Education and Outreach Materials

Task 2.1 Education materials

The Contractor shall develop and update 508-compliant education materials on the following topics. CMS and other HHS agencies may suggest new topics throughout the Task Order period of performance. The Contractor is also welcome to recommend additional topics and discuss how these proposed topics may enhance the government’s efforts to attain the Triple Aims.

o eCQMs o PRO-PMs o Outcome measures o Risk adjustment o Updates to Measure Submission process o Contractor’s resources for measure developers (e.g. technical assistance on measure development) o Updates to Endorsement/maintenance review process o Other topics

The primary target audience of these materials include CMS/HHS measure leads, CMS/HHS-funded measure developers, and members of multi-stakeholder committees for the projects under Tasks 1.1 and 1.2. These materials may also be made available to the public, pending approval of the IDIQ and the Task Order CORs. These education materials can be in the form of slide decks, FAQs, guidebooks, webinars, video- or audio-recordings, etc. The purpose is to provide easily accessible information for CMS/HHS staff or CMS/HHS-funded measure developers with limited experience to learn the key concepts related to measure development and the endorsement/maintenance review process.

For education events in the webinar format, the Contractor shall be responsible for hosting the webinars and presenting these materials. Writing notifications of upcoming webinars, along with call-in numbers and/or URLs to the webinars, shall be sent to CMS and made public in advance.

The number of monthly webinars and special topic webinars that the Contractor shall conduct for each contract year is as follows:

Contract Year Number of monthly webinars

Number of Special Topic webinars

Total number of webinar for each year Base Year (2017- 2018) 11 2 13

OY 1 (2018 – 2019) 12 3 15

OY 2 (2019 – 2020) 12 3 15

OY 3 (2020 – 2021) 12 3 15

OY 4 (2021 – 2022) 12 3 15

Total 59 14 73

The Contractor shall also conduct up to two (2) measure developer workshops every contract year. Some of these workshops should target novice developers, while others should address the needs of experienced developers. The Contractor is encouraged to propose topics for each workshop to the IDIQ and the Task Order CORs for approval.

The Contractor shall also conduct up to twenty-five (25) conference calls each contract year of this Task Order for the purpose of educating CMS measure leads and CMS-funded developers on measure development issues and the CDP.

After each webinar, the Contractor shall send the electronic version of all the education/presentation materials, including audio recordings, to the IDIQ and the Task Order CORs. The Contractor shall make these education/presentation materials and recordings publicly available on the Contractor’s official website after they were held and send the URLs to the IDIQ and the Task Order CORs. The Contractor shall also make these materials and recordings easily searchable on their website.

The Contractor shall keep these education materials updated to reflect any changes to the CDP, new requirements for endorsement/maintenance reviews, or new legislations or regulations that may impact these process or requirements. In addition, the Contractor shall obtain written approval by the IDIQ and the Task Order CORs before implementing any revisions. Once these revisions are implemented, the Contractor shall send written notifications to the IDIQ and the Task Order CORs.

Task 2.2 Online Database of Performance Measures

The Contractor shall develop and maintain its standard process for updating measure information of HHS developed and CMS program consensus-based endorsed and maintained performance measures on the Contractor’s online database for public access.

Task 3. Project Management

Task 3.1 Kickoff Meeting

The Contractor shall hold a kickoff meeting via teleconference for the tasks to be completed under this Task Order. The Contractor must coordinate the kickoff meeting with the IDIQ COR and the Task Order COR. The Contractor shall go over the work plan and approach to meeting requirements under this Task Order, the draft Project Management Design, and the Risk Mitigation Plan (discussed below).

Materials for the kickoff meeting must be shared with the IDIQ COR and the Task Order COR prior to the kickoff meeting. The Contractor shall incorporate CMS feedback in the final version of these materials.

Task 3.2 Project Management Design and Risk Mitigation Plan

Task 3.2.1 Project Management Design

As outlined in the Umbrella IDIQ contract, Section II.B., the Contractor must submit a Project Management Design, in Microsoft Project or an agreed upon alternative, that addresses the activities and steps to be conducted for this Task Order. A draft Project Management Design is due to the IDIQ COR and the Task Order COR by a CMS-approved due date. The Contractor shall include the following information in the Project Management Design:

a. A timeline for all the tasks and projects in this Task Order;

b. An outline of consensus-based processes that will meet the requirements for this Task Order;

c. Identification of the staff assigned to conduct the work and their contact information;

d. A list of the deliverables and their due dates; and

e. Any other information the IDIQ and Task Order CORs find relevant for the management of the work to be conducted.

Task 3.2.2 Risk Mitigation Plan

The Contractor shall develop a detailed risk mitigation plan for this Task Order. This plan shall include the following information:

i. All the deliverables, the deliverable numbers, due dates, and their dependencies.

ii. Anticipated risks that could impact the deliverable timeline, deliverable quality, or costs for completing this Task Order. For each anticipated risk, discuss:

1. The background and the possible cause(s);

2. Potential impact on the timeline, cost, and/or deliverable quality;

3. Options for mitigation, and the pros and cons of each option

4. Recommendation and rationale

The risk mitigation plan shall be submitted to the IDIQ and the Task Order CORs for review and feedback in advance of the kick-off meeting. The Contractor shall incorporate any changes by the IDIQ and the Task Order CORs into a revised version of the plan to be presented at the kick-off meeting.

The Contractor shall continue to update the plan throughout the performance period of this task order, based on any new information and the input from the IDIQ and the Task Order CORs. The plan shall be a standing agenda item for the weekly conference calls. The Contractor shall also provide an update on it in the monthly progress reports of this task order.

Task 3.3 Monthly Progress Reports

As outlined in Section II.B. of the Umbrella IDIQ contract, the Contractor must submit a Monthly Progress Report. The report shall include:

• A full review of accomplishments during the previous month;

• A detailed and updated Risk Mitigation Plan to deal with anticipated and on-going problem(s) and if appropriate, a proposal of new delivery or completion dates. See Task 3.2.2 for details on the information to be provided;

• Tracking of each measure submitted to the projects under this Task Order;

• Identification of each measure submitted to projects under this Task Order and the

CMS programs under which they are implemented, such as the Hospital Readmissions Reduction Program; and

• Planned activities for the next month.

Task 3.4 Weekly Conference Calls

The Contractor shall hold weekly conference calls with the IDIQ COR and/or the Task Order COR to go over current activities under this Task Order. These activities include performance measures undergoing the consensus-based processes, the endorsement and maintenance process proceedings, and the final report deliverables.

The Contractor shall solicit agenda items from the IDIQ and the Task Order CORs, prepare and disseminate the agenda, pertinent discussion materials, and previous meeting minutes no later than one (1) business day prior to the meeting.

Task 3.5 Standing and Coordinating Committee Meeting summaries The Contractor shall prepare a summary to document the purposes, measures discussed, and decisions/recommendations for each standing and coordinating committee meeting. The meetings summarized in these documents shall include in-person meetings, webinars, and conference calls in which standing committees and coordinating committee members discuss measures being reviewed for endorsement or maintenance. The purpose of these summaries is for the IDIQ and the Task Order CORs to provide timely update to CMS measure leads and leadership about the status of individual measures and to inform policy decisions. These summaries shall be professionally-edited. The language of the report should be concise, objective, factual, and evidence-based and use plain language. The report should be a stand-alone document that includes all the necessary background and details to enable readers with little prior knowledge of the Contractor’s work to understand the content. The report also should avoid the use of adverbs and adjectives that represent self-appraisal or appraisal of issues not included in the contract scope of work, and exclude subjective statements or assessments by the Contractor about the success or other valuations of the deliverables produced through this IDIQ. These summaries shall be submitted to the IDIQ and the Task Order CORs within five (5) business days after each meeting.

Task 3.6 Quarterly debriefings on Consensus Development Process (CDP)

The Contractor shall set up and attend conference calls with the Task Order and IDIQ CORs, HHS-funded measure developers, and the HHS measure leads who work with the developers to discuss successes, challenges, and lessons learned. These measure developers are likely to be those who have recently gone through a CDP. The purposes of these calls are for the Contractor to answer questions about the process that the developers had just undergone, and for the developers and measure leads to provide feedback to the Contractor on how to improve the CDP. The number of debriefings is up to four (4) per year. Each conference call will last up to 30 minutes.

The Contractor shall work with the Task Order and IDIQ CORs on the HHS measure leads and HHS-funded measure developers to be invited. Prior to each call, the Contractor shall disseminate the call-in number, agenda, and relevant meeting materials to all the conference call attendees. After each call, the Contractor shall document the discussion under the headings of successes, challenges, and lessons learned in a meeting minute, and submit the minute to the Task Order and IDIQ CORs for approval.

Task 3.7 Consensus Development Process (CDP)-Measure Application Partnership (MAP) integration

The CDP-MAP integration aims at providing a ‘feedback loop’ to members of the MAP Work Groups on the performance of the measures in the Measures Under Consideration (MUC) list that are recommended for rule-making, the development of the MUC measures given the ‘continuous development’ category, and to provide any updates on the endorsement status of these measures. The goal of the CDP-MAP integration is to improve information sharing, efficiency, and accountability of the two otherwise separate processes. In particular, this process is expected to reduce redundancy in measure review efforts, and allow CMS the flexibility to have a fully-developed measure reviewed or included in the Measure Under Consideration (MUC) list within the shortest time possible. Since 2016, CMS has been participating in the planning and piloting of the CDP-MAP integration. For this Task Order, the Contractor shall continue to develop, update, and review this process. The Contractor shall submit a draft plan for any updates to the CDP-MAP integration to the IDIQ and the Task Order CORs for review. The Contractor shall discuss with CMS the feasibility and level of effort of CMS’ feedback and incorporate all the mutually-agreed upon changes in the final version of the plan. The Contractor shall implement the final version of this plan upon CMS approval.

Task 4 Annual and Task Order Final Reports

Task 4.1: Annual Report

The Contractor shall prepare four (4) Annual Reports, each of which shall document all the tasks, projects, and deliverables completed for each Task Order year. The Task Order years and corresponding time periods are listed in the table below:

Task Order year Measures submitted during this time period 1 (Base Year) 9/27/2017 – 9/26/2018 2 (Option Year 1) 9/27/2018 – 9/26/2019 3 (Option Year 2) 9/27/2019 – 9/26/2020 4 (Option Year 3) 9/27/2020 – 9/26/2021 Note: The Annual Report is not required for TO year 5 (OY 4).

The Contractor shall submit an outline for each Annual Report to the IDIQ and the Task Order CORs for review and feedback, which the Contractor will incorporate into the final outline.

The report shall contain a description of the problems/barriers encountered during the Task Order year, the actions taken to rectify such problems, and lessons learned. The purpose of this report is to improve accountability and enable CMS to enhance the efficiency of future endorsement/maintenance processes. The report shall also discuss the Contractor’s experience implementing LEAN processes to improve the efficiency of the resource use for the endorsement/maintenance processes, and discuss options for the future.

For each Annual Report, the Contractor shall collect and report the number of measures by following characteristics/variables:

• Type (process, outcome, PRO-PM, etc.)

• Data source (EHR, survey, claims, registry, chart, etc.)

• Measure steward (CMS, other HHS, non-HHS)

• Risk adjustment (yes/no; SES/non-SES)

• Topic (e.g. care coordination, peri-natal health, population health, etc.)

• Setting (e.g. hospital-only vs. cross-setting)

• Population (Medicare FFS-only, Medicare ACO-only, Medicaid MCO-only, all-payer, etc.)

• Purpose: Value-based Payment vs. quality reporting vs. quality improvement

vs. other purposes

• Attribution

- Single vs. multiple attribution

- Retrospective vs. prospective attribution

- Source: Patient attestation vs. data-driven

- Alternative Payment Model (e.g. shared savings, bundled payment, Comprehensive Primary Care, etc.)

• Endorsement status

• Other variables of interest

The Contractor is welcome to recommend analysis of additional measure characteristics or aspects of the endorsement/maintenance processes that may be of interest to CMS and other HHS agencies, and discuss the rationale of the recommendations.

For each variable, the Contractor shall provide raw numbers and percentages by category (e.g. In terms of measure type, 60% of the submitted measures are process measures, 25% are outcome measures, and 5% are patient-reported outcome performance measures). The Contractor shall also provide cross-tabulations of some of the variables (e.g. measure type by measure steward, purpose by setting, etc.). The results of cross-tabulations shall include numbers and percentages for each cell, row, and column, and the total number. The Contractor will not be required to conduct multivariate analysis or significance testing.

For the fourth Annual Report, which discusses activities in Option Year 3, the Contractor shall also include a chapter on risk assessment for the transition between the last contract year (Option Year 4) of this task order under the current IDIQ and the Base Year of an endorsement/maintenance task order under a new IDIQ. The Contractor shall assume 1) that the new IDIQ will be awarded immediately after the current IDIQ expires; and 2) the new IDIQ may or may not be awarded to a different contractor. The risk assessment chapter shall discuss all the potential risks that could result from the transition. For each type of risk, the Contractor shall discuss:

• the potential source(s);

• the likelihood (high, medium, low);

• the potential impact on schedule (for the task order as well as for CMS’ quality reporting and payment programs), quality, and cost;

• options for risk mitigation, and the pros and cons for each option; and

• Recommendation for the best option, and the rationale for the recommendation.

The Contractor is welcome to propose additional topics to be included in the risk assessment discussion.

Each Annual Report should be professionally edited, written in plain language, and 508 compliant. The language of the report should be concise, objective, factual, and evidence-based and use plain language. Each report should be a stand-alone document that includes all the necessary background and details to enable readers with little prior knowledge of the Contractor’s work to understand the content. The Contractor also should avoid the use of adverbs and adjectives that represent self-appraisal or appraisal of issues not included in the contract scope of work, and exclude subjective statements or assessments about the success or other valuations of the deliverables produced through this IDIQ.

The Contractor shall submit a draft of each Annual Report to the IDIQ and the Task Order CORs for review and feedback. The Contractor shall ensure that the draft reports are professionally-formatted and -edited to the extent that they are ready for public dissemination. The Contractor shall incorporate the feedback into the final version of the Annual Report. The Contractor has to obtain the written approval of the IDIQ and the Task Order CORs before publicly disseminating the finalized version of each report.

Task 4.2 Task Order Final Report

The Contractor shall prepare a final, comprehensive report of all the tasks, projects, and deliverables completed under this Task Order since Task Order inception. This report shall include the following discussions:

• A summary of all the major endorsement/maintenance activities.

• How endorsement/maintenance has been done similarly or differently from before September 2017, including the strengths and weaknesses of the current approach compared to before September 2017.

• Experience implementing LEAN processes and recommendations for future years.

• A discussion on the lessons learned since Task Order inception

Summary statistics of all the measures submitted since Task Order inception. This includes yearly trends of the following measure characteristics/variables:

Type (process, outcome, PRO-PM, etc.)

Data source (EHR, survey, claims, registry, chart, etc.)

Measure steward (CMS, other HHS, non-HHS) Risk adjustment (yes/no; SES/non-SES) Topic (e.g. care coordination, peri-natal health, population health, etc.)

Setting (e.g. hospital-only vs. cross-setting) Population (Medicare FFS-only, Medicare ACO-only, Medicaid

MCO-only, all-payer, etc.)

Purpose: Value-based Payment vs. quality reporting vs. quality improvement vs. other purposes Attribution

• Single vs. multiple attribution

• Retrospective vs. prospective attribution

• Source: Patient attestation vs. data-driven

• Alternative Payment Model (e.g. shared savings, bundled payment, Comprehensive Primary Care, etc.)

Endorsement status Other variables of interest

The Contractor is welcome to recommend analysis of additional measure characteristics or aspects of the endorsement/maintenance processes that may be of interest to CMS and HHS, and discuss the rationale of the recommendations.

As in the Annual Reports, the Contractor shall provide raw numbers and percentages for each variable by category, and cross-tabulations of some of the variables in the Task Order Final Report. The results of cross-tabulations shall include numbers and percentages for each cell, row, and column, and the total number. The Contractor will not be required to conduct multivariate analysis or significance testing. The discussion in the Task Order Final Report shall focus on the annual trends since Task Order inception, and the implications of these trends for measure methodology, the evolving approaches in measure quality of care or linking quality to the Triple Aims.

The Contractor shall submit an outline for the Task Order Final Report to the IDIQ and the Task Order CORs for review and feedback, which the Contractor will incorporate into the final outline.

The Task Order Final Report should be professionally edited, written in plain language, and 508 compliant. The language of the report should be concise, objective, factual, and evidence-based and use plain language. Each report should be a stand-alone document that includes all the necessary background and details to enable readers with little prior knowledge of the Contractor’s work to understand the content.

The Contractor also should avoid the use of adverbs and adjectives that represent self-appraisal or appraisal of issues not included in the contract scope of work, and exclude subjective statements or assessments about the success or other valuations of the deliverables produced through this IDIQ.

The Contractor shall submit a draft of the Task Order Final Report to the IDIQ and the Task Order CORs for review and feedback. The Contractor shall ensure that the draft report is professionally-formatted and -edited to the extent that it is ready for public dissemination. The Contractor shall incorporate these feedback into the final version of the Task Order Final Report. The Contractor has to obtain the written approval of the IDIQ and the Task Order CORs before publicly disseminating the finalized version of the report.

Task 5 Technical Support for the Measures Management System (MMS) BluePrint

The Contractor shall participate in reviewing and providing feedback to the discussions of the measure endorsement/maintenance processes in the draft versions of upcoming releases of the MMS BluePrint. The feedback may take the form of track changes in the Microsoft Word ® documents of the drafts. The Contractor may be asked by the IDIQ COR or the Task Order COR to communicate and coordinate with the CMS contractor who develops and updates the MMS BluePrint, but will not be required to attend regular project calls. The Contractor shall send feedback to the CMS BluePrint developing contractor by a due date approved by the IDIQ COR or the Task Order COR.

C. Period of Performance

The Period of Performance is anticipated to be from 9/27/2017 through twelve (12) months, with four (4) options years if HHS chooses to exercise.

III. SECTION 508 - ACCESSIBILITY OF ELECTRONIC AND INFORMATION

TECHNOLOGY

(a) This SOW, PWS, or TO is subject to Section 508 of the Rehabilitation Act of 1973 (29 U.S.C. 794d) as amended by the workforce Investment Act of 1998 (P.L. 105-220).

Specifically, subsection 508(a)(1) requires that when the Federal Government procures Electronic and Information Technology (EIT), the EIT must allow Federal employees and individuals of the public with disabilities comparable access to and use of information and data that is provided to Federal employees and individuals of the public without disabilities.

(b) The EIT accessibility standards at 36 CFR Part 1194 were developed by the Architectural and Transportation Barriers Compliance Board ("Access Board") and apply to contracts and task/delivery orders, awarded under indefinite quantity contracts on or after June 25, 2001.

(c) Each Electronic and Information Technology (EIT) product or service furnished under this contract shall comply with the Electronic and Information Technology Accessibility Standards (36 CFR 1194), as specified in the contract, as a minimum. If the Contracting Officer determines any furnished product or service is not in compliance with the contract, the

Contracting Officer will promptly inform the Contractor in writing. The Contractor shall, without charge to the Government, repair or replace the non-compliant products or services within the period of time to be specified by the Government in writing. If such repair or replacement is not completed within the time specified, the Government shall have the following recourses:

1. Cancellation of the contract, delivery or task order, purchase or line item without termination liabilities; or

2. In the case of custom Electronic and Information Technology (EIT) being developed by a contractor for the Government, the Government shall have the right to have any necessary changes made or repairs performed by itself or by another firm for the noncompliant EIT, with the contractor liable for reimbursement to the Government for any expenses incurred thereby.

(d) The contractor must ensure that all EIT products that are less than fully compliant with the accessibility standards are provided pursuant to extensive market research and are the most current compliant products or services available to satisfy the contract requirements.

(e) For every EIT product or service accepted under this contact by the Government that does not comply with 36 CFR 1194, the contractor shall, at the discretion of the Government, make every effort to replace or upgrade it with a compliant equivalent product or service, if commercially available and cost neutral, on either a contract specified refresh cycle for the product or service, or on a contract effective option/renewal date; whichever shall occur first.

Section 508 Compliance for Communications

The Contractor shall comply with the standards, policies, and procedures below. In the event of conflicts between the referenced documents and this SOW, PWS, or TO, the SOW, PWS, or TO shall take precedence. The Contractor shall ensure that all the documents shared with other CMS contractors are 508 compliant.

Rehabilitation Act, Section 508 Accessibility Standards

1. 29 U.S.C. 794d (Rehabilitation Act…