HT0011-20-R-0043 HFAS RFP Attachment 1 - Performance Work Statement (PWS).pdf

Department of Defense Defense Health Agency

Performance Work Statement

Military Medical Treatment Facility Healthcare Facility Accreditation Services

Medical Affairs

Clinical Support Division, Clinical Quality Management Branch Accreditation and Compliance Program

Solicitation Number: HT0011-20-R-0043 Version: 1

Date: September 10, 2020

PART 1

1.0 GENERAL INFORMATION

1.1 This is a non-personal services contract to provide military medical treatment facilities (MTFs) with healthcare organization accreditation and Patient Centered Medical Home (PCMH) certification by an external, nationally recognized healthcare accreditation organization (AO).

1.2 Description of services/introduction: The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-personal services necessary to perform MTF accreditation and PCMH certification as defined in this performance work statement (PWS) except for those items specified as government-furnished property and services. The contractor shall perform to the standards in this PWS. The contractor shall comply with all applicable laws, rules and regulations.

1.3 Background: The Department of Defense (DoD) is committed to providing quality healthcare. Achieving and maintaining accreditation by an established, nationally recognized, external AO provides objective feedback to assess compliance with healthcare standards and builds stakeholder confidence in the quality of healthcare delivered in the Military Health System (MHS). Continually developing the knowledge and skills of MTF staff on accreditation standards, the survey process and compliance monitoring are essential for continuous standards compliance to ensure safe, quality care for beneficiaries.

This requirement for accreditation is mandated by Department of Defense Instruction (DoDI) 6025.13, Medical Quality Assurance (MQA) (See RFP HT011-20-R-0043, PWS Attachment 1

– DoDI 6025.13 Medical Quality Assurance and Clinical Quality Management in the Military Health System) and Clinical Quality Management in the Military Health System (MHS) and the Defense Health Agency (DHA) Procedural Manual (PM) 6025.13, Clinical Quality Management in the Military Health System, volumes 1-7. The directives require MHS MTFs to maintain accreditation by an external nationally recognized AO. See RFP HT0011-20- R-0043, PWS Attachments 2a-h to include the following:

• PWS Attachment 2a – Implementation Guidance Memo for DHA Procedures Manual, “Clinical Quality Management in the MHS, Volumes 1-7;

• PWS Attachment 2b – DHA PM 6025.13 Clinical Quality Management in the MHS, Volume 1, General Clinical Quality Management;

• PWS Attachment 2c – DHA PM 6025.13 Clinical Quality Management in the MHS, Volume 2, Patient Safety;

• PWS Attachment 2d – DHA PM 6025.13 Clinical Quality Management in the MHS, Volume 3, Healthcare Risk Management;

• PWS Attachment 2e – DHA PM 6025.13 Clinical Quality Management in the MHS, Volume 4, Credentialing and Privileging;

• PWS Attachment 2f – DHA PM 6025.13 Clinical Quality Management in the MHS, Volume 5, Accreditation and Compliance;

• PWS Attachment 2g – DHA PM 6025.13 Clinical Quality Management in the MHS, Volume 6, Clinical Measurement;

• PWS Attachment 2h – DHA PM 6025.13 Clinical Quality Management in the MHS, Volume 7 – Clinical Quality Improvement).

The Clinical Quality Management (CQM) Accreditation and Compliance Program provides oversight for accreditation of DHA MTFs and focuses on a comprehensive, systematic process of review across the MHS, which allows MTFs to demonstrate their ability to meet DoD policy mandates, regulatory requirements, and healthcare standards. Accreditation of the MTFs has historically been accomplished by the Military Services through separate contracts. The current volume and accreditation program types from across the Services include: 48 hospitals, 85 free-standing ambulatory clinics, one home health program and 45 behavioral health clinics (See RFP HT0011-20-R-0043, PWS Attachment 3 – DoD MTF Accreditation Status Table) Hospital surveys include ambulatory clinics and behavioral health clinics. Dental clinics are included in hospital and free-standing ambulatory clinic surveys when listed in the services provided at the

MTF.

The MHS is in the process of realigning the MTFs from the Military Services to DHA, as mandated by the fiscal year 2017 National Defense Authorization Act, section 702. The Service Headquarters will focus on military readiness and operational healthcare. The DHA assumed authority, direction, and control of the continental United States (CONUS) MTFs to include those located in Alaska, Hawaii, and Puerto Rico as of October 25, 2019. The remaining outside the continental United States (OCONUS) MTFs will similarly transition to DHA authority, direction and control in a phased approach by September 30, 2021. Before, during and after the transition, the DHA and Services will continue to work in collaboration to ensure safe, quality healthcare is provided in the MHS. The transition plan structures the MTFs into Markets (See RFP HT0011-20-R-0043, PWS Attachment 4 – DHA Transition Implementation Plan 3 v6 Market Diagrams). A Market is a group of MTFs that operate as a system: sharing patients, providers, functions, and budgets, across facilities, in order to improve the delivery and coordination of health services to drive value for beneficiaries. Two Defense Health Regions will manage the OCONUS MTFs after transitioned to DHA. The Markets and Regions report MTF performance to DHA. The current version of the transition plan identifies 21 large markets, a Small Market and Stand-alone Office (SSO) with 16 small markets and 69 stand-alone ambulatory clinics and two overseas regions each comprised of 5 markets.

Changes to the current number of facilities requiring accreditation are anticipated as the transition progresses and ongoing assessments of existing MTFs are completed. The change in structure from Service centric MTFs to DHA will result in realignment of facilities requiring accreditation to the new market design. The changes from the transition will require the Contractor have the capability to adjust to an increase in the total volume of facilities requiring accreditation. The current projected change in volume is an increase of 30 free-standing ambulatory clinics and an increase in dental clinic accreditation. An increase in behavioral health accreditations is anticipated as the transition progresses to support standardization of accreditation programs across the DHA.

1.4 Objectives: The objectives outlined below represent expected performance outcomes for the contract and are supported by the technical requirements in the performance work statement.

The acceptable performance standards are outlined further in the contract. Where specific performance standards are not stated in the contract, the contractor shall use healthcare industry leading practices and current standards.

1.4.1 Obtain healthcare organization accreditation from a nationally recognized accrediting organization for MTFs with hospital, ambulatory clinics, dental clinics, ambulatory surgical centers, behavioral healthcare, virtual/telehealth services and home health care services through an onsite survey process.

1.4.2 Acquire certification of MTF PCMH settings through an onsite assessment to ensure compliance with criteria and standards for the medical home model as directed by DHA-IM 17- 004.

1.4.3 Advance the development and implementation of the strategies and systematic approach to DHA’s high reliability journey.

1.4.4 Utilize current evidence-based standards focused on the provision of safe, quality care in the MTFs.

1.4.5 Enhance patient safety based on standards developed through analysis of healthcare industry risks and safety events and provide MTF specific feedback to support journey to zero preventable harm.

1.4.6 Demonstrate compliance with nationally recognized evidence-based standards through independent, impartial onsite MTF accreditation surveys on a triennial basis.

1.4.7 Develop knowledge and skills necessary to understand the standards and implement processes, systems and structures to continuously meet the intent of the standards through self-assessment tools, educational materials and training.

1.4.8 Measure, evaluate, and compare clinical quality performance to national standards and benchmarks to identify superior quality healthcare services and opportunities for improvement for DoD to utilize in the advancement of CQM in the MHS.

1.5 Scope: The Military Medical Treatment Facility Accreditation contract provides the foundation for clinical quality management to build a program based on nationally recognized, evidence-base standards integrated with high reliability principles and continuous standards compliance. The contracted services include accreditation of MHS healthcare facilities by an external, nationally recognized accreditation organization through an onsite survey process to support DoD in providing safe, quality healthcare. The types of healthcare services provided by DoD requiring accreditation include hospital, virtual/telehealth services, ambulatory clinics, dental clinics, ambulatory surgical centers, behavioral healthcare (inpatient units and ambulatory clinics), and home health care. The contract services include certification of MTF PCMH services to demonstrate compliance with national criteria and standards for the medical home model. The services provided through the Military Medical Treatment Facility Accreditation contract include initial accreditation and certification for newly realigned MTFs as well as the sustainment of existing accreditation and certification status for all other MTFs. Coordination of the timing of accreditation and certification is essential to prevent lapses in MTF accredited and PCMH certified status.

The contracted services support maintenance of accreditation through tools to support continuous compliance and knowledge/skills development for DHA MTF, Market, Region, Headquarter, and Service staff. The tools support self-assessment for use by DHA MTFs, Markets, Regions and Headquarters to determine and document compliance with standards, identify specific risk points, and analyze organizational and enterprise performance to develop strategies for clinical quality improvement Training and skill development topics include the accreditation and certification requirements, standards, survey process, reporting and identified areas on non-compliance.

1.6 Period of Performance (PoP):

The period of performance shall be for one (1) Base Year of 12-months and four (4) 12-month option years. The Period of Performance reads as follows:

Name Start End Base Period Date of Award Through 12 months of performance Option Period 1 Expiration of Base Period Through 12 months of performance Option Period 2 Expiration of Option Period 1 Through 12 months of performance Option Period 3 Expiration of Option Period 2 Through 12 months of performance Option Period 4 Expiration of Option Period 3 Through 12 months of performance

1.6.1 Transition: Transition-in/transition-out period.

1.6.1.1 Transition-in period. The Government has scheduled a 45-day transition-in period. The contractor shall develop a transition-in plan. The transition-in plan (Deliverable 1) shall facilitate the accomplishment of a seamless transition from the current contractor and contract requirements to the new contractor and contract requirements. The period between the award date and full performance start date constitutes the transition-in period. Full performance start date is 01 January 2021. Transition-in performance is defined as time period the contractor is expected to review and confirm understanding of contract requirements; meet DoD contractor onboarding requirements, develop full understanding of DHA command and market structure;

align accreditation dates for existing and any new accreditation surveys to prevent MTF non-accreditation; and prepare for execution of contract deliverables. The plan shall include communication between the two contractors and the COR to facilitate transfer of information.

During the transition-in period, the contractor shall prepare to meet all contract requirements and ensure incoming contractor personnel are functionally trained and qualified on the full performance start date. The COR will make information on DHA structure and market design accessible to the contractor during the transition-in period. See Part 7, Deliverable Schedule Table, Deliverable 1.

1.6.1.1.1 The contractor shall comply with transition-in requirements of the DHA, as listed in paragraph 1.11.1, for contractors needing to be issued Common Access Card (CAC) identification, including Department of Defense (DoD) and DHA-directed training and forms submission, prior to network access.

1.6.1.2 Transition-out period. The transition-out plan (Deliverable 2) shall facilitate the accomplishment of a seamless transition from the incumbent to an incoming contractor/Government personnel at the expiration of the contract. The plan shall include communication between the two contractors with the COR, to enable transfer of information such as the accreditation schedule for MTFs, to limit the risk of loss of accreditation during transition. See Part 7, Deliverable Schedule Table, Deliverable 2.

1.6.1.2.1 The contractor shall comply with transition-out requirements of the DHA for contractors who generate “records” as defined by DoD (records manual), including DoD-directed disposition of records, and others displayed on the In/Out (I/O) Processing Portal.

1.7 Administrative specifications

1.7.1 Place of performance: The work to conduct the accreditation and certification surveys is performed at the MTFs located CONUS and OCONUS. Services other than surveys are performed at the contractor’s location or a designated site agreed to by the Government if the contractor’s location is unable to meet a requirement of the contract such as a venue for knowledge development or training.

1.7.2 Recognized Federal holidays: The contractor is not required to perform services on Federal holidays to include:

New Year’s Day Labor Day Martin Luther King Jr.’s Birthday Columbus Day President’s Day Veteran’s Day Memorial Day Thanksgiving Day Independence Day Christmas Day

1.7.3 Hours of operation: Exclusive of travel, the contractor is responsible for conducting business Monday thru Friday except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The Contractor must at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS, when the Government facility is not closed for the above reasons.

1.7.4 Emergency Services: Not applicable

1.7.5 Conduct: Contractor personnel shall adhere to standards of conduct as established by the DHA Director.

1.8 Contractor travel: Contractor shall be required to travel within and outside of the Continental United States (CONUS) to conduct surveys and provide accreditation-related services during performance of this contract. The contractor may be required to travel to off-site training locations and to ship training aids to these locations in support of the PWS. Contractor shall be authorized travel expenses consistent with the cost principles and procedures in FAR Part 31.2, Travel Costs and the limitations of funds specified in this contract. All travel requires

Government approval/authorization and notification to the Contracting Officer Representative (COR). See RFP HT0011-20-R-0043, PWS Attachment 5 – CONUS Site Table for MTF Accreditation

Arrangements for and costs of all travel, transportation, meals, lodging, and incidentals are the responsibility of the Contractor. All travel and transportation shall utilize commercial sources and carriers. The Government shall not pay for business class or first-class travel. Contractors shall utilize FAR 31.205-46 Travel Costs for adherence to allowable and allocable travel costs.

The Government will not allow any burden rates applied to travel costs. No burdens, indirect rates, or G&A may be charged to travel. Only direct travel costs that the COR has preapproved and that the COR finds allowable and allocable may be charged to the contract.

1.8.1 DHA Foreign Travel Requirements. This contract includes activity that will require Contractor travel to destinations outside of the United States. See RFP HT0011-20-R-0043, PWS Attachment 6 – OCONUS Site Table for MTF Accreditation. The Contractor shall ensure that assigned participants allow sufficient lead-time to obtain valid passports, country clearances, and immunizations to support project activities. The contractor shall travel using the lowest cost mode transportation commensurate with the mission requirements. When necessary to use air travel, the contractor shall use the tourist class/economy class. First class/business class tickets are not authorized. The Contractor shall comply with requirements in the DoD Electronic Foreign Clearance Guide found at https://www.fcg.pentagon.mil/fcg.cfm for all travel outside the United States. The contractor shall adhere to any specialized training requirements and country/theater clearance lead times as specified in the FCG via an APACS account (https://apacs.milcloud.mil) if they do not have .mil/.gov domain permissions. In the event the Contractor does not have .mil/.gov domain permissions they will be required to designate a person, subject to CO/COR approval, as an Executive Agent possessing this sponsorship and able to access the FCG electronically for CONUS & OCONUS travel clearances. In addition, the Status of Force Agreements (SOFAs) for the identified foreign countries listed in PWS Attachment 6 are enclosed. See HT0011-20-R-0043, PWS Attachment 7 – SOFA(s).

Upon return from foreign travel, the Contractor’s Facility Security Officer (FSO), or designated company official is responsible to conduct any required debriefings based on the traveler’s encounter with any reportable situations. If the traveler has a situation to report, the FSO must contact DHA security (dha.ftv@mail.mil) with the following information (notifications shall not contain any classified information):

• Date/Time of Incident

• Location of Incident

• Level of Information involved (if involved and/or know)

1.8.2 Travel Reporting Reserved

1.9 Other Direct Costs (ODC): Not applicable.

1.10 Quality

https://www.fcg.pentagon.mil/fcg.cfm https://apacs.milcloud.mil/ mailto:dha.ftv@mail.mil

1.10.1 Quality Control (QC): The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with PWS, Part 8 – Performance Requirements Summary (PRS). The contractor shall develop and implement procedures to identify, prevent, and ensure no recurrence of defective services. The contractor’s quality control program is the means by which the work complies with stated requirements. The contractor shall provide an electronic copy of the Quality Control Plan (QCP) (Deliverable 3) to the COR and Contracting Officer (CO) within 30 business days after contract award. A comprehensive written QCP shall be submitted to the CO and COR within 5 business days when changes are made thereafter. After acceptance of the QCP the contractor shall receive the CO’s acceptance in writing of any proposed change to his QC system. See Part 7, Deliverable Schedule Table, Deliverable 3.

1.10.2 Quality assurance: The government will evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan provides a systematic method for the Government to evaluate performance and to (See RFP HT0011-20-R-0043, PWS Attachment 8 – Quality Assurance Surveillance Plan (QASP) ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

1.11 Contractor personnel

1.11.1 CAC requirements: Not applicable.

1.11.2 Contractor onboarding and training: Not applicable.

1.11.3 Physical Security: The contractor shall be responsible for safeguarding all government equipment, information and property provided for contractor use during the onsite surveys.

1.11.4 Key control: Not applicable.

1.11.5 Lock combinations: Not applicable.

1.12 Key personnel (Contractor): The contractor shall provide a contract manager (CM) who shall be responsible for the performance of the work. The name of this person and an alternate contract manager (ACM) who shall act for the contractor when the manager is absent shall be designated in writing to the CO. The contract manager or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The contract manager or alternate shall be available between 9:00 a.m. to 5:00 p.m. Monday thru Friday except Federal holidays or when the government facility is closed for administrative reasons.

1.12.1 The contractor CM and ACM qualifications include subject matter expertise in the accreditation process, standards development, survey scheduling, survey process, survey results reporting, accreditation decisions, and appeal process. The CM and ACM must have knowledge of DoD contracting requirements related to this PWS to ensure compliance with regulations.

1.12.1.1 The contractor shall provide the contact information to include e-mail address and telephone number to the COR for the CM within three (3) business days after contract award.

The contractor shall provide the contact information to include e-mail address and telephone number to the COR for the ACM within 15 business days of contact award. Any changes to the designated individual(s) and the contact information shall be provided to the COR within three

(3) business days of occurrence.

1.12.1.2 The contractor CM or ACM shall provide CO and/or COR shall respond to DoD inquiries relating to the contract within 2 business days.

1.12.2 The contractor shall provide a single point of contact as a DoD Account Manager (AM) with an Alternate Account Manager (AAM) for the contract. The AM or AAM (s) shall be responsible for coordinating with the COR and supporting the Accreditation Leads at the DHA, Markets, Regions and MTF’s throughout the accreditation process. The COR provides administrative and technical oversight for the contract requirements and serves as the point of contact for the AM and AAM for contract execution.

1.12.2.1 The contractor AM and AAM shall be subject matter expertise in the accreditation process, standards development, survey scheduling, survey process, survey results reporting, accreditation decisions, and appeal process. Additionally, the contractor AM and AAM shall provide access to subject matter experts in the contractor’s internal products and services such as software programs, application processing, agenda planning, survey process and survey reports analysis.

1.12.2.2 The contractor AM or AAM shall assist the DHA in obtaining information on the contractor accreditation program and respond to DoD inquiries within 2 business days.

1.12.2.3 The contractor AM or AAM shall provide support in accessing and utilizing any contractor electronic based services and communication systems.

1.12.2.4 The AM or AAM shall be available for telephone and e-mail consultation and assistance during the application process, as well as, before and after surveys, for MTFs, Regions, Markets, DHA, and the COR.

1.12.2.5 The contractor AM or AAM shall coordinate a quarterly meeting to discuss updates and pending changes to the accreditation programs and survey process.

1.12.2.6 The contractor AM or AAM shall be available between 9:00 a.m. to 5:00 p.m. Eastern Standard Time Monday thru Friday except Federal holidays or when the government facility is closed for administrative reasons.

1.12.2.7 The contractor shall provide the contact information to include e-mail address and telephone number to the COR for the AM within three (3) business days after contract award.

The contractor shall provide the contact information to include e-mail address and telephone number to the COR for the AAM within 15 business days of contact award. Any changes to the designated individual(s) and the contact information shall be provided to the COR within three

(3) business days of occurrence.

1.13 Data rights.

1.13.1 In the performance of this contract, the Contractor may have access to data and information proprietary to a Government agency or to another Government Contractor, or of such nature that its dissemination or use, other than as specified in this contract, would be illegal or otherwise adverse to the interests of the Government or others. The Contractor and its personnel shall not retain beyond the term of this contract, divulge, or release data or information developed, derived from or obtained under performance of this contract, except to authorized Government personnel or upon written approval of the CO. The Contractor and its Contractor personnel shall not retain, use, disclose, or reproduce proprietary information bearing a restrictive legend, other than as specified in the contract.

1.13.2 The contractor shall be considered part of the DoD medical quality assurance program and agree to comply with the provisions of Title 10 United States Code Section 1102 regarding the confidentiality and privilege of information produced in the course of this contract. The contractor shall abide by all referenced Title 10 United States Code Section 1102 requirements for release of quality assurance documentation.

1.13.2.1 The contractor shall work with DoD personnel in the accreditation process as part of the medical quality assurance program designed to improve the quality and safety of health care provided in the DoD. The confidentiality of documents and information utilized in the accreditation process shall be maintained in order to preserve the integrity of the accreditation process. Confidential information includes:

1.13.2.1.1 The Official Accreditation Report, unless its release is required by a government agency; federal or state and approved by the COR.

1.13.2.1.2 Information learned from the organization that is used to determine compliance with specific accreditation standards.

1.13.2.1.3 An organization’s comprehensive systematic analyses and related corrective action plan(s) prepared in response to a sentinel event or in response to other circumstances specified by the contractor.

1.13.2.1.4 The Organization’s self-assessment activity results and related action plan and measures of success.

1.13.2.1.5 All other materials that may contribute to the accreditation decision.

1.13.3 The contractor shall negotiate a Business Associate Agreement (BAA), Data Sharing Agreement (DSA), Health Insurance Portability and Accountability Act (HIPAA) and other information protection agreements with DHA for MTF functions included in accreditation services.

1.13.3.1 The contractor’s agreements shall indicate that the contractor is considered a partner of the DoD medical quality assurance program and abide by Title 10 United States Code Section 1102 regarding the confidentiality and privilege of information produced from accreditation services.

1.13.3.2 The contractor shall ensure the language in agreements complies with federal law.

Modifications or addendums to the agreements will be coordinated with the DHA Office of General Counsel through the COR.

1.13.4 Contractors shall provide a pubic reporting capability to display MTF accreditation status with the facilities and services included in the accreditation process to provide relevant and useful information about the accreditation of the MTFs for beneficiary and the public to review.

1.13.5 Contractors shall obtain approval from the COR before release of information resulting from the requirements of this contract.

1.14 Reporting

1.14.1 Contractor Manpower Reporting (CMR): Reserved.

1.14.2 Non-Disclosure Agreement (NDA): All contractor personnel who will obtain access to proprietary, classified, or confidential information or any information release of which is protected or governed by law or regulation associated with DHA acquisitions shall be required to complete and sign a DHA Contractor NDA (DHA Form 49) prior to beginning work on the subject contract. The Contractor shall execute an NDA on behalf of the company and shall ensure that all staff assigned to, including all subcontractors and consultants, or other personnel performing on contract/Task order execute an NDA protecting the procurement sensitive information of the Government and the proprietary information of other contractors. The NDA shall be executed not later than first day of employment and to be renewed upon exercising a contract option period. Assignment of staff who has not executed this statement or failure to adhere to this statement shall constitute default on the part of the Contractor. The contractor shall maintain originally signed NDAs of individual employees and provide electronic to the COR (Deliverable 4). See Part 7, Deliverable Schedule Table, Deliverable 4.

1.14.3 Government’s COR: The COR monitors all technical aspects of the contract and assists in contract administration. The COR is authorized to perform the following functions: assure that the Contractor performs the technical requirements of the contract; perform inspections necessary in connection with contract performance; maintain written and oral communications with the Contractor concerning technical aspects of the contract; issue written interpretations of technical requirements, including Government drawings, designs, specifications; monitor Contractor's performance and notifies both the CO and Contractor of any deficiencies; coordinate availability of government furnished property; and provide site entry of Contractor personnel. A letter of designation issued to the COR, a copy of which is sent to the Contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting contract.

1.14.4 Post award conference/periodic progress meetings: The Contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. The CO, COR, and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance. At these meetings the CO will apprise the contractor of how the government views the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the government.

1.14.4.1 The contractor shall coordinate an in person face-to-face meeting or teleconference with the DHA Accreditation and Compliance Program Leads and the COR at a minimum of quarterly to discuss accreditation standards, continuous standards compliance, survey readiness, and quality issues that affect MTF accreditation.

1.15 Contractor Identification

1.15.1 Contractor surveyors performing services in a contractor capacity in a Government facility are required to possess and wear an identification badge that displays his or her name and the name of their company.

1.15.2 Contractor personnel will be required to attend meetings or otherwise communicate with Government and/or other contract representatives to meet the requirements of this order.

Contractor personnel shall make their contractor status known during introductions.

1.15.3 Contractor personnel, while performing in a contractor capacity, are prohibited from using their retired or reserve component military rank or title in any written or verbal communications associated with the contracts in which they provide services.

1.16 Contractor Access to Health Affairs (HA)/DHA Network(s) Not applicable

1.17 Personnel Security Not applicable

PART 2

2.0 DEFINITIONS, ACRONYMS, AND APPLICABLE

PUBLICATIONS/INSTRUCTIONS

2.1 Definitions

2.1.1 Category D: Information Technology (IT) and Telecommunications Services (called D- Services)

2.1.2 Category R: Support (Professional/Administrative/Management) Services (called R- Services)

2.1.3 Contracting Officer (CO): A person with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings.

2.1.4 Contracting Officer’s Representative (COR): An individual, including a contracting officer’s technical representative (COTR), designated and authorized in writing by the contracting officer to perform specific technical or administrative functions. This individual does NOT have authority to change the terms and conditions of the contract.

2.1.5 Market: A group of MTFs that operate as a system: sharing patients, providers, functions, and budgets, across facilities in order to improve the delivery and coordination of health services to drive value for beneficiaries.

2.1.6 Military Medical Treatment Facilities (MTFs): Any DoD facility, outside of a deployed environment, constructed primarily for health care or as otherwise determined by the Secretary of Defense to be an MTF.

2.1.7 Non-personal services contract: a contract under which the personnel rendering the services are not subject, either by the contract’s terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees.

2.1.8 Operational healthcare units: deployable units that while at home station are treating only active duty personnel and reserve component members on duty status

2.1.9 Quality Assurance Surveillance Plan (QASP): An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance. The Government may either prepare the quality assurance surveillance plan or require the offerors to submit a proposed quality assurance surveillance plan for the Government’s consideration in development of the Government’s plan.

2.1.10 Quality Control Plan (QCP): A contractor developed and maintained document to ensure services are performed in accordance with the contract requirements. The contractor implements procedures to prevent, identify, and ensure no recurrence of defective services.

2.2 Acronyms:

AAM Assistant Account Manager ACM Alternate Contract Manager AM Account Manager ADP/IT Automated Data Processing/Information Technology AIS Automated Information System AO Accreditation Organization AQL Acceptable Quality Level ARRT Acquisition Requirements Roadmap Tool ATO Authority to Operate BAA Business Associate Agreement CAC Common Access Card CAP Cloud Access Point CDI Covered Defense Information CDRL Contract Data Requirement List CE Computing Environment CIO Chief Information Officer CJCSM Chairman of the Joint Chiefs of Staff Manual CM Contract Manager CMR Contractor Manpower Reporting CNSSI Committee on National Security Systems Instruction CO Contracting Officer(s) CONUS Continental United States (excludes Alaska and Hawaii) COR Contracting Officer Representative COTR Contracting Officer's Technical Representative CSP Cloud Service Provider CSSP Cyber Security Service Provider CUI Controlled Unclassified Information DAD-A Deputy Assistant Director for Acquisition DC3 DoD Cyber Crime Center DD 254 Department of Defense Contract Security Requirement List (if applicable) DFARS Defense Federal Acquisition Regulation Supplement DHA Defense Health Agency DISA Defense Information System Agency DoD Department of Defense DoDI Department of Defense Instruction DoDM Department of Defense Manual DSA Data Sharing Agreement EULA End User License Agreement EVM Earned Value Management FAR Federal Acquisition Regulation FedRAMP Federal Risk Authorization and Management Program FISMA Federal Information Security Management Act FSO Facilities Security Officer HA Health Affairs

HIPAA Health Insurance Portability and Accountability Act HCA Head of the Contracting Activity HIT Health Information Technology IGCE Independent Government Cost Estimate IA Information Assurance I/O In/Out Processing Portal IS Information System IT Information Technology ISCM Information Security Continuous Monitoring MHS Military Health System MTF Military Medical Treatment Facility NCR National Capitol Region NDA Non-Disclosure Agreement NIST National Institute of Standards and Technology OCONUS Outside Continental United States (includes Alaska and Hawaii) ODC Other Direct Costs OSD Office of the Secretary of Defense P-ATO Personal Authorization to Operate PCMH Patient Centered Medical Home P&R Personnel and Readiness PGI Procedures, Guidance and Information PHI Protected Health Information PII Personally Identifiable Information PIT Platform Information Technology PK Public Key PKI Public Key Infrastructure POC Point of Contact PoP Period of Performance PPSM Ports, Protocols, and Services Management PRS Performance Requirements Summary PSP Personnel Security Program PWS Performance Work Statement QA Quality Assurance QAP Quality Assurance Program QASP Quality Assurance Surveillance Plan QC Quality Control QCP Quality Control Plan RFP Request for Proposal RFQ Request for Quotation RMF Risk Management Framework SP Special Publication SRG Security Requirements Guides STIG Security Technical Implementation Guides TOS Terms of Service US United States XML Extensible Markup Language

2.3 Applicable Publications, DHA Administrative Instructions (AI), etc.

2.3.1 DoD Instruction (DoDI) 6025.13 Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS)

2.3.2 Defense Health Agency Procedural Manual (DHA-PM) 6025.13 Defense Health Agency Clinical Quality Management in the Military Health System, Volumes 1-7

2.3.3 Title 10 United States Code Section 1102 Confidentiality of Medical Quality Assurance Records

2.3.4 DoDI 8582.01 Security of Non-DoD Information Systems Processing Unclassified Nonpublic DoD Information

2.3.5 DoDD 8140.01 Cyberspace Workforce Management

2.3.6 DoD 8570.01-M Information Assurance Workforce Improvement Program

PART 3

3.0 GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

The Requiring Activity Authority has assessed the need for Government Furnished Property, Equipment, and Services and determined:

3.1 Services: The Government:

☒ Will NOT provide Government Furnished Services in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Government Furnished Services required in support of this contract/task orders. These Services are described below:

3.2 Facilities: The Government:

☒ Will NOT provide Facilities in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Facilities in support of this contract/task orders. The Government provided Facilities are described below:

3.3 Utilities: The Government:

☒ Will NOT provide Utilities in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Utilities in support of this contract/task orders. The Government provided Utilities are described below:

3.4 Equipment: The Government:

☒ Will NOT provide Equipment in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ WILL provide Equipment in support of this contract/task orders. The Government provided Equipment is described below:

3.4.1 Procurement Integrated Enterprise (PIEE), GFP Module Application Not Applicable

3.5 Materials: The Government:

☒ Will NOT provide Materials in support of this contract/task order. As a result, this paragraph is Not Applicable.

☐ IS providing Materials in support of this contract/task orders. The Government-provided Materials are described below:

PART 4

4.0 CONTRACTOR FURNISHED ITEMS AND SERVICES

4.1 General: The Contractor shall furnish all supplies, equipment, software, tools, transportation, facilities, services personnel, supervision and other items required to perform work listed under Section 5 of this PWS.

4.2 Secret Facility Clearance: Not applicable.

4.3 Materials: The Contractor shall provide the services and materials needed to meet the requirements under this PWS.

4.4 Equipment: The Contractor shall furnish all equipment needed to meet the requirements under this PWS.

4.5 Facilities: The Contractor shall furnish facilities needed to meet the requirements of the contract other than the time the surveyors are on-site for survey.

PART 5

5.0 SPECIFIC TASKS

5.1 Accreditation and Certification Requirement

5.1.1 The contractor shall provide accreditation for all of the services required by the DoD to include hospitals (inpatient, outpatient, dental and telehealth), ambulatory (free standing, telehealth, dental and ambulatory surgical centers), behavioral health (inpatient, outpatient, telehealth, educational, and developmental intervention services), and home health care.

5.1.1.1 The contractor providing AO services shall be a Centers for Medicare & Medicaid Services (CMS) approved accreditation source for all applicable DoD required program (i.e.

hospital, ambulatory surgical center and home health).

5.1.1.2 The contractor shall complete the required accreditation and PCMH certifications consistent with the MTF’s current accreditation cycle to prevent causing a lapse in MTF accreditation or certification status.

5.1.1.3 The contractor shall provide a single accreditation process, survey and award for all services and programs included in the scope of the MTF’s accreditation process.

5.1.1.3.1 Operational healthcare units (deployable units that while at home station are treating only active duty personnel and reserve component members on duty status) under the oversight of the Services may for accreditation purposes be affiliated with the MTF such as by memorandum of agreement, to be covered by the MTF’s accreditation.

5.1.1.4 The contractor shall provide MTFs a seamless accreditation process and onsite survey when subcontractors are utilized to provide the required accreditation services.

5.1.1.4.1 The contractor shall integrate subcontractor standards into a single set of accreditation program standards, a consolidated survey process and single survey report.

5.1.1.5 The Contractor’s seamless accreditation process and onsite survey shall include a survey team leader with a coordinated survey team and one survey agenda utilizing consistent core standards across programs, as appropriate.

5.1.2 The contractor shall provide PCMH certification services for MTF patient centered medical homes through an onsite assessment to ensure compliance with nationally recognized standards for medical home model.

5.1.2.1 The contractor shall align PCMH onsite certification assessment with MTF accreditation survey schedule.

5.2 Accreditation Certificate Display and Use

5.2.1 The contractor shall provide the MTFs with accreditation certificate(s) (Deliverable 5) identifying each accreditation program surveyed. See Par 7, Deliverable Schedule Table, Deliverable 5.

5.2.2 The contractor shall provide the MTFs with a certificate documenting successful PCMH certification (Deliverable 6). See Part 7, Deliverable Schedule Table, Deliverable 6.

5.2.3 The contractor shall provide the MTF with the ability to obtain additional copies of the accreditation certificate, if requested.

5.2.4 The contractor shall permit accredited MTF to display the contractor’s accreditation seal and certificate to publicize the MTF’s achievement of accreditation.

5.3. Accreditation and Certification Standards

5.3.1 The contractor shall develop, maintain and provide accreditation standards for the services provided by DoD to include hospitals (inpatient, outpatient, dental and telehealth), ambulatory (free standing, telehealth, dental and ambulatory surgical centers), behavioral health (inpatient, outpatient, telehealth, educational, and developmental intervention services), and home health care, as appropriate.

5.3.1.1 The contractor shall develop, maintain and provide accreditation standards based on input from healthcare industry recognized sources such as clinical providers, professional organizations, expert consensus, subject matter experts, scientific literature, evidence-based practice guidelines, consumers and government agencies (including Centers for Medicare and Medicaid Services).

5.3.1.2 The contractor shall develop, maintain and provide current standards for DHA accredited MTFs focused on patient safety trends and goals in the healthcare industry and based on information gathered from relevant health care experts, providers, practitioners, and other parties interested in affecting the quality and safety of health care and the identification of achievable solutions to these issues.

5.3.1.3 The contractor shall base the addition of new standards on the impact to patient safety and quality of care; positive effect on healthcare outcomes, compliance with laws and regulations; and the ability for accurate, timely measurement.

5.3.1.4 The contractor shall develop and maintain PCMH standards for certification based on input from healthcare industry recognized sources such as clinical providers, professional organizations, expert consensus, subject matter experts, scientific literature, evidence-based practice guidelines, consumers and government agencies (including Centers for Medicare and Medicaid Services).

5.3.2 The contractor shall provide consistent standards across accreditation programs (hospitals, ambulatory clinics, behavioral health and home health care) for survey requirements applicable to multiple accreditation programs such as governing body, human resources, leadership, quality assessment/performance improvement, medical records, information management, infection control, patient rights, and physical environment where applicable.

5.3.2.1 The contractor shall provide MTFs, Markets, Regions, and DHA with an integrated set of standards if subcontractors provide accreditation services to meet DoD programs requiring accreditation.

5.3.3 The contractor shall provide DHA MTFs, Markets, Regions, and Headquarters with access to an electronic copy of the contractor’s accreditation standards manual (Deliverable 7) for each applicable accreditation program and PCMH certification standards (Deliverable 8). See Part 7, Deliverable Schedule Tables, Deliverables 7 and 8.

5.3.3.1 Access to the applicable electronic accreditation program standards manuals shall be based on the MTF’s submitted accreditation application.

5.3.4 The contractor shall provide DHA MTFs, Markets, Regions, and Headquarters with paper copies of the standards manuals (Deliverable 9) for each applicable accreditation program and PCMH certification standards (Deliverable 10) with ongoing updates. See Part 7, Deliverable Schedule Table, Deliverables 9 and 10.

5.3.4.1 The volume of manuals required will be coordinated through the COR.

5.3.5 The contractor shall provide updates to the standards and certification requirements (Deliverable 11) at a minimum of six months prior to taking affect. See Part 7, Deliverable Schedule Table, Deliverable 11.

5.3.6 The contractor shall provide a team of knowledgeable health care professionals to provide accreditation and PCMH certification standards interpretations or clarifications to DHA, Markets, Regions and MTF staff, as needed.

5.3.6.1 The contractor shall respond to DHA, Market, Region and MTF questions on standards either telephonically or via electronic submission.

5.3.6.2 The contractor shall provide responses to standards questions and provide feedback to the DHA, Markets, Regions and MTFs within five business days for an electronic response or two business days for a phone response.

5.4 Accreditation Survey Process

5.4.1 The contractor shall establish and adhere to documented guidelines for MTF accreditation surveys. The survey guidelines shall be provided to MTFs, Markets, Regions and DHA Headquarters during transition in and when the guidelines are changed.

5.4.1.1 The contractor shall provide written guidance on the survey process (Deliverable 12) to support MTFs with preparation for survey and DHA Markets, Regions, and Headquarters with oversight of the accreditation program. The surveyors shall adhere to the survey guide. See Part 7, Deliverable Schedule Table, Deliverable 12.

5.4.2 The contractor shall provide a team of subject matter experts to serve as surveyors for onsite surveys based on MTF size and the healthcare services offered.

5.4.2.1 The contractor shall ensure the team of subject matter experts have demonstrated knowledge of the standards, skill in conducting a survey, and expertise in reporting areas of standards compliance as well as required improvements based on the specific healthcare setting undergoing survey,

5.4.2.2 The Contractor shall designate a Surveyor Team Leader or Leaders assigned to survey MHS facilities for each accreditation cycle.

5.4.2.3 The Contractor shall ensure surveyors are prepared to present a government issued identification document or other required documentation, such as a state driver’s license, to gain entry to the military installation.

5.4.2.4 Prohibition on the Use of Surveyors as Consultants. The contractor’s accreditation surveyors shall not be used as consultants to the DHA MTFs, Markets, Regions, or Headquarters.

5.4.3 The contractor shall schedule and conduct routine unannounced onsite MTF accreditation surveys, to assess standards compliance.

5.4.3.1 The contractor shall conduct the MTF triennial accreditation surveys in a timely fashion based on the current effective date for accredited status to…