Att 1 - DAD-MA PSP PWS Final Revised.pdf

Attachment 1 – Performance Work Statement (PWS)

Department of Defense Defense Health Agency (DHA)

Performance Work Statement (PWS)

DHA Patient Safety Program Contract for Military Treatment Facilities (MTFs)

Clinical Quality Management (CQM)/Patient Safety Program (PS Program)

Medical Affairs, Clinical Support Division, CQM, PS Program

Solicitation Number: HT001124R0080 Version: #2

Date: 6 September 2024

PART 1

1.0 GENERAL INFORMATION

1.1 This is a non-personal services contract to provide Defense Health Agency (DHA) Patient Safety Program (PS Program) Contract for Medical Treatment Facilities.

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 Patient Safety Services (PSS) 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.

1.3 Background: The DHA PS Program is a comprehensive program providing products, services, and educational and training resources to promote safety and prevent harm, as mandated by National Defense Authorization Act and DoDI 6025.13. The DHA PS Program contributes to the DHA’s focus to achieve DHA strategic objectives, centered on Readiness— Ready Medical Force and Medically Ready Force—across all environments. Supporting the objective is the goal to achieve zero preventable harm and provide patient-centered, evidence-based care to improve patient outcomes. The DHA PS Program provides products, services, and support to enable frontline healthcare personnel to eliminate harm and promote a culture of safety. The DHA PS Program is managed out of the Clinical Quality Management (CQM) Branch in the Clinical Support Division under the Deputy Assistant Director for Medical Affairs (DAD MA) within the DHA. The Chief of the DHA PS Program manages program operations in collaboration with the Patient Safety Improvement Collaborative (PSIC).

1.4 Objectives: The primary functions of the DHA PS Program are to promote a strong culture of safety to eliminate preventable patient harm by engaging, educating, and equipping patient care teams to institutionalize evidence-based, DHA safety practices. (1) Manage Patient Safety (PS) Events. Eliminate harm through identification, investigation, and mitigation of PS events.

(2) Support a Learning Organization. Strengthen systems through the implementation of and lead sustainable, positive change; respectful and inclusive behaviors are instinctive and serve as behavioral norms for the organization; and the physical and psychological safety of patients and the workforce are both highly valued and ardently protected.

1.5 Scope: The DHA commitment to delivering quality, evidence-based, safe care cannot be overstated. This requires on-going cultural changes throughout the enterprise, ultimately resulting in the DHA becoming a High Reliability Organization (HRO). It is the DHA’s intent to accomplish these goals through the execution of a contract encompassing patient safety personnel at numerous Military Treatment Facilities (MTFs) coupled with training materials keyed to foster a workplace-based safety cultural transformation, guided by experts in patient safety at DHA. Services include expertise and experience required by Patient Safety Specialists (PSS), Patient Safety Assistant Coordinators (PSAC), and/or Patient Safety Data Analysts (PSDA) at both inpatient and outpatient MTFs. This contract also clarifies the intent and expected range of annual review deliverables submitted by MTF PS contractors.

1.6 Period of Performance (PoP):

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

1.6.1 Transition: Transition-in/Transition-out period. See PWS Part 7, Technical Exhibit 1 - CDRL 007 – Transition Plan.

1.6.1.1 Transition-in period: Full performance start date is Date of Award with an expectation of no-gap in performance. Transition-in performance is defined as the first 30 days of contract period of performance start date. During the transition-in period, the contractor shall prepare to meet all contract requirements and ensure incoming personnel are functionally trained and qualified on the full performance start date except cybersecurity requirements, which must be fully adhered during transition and full performance periods. The remaining incoming personnel shall be trained and qualified upon contract start. All positions are recommended to be filled within the 30 calendar day transition period.

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 shall facilitate the accomplishment of a seamless transition from the incumbent to an incoming contractor/Government personnel at the expiration of the contract. Contractor shall provide an Outgoing Transition Plan, due to this no-gap in performance, with hand-offs to the appropriate Government official at the MTF level and the COR.

1.6.1.2.1 The contractor shall comply with transition-out requirements of the DHA for contractors who have been issued a CAC or 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 following are the primary locations for onsite support:

AF/Place of Performance PSS PSAC PSDA **DHA/PSC Eglin AFB, FL, 96 MDG 1 JB Andrews, MD, 779 MDG 1 *JB Elmendorf-Richardson, AK, 673 MDG 1 JB Langley-Eustis, VA, 633 MDG 1 JB San Antonio-Lackland, TX 2 Keesler AFB, MS, 81 MDG 1 Nellis AFB, NV, 99 MDG 1 *RAF Lakenheath, England, 48 MDG 1 Travis AFB, CA, 60 MDG 1 1 Wright-Patterson AFB, OH, 88 MDG 1 Altus AFB, OK, 97 MDG 1 Barksdale AFB, LA, 2 MDG 1 Beale AFB, CA, 9 MDG 1 Buckley AFB, CO, 460 MDG 1 Cannon AFB, NM, 27 SOMDG 1 Columbus AFB, MS, 14 MDG 1 Davis-Monthan AFB, AZ, 355 MDG 1 Dover AFB, DE, 436 MDG 1

Dyess AFB, TX, 7 MDG 1

Edwards AFB, CA, 95 MDG 1 Ellsworth AFB, SD, 28 MDG 1 Fairchild AFB, WA, 92 MDG 1 FE Warren AFB, WY, 90 MDG 1 *Geilenkirchen NATO AB, Germany, 470 ABS 1 Goodfellow AFB, TX, 17 MDG 1 Grand Forks AFB, ND, 319 MDG 1 Hanscom AFB, MA, 66 MDG 1 Hill AFB, UT, 75 MDG 1 Holloman AFB, NM, 49 MDG 1 Hurlburt Field, FL, 1 SOMDG 1 JB Charleston, SC, 437 MDG 1 JB McGuire-Dix-Lakehurst, NJ, 87 MDG 1 Kirtland AFB, NM, 377 MDG 1 Laughlin AFB, TX, 47 MDG 1 Little Rock AFB, AR, 19 MDG 1 Los Angeles AFB, CA, 61 MDG 1 Malmstrom AFB, MT, 341 MDG 1

AF/Place of Performance PSS PSAC PSDA **DHA/PSC Maxwell AFB, AL, 42 MDG 1 McConnell AFB, KS, 22 MDG 1 Minot AFB, ND, 5 MDG 1 Moody AFB, GA, 23 MDG 1 Patrick AFB, FL, 45 MDG 1 Peterson AFB, CO, 21 MDG 1 Pope Field, NC, 43 MDS 1 Robins AFB, GA, 78 MDG 1 Scott AFB, IL, 375 MDG 1 Seymour Johnson, NC, 4 MDG 1 Shaw AFB, SC, 20 MDG 1 Sheppard AFB, TX, 82 MDG 1 Tinker AFB, OK, 72 MDG 1 Tyndall AFB, FL, 325 MDG 1 Vance AFB, OK, 71 MDG 1 Vandenberg AFB, CA, 30 MDG 1 Whiteman AFB, MO, 509 MDG 1

Navy/Place of Performance PSS PSAC PSDA DHA/PSC Pensacola, FL 1 Portsmouth, VA 3 New England, RI 1 San Diego, CA 2 Corpus Christi, TX 1 ++Lovell FHCC (Dental & Recruit’s Only), IL 1 Twentynine Palms, CA 1 Annapolis, MD 1 Lemoore, CA 1 Quantico, VA 1 *Naples, Italy 1

Camp LeJeune, SC 1

**Potential DHA FTE Personnel** 3**

Total MTF Level FTEs: 15 Navy, 56 AF = Total 71 (**Potential w/Option yrs.: 15 Navy, 56 AF, 3 DHA 1 CM = 75) ++ Position collocated w/VA (locations embedded @ 1.12.11++ Total MTFs (54 AF & 12 Navy = 66 MTFs) Total FTE Full Contract 71 + 1 CM = 72 Personnel

3**

1.7.2 Recognized Federal holidays: Contractor service is not required on the following holidays.

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

1.7.3 Mission/Emergency Essential. None of the services listed in this PWS are mission/emergency essential.

1.7.4 Duty Hours. Normal duty hours are between 6:00 AM to 7:00 PM, Monday through Friday (excluding Federal Holidays) and Family/Down Days when published. Contractor can choose to telework or take PTO. Decision should be made between the contractor and contract supervisor.

Contractor does not need to report time worked in Defense Medical Human Resources System – internet (DMHRSi). This is centralized contract managed by DHA and therefore there are no Functional Requirements Evaluator Designees (FRED).

1.7.5 Conduct of Contractor Personnel. The CO may require the Contractor to remove from the job site Contractor personnel working under this contract. Removal from the job site or dismissal from the premises shall not relieve the Contractor of the contract requirements.

1.7.6 Contractor personnel shall be required to observe Government facility parking, safety and DHA regulations that apply to all facility employees. Alcoholic beverages on the job are prohibited. There shall be no loud, profane, or abusive language used on the job. Contractor personnel shall present a neat well-groomed appearance. Neat, clean, casual business attire clothing shall be worn.

1.7.7 Telecommute. Telecommuting is authorized on an ad-hoc or situational basis in the event of unplanned closure of the facility to include, but not limited to, natural disasters, military emergency or severe weather and will be at the COR’s discretion. The Contractor may propose an alternate work location from a secure location. The Contractor shall ensure continuity and timeliness in completing tasks while telecommuting. The Government COR will have final approval of all telecommuting requests.

1.7.8 Telecommute and schedules. These special and emergency accommodations will also apply when traveling Temporary Duty (TDY) to locations that prohibit direct access to military computer systems. A laptop with a Virtual Private Network (VPN) account and Common Access Card (CAC) will be issued by each MTF (if available); accessibility shall also be provided by the Government in the event telecommuting is authorized. The contractor is responsible for the internet access and all other necessary equipment needed to deliver this service outside the MTF.

Additionally, remote positions do exist within the contract when agreed upon by the contract PM and the COR. These situations may be approved for high level performance positions and the best candidate cannot relocate—approval by the contractor PM and the COR in the best interest of the governments mission requirements.

1.8 Contractor travel: Travel Requirements. Travel may be required during the performance period of this contract at the request of the Government. Travel may include conference attendance, MTF travel for mentoring, evaluation, or assistance to another MTF. All travel requires approval/authorization and notification from the Contracting Officer Representative (COR) of Contracting Office. The Contractor shall not be reimbursed for local travel within the Falls Church commuting area as well as the local commuting area for each location listed in

1.7.1. 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. All travel costs are being rolled up into the FFP Services CLINs for base and all option years. The Contractor shall coordinate travel requirements with the COR/Alt. COR, no less than fourteen (14) business days prior to travel date and receive COR/Alt. COR authorization for all travel. Travel to and from work shall be considered a cost of doing business and shall not be reimbursable. All travel shall be in accordance with PWS and the Joint Travel Regulations (JTR). For overseas travel, the Contractor PM & COR will provide support to contractor and contractor employees with all logistical requirements necessary for contractor personnel to travel overseas (i.e., Status of Force Agreements (SoFAs), Country Clearances, etc.).

1.8.1 The COR will notify the Contractor no later than 14 calendar days or (30 calendar days for OCONUS) in advance of any scheduled travel requirements. Notification will include specific travel dates, in-scope work tasks to be accomplished, and the specific Contractor personnel required to travel. The COR will provide notice of any urgent unscheduled CONUS or OCONUS travel requirements no later than five (5) calendar days prior to the required travel start date.

1.8.2 The Contractor shall send an email to the COR with a written travel itinerary meeting Government parameter along with a written request to proceed no later than 10 calendar days prior to the travel start date. For urgent unscheduled travel requirements, the Contractor shall send an email with the itinerary and request to proceed no later than four (4) calendar days prior to travel.

1.8.3 The COR will grant authorization to proceed no later than seven (7) calendar days prior to the travel start date, or no later than three (3) calendar days prior to the travel start date for urgent unscheduled travel requirements. If the COR denies authorization to proceed, Contractor personnel shall not travel, and the travel event concerned shall not be invoiced and will not be paid for under the contract. Only those travel events which are authorized in advance by the COR and fulfilled by the Contractor are billable under this contract.

1.8.4 The Contractor shall submit a travel report to the COR five (5) business days after each trip completion. Travel report format shall include a minimum of the following: dates of travel, destination, purpose, individuals contacted, brief synopsis, issues and challenges, recommendations, and the traveler’s signature. The Contractor shall provide the Travel Itinerary to include location, frequency, number of attendees, total cost, and justification for travel.

1.9 Permanent Change of Station (Overseas Only)

1.9.1 Contractor relocation for foreign overseas positions. Employees hired in the Continental United States shall be reimbursed at a rate not greater than Department of State Standardized Regulations (DSSR) and must be justified based on actual costs provided in a trip report. DSSR is the controlling regulation for allowances and benefits available to all U.S. Government civilians assigned to foreign areas. Contractor civilians hired in the United States and assigned to foreign areas under this contract may receive the allowances and benefits in the DSSR but shall not receive allowance and benefits more than those identified in the DSSR. No more than one relocation payout in the base year, per overseas position for the duration of the contract, regardless of exercised options, will be authorized. Government will only fund movement to OCONUS locations [*RAF Lakenheath, England, 48 MDG, *Geilenkirchen NATO AB, Germany, 470 ABS, and *Naples, Italy] for the three (3) OCONUS PSAC positions, not from OCONUS locations. CONUS PCS is not funded nor authorized.

1.9.2 The Government will not issue travel orders for contract employees. For PCS travel of contract employees, the contractor will provide a written request, with cost estimate, for a travel authorization to COR at least 14 days (30 calendar days OCONUS) prior to the date of departure.

Request will include Name, Social Security Number (SSN), home address, departure date, duty location, and position. COR will provide the contractor with a written approval for the PCS.

1.9.3 PCS costs for new employees will be the initial responsibility of the contractor. The contractor shall submit for reimbursement an invoice to the Government itemizing the expenditures incurred at the completion of the PCS move. Copies of the documents/receipts will accompany the invoice.

1.9.4 Contract employees are authorized 8,000 pounds of household goods and one vehicle (where authorized by International Agreement/host-nation law) shipped from CONUS to OCONUS and return to original destination.

1.9.5 Contract employees are allowed 7 days temporary lodging allowance (TLA) in accordance with the Joint Travel Regulation rates. Contractor shall submit supporting documentation for each contract employee for payment of TLA from CONUS and return to original destination.

1.9.6 The Government will only pay transportation costs for one full time equivalent per position for a five-year individual contract employee period. If a contract employee vacates their position before the end of their contract period, the contractor shall be responsible for the replacement cost to refill the vacant position.

1.9.7 If the government requires a contract employee to vacate, PCS costs may be reimbursed up to 8,000 pounds of household goods and one vehicle.

1.10 Quality

1.10.1 Quality Control (QC): The contractor shall develop and maintain an effective QC program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure nonrecurrence of defective services. The contractor’s QC program is the means by which the work complies with stated requirements. The initial evaluation of Contractor performance is a joint determination by the multi-functional team that the Contractor has successfully started performance, completed transition, is fully operational, and is within the estimated cost, schedule, and performance parameters of the contract. The initial evaluation will be conducted by the Government within 30 business days after award and submitted to the CO and COR within 5 working days when changes are made thereafter. After acceptance of the Quality Control Plan (QCP) the contractor shall receive the CO’s acceptance in writing of any proposed change to his QC system. See PWS Part 7, Technical Exhibit 1 - CDRL A001 – Quality Control Plan (QCP).

1.10.2 Quality Assurance (QA): 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 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). Further, the QASP provides the COR with a proactive way to avoid unacceptable or deficient performance and provides verifiable input for the required Past Performance Information Assessments. The QASP will be finalized immediately following award and a copy provided to the Contractor After award. The QASP is a living document and may be updated by the Government as necessary. See Attachment 3 – Quality Assurance Surveillance Plan (QASP).

1.11 Contractor personnel

1.11.1 Common Access Card (CAC) requirements: For all contractors who will work in Government facilities, the Facilities Security Officer (FSO)/Company's Security point of contact (POC) will provide the Government all the required information per the DHA CAC request process current version 2.1, January 2018, or more recent when updated. See Attachment 4 – PWS 7.1.1 - CAC Request Process and Attachment 5 – PWS 7.1.1 - DMDC TASS Application Sheet. A CAC is the standard identification for eligible DoD contractor personnel.

1.11.1.1 The contractor shall return all CACs to the SGH/CMO or COR upon the departure of the contractor(s).

1.11.2 Contractor onboarding and training. The contract program manager and alternates MAY contact the MTF POCs (as determined by the SGH/CMO) directly with a “cc” to the COR to expediate onboarding for the DHA PS Program. Delay of POCs to return emails to the contract program manager and alternates will delay onboarding and thus to the PS Program at the MTF.

COR will notify the Senior MTF leadership when POCs do not comply and thus causing this delay. All employees must have attended DHA PS Professionals Course within the last 5 years.

If newly hired employee has not attended DHA PSPC within the last 5 years, new employees must attend next available course after contract start, unless there are extenuating circumstances, then coordinate with the COR. The Government will pay for the class when class slots are available. Additionally, they also need to attend the Clinical Quality Management (CQM) course within the first year. The contractor shall complete all requirements, training, and forms as prescribed in the following requirements:

1.11.2.1 The DHA’s “Onboarding Checklist for Contractor Employees” is located at the DHA Onboarding and Offboarding Portal at https://info.health.mil/cos/admin/hr/IO/SitePages/Home.aspx

1.11.2.2 The DHA’s contractor training instructions – see Attachment 6 – PWS 7.1.2 – DHA Mandatory Contractor Training List. The current version can be found on J7 Education and Training SharePoint: https://info.health.mil/edu/MTFDIV/to/SitePages/Home.aspx

1.11.2.3 The contractor shall comply with onboarding requirements of the DHA for contractors needing to be issued CAC identification, including DoD- and DHA-directed training and forms submission, prior to network access, as displayed in the In/Out-Processing Portal at:

https://info.health.mil/cos/admin/hr/IO/SitePages/home.aspx (note: Public Key Infrastructure (PKI)-restricted, printed versions available).

1.11.3 Physical Security: The contractor shall be responsible for safeguarding all government equipment, information and property provided for contractor use. At the close of each work period, government facilities, equipment, and materials shall be secured.

1.11.4 Key control: The contractor shall establish and implement methods of making sure all keys/key cards issued to the contractor by the Government are not lost or misplaced and are not used by unauthorized persons. NOTE: All references to keys include key cards. No keys issued to the contractor by the Government shall be duplicated. The contractor shall develop procedures covering key control that shall be included in the QCP. Such procedures shall include turn-in of any issued keys by personnel who no longer require access to locked areas.

The contractor shall immediately report any occurrences of lost or duplicate keys/key cards to the CO.

1.11.4.1 In the event keys, other than master keys, are lost or duplicated, the contractor shall, upon direction of the CO, re-key or replace the affected lock or locks; however, the Government, at its option, may replace the affected lock or locks or perform re-keying. When the replacement of locks or re-keying is performed by the Government, the total cost of re-keying or the replacement of the lock or locks shall be deducted from the monthly payment due the contractor.

In the event a master key is lost or duplicated, all locks and keys for that system shall be replaced by the Government and the total cost deducted from the monthly payment due the contractor.

1.11.4.2 The contractor shall prohibit the use of Government issued keys/key cards by any persons other than the contractor’s employees. The contractor shall prohibit the opening of locked areas by contractor employees to permit entrance of persons other than contractor employees engaged in the performance of assigned work in those areas, or personnel authorized entrance by the CO.

1.11.5 Lock combinations: The contractor shall establish and implement methods of ensuring that all lock combinations are not revealed to unauthorized persons. The contractor shall ensure that lock combinations are changed when personnel having access to the combinations no longer have a need to know such combinations. These procedures shall be included in the contractor’s

QCP.

https://info.health.mil/cos/admin/hr/IO/SitePages/Home.aspx https://info.health.mil/edu/MTFDIV/to/SitePages/Home.aspx https://info.health.mil/cos/admin/hr/IO/SitePages/home.aspx

1.12 Key personnel (Contractor): The contractor shall provide a Contract Manager (CM) and Alternate Contract Manager (CM) who shall be responsible for the performance of the work.

The name of this person and an alternate who shall act for the contractor when the manager is absent shall be designated in writing to the CO. The CM or alternate CM shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The CM shall be available Monday thru Friday except Federal holidays or when the government facility is closed for administrative reasons. Minimum qualifications for all key personnel are listed below:

CONTRACT MANAGER (CM) /ALTERNATE CONTRACT MANAGER (CM)

• An undergraduate degree in any field;

• A minimum of 10 years of healthcare experience within a hospital or clinic;

• Patient Safety healthcare experience;

• National Certification in Patient Safety (CPPS) is highly recommended; however, other nationally recognized patient safety certifications (such as CPHQ) shall be considered and accepted in lieu of CPPS;

• Additionally, a CM with a deep understanding and functioning knowledge of patient safety tasks and programs is required.

1.12.1. Key Personnel. Key Personnel proposed pre-award, or replacement Key Personnel (authorized in writing by the Contracting Officer), shall not be replaced for a period of twelve

(12) months after award, except for:

• Serious, prolonged illness (that onset after the Contractor's submission of that Key Person's resume to the Government);

• death;

• in the case of a Key Person who was a Contractor employee when the Contractor submitted his or her resume to the Government, the Key Person leaves the Contractor's employer for reasons other than retirement and does not commence work for a subcontractor working on this contract or commence work for the Contractor after a hiatus.

1.12.2. The Contractor agrees that it has a contractual obligation to mitigate the consequences of the loss of Key Personnel and shall promptly secure any necessary replacements in accordance with this PWS. Failure to replace a Key Person pursuant to this contract without a break in performance shall be considered a condition endangering contract performance and may provide grounds for termination.

1.12.3 Substitutions of Key Personnel proposed to the COR shall have qualifications equal to or superior to the Key Personnel minimum requirements contained in the RFQ/RFP that resulted in this award. The Contractor shall submit those qualifications to the COR in writing (e.g., résumés, curriculum vitae) at least two (2) weeks (or as the COR otherwise agrees in writing) before Key Personnel may be replaced. Official approval of key personnel shall be made by the CO. No Key Personnel can be replaced without CO authorization and written notification from the COR.

Substitute Key Personnel must submit necessary clearance information before commencing performance and with sufficient lead-time to avoid a break in performance of the subject labor category.

1.12.4 Personnel Safety. Contractor shall fill vacant positions in a timely manner with qualified personnel consistent with the associated position.

1.12.5 Contractor shall have all positions filled at the start of the period of performance.

1.12.6 Ensure continuation of services during personnel absences due to sickness, leave, and voluntary or involuntary termination from employment such that impact to the Government is minimal.

1.12.7 Substitute/Replacement personnel:

1.12.8 For OCONUS locations, the Contractor shall fill the vacated position no later than thirty

(30) calendar days after the position has become vacant.

1.12.9 For CONUS location the Contractor shall fill the vacated position no later than fourteen

(14) calendar days after the positions has become vacant.

1.12.10 The Contractor shall promptly notify the CO and COR within two (2) calendar days of “awareness of” any projected vacancies.

1.12.11++ The contractor shall provide Patient Safety Assistant Coordinators for selected clinical services at the Captain James A. Lovell Federal Health Care Center that pertain to recruitment and dental functions only. The locations that fall under this contractor’s purview include:

USS Tranquility Branch Medical Clinic USS Osborne Dental Clinic USS Red Rover In-Processing Medical-Dental Facility Zachary and Elizabeth Fisher Medical-Dental Clinic

1.13 Data rights: RESERVED.

1.14 Reporting

1.14.1 Contractor Manpower Reporting (CMR): Contractor Manpower Reporting (CMR):

Please refer to DFAR 252.204-7023 REPORTING REQUIREMENTS FOR CONTRACTED SERVICES (JUL 2021) and DFAR 252.204-7023 REPORTING REQUIREMENTS FOR CONTRACTED SERVICES--ALTERNATE I (JUL 2021) which are incorporated into the Contract for specific manpower reporting requirement.

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 copy to the COR. See Attachment 7 – PWS 7.2 - DHA Form 49, DHA Contractor Non-Disclosure Agreement and PWS Part 7, Technical Exhibit 1 - CDRL 006 – DHA Form 49 NDA.

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 FAR 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.

1.15 Contractor Identification

1.15.1 Contractor personnel 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. All contractor personnel shall identify themselves as contractor support personnel in all forms of communication with all entities with whom DHA/Deputy Assistant Director for Acquisition (DAD-A)/Head of the Contracting Activity (HCA) has business dealings. The contractor shall: Answer all telephone calls and have a personalized voice message with an introductory statement that includes the fact that the person is contractor support personnel. Ensure all those with whom the person interacts in any face-to-face dealings while supporting the DAD-A understands that the person is contractor support personnel.

Include a title block in all emails that states the fact that the person is contractor support personnel. Ensure all those with whom the person interacts in any face-to-face dealings while supporting DHA/DAD-A/HCA understands that the person is contractor support personnel.

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 contract.

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)

1.16.1 FSO/Company's Security POC shall notify the DHA Personnel Security Office after being awarded a contract that requires access to a DoD system. Contractor personnel requiring access to the HA/DHA networks for performance of their tasks require a background investigation and the security awareness training. The contractor shall be prepared for this process as it could take two (2) or more weeks. The FSO/Security POC shall submit a Standard Form (SF) 85/86 to DHA's Personnel Security Office for a background investigation.

1.16.2 Company's FSO/Security POC must notify the Personnel Security Office when the contractor has submitted the SF-85/86. The FSO/Security POC, or the COR must notify the DHA Personnel Security Office in writing of a contractor's termination from the contract, including the termination date.

1.17 Personnel Security

1.17.1 The contractor shall comply with DoD 8140.03, Cyberspace Workforce Qualification and Management Program” February 15, 2023 as amended; 8500.01, “Cybersecurity”, dated October 7, 2019; DoD Manual (DoDM) 6025.18, “Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule Compliance in DoD Health Care Programs” dated March 3, 2019; Department of Defense Instruction (DoDI) 6025.18 “HIPAA Privacy Rule Compliance in DoD Health Care Programs”, dated March 13, 2019; and DoDM 5200.02 “Procedures for the DoD Personnel Security Program (PSP),” incorporation change 1, effective October 29, , 2020. Contractor responsibilities for ensuring personnel security include, but are not limited to, meeting the following requirements:

1.17.1.1 Follow the DHA Personnel Security Office guidelines for submittal of security clearances. Contact the DHA Personnel Security Office for guidance on the appropriate background investigation required for personnel on the contract. The DHA Personnel Security Office can be reached at (703) 681-2286.

1.17.1.2 Initiate, maintain, and document personnel security investigations appropriate to the individual’s responsibilities and required access to Controlled Unclassified Information (CUI).

1.17.1.3 DHA Personnel Security Office does not deny any access to any automated information system (AIS), network, or Controlled Unclassified Information (CUI). If a contractor receives an unfavorable background investigation, the request for access will be sent back to the FSO for further action. Any unfavorable adjudication will result in DHA Personnel Security Office not signing off on any access request.

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 CO 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 Nonpersonal 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. Government or active-duty personnel will not supervise or act as a supervisor to non-personal service contractors.

2.1.6 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 QASP or require the offerors to submit a proposed quality assurance surveillance plan for the Government’s consideration in development of the Government’s plan.

2.1.7 RESERVED

2.2 Acronyms:

AIS Automated Information System APL Approved Products List APL AQL Acceptable Quality Level ARRT Acquisition Requirements Roadmap Tool ATO Authority to Operate B2B Business-2-Business BAA Business Associate Agreement BE Bioenvironmental Engineering CAC Common Access Card CAP Cloud Access Point

CC Commander CCEVS Common Criteria Cybersecurity Evaluation and Validation

Scheme CCQAS Centralized Credentials Quality Assurance System CDI Covered Defense Information CDRLs Contractor Data Requirements List CE Computer Environment CDRL Contract Data Requirement List CFR Code of Federal Regulations CIO Chief Information Officer CIRB Critical Incident Review Board CJCSM Chairman of the Joint Chiefs of Staff Manual CMMC Cybersecurity Maturity Model Certification 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 CPAR Contractor Performance Assessment Reports CPG Clinical Practice Guideline CPHQ Certified Professional in Healthcare Quality CPMD Clinical Quality Management Division CQA Clinical Quality Assurance CQI Continuous Quality Improvement CQMD Clinical Quality Management Division CRRA Capabilities Review and Risk Assessment CSA Comprehensive Systematic Analysis CSP Cloud Service Provider CSSP Cyber Security Service Provider CUI Controlled Unclassified Information CVS Contractor Verification System DA Data Analyst DAD-A Deputy Assistant Director for Acquisition DC3 DoD Cyber Crime Center DD Form 254 Department of Defense Contract Security Requirement List (if applicable) DB Design-Build DBB Design-Bid-Build DFARS Defense Federal Acquisition Regulation Supplement DHA Defense Health Agency DHN Defense Health Network DISA Defense Information System Agency DoD Department of Defense DoDD Department of Defense Directive

DoDI Department of Defense Instruction DSAs Data Sharing Agreements DSAA Data Sharing Agreement Application DMHRSi Defense Medical Human Resources System - internet DMZ Demilitarized Zone DoD Department of Defense DoDD Department of Defense Directive DoDM Department of Defense Manual DPCLO DHA Privacy and Civil Liberties Office DSSR Department of State Standardized Regulations DUA Data Use Agreement ECOMS Executive Committee of the Medical Staff E/T Education & Training EMEDS Expeditionary Medical Support ERC En Route Care eMSM Enhanced Multi-Service Markets EULA End User License Agreement EVM Earned Value Management FAC Functional Accounting Code FAR Federal Acquisition Regulation FCI Federal contract information FE Facilities Enterprise FedRAMP Federal Risk Authorization and Management Program FISMA Federal Information Security Modernization Act FM Facility Management FMEA Failure Mode and Effects Analysis FOIA Freedom of Information Act FRCS Facility Related Control Systems FRED Functional Requirements Evaluator Designees FSO Facilities Security Officer FTE Full-Time Equivalent GFI Government Furnished Information GFE Government Furnished Equipment HA Health Affairs HAZMAT Hazardous Materials HEART Healthcare Event Analysis Response Team HCA Head of the Contracting Activity HFACS Human Factors Analysis and Classification System HFE Human Factors Engineering HIPAA Health Insurance Portability and Accountability Act HIT Health Information Technology HQ US/SG Headquarters United States Surgeon General HRO High Reliability Organization IA Information Assurance IAW In accordance with IG Inspector General

IGCE Independent Government Cost Estimate IHI Institute for Healthcare Improvement IM/IT Information Management/Information Technology IO Initial Outfitting I/O In/Out Processing Portal IP Infection Prevention IPv Internet Protocol Version IS Information System ISP Internet Service Provider IT Information Technology ISCM Information Security Continuous Monitoring IV&V Independent Verification & Validation JA Judge Advocate JKO Joint Knowledge Online JPSR Joint Patient Safety Reporting JPSRS Joint Patient Safety Reporting System MAJCOM Major Command MDG Medical Group MDGI Medical Group Instructions MedCOI Medical Community of Interest MEMO Medical Equipment Management Office MERC Medical Equipment and Repair Center MES Mission Essential Services MHS Military Health System MICT Medical Internal Control Toolkit MII Medical Incident Investigation MIL-STD Military Standard MLC Medical Law Consultant MTFs Military Treatment Facilities NAHQ National Association for Healthcare Quality NCR National Capitol Region NCQA National Committee for Quality Improvement NDA Non-Disclosure Agreement NEF Nurse Executive Function NEMC Nurse Executive Management Committee NIAP National Information Assurance Partnership NIST National Institute of Standards and Technology NLT No later than NOTAMS Notice to Airman NPSGs National Patient Safety Goals OASD (HA) Office of Assistant Secretary of Defense for Health Affairs OCONUS Outside Continental United States (includes Alaska and Hawaii) ODC Other Direct Costs OPM Office of Personal Management OSD Office of the Secretary of Defense PA Privacy Act

P-ATO Personal Authorization to Operate P&R Personnel and Readiness PCE Potentially Compensable Event PDT Project Delivery Team PGI Procedures, Guidance and Information PHI Protected Health Information PI Performance Improvement PII Personally Identifiable Information PIT Platform Information Technology PK Public Key PKI Public Key Infrastructure PMO Program Management Office POA&M Plan of Action and Milestones POC Point of Contact PoP Period of Performance PP Personal Property PPSM Ports, Protocols, and Services Management PRA Proactive Risk Assessment PRS Performance Requirements Summary PS Patient Safety PSC Patient Safety Consultant PSA Patient Safety Assistant PSAC Patient Safety Assistant Consultant PSDA Patient Safety Data Analyst PSP Patient Safety Professional (within this PWS) PSP Personnel Security Program (as applicable within the sentence) PSR Patient Safety Report PSS Patient Safety Specialist PWS Performance Work Statement QA Quality Assurance QAP Quality Assurance Program QASP Quality Assurance Surveillance Plan QC Quality Control QCP Quality Control Plan QM Quality Management RFP Request for Proposal RFQ Request for Quotation RM Risk Management RMF Risk Management Framework SDHA Secretary of the Air Force SEB Standard Evaluation Board SEV Safety Education Visits SG Surgeon General SGH/CMO Chief of Medical Staff SGH/CMOQ Clinical Quality Management Division SME Subject Matter Expert

SOFA Status of Forces Agreement SP Special Publication SPRS Supplier Performance Risk System SQL Structured Query Language SRM Sustainment, Restoration and Modernization SRG Security Requirements Guides STIG Security Technical Implementation Guides TeamSTEPPS® Team Strategies and Tools to Enhance Performance and Patient

Safety TJC The Joint Commission TMA Tricare Management Activity TOS Terms of Service UEI Unit Effectiveness Inspection US United States UFC Unified Facilities Criteria VPN Virtual Private Network XML Extensible Markup Language

2.3 Applicable Publications, DHA Administrative Instructions (AI), etc. : Additional NIST References and Related DoD Issuances. The references below support the IA requirements outlined in the following paragraphs.

Refer to the current versions of the following:

1. DoDI 6025.13

2. DHA-PM 6025.13 Clinical Quality Management

3. DHA-PM 6025.13 Implementation Guide

4. 48 CFR Parts 204, 212, and 252 as amended by 76 FR 69273 - 69282 /Vol. 78, No. 222

5. NIST Special Publication (SP) 800-53, in accordance with DFARS 252.204-7012

"Security and Privacy Controls for Federal Information Systems and Organizations"

6. NIST SP 800-53A, in accordance with DFARS 252.204-7012 "Guide for Assessing the

Security Controls in Federal Information Systems and Organizations"

7. NIST SP 800-37, in accordance with DFARS 252.204-7012 "Guide for Applying the

Risk Management Framework to Federal Information Systems"

8. NIST SP 800-34, in accordance with DFARS 252.204-7012 "Contingency Planning

Guide For Federal Information Systems"

9. DoDD 5230.09 "Clearance of DoD Information for Public Release," August 22, 2008.

10. DoDI 8510.01 "Risk Management Framework (RMF) for DoD Information Technology

(IT)," July 19, 2022

11. Health Insurance Portability and Accountability Act (HIPAA)

12. Security Standards, Final Rule," February 20, 2003

13. DoD 5400.11-R, DOD Privacy Program

14. DoD 5200.2-R, DoD Personnel Security Program

15. OMB M-06-16, Protection of Sensitive Agency Information

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 provide Government Furnished Services required in support of this contract. These Services are described below: The government will provide facilities, utilities, equipment, and materials as described below.

3.2 Facilities: The Government:

☒ WILL provide Facilities in support of this contract. The Government provided Facilities are described below: The MTF will provide a physical address/location of the building suite/ room/cubicle where the contractor needs to provide services such as desk space, telephones, computers/laptops, and other necessary items to maintain an office environment.

3.3 Utilities: The Government:

☒ WILL provide Utilities in support of this contract. The Government provided Utilities are described below: all utilities will be available for the contractors use in performance of taskers as outlined in this PWS.

3.4 Equipment: The Government:

☒ WILL provide Equipment in support of this contract. The Government provided Equipment is described below:

The Government will provide ancillary equipment to include telephones, facsimile machines, copiers and computer equipment to include laptops for use in performance under this contract.

This equipment is authorized for transaction of official Government business only and shall not be used for personal business. Telephones, facsimile machines and computer equipment to include laptops are subject to communications security monitoring at all times. Contractor and subcontract employees may be issued keys signed for at scheduled and unscheduled key control inspections. The contractor shall be required to reimburse the Government for lost keys, or lockset (if lockset is required to be replaced) as a result of lost keys. The cost of replacement of keys/locksets may be deducted from payments to the contractor. Items issued will remain the property of the Government and the contractor will maintain proper accountability of issued equipment. Equipment shall not be removed from the facilities shown in paragraph 3.2 above, unless otherwise specified in the PWS. They are to be used, turned in and/or disposed of as directed by the COR or CO. Government laptops will also be provided for the 3 DHA full remote Patient Safety Consultant (PSC) positions and 1 Contract Manager (CM). Laptops furnished to the 3 DHA PSC/1 CM full remote contractors must be tracked by the Contractor for accountability. Telework is permissible within this contract with approval of the COR and Contractor supervisor.

3.4.1 Procurement Integrated Enterprise (PIEE), GFP Module Application The contractor shall be responsible for obtaining and maintaining access, training and successful operation of the PIEE/GFP Module application for the entirety of the contract PoP. The PIEE GFP Module application is located at the following website: https://wawf.eb.mil/piee-landing/.

Access to PIEE/GFP Module application training materials and in-depth information applicable to the contractor’s responsibilities regarding GFP can be found at the…