TQMC_Section_C_PWS_3-10-15.docx

SECTION C, DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

TRICARE Quality Monitoring Contract (TQMC) Description/Specifications/Work Statement

1.0 GENERAL

1.1 SCOPE

The Defense Health Agency (DHA), formerly known as the TRICARE Management Activity (TMA), supports the delivery of integrated, affordable, and high quality health services to 9.5 million beneficiaries of the Military Health System (MHS) and is responsible for shared services, functions, and activities of the MHS and other common clinical and business processes in support of the Military Services. The DHA serves as the program manager for the TRICARE health plan, medical resources, and the market manager for the National Capital Region (NCR) Enhanced Multi-Service Market (eMSM).

1.1.1 The MHS is a complex integrated healthcare system that consists of healthcare delivery, medical education, public health, private sector partnerships and innovative medical research and development. The MHS has two major care delivery systems. The direct care system provides care through military treatment facilities (MTFs). The purchased care system provides care through private sector contractors, including the Designated Providers (DP) under the Uniformed Services Family Health Plan (USFHP), the three managed care support contractors (MCSCs), the TRICARE Overseas Program (TOP) contractor, the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC), TRICARE Dental Program (TDP) and the pharmacy contractor.

1.1.2 This contract meets the regulatory requirements of TRICARE’s Quality and Utilization Peer Review Organization Program (Code of Federal Regulations 32 CFR 199.15; and DOD Instruction and Manual 6025.13, Medical Quality Assurance and Clinical Quality Management in the Military Health System.

1.1.3 The purpose of this contract is to assist the Clinical Support Division (CSD) in assessing and improving the quality of care delivered under the TRICARE benefit across the direct and purchased care systems. This contract will assist DHA in decreasing unwarranted variation, implementing proven clinical and business practices, and creating an environment for learning and continuous improvement across the MHS. This contract will also support DHA with the management of clinical quality performance measurement to validate the quality of care.

1.1.3.1 TRICARE quality monitoring is accomplished through a variety of tasks supporting the direct care and purchased care systems. These include unbiased data collection, analysis and reporting of clinical quality measures, and comparison with national healthcare benchmarks; reviewing, evaluating, and reporting on published clinical care studies, evolving practices, and other data to identify superior quality healthcare services and recommend means to transfer successes; and conducting comprehensive, timely medical peer reviews to ensure medically appropriate healthcare is provided.

1.2 DIRECT CARE: Direct care is provided at military hospitals and military medical clinics worldwide. Oversight of these facilities is provided by each military Service headquarters command. The scope of work for direct care includes the following:

1.2.1 Conducting clinical quality studies within the direct care system, which DHA identifies as having significant importance to the MHS mission and beneficiaries.

1.2.1.2 Collecting, submitting and presenting the National Hospital Quality Measures data for comparative analysis with healthcare organizations nationwide and to support the accreditation of Department of Defense (DOD) hospitals.

1.2.1.3 Collecting, analyzing and displaying MHS clinical quality measures data with nationally comparable benchmarks in support of the MHS Strategic Plan.

1.2.1.4 Conducting external reviews of MTF Standard of Care (SOC) cases.

1.3 PURCHASED CARE: Purchased care is provided worldwide. The scope of work for purchased care includes the following:

1.3.1 Conducting clinical quality studies within the purchased care system, which DHA identifies as having significant importance to the MHS mission and beneficiaries.

1.3.2 Conducting reviews of medical, surgical and mental health cases to determine the medical necessity and appropriateness of care provided.

1.3.3 Assessing evolving practices, devices, medicines, treatments and procedures.

1.3.4 Certifying behavioral health facilities.

1.4. MHS CARE: The scope of work applies to the entire MHS (both direct and purchased care systems) and includes the following:

1.4.1 Conducting clinical quality studies, which cross both systems of care and DHA, identifies as having significant importance to the MHS mission and beneficiaries.

1.4.2 Accessing, analyzing, and reporting health plan quality data for both systems of care for comparative analysis with national benchmarks.

1.4.3 Conducting monthly, interactive, web-based seminars focused on clinical quality topics that promote knowledge transfer and the sharing of best practices in healthcare quality and safety.

1.5 OBJECTIVES: The objective of this contract is two fold: To support the MHS mission of greater integration of the direct and purchased care delivery systems, and the overarching support of the MHS’s Quadruple Aim of Rediness, Population Helath, Experience of Care, and Per Captia Cost.

1.5.1 The objectives below represent the expected performance outcomes for this contract and are supported by the technical requirements. The acceptable performance standards are explained further in the TRICARE Manuals, DOD policy and regulations,, and the contract. Where specific performance standards are not stated, the contractor shall use healthcare industry best practices.

1.5.2 The contract performance objectives are:

1.5.2.1 Provide timely and accurate independent and impartial evaluation of the healthcare provided to MHS beneficiaries to ensure quality of care, medical utilization and patient safety.

1.5.2.2 Provide timely, comprehensive reviews that are consistent with the TRICARE requirements to ensure that appropriate levels of healthcare are provided for all beneficiaries.

1.5.2.3 Measure, evaluate and compare clinical quality performance to national benchmarks to develop recommendations that transfer successes and identify superior quality healthcare services.

1.5.2.4 Support MHS initiatives for data transparency (Presidential Executive Order 13410, August 28, 2006; and Health Affairs Policy Memorandum for MHS Care Quality Assurance Data Transparency, dated October 20, 2010).

1.5.2.5 Use an effective management approach to provide the necessary services, incorporating best business practices when practicable.

1.5.2.6 Ensure all services and systems are fully operational at the start of the Option Year 1 with minimal disruption of services.

2.0 DOCUMENTS:

2.1 The following documents, including the changes identified below, are hereby incorporated by reference and made a part of the contract. These documents form an integral part of this contract. Documents incorporated into this contract by reference, have the same force and effect as if set forth in full text. The manuals and CFR 199 are located at http://manuals/tricare.osd.mil.

· Title 10, United States Code (USC), Chapter 55

· 32 (CFR), Part 199, Civilian Health and Medical Program of the Informed Services (CHAMPUS)

· TRICARE Operations Manual (TOM) 6010.6 –M, dated February 1, 2008 through Change ___

· TRICARE Policy Manual (TPM) 6010.57-M, dated February 1, 2008 through Change ____

· TRICARE Reimbursement Manual (TRM) 6010.58 M. dated February 1, 2008 through Change ___

· TRICARE Systems Manual (TSM) 7950.2-M dated February 1, 2008 through Change ___

· DOD Instruction 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS), as revised.

· DOD Manual 6025.13, Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System (MHS), as revised.

· Presidential Executive Order 13410, August 28, 2006;

· Health Affairs Policy Memorandum for MHS Care Quality Assurance Data Transparency, dated October 20, 2010

2.2 The TRICARE Manuals provide instruction, guidance and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations and may not be interpreted in contradiction thereto. Among the manuals, the TPM and the TRM are equal and take precedence over the TSM and TOM, and the TSM takes precedence over the TOM.

2.3 The TRICARE manuals are updated/revised frequently. TRICARE contractors will generally be provided the opportunity for comment prior to these updates/revisions. The contractor shall establish a business process to ensure that the most current versions of the TRICARE manuals (as implemented via contract modifications) are used by all contractor and subcontractor personnel in the performance of their duties in support of the contract.

3.0 DEFINITIONS AND ACRONYMS: Definitions and Acronyms are listed in the TRICARE Operations Manual, Appendix A.

4.0 GOVERNMENT FURNISHED EQUIPMENT (GFE) AND INFORMATION (GFI):

4.1. Government Furnished Equipment (GFE). The CSD Contracting Officer’s Representative (COR) will provide the contractor with laptop computers in a quantity sufficient to access MTF electronic medical records either remotely or on-site for data abstraction. These computers will remain the property of DHA at the end of the contract (Attachment J-24, Government Furnished Equipment List).

4.2. Government Furnished Information (GFI). The COR will assist the contractor with obtaining either paper or electronic copies of medical records or electronic access to medical records and data to meet specific requirements under this contract. The contractor shall maintain compliance with all Information Assurance (IA) and privacy requirements at all times.

4.3 The COR will assist the contractor with obtaining all required documentation and access to the healthcare quality data contained in the MHS Population Health Portal (PHP). The MHS PHP is a secure, web-based tool managed by the DHA, which contains administrative and clinical data for both the direct care (MTFs) and purchased care systems.

5.0 CONTRACTOR FURNISHED ITEMS:

5.1 The contractor shall furnish all necessary labor, facilities, systems, equipment, and supplies, and other items as required for the satisfactory performance of this contract.

5.2 The contractor shall ensure that all employees, consultants, and subcontractors supporting the TQMC sign the DHA Non-Disclosure/Non-Use Agreement, (CDRL: R080) before performing any work. The contractor shall also ensure that all staff understand and adhere to the terms of the non-disclosure statement, protecting all Health Insurance Portability and Accountability Act (HIPAA), Protected Health Information (PHI), Personally Identifiable Information (PII), and procurement sensitive information of the Government and the proprietary information of other contractors (see Section H, paragraph 2.).

6.0. TECHNICAL REQUIREMENTS:

These technical requirements represent specific tasks, outcomes, and/or standards to which the contractor that shall perform in support of the above objectives.

6.1. PROGRAM MANAGEMENT:

6.1.1 The contractor shall designate a single manager to oversee the tasks of this contract, supervise staff assigned to the tasks, and ensure that the tasks of the contract are performed efficiently, accurately, on time, and in compliance with the requirements of this document. The manager shall provide the COR with ongoing status updates of the tasks and any issues relating to the contract. The contractor shall establish and maintain sufficient and appropriate management, staff, management support services, resources and facilities necessary to achieve and maintain compliance with the requirements of this contract.

6.1.2 The contractor shall ensure all personnel, to include subcontractors, are qualified to perform their assigned responsibilities in terms of credentials, education, training and experience.

6.1.3 The contractor shall utilize a nationally recognized process to document its review and verification the credentials, and maintain current and accurate records, for all healthcare reviewers under this contract. The contractor shall conduct the credentials verification process when the reviewer is first considered for employment or contract, and at least every three (3) years after the individual has assumed reviewer responsibilities. The contractor shall ensure that all credentialed staff maintain the required qualifications and certifications while performing under this contract. Credentialing files shall be available for inspections and audit by the COR upon request.

6.1.4 The contractor shall obtain the services of actively practicing, board-certified, licensed doctors of medicine and osteopathy and dentists as necessary to perform the services of the contract. These professionals shall review services provided by the various MHS medical and dental specialties and subspecialties, as identified by the American Board of Medical Specialties, the Bureau of Osteopathic Specialists and the National Certifying Boards for Dental Specialties. Active participation means practicing a minimum of 20 hours per week.

6.1.5 Section J, Attachment J-21, TQMC Specialty Reviewer Types, provides historical information regarding specialty types utilized for reviews under this contract. The list is not all inclusive because DHA may require other types of reviews in the future. As an example, in the most recent contract, the services of a forensic pathologist were required for a review. If a review requires a specialty not previously identified the contractor may request a 30-day extension for the review to secure those specialty provider services.

6.1.6 The contractor shall provide actively practicing non-physician reviewers of all the provider types set forth in 32 CFR 199.6, TRICARE Authorized Providers.

6.1.7 The contractor shall have procedures and policies in place that shall ensure independent and objective reviews consistent with healthcare industry best practices.

6.1.8 Program Management Plan: The contractor shall develop a Program Management Plan (PMP) (CDRL AP030) for DHA’s approval. The PMP shall consist of control policies and procedures in accordance with standard industry practices for project administration, execution and tracking. The COR will use the PMP to validate whether the contractor’s performance is consistent with its PMP.

6.1.8.1. The contractor shall notify the Government of key milestones and issues that are directly related to the scope of the contract both verbally and in writing. At a minimum, the contractor shall address the following in its PMP:

· All technical activities (including documentation development)

· An estimate of the timing, duration and level of effort (by labor category) for all performance elements.

· A matrix of all personnel assigned to the program and total aggregate level of effort for each performance elements.

· Project plan with a detailed schedule that identifies all tasks and key milestones in a format agreed to by the COR. Quality assurance processes and monitoring methods.

· The contractor’s processes for notification to the Government of all government personnel resources, documentation, or any GFE required for accomplishing the performance elements.

· Risk identification, tracking and mitigation approach.

· The contractor’s process for tracking the status of the deliverables.

· The contractor’s plan to meet all DOD IA accreditation and certification requirements, Data Use Agreements, Authorization to Operate (ATO), and personnel clearances to access DOD data systems. (CDRL A020, DOD/NIST Certification Report).

6.1.9 Contractor Manpower Reporting: Enterprise-Wide Contractor Manpower Reporting Application (eCMRA). Annually, the contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for DHA via a secure data collection site. The contractor is required to completely fill in all required data fields at http://www.ecmra.mil/. Data will be for the labor executed during the period of performance for the fiscal year (FY), which runs October 1 through September 30. While data may be reported any time during the FY, the contractor shall report all data no later than October 31 of each calendar year, beginning with 2016. Contractors may direct questions to the eCMRA Help Desk at: http://www.ecmra.mil.

6.1.10 Monthly Progress Report (MPR) : By the 10th day after the end of each month, the contractor shall submit a MPR outlining the progress, status, any problems or issues encountered, and specific information on workload during the preceding month to substantiate the monthly invoice and services rendered in the previous month. (CDRL M060, Monthly Progress Report).

6.1.11. Quality Management: The contractor shall establish and continuously operate an Internal Quality Management Program (IQMP) covering every aspect of the contractor’s operation to ensure control, accuracy, and timeliness, effective at the start of Option Year 1 and continuing through the life of the contract.

6.1.11.1 The contractor shall assess its compliance with qualitative and quantitative standards, identify problems, and identify corrective actions planned or to be initiated. The contractor shall submit its IQMP plan 60 days prior to the start of Option Year 1 and shall update the plan annually in collaboration with the COR within 30 days following the start of each option year. The IQMP plan (CDRL AP020, Internal Quality Management Program Plan) will detail all aspects of the contractor's quality program including the major components of the program, quality control activities, quality assurance functions, risk management, organizational responsibilities for quality management, and how identified quality problems will be monitored and resolved. Quarterly, the contractor shall submit a report detailing its compliance with these quality program elements as described in its IQMP Plan(CDRL: Q080, Internal Quality Management Report).

6.1.12. Continuity of Operations Plan: The contractor shall prepare and submit a COOP to the Government ten (10) days after contract award, and shall maintain an up-to-date plan with annual submission (CDRL: AP010, Continuity of Operations Plan). The COOP shall document contractor plans and procedures to maintain DHA support should an actual disaster be declared affecting normal operations. The COOP shall include the following:

· A description of the contractor’s disaster management procedures and policy,

· A description of how the contractor will account for their employees during a disaster,

· Planned temporary work locations or alternate facilities,

· How the contractor will communicate with DHA during disasters,

· A list of primary and alternate contractor points of contact, each with primary and alternate:

· Telephone numbers

· e-Mail addresses,

· Procedures for protecting Government furnished equipment (if any),

· Procedures for safeguarding sensitive and/or classified Government information (if applicable) to include PHI and PII.

· Procedures for ensuring on time abstraction and submission of the Joint Commission (JC) ORYX® data.

6.1.12.1 The COOP shall be activated immediately after determining that a disaster has occurred, shall be operational within 12 hours of activation, and shall be sustainable until the disaster situation is resolved and normal conditions are restored or the contract is terminated, whichever comes first. In case of a threat to life, the COR shall immediately make contact with the contractor to ascertain the status of any contractor personnel who were located in Government controlled space affected by the disaster. When any disruption of normal, daily operations occur, the contractor and COR shall promptly open an effective means of communication and verify:

· Key points of contact (Government and contractor),

· Temporary work locations (alternate office spaces, telework, virtual offices, etc.),

· Means of communication available under the circumstances (e.g. email, webmail, telephone, FAX, courier, etc.),

· Essential work products expected to continue production by priority.

6.1.12.2. The Government and contractor must make use of the resources and tools available to continue DHA contracted functions to the maximum extent possible under disaster circumstances. Contractors must obtain approval from the COR and CO prior to incurring costs exceeding those allowed under the terms of this contract. Regardless of contract type, and of work location, contractors performing work in support of authorized tasks within the scope of their contract shall charge those hours accurately in accordance with the terms of this contract.

6.1.13. Meeting Attendance: The CO may require the contractor to participate in other MHS meetings, such as contractor roundtables, annual conferences, or summits. The contractor may participate in these meetings by telephone conference call, video telephone conference (VTC), or in person. If required, the CO may authorize the contractor to travel to attend a specific meeting(s) in person.

6.2. TRANSITION

6.2.1 Transition-In: The incoming contractor will have time critical tasks to perform during the transition that must be accomplished before the contractor can begin providing the required services on the first day of option year 1. The contractor may accomplish some of these tasks concurrently with others. However, there are certain tasks, which the contractor must accomplish and receive government approval before the contractor can proceed.

6.2.1.1 Transition-In Plan: The TQMC contractor shall submit a comprehensive Transition-In Plan to the Contracting Officer no later than 5 days following contract award (CDRL OT010, Transition-In Plan). The plan shall address all events and milestones that need to occur for each functional area described in this contract to enable the start of services under this contract. The plan will be used to manage, track and evaluate the contractor’s performance during transition. This plan shall clearly describe the contractor’s control policies and procedures in accordance with standard industry practices for project administration, execution and tracking to ensure a seamless transition.

6.2.1.2 Post-Award Conference. The contractor shall attend a post-award conference with the Contracting Officer and other DHA representatives at a location determined by DHA.

6.2.1.3 The contractor shall keep the COR informed on its progress during transition-in via a weekly report including key transition milestones and issues submitted in an electronic format and by a method (e.g., email, fax) agreed to by the COR during the post award meeting (CDRL W010, Transition-In Weekly Report).

6.2.1.4 The contractor shall coordinate with the incumbent contractor to transfer website content and all active files including, but not limited to National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS®), JC ORYX®, facility certification files,. The incumbent contractor shall organize the files and prepare a transmittal document detailing the status of record and the reason the record has been retained.

6.2.2. Transition Out:

6.2.2.1 The contractor shall develop Transition-Out Plan (CDRL OT020 ) for the COR’s approval. The contractor and COR shall use the Transition-Out Plan to manage, track and evaluate the contractor’s transition out performance.

6.2.2.2 The contractor shall complete all work assigned and all reconsideration appeal requests received during the option year to include all associated reports.

6.2.2.3 The contractor shall keep the COR informed on its progress during the transition-out phase via a weekly report submitted in a format and by a method (e.g., email, fax) agreed to by the COR prior to the post award meeting (CDRL W020, Transition-Out Weekly Report).

6.2.2.4 For all active files, the contractor shall organize the files and prepare a transmittal document detailing their status. The contractor shall package all data and documents to transfer to the incoming contractor(s) in an organized and orderly fashion, undamaged, and ready for immediate retrieval. The preferred method for transmission of all documents, files, and data is electronic, via CD/DVD or other secure means. Throughout the transition period (and NLT than the start of Option Year 1. the outgoing contractor shall answer in writing any questions from the incoming contractor and COR within 5 business days after receipt.

6.2.2.5. The contractor shall participate in any transition-out meetings between the Government and the incoming contractor(s).

6.2.2.6. The outgoing contractor shall transition all remaining contract data back to the Government as directed by the COR.

6.3 PERFORMANCE MEASUREMENT AND REPORTING

6.3.1 HEALTH PLAN CLINICAL QUALITY MEASURES (Direct and Purchased Care)

6.3.1.1 The MHS Population Health Portal (MHS PHP) contains MHS clinical quality data for outpatient performance measurement. Each month the contractor shall download MHS PHP data and then analyze and report health plan clinical quality measure data for all MTFs and purchased care network providers (CDRL Q010, Health Plan Data Reporting). DHA currently uses selected NCQA HEDIS® measures. DHA reserves the right to change its clinical quality measures as necessary to meet DHA’s mission. The contractor shall identify the appropriate national comparable performance/benchmark for each measure, observed trends and opportunities for improvement.

6.3.1.2 The contractor shall post Health Plan Clinical Quality Measures data on the DHA-designated secure web site. DHA CSD shall determine authorized users.

6.3.1.3 In order to support MHS transparency initiatives, the contractor shall post MHS PHP data analysis with display (i.e. statistical process control charts, bar graphs, line charts) by MTF, Service, Region, eMSM, DP and MHS level.

6.3.1.4 The contractor shall be, or retain the services of, an NCQA-certified vendor to perform an annual HEDIS® Compliance Audit of the MHS Population Health Portal of DHA selected HEDIS® measures (CDRL A010, HEDIS Audit).

6.3.2 NATIONAL HOSPITAL QUALITY MEASURES (NHQM) (Direct and Purchased Care):

6.3.2.1 Centers for Medicare and Medicaid Services (CMS) Hospital Compare Measures.

6.3.2.1.1 Each quarter the contractor shall download National Hospital Quality Measures (NHQM) data from the CMS Hospital Compare website for all participating facilities. The contractor will then identify whether each facility is a participating purchased care provider in order to analyze and compare facilities by any given region. Additionally, the contractor shall provide a raw data file for the corresponding geographical area to each TRICARE Regional Office (TRO) in order for the TRO to conduct further analysis (CDRL Q050, National Hospital Quality Measures Raw Data File).

6.3.2.1.2 Each quarter, the contractor shall download inpatient MTF NHQM data from the DHA-designated database to compare with purchased care and direct care hospital quality performance and national quality benchmarks.

6.3.2.1.3 There are additional NHQM data that are not currently in the DHA-designated database for inpatient MTFs. Therefore, the contractor shall conduct chart abstraction of inpatient MTF medical records to obtain data for any remaining Hospital Compare ‘Timely and Effective Care’ measures in order to compare with civilian network Hospital Compare quality performance and national quality benchmarks. The contractor may use the most cost effective means available to access each inpatient MTF’s medical data.

6.3.2.1.4 The contractor shall develop a quarterly report and briefing for presentation which includes a comparative analysis between DOD and national performance for each quality measure complete with displays by MHS, direct care and by purchased care (CDRL Q060, National Hospital Quality Measure Reports).

6.3.2.1.5 The contractor shall provide all analyses to the COR and other authorized recipients via a secure website. The contractor shall also include graphical displays (i.e. statistical process control charts, bar graphs, line charts) stratified by MHS, direct care (inpatient MTFs, Service branch, eMSM, and purchased care (TRO, and DP) (CDRL M010, Secure Web Portal).

6.3.2.1.6 The contractor shall submit inpatient MTF “Timely and Effective Care” measures data to CMS for inclusion in the Hospital Compare database.

6.3.3 JOINT COMMISSION ORYX® HOSPITAL QUALITY MEASURES (Direct Care)

6.3.3.1 Each quarter the contractor shall abstract medical records to obtain, analyze, display and report the data for all approved Joint Commission ORYX® core measures (12 sets currently available) for all inpatient MTFs (CDRL Q020, ORYX® Data Reporting). The contractor shall use the most cost effective means available to access each inpatient MTF’s medical data.

6.3.3.2 The contractor shall use the ORYX® methodology to identify the applicable patient population for each core measure and define the appropriate data collection process. In addition, the contractor shall continue each quarter’s data collection for a subsequent quarter and submit any additional cases meeting the ORYX® methodology to the Joint Commission.

6.3.3.2.1. The contractor shall make the data available in the JC vendor website so users can drill down to the patient level. The contractor shall also provide data analysis with display (i.e. statistical process control charts, bar graphs, line charts) for each participating MTF, the Services/NCR, and MHS level. The contractor shall also provide data for national comparative benchmarks. The contractor shall note and share best practices across the MHS. For measures in which any MTF is significantly below national performance rates as identified in quarterly reports, the contractor will review the healthcare quality or other relevant literature to identify best practices and provide the information to CSD, Service representatives, and the MTF(s).

6.3.3.3 Not later than 90 days after the JC’s release of new National Hospital Measure Sets, the contractor shall review and inform to CSD the applicability to inpatient MTFs, the volume of patient records for the past year that would meet the specifications for the new measures, and the proposed data collection processes.

6.3.3.4 The contractor shall ensure the MTF-specific patient level data created from measure data collection and analysis are available to authorized users as determined by CSD and Service Quality Leaders. There will be approximately 300 users authorized to access this ORYX® data.

6.3.3.5 The contractor shall prepare a quarterly report complete with presentation briefing which includes a comparative analysis between the national performance rates and benchmarks for each clinical performance measure. (CDRL Q030, ORYX® Data Submission)

6.3.3.6 The contractor shall submit the MTFs’ ORYX® Core measure data according to Joint Commission criteria (CDRL Q030, ORYX® Data Submission) to support MTF JC accreditation. The contractor shall be, or retain the services of, a JC-certified vendor to submit the inpatient ORYX® data. If the contractor fails to submit ORYX® data on time, DHA shall assess the penalty identified in Section H, paragraph 1.

6.3.3.7 Annually, the contractor shall coordinate with the inpatient MTFs and the clinical quality leaders for each Service to select JC ORYX® core measures for submission to the Joint Commission to ensure a successful transition to any new core measure sets.

6.3.3.8 DHA does not currently have the capability to transmit ORYX® e-measures but reserves the right to add this capability in the future.

6.3.4. INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI) GLOBAL TRIGGER TOOL (GTT) (Direct Care)

6.3.4.1 Using the IHI GTT and methodology to identify any triggers and resultant harms, to include the level of harm associated with the trigger analysis, the contractor shall randomly select and review 10 inpatient charts every 2 weeks from each of the inpatient MTFs. The contractor may use the most cost effective means available to access each inpatient MTF’s medical data.

6.3.4.2 If the COR determines access to medical records is limited, the contractor may alternatively review 20 charts once each month. Information on the IHI GTT can be found at http://www.ihi.org/resources/Pages/IHIWhitePapers/IHIGlobalTriggerToolWhitePaper.aspx.

6.3.4.3 The contractor shall utilize fully trained and experienced clinical staff as defined in Section J, Attachment J-22, IHI Global Trigger Tool White Paper, to quickly and efficiently perform the chart reviews.

6.3.4.4 The contractor shall develop and provide each inpatient MTF with a monthly report of identified triggers and identified harms by trigger and category. In addition, the contractor shall submit a consolidated control chart of progress over time to include Adverse Events per 1,000 Patient Days; Adverse Events per 100 Admissions; and Percent of Admissions with an Adverse Event (CDRL M020, Global Trigger Tool-MTF Report).

6.3.4.5 The contractor shall provide a monthly report of GTT data for each military Service and NCR Medical Directorate (MD) as well as for the direct care system (all Services and NCR-MD). The contractor will list individual data for each site, and aggregating data by trigger and category. In addition, the contractor shall include a control charts listing of Adverse Events per 1,000 Patient Days; Adverse Events per 100 Admissions; and Percent of Admissions with an Adverse Event (CDRL M030, Global Trigger Tool – Service, DHA and System Level Reporting).

6.3.4.6 Beginning Option Year 1, the contractor shall conduct a monthly teleconference with each inpatient MTF (approximately 54 per month) to review its data, and offer the MTF the opportunity to ask questions about their data and receive education regarding the GTT and what their data shows. For Option Year 2, the contractor shall conduct quarterly teleconferences (approximately 54 per quarter) with the inpatient MTFs. For Option Year 3, the contractor shall conduct teleconferences on an as-needed basis, in coordination with each MTF. The contractor shall develop a monthly “Frequently asked Questions (FAQ)” report based upon the outcomes of these teleconferences (CDRL M040, Global Trigger Tool-FAQ Report).

6.4. BEHAVIORAL HEALTH FACILITY CERTIFICATION (Purchased Care) The contractor shall determine whether network Residential Treatment Centers (RTC), freestanding Substance Use Disorder Rehabilitation Facilities (SUDRF) and freestanding Psychiatric Partial Hospitalization Programs (PHP) meet TRICARE requirements for authorized provider status in accordance with the provisions of 32 CFR 199.6 and the TPM, Chapter 11. The contractor will review each facility’s initial certification or recertification application and recommend approval or disapproval to DHA. The contractor shall maintain a current listing of available mental health facilities (Section J, Attachment J-11, Mental Health Facility Certification Listing) and provide this list monthly to the DHA (CDRL M050, Behavioral Health Certification List).

6.4.1 After receiving the facility’s initial application, the contractor shall calculate the facility’s initial reimbursement rates for RTCs, using the methodology in the TRM, Chapter 7. The contractor will note this rate on the facility’s TRICARE participation agreement in accordance with Section J, Attachment J-7, Behavioral Health Facilities.

6.4.2 The contractor shall conduct reconsiderations of denials for facility initial certifications or re-certifications in accordance with Section J, Attachment J-7, Behavioral Health Certification.

6.4.3 The contractor shall provide the technical and professional expertise to perform and report its on-site review of behavioral health facilities (CDRL R030, Assessment Reports of Behavioral Health Facilities). The contractor shall evaluate the qualifications and capabilities of designated facilities to provide specialized behavioral health treatment that complies with 32 CFR 199.6 and TPM, Chapter 11, Addendum H. The COR will determine which facilities the contractor will visit based on the processed applications, utilization and customer complaints or comments regarding facilities. Most reviews will be unannounced. Based upon its findings, the contractor will recommend to DHA whether to certify or decertify the facility. If the results indicate an imminent threat to beneficiary safety, the contractor shall notify the COR as soon as possible, but no later than the next business day.

6.4.4 The contractor shall provide an on-site review team composed of the appropriate professional expertise to meet the facility review requirements. The team members shall meet the qualifications for their respective provider type, consistent with 32 CFR 199.6. The COR shall approve the composition of the review team for each site visit. DHA anticipates each review will require 2 days on-site. Based on the required elements for review, a facility certification or recertification on-site team historically has consisted of a psychiatrist, a licensed clinical social worker and a licensed psychiatric advanced practice nurse. DHA estimates there will be approximately 20 behavioral health on-site facility reviews per year.

6.5 MEDICAL REVIEWS

The contractor shall perform the following types of medical reviews: Medical Necessity (Reconsideration) Appeal Case Reconsiderations (both Internal and External –see Attachment J-6 Part 1, Description of Internal and External Reviews), MTF Standard of Care Malpractice Reviews, Active Duty Service Member (ADSM) Standard of Care (SOC) Reviews, and CO-directed Quality of Care (QOC) Reviews.

6.5.1 QUALITY AND UTILIZATION REVIEWS (Purchased Care):

The following applies to all purchase care medical record reviews. The contractor shall review each purchased care medical record in accordance with 32 CFR 199.15 as follows:

6.5.1.1 The contractor shall review medical, surgical, and mental health cases to determine the medical necessity and appropriateness of care. To carry out this review, the contractor shall use generally accepted standards, norms and criteria for medical necessity appropriateness. The contractor shall identify cases of potential inappropriate medical care and potential preventable care and admissions that are not a TRICARE benefit. The contractor shall complete all case reviews within 30 days of receipt of the medical record from the purchased care contractor.

6.5.1.2 For each case selected for review by DHA, the contractor shall review whether the respective purchased care contractor is performing pre-authorizations and retrospective and prepayment review, consistent with TOM, Chapters 7 and 13.

6.5.1.3 The contractor shall report potential cases of fraud and abuse, consistent with 32 CFR 199.9. Potential cases of fraud and abuse shall be referred to the DHA Program Integrity Office, in accordance with TOM, Chapter 13.

6.5.1.4 If the selected case is covered by the Diagnostic Related Group (DRG) payment system or the Skilled Nursing Facility (SNF) Prospective Payment System, the contractor shall review the medical record to determine if the diagnostic and procedural information match the discharge status per TRM, Chapter 8, Section 2.

6.5.1.5 The contractor shall apply appropriate quality screens and medical judgment to identify potential quality issues. These quality reviews shall utilize both process and outcome measures that focus on deficiencies in the delivery of healthcare that result in an adverse effect on the patient. For example, if reviewing potential adverse drug events, the contractor will use industry best practice tools, such as the Institute for Healthcare Improvement (IHI) Adverse Drug Event Trigger Tool, Agency for Healthcare Research and Quality (AHRQ) tools or others as identified by the contractor in their IQMP Plan (CDRL AP020, Internal Quality Management Program Plan). If the contractor changes its quality review process or tools, then the COR shall review these changes prior to contractor’s implementation.

6.5.1.6 If the contractor reviews a purchased care medical record in accordance with Section C, paragraph 6.5.1.1., and the contractor identifies a potential quality issue, the contractor shall perform peer review, which is the assessment of the quality of medical care carried out by a healthcare professional, including any such assessment of professional performance. The contractor shall retain the services of a board-certified licensed physician, who is actively practicing in the clinical area being reviewed, to confirm potential quality issues, utilization concerns, inappropriate medical care or preventable admissions. The contractor shall complete the peer review within 45 days of receipt.

6.5.1.7 At least 30 days prior to the start of each option year, the contractor shall obtain the TRICARE DRG Grouper software, developed by Health Information Systems, 3M Health Care and the Resident Assessment Validation and Entry (RAVEN) system, products by the Centers for Medicare and Medicaid Services (CMS).

6.5.1.8 A data dictionary for the DP-selected cases is provided at Section J, Attachment J-4, M2 Data Dictionary. Additionally, the data fields from TRICARE Encounter Data (TEDs) for the MCSC-selected cases are provided at Section J, Attachment J-3, MDR Data Dictionary.

6.5.1.9 Quarterly, the contractor shall provide an analysis to each purchased care contractor of quality issues, utilization concerns, coding irregularities, suspected fraud and abuse, inappropriate medical care, preventable admissions, and care that is not a TRICARE benefit. This analysis shall be of sufficient detail that the respective purchased care contractor is able to understand the concerns and respond to the findings. The purchased care contractor shall have an opportunity to review the issues identified and must respond in writing to issues within 45 calendar days of this report per TOM Chapter 7, Section 3.

6.5.1.10 The contractor shall track and report to CSD the purchased care contractors’ performance regarding the submittal of selected medical records to the reviewer and their responses to the issues (TOM Chapter 7, Section 3). (CDRL Q070, Purchased Care Contractor Performance Report).

6.5.2 MEDICAL NECESSITY RECONSIDERATION REVIEWS (SECOND LEVEL APPEALS) (Direct and Purchased Care):

6.5.2.1 The contractor shall conduct medical necessity reconsideration reviews and issue decisions per TOM Chapters 12 and 24. These reviews and decisions shall be in accordance with the waiver of liability provisions in TPM Chapter 1, Section 4.1 These reviews shall include medical necessity appeals from the purchased care contractors identified in paragraph 1.1.1, and MTFs (including those from ADSMs).(CDRL R020, Medical Necessity Reconsideration Reviews (Second Level Appeals)).

6.5.2.2 The contractor shall process medical necessity pharmacy appeals in accordance with TOM Chapter 12, Sections 3 and 4.

6.5.2.3 For locations outside the continental US (OCONUS) the contractor shall consider the standard of care available in the location when providing medical necessity reconsiderations and second level appeals per TOM Chapter 24. The contractor shall not be responsible for translation of medical records in support of the appeals process.

6.5.3 INTERNAL/EXTERNAL REVIEWS (Direct and Purchased Care):

6.5.3.1 The contractor shall conduct internal and external case reviews to assist the Office of General Counsel (OGC) Appeals and Hearings (See Section J, Attachment J-6, Part 1, Description of Internal and External Reviews)(CDRLs: R070 and R090). The contractor shall also provide peer reviewers to serve as expert witnesses for medical appeal administrative hearings and proceedings (See Section J, Attachment J-6, Part 2, Witness Hearing, Trial Attendance, Discovery, and Attendance at DHA Conferences-Ordering Process).

6.5.3.2 When CSD requires medical reviews for a former service member enrolled in the TRICARE Transition Assistance Management Program (TAMP), the CO shall issue a task order to the contractor to review the beneficiary’s records. The contractor shall provide a board-certified licensed physician in the appropriate medical specialty for the beneficiary’s medical condition who will determine if the medical condition can be fully resolved in an extra 180-day period of coverage under TAMP per TOM Chapter 17, Section 3, paragraph 2.5. DHA estimates there will be fewer than five per year.

6.5.4 STANDARD OF CARE (SOC) (CDRL R010, Standard of Care (SOC) Reviews /Quality of Care (QOC) Reviews) (Direct Care):

Direct care SOC reviews are external reviews of MTF cases in which the military Service initially determined an adverse event was not the result of any MTF practitioner’s failure to meet the standard of care in effect when the event occurred. At the request of the military Services Risk Management Offices, the contractor shall conduct external reviews of paid malpractice claim cases in which the military Service’s preliminary determination is that the malpractice payment was not caused by failure of any practitioner to meet the standard of care. The contractor shall complete SOCs reviews in accordance with DOD Manual, 6025.13, Enclosure 9, Section 2. The contractor shall complete the SOC review within 30 days of receipt of the record from the respective Service. A 15-day extension may be requested if needed documentation is missing or the contractor lacks a particular specialty reviewer not identified previously to the contractor.

6.5.4.1 When the case involves a physician, the contractor shall provide a board-certified licensed physician peer reviewer with an active clinical practice in the same specialty as the physician whose care is being reviewed.

6.5.4.2 If the case involves a non-physician provider, the contractor shall provide a practitioner peer reviewer of the same type specialty provider as the provider whose care is being reviewed.

6.5.4.3 Any peer reviewer shall limit his/her determination to his/her specialty or area of qualification. The contractor’s peer reviewer(s) shall not be required to testify.

6.5.4.4 When a case involves more than one specialty, the contractor shall prepare a separate report for each specialty. Each specialty report is considered a separate review.

6.5.4.5 Although the Feres Doctrine prohibits ADSM from filing a malpractice claim, the Services review unexpected injuries or adverse patient outcomes in ADSMs for SOC determinations, including those cases that result in the payment of a disability claim or death benefit. The contractor shall complete these SOC reviews in the same manner as those involving paid malpractice claims.

6.5.5 QUALITY OF CARE REVIEWS (CDRL R010 Standard of Care (SOC) Reviews /Quality of Care (QOC) Reviews) (Direct and Purchased Care): A quality of care review is done when DHA identifies a quality concern regarding care provided within the MHS. The contractor shall conduct these reviews in the same manner as SOC reviews.

6.5.5.1. The contractor shall treat all information involved in the standard of care and quality of care review process as quality assurance information which is confidential, non-releasable, and protected in accordance with TOM Chapter 7 and DOD M 6025.13, Enclosure 2.

6.6 QUALITY IMPROVEMENT STUDIES:

6.6.1 CLINICAL QUALITY IMPROVEMENT STUDIES (Direct and Purchased Care):

A quality improvement study is an assessment of a patient care problem for the purpose of improving patient care through peer analysis, intervention, resolution of the problem, and follow-up. The focus of the studies is to improve MHS performance and not the development of generalizable knowledge. Studies may be specific to direct care, purchased care or the entire MHS. Clinical Quality Studies may be performed using data obtained via administrative means utilizing DHA databases and/or medical record abstraction.

6.6.1.1 Any purchased care medical record reviewed during the course of performing a clinical quality improvement study shall follow the requirements of 32 CFR 199.15 as stated in paragraph 6.5.1.

6.6.1.2 The CO will issue a task order for a specific study topic to the contractor to collect, measure, synthesize, analyze, report findings and formulate recommendations based on prevailing healthcare standards and evidence-based practices. The contractor may use the most cost effective means available to access each inpatient MTF’s medical data. The contractor shall produce a study report comparable to the quality of performance improvement studies presented in professional medical healthcare literature (CDRL R050, Quality Improvement Studies).

6.6.1.3 The contractor shall propose at least twelve quality improvement study topics per year for DHA’s consideration based on a thorough review and analysis of information gathered from HA, DHA, the Services and purchased care contractors. The contractor may also recommend study topics based on current trends in the healthcare industry, findings from previous MHS quality improvement studies, or the results of outcome measures from MHS data. The contractor shall also recommend study topics for the purpose of evaluating the quality of care provided across the entire MHS as an integrated healthcare system. DHA estimates there will be two quality improvement studies per year.

6.6.1.4 For all purchased care medical records reviewed in the performance of a quality improvement study, the contractor shall apply appropriate quality screens and medical judgment to identify potential quality issues. These quality reviews shall utilize both process and outcome measures that focus on deficiencies in the delivery of healthcare that result in adverse effects on the patient.