IHS-25-RFI-DraftSOW-1493358.pdf

IHS-25-RFI-DraftSOW-1493358

SCOPE OF WORK

Draft: Indian Health Service Healthcare Leadership and Management Support Contract

1. Purpose: The purpose of this contract is to provide expertise in the areas of hospital leadership mentoring, including the executive team (C-suite), support maintenance of The Joint Commission (TJC) accreditation standards and elements of performance (EPs) and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) within the Indian Health Service (IHS) system, and provide development of organizational gap analysis to improve and sustain hospital accreditation and compliance with CoPs, including, but not limited to leadership and governance, infection prevention and control, patient safety, plant facility safety (environment of care and life safety standards) the credentialing and privileging, nursing, laboratory, radiology and Quality Assessment and Performance Improvement (QAPI) functions, according to accreditation standards and EPs and CoPs (further referred to as accreditation support).

2. Scope: Provide 2-3 expert consultants to provide daily on-site support at multiple facilities (up to 4 facilities at a time) with: accreditation and CoP support, leadership and management development, project management of initial gap analysis and education at sites within the IHS federally operated hospitals, critical access hospitals and ambulatory care centers as well as providing support to Area and Headquarters staff related to the functions of this contract.

3. Period and Place of Performance: Work shall be performed at Indian Health Service facilities across the United States. Should COVID-19 or other public health emergency restrictions at the local, state, or national level preclude travel to necessary facilities, the work shall be temporarily performed virtually until conditions permit travel. The Period of Performance shall be 1 Base Year of 12 months and four 12-month option years.

4. Contract Format/Type: TBD

5. Background: The Indian Health Service (IHS) provides ambulatory health services to Tribal nations across the United States. The user population is approximately 2.56 million American Indians and Alaska Natives. These primary, specialty, oral health, and inpatient behavioral health services occur in 24 hospitals, 51 ambulatory health care centers, and 6 Youth Regional Treatment Centers (YRTCs provide behavioral health inpatient services). IHS healthcare facilities are accredited and/or certified to incentivize delivering high-quality, safe, evidence-based care and support third-party billing for eligible patients. IHS’s mission is “to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.”

The IHS has experienced issues maintaining accreditation and quality of care at individual facilities, resulting in losing facility accreditation or the threat of loss. To address these issues, IHS has utilized site-by-site contract support and various strategies to support facility leadership in ensuring they can meet IHS’s mission. While positive results have been achieved, a more comprehensive approach with a contract prepared in advance of accreditation issues being identified is essential to more effectively addressing problems when identified and ensuring that a mechanism for ongoing support and engagement is available to ensure Facility, Area, and Headquarters can maintain the highest medical quality standard.

6. Objectives:

The Indian Health Service requires a Contractor that can provide onsite support to between 1 to 4 sites within the Indian Health Service system simultaneously, geographically disbursed across the continental United States. Support shall involve approximately 2 to 3 full-time staff equivalents engaged full-time at each site during engagements, with specialists providing expertise on a more limited basis.

7. Task Areas:

7.1 Task Area 1- Facility Support:

The Contractor shall be required to provide customized support to individual Indian Health Service facilities as identified by IHS. The services within this task area include the following:

7.1.1 Conducting onsite validation of each facility’s compliance with the Centers for Medicare & Medicaid Services (CMS) or The Joint Commission (TJC), as appropriate, on an annual basis with a gap analysis of vulnerabilities and a corrective action plan (CAP) presented to facility, service area and HQ leadership, including trending issues/challenges across entities and providing a “roll-up” report to service areas and HQ - this will help the system understand where there may be systemic issues across the enterprise that shall enhance proactive responses.

7.1.2 Providing ongoing support for resolution of issues identified in the CAP, working with Facility, Area, and Headquarters staff to complete CAP items. These shall include, but are not limited to:

Assessing survey readiness, conducting mock surveys, or preparing for review by other oversight organizations, including OSHA, NFPA, CDC, ACOG, AWHONN, AORN, AAMI, ISMP, etc. Review facility infrastructure, including food services.

Providing facility leadership mentoring, including the Chief Executive Officers (CEO), Chief Medical Officers (CMO), Chief Operating Officers (COO), Chief Nursing Officer (CNO), Office of Environmental Health and Engineering, Life Safety Officers, laboratory and others hospital services as appropriate. This would include, but not be limited to, face-to-face provider education regarding the Restraint and Seclusion process and policy, nursing services, and communications and leadership issues.

Conducting medical quality review, review of medical staff credentialing, and clinical documentation improvement. This shall include expert consultation to evaluate the quality and performance of the IHS and its ability to meet standards of care, including but not limited to review of medical information and personnel information and the production of written reports and other briefing materials, both for internal and external audiences.

Any reviews require the contractor staff to ensure all IHS and patient data is confidential and complies with the Privacy Rule published to implement the Health Insurance Portability and Accountability Act of 1996 requirements and all other relevant patient privacy laws and regulations. IHS information is not subject to disclosure by contractor staff except as permitted or required by law or regulation.

Providing specialized expert consultation in areas such as, but not limited to, infection prevention, central sterile processing, the environment of care, life safety, and ambulatory care.

Helping establish and maintain a process for identifying and resolving adverse events, problems, and resolutions. This shall include a patient advocate program, a complaint and Grievance program, and a root cause analysis using IHS's established process.

Reviewing facility communication, accountability, and processes. Support activities shall include, but are not limited to, project management, communication workshops, process redesign, and identifying accountability challenges.

Reviewing facility-level policy and procedure reviews/revisions, including sustainability.

Review and validate training and staff competencies.

Supporting Quality Assessment/Performance Improvement (QA/PI) efforts, including quality team development and support, including the Quality Scorecard.

Addressing specific Departmental or programmatic issues and assist the facility in addressing them as identified.

Conducting transition planning activities after engagements to ensure Contractor efforts are integrated into federal operations.

7.2 Task Areas 2- Facility Governance and Governing Body’s (GB) Support

Under this task area, the contractor shall perform the following activities:

The contractor shall review current GB practices at each level to develop a concrete understanding of GB operations, function, and, most importantly, value to attendees.

The contractor shall define and educate on each level's core GB roles and responsibilities constructs.

The contractor shall determine what information is appropriate and necessary at the local level and what information is then required for communication to the service area and ultimately to the HQ level. This shall include, but is not limited to:

o Quality and safety information.

o Medical staff information, including credentialing/privileging o The level of detail should be appropriate to the level of review: details not necessary at the service and HQ level; however, anomalies or significant outliers should be discussed).

o Regulatory compliance.

o Fiduciary obligations, including short-term and long-term budgeting, specifically financial stability issues. Familiarity with federal budgeting, procedures, and third-party collections.

o Any personnel issues or other resourcing issues.

o Any policy or plan approval as necessary and required by regulatory agencies.

Determine the best approaches and methodology for consistency and conciseness of required information.

o Ensure reporting is an impactful and appropriate reporting structure.

o Information sharing and direction vertically, responses to and from the board, and ensuring information is entirely shared bi-directionally.

o Define minimum expectations and performance metrics for each entity o Crafting appropriate, meaningful agendas

Understanding purposeful presentations that lead the board to informed decision-making.

Simplifying minutes for ease of information capture and review.

Improving board functioning to promote proactive board involvement and reduce reactive responses:

o Enhancing information flow and transparency.

o Focusing on communication and change management from the governance level.

Enhance reporting and analysis at the governance level to better recognize systems/processes needing improvement and train the board to require analysis of direction, rate, variability, and magnitude of change.

7.3 Task Area 3- System-Wide Programmatic, Analytical, and Policy Support

As requested, the contractor shall assist the IHS in the creation of system-wide programs or provide analytical or policy support for policy areas identified in this contract:

As requested, assist IHS in creating a system-wide quality program (as allowed by CMS and

TJC)

As requested, assist IHS in creating a system-wide patient safety program.

As requested, assist IHS in creating a system-wide infection control and prevention program.

Provide policy and programmatic support as requested. This shall require the production of any necessary analytical or other documents. This may include financial or cost information, and the vendor would be required to be familiar with federal budgeting, procedures, and third-party collections.

8 Task Area 4- Credentialing Support:

Under this task area, the contractor shall:

Conduct ongoing credentialing specialist training to prepare IHS credentialing specialists for certification.

Provide any requisite support for credentialing, including examining medical staff information provisioning, including credentialing/privileging.

9 Anticipated Deliverables / Schedule:

9.1 Post-award Kickoff Meeting: Within 7 business days of the contract award, the Government shall conduct a post-award kickoff meeting virtually, a specific date and time to be mutually agreed upon.

9.2 Monthly Project Status Reviews: Monthly status meetings will be conducted in the First Week of each month. The Contractor is responsible for reporting the previous month’s activities (including any risks, issues, or concerns and actual or recommended actions for their mitigation) and projected activities for the following month. Written materials shall be delivered electronically.

9.3 Program Management Review: The Government shall conduct monthly program management reviews in combination with monthly Project Status Reviews virtually to review the progress of the program, identify any risks, issues, or concerns, and provide feedback on the Contractor’s progress and performance. The contractor shall provide written data and verbal presentations as to the financial status of the project (projected vs. incurred costs), as well as any identified risks, issues, or concerns (and their mitigation or its mitigation plans). Written materials shall be delivered electronically.