JAFY260461 HFAS FINAL_Redacted.pdf

CUI

Control Number: JAFY26-0461

Source Selection Information - See FAR 2.101 and 3.104-4

Justification and Approval (J&A) for Other Than Full and Open Competition

For Federal Acquisition Regulation (FAR) Part 6

1. Identification of the Agency and Contracting Activity:

Requiring activity is the Defense Health Agency (DHA), Clinical Support Division, Medical Affairs. The Contracting Activity for this acquisition is the Defense Health Agency Contracting Activity (DHACA), Professional Services Contracting Division, Branch B.

2. Nature and/or Description of Action being Approved:

This is an individual J&A. The action being approved is for a single firm fixed-price contract to The Joint Commission (TJC). The Contractor will perform nationally recognized healthcare organization accreditation certifications for the DHS Military Medical Treatment Facilities (MTFs).

The contract is expected to begin 01 April 2026 and end 31 December 2030, with a 9-month base period and four 12-month option periods. The contract will include FAR clause 52.217-8, Option to Extend Services, should a need as described in FAR 37.111, Extension of Services, be appropriate.

3. Description of Supplies/Services:

The Contractor will be expected to provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items and non-persona services necessary to perform MTF accreditations and Patient-Centered Medical Home (PCMH) certifications.

- Provide onsite accreditation consistent with the MTF 36-month accreditation cycle in order to assess standards compliance and support healthcare quality and safety.

- Conduct patient and system tracers and appropriate interviews to assess compliance with

Accreditation Organization (AO) standards. Examples include Infection Control, Data Use, Medication Management, Competency Assessment, Patient Flow, Process Improvement, Emergency Management, Suicide Risk as applicable, and Environment of Car Session, if applicable.

- Conduct a Life Safety Assessment, to assess compliance with the Life Safety Code. This includes examining egress paths, doors, stairways, and above-the-ceiling areas; noting the presence of smoke and fire dampers, smoke detectors, fire extinguishers, exit signs, and egress illumination devised; and reviewing fire-resistance rating of door and partitions.

- Prepare a full written report electronically to the MTF Point of Contract (POC), Network POC and the Contracting Officer Representative (COR), no later than ten (10) business days of the completion of the on-site healthcare accreditation visit. The report includes non-compliant findings, states the standards, states the elements of performance, and states specific, tailored comprehensive recommendations for corrections.

- Provide relevant education and consultation as determined by the on-site surveyors.

The contract is a follow-on and will continue to provide Medical Treatment Facility Accreditation that standardizes the MTF accreditation process across more than 300 clinics and hospitals. A sole source contract is sought as TJC is the only known vendor that provides the specific features and capabilities required for the comprehensive assessment of over 3,400 accreditation standards and supports the DHA Accreditation Assist Visit (Mock Survey) Program. TJC provides consistent standards across the accreditation programs, including hospitals, ambulatory clinics, behavioral health and home health care.

There are multiple highly specialized elements of the services provided by TJC that reduce unacceptable delays and substantial duplication of costs that would not be recovered through competition. TJC provides Tracers with Accreditation Manager Plus, which are software solutions that give organizations access to a comprehensive library of tracer questions linked to standards and Elements of Performance (EPs) which helps track data for survey readiness. The electronic tools allow organizations to electronically collect, analyze and visualize real-time data.

The electronic tool eliminates hours of manually manipulating data by accessing user-friendly, interactive dashboards and easy-to-build automated reports that help organizations proactively identify risk areas, prioritize improvements, compare key performance indicators, document change and track progress over time. The tools also allow organizations to compare performance to national Joint Commission benchmarks, track and approve Plans of Corrections, download and submit a Joint Commission required Focused Standards Assessment, track Plans of Action, and seamlessly integrate data from Mock Surveys conducted internally and by DHA vendors.

Market research and evaluation of other potential vendors were conducted prior to the incumbent capacity to manage the volume of facilities that require tracking, is a unique combination only known to be available from TJC.

Survey requirements are applicable to multiple accreditation programs such as governing body, human resources, leadership, quality assessment, performance improvement, medical records, information management, infection control, patient rights, and physical environment, where compliance assessment process using tracer methodology and allows DHA staff to develop, conduct, document, track, and trend tracer activity online throughout multiple organizational layers, including MTF, Network, and DHA. Again, the highly specialized tools available from TJC are unique to TJC.

s effective and efficient on-site assist visits and generates a consolidated report entered by individual assessors as well as aggregation report for MTFs across a Network, multiple Networks, and the DHA Headquarters.

Other vendors do not possess the necessary technology or tools to meet the DHA Accreditation

Those needs include the ability to digitally manipulate data, pinpoint risk areas, identify root and causative factors, prioritize areas for improvement, assist with effectively allocating available resources, electronically changing documents and monitoring progress.

The contract currently in place, covering the same requirements included herein, was issued under Full and Open Competition. The approach resulted in a single, qualified vendor capable of accomplishing all the requirements. Additionally, the more recent Request for Information, issued in April 2025, resulted in no other vendors capable of covering the capacity needed to

Further research into the industry shows the only other approach to meet all the requirements is to split them and award multiple contracts to cover different elements of the requirement, resulting in higher overall costs inherent in competing, awarding and administering multiple contracts. In July 2025, conclusions of the Department of Government Efficiency review of the project resulted in approval of moving forward with the single contract approach.

The incumbent, TJC, can provide all the services required by Department of Defense (DoD), and is currently performing very successfully as the Contractor under the DHA Healthcare Facility Accreditation Services contract. The market research revealed TJC has been a Centers for Medicare and Medicaid Services (CMS) recognized AO since the 1960s and has the largest number of accreditation programs recognized by CMS. TJC accredits the most extensive array of healthcare facilities, including all types under this requirement. Knowledge development and self-assessment tools are available from TJC to support MTFs with continuous standards compliance not known to be available elsewhere. Information from the self-assessment is recorded in the designated electronic tool provided by the AO. No other accrediting organization has an electronic web-based tool to record self-assessments. Therefore, selecting an accrediting organization without an electronic self-assessment tool would put MTFs at risk of being non-compliant with DHA and DoD Policies.

6. Efforts to Obtain Competition:

Market research provided below in Section 8 details efforts to obtain sources of competition during the past six months, with no qualified source identified other than TJC. Additionally, the previous contract was competed with Full and Open Competition, in an effort maximize opportunities to compete for the requirement. Only one compliant and responsible vendor replied to the previous solicitation, resulting in a fair and reasonably priced negotiated contract, awarded to TJC.

A Notice of Intent (NOI) to Sole Source was issued in November 2025. After the opportunity to respond was open for two weeks there were no capability statements submitted for consideration.

The two responses received were communications affirming their organizations could not accomplish the requirement as a whole. The two respondents were 1) , who provided no capability statement, but offered to assist DHA with developing the Performance Work Statement for the requirement, and 2) , who stated they are not capable of providing all the services under the single requirement.

7. Actions to Increase Competition/Remove or Overcome any Barriers to Competition:

There are no notable changes to the accreditation industry, standards of the industry or the requirement needing fulfillment for the Government, since the previous contract was competed using full and open competition. The Government will continue to monitor the industry to identify any potential barriers to competition. Future efforts will utilize effective market research strategies to identify other potential vendors who could successfully support the scope of the requirement.

8. Market Research:

Two market research activities were conducted to provide consistent information on the availability of the services to meet the DoD accreditation requirements. Additionally, the information gathered aligns with historical information available from the contracted accreditation services purchased over the past few years.

One activity included searches of multiple existing business and contract databases. Results from the Small Business Administration database revealed eight potential vendors, based on the applicable North American Industry Classification System (NAICS) 813920 and critical keywords Health Care Accreditation. None of the vendors identified the applicable NAICS as primary, only secondary or tertiary. None provided complete health care accreditation services, instead focusing on narrower aspects of such services. For example, the capabilities focused on support of ambulatory care or behavioral health or hospital accreditation, but not all three, as is reflected in the Government needs. Searching existing General Services Administration contracts resulted in no existing contracts providing the scope of needed services.

The second activity included a Request for Information (RFI). The RFI was conducted to further expand the gathering of market research data, identified as HT001125RFI0217, titled Healthcare Facility Accreditation Services. The posting was initiated on SAM.gov on 10 April 2025 and ended on 25 April 2025. responses were received. Information from the submissions was technically analyzed to understand their capabilities.

One response, from , did not include sufficient information to determine the vendor's capabilities. It was a generalized document, not aligned with the requested elements published offerings, they were found incapable of fulfilling all the G second response, from included sufficient detail to assess capabilities. The vendor is considered capable of meeting some aspects of the Government need, but not to an extent required to provide full accreditation services. The vendor is capable of helping an organization prepare to qualify for accreditation but not provide the actual accreditation certifications. The ability to provide the accreditation certification portion of the Government's requirement is critical to successfully accomplish the contract.

The market research also revealed organizations in the healthcare accreditation services market, beyond the RFI responses, to have some of the capabilities to meet a portion of the requirements in the DoD performance work statement. Similar to the capabilities of RFI respondent they can either provide support services as a single offeror or as a prime Contractor with subcontractors to ensure compliance but not provide all the necessary levels of external accreditation certifications needed by the Government. Only the incumbent Contractor TJC has been found to offer all the accreditation programs and support services required by DoD to comply with mandates.

9. Other Facts:

a. Procurement History:

(1) Is this a new requirement? No.

(2) If 7.a.(1) is No, was the action just prior to this one competed?

Yes. The prior requirement was competed as Full and Open Competition, with a single responsible offer received, awarded under HT001121D0001.

(3) If 7.a.(2) is Yes, what has changed where this action cannot be competed?

This action cannot be competed because there is no reasonable expectation that results will differ, if competed again at the same level previously attempted. Market research, requests for information and public notices conducted since the prior competition show there are no additional potential vendors identified that can meet the full scope of the requirement. Results from another Full and Open Competition effort are expected to be the same, resulting in a single responsible offeror.

b. Additional Information: None.

10. Interested Sources:

The following sources have responded to various public notices, detailed above regarding the RFI and NOI:

. They were rejected as sources able to meet all the requirements, based on representations made in their responses.

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14. Legal Review:

I have reviewed this justification and have found it to be legally sufficient.

Attorney Defense Health Agency Office of General Counsel

15. Contracting Officer Certification: I certify this justification is accurate and complete to the best of my knowledge and belief.

VICKI L. WHITEMAN

Contracting Officer Professional Services Contracting Division Defense Health Agency Contracting Activity

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Review

I have reviewed this justification and find it adequate to support the sole source acquisition.

Concurrence

Chief of the Contracting Office Professional Services Contracting Division Defense Health Agency Contracting Activity

Concurrence

Competition Advocate Defense Health Agency

Approval

Based on the foregoing justification, I hereby approve the procurement of Healthcare Facilities Accreditation Services, with a potential value of $ , on an other than full and open competition basis pursuant to the authority of 10 USC 3204(a)(1), as implemented in FAR Part 6.302-1(a)(2)(iii)(A). Only One Responsible Source and No Other Supplies or Services Will Satisfy Agency Requirements, subject to availability of funds, and provided that the supplies and/or services herein described have otherwise been authorized for acquisition.

Head of the Contracting Activity Defense Health Agency