Just Culture SOW.pdf

Statement of Work Naval Medical Center, San Diego, California

1.0 Scope. This contract requires the contractor to provide education services at the Naval

Medical Center, San Diego, CA (NMCSD).

2.0 Background. Naval Medical Center, San Diego, California is a 277 bed multi-specialty hospital and ambulatory military medical treatment facility (MTF) in the San Diego area. The scope of services includes adult, pediatric and neonatal intensive care units, full service emergency department, 18 operating rooms, a rehabilitation center for combat casualties, 11 primary care clinics for more than 92,000 enrolled beneficiaries of all ages extending from San Diego to Imperial county and 10 dental clinics providing active duty care.

3.0 Requirement. The contractor shall provide no expiration online education services as outlined below:

ITEM QUANTITY Comments

Leadership Briefing - Webinar

Just Culture Master Certification Course

2 Will be the program managers

Just Culture Champions

20 Will be trainers 1 per Directorate ( 13) plus 5 from Patient Safety/QM

Super-Users -includes Just Culture Training for Managers

300 Targeting

DIVO, CNS,

DH levels with this training

Train the - Trainer 5 hour course to prepare Super-Users and Champions to lead in- person, scenario-based training sessions for managers

1 This will assist managers to better understand the application of these concepts

3.2 Health Insurance Portability and Accountability Act (HIPAA).

The Contractor shall comply witl1 all requirements of the Health Insurance P01tability and Accountability Act of 1996 (HIPAA) (Pub. L. 104-191), as implemented by the HIPAA Privacy and Security Rules codified at 45 C.F.R. Parts 160 and 164, and as further implemented within the Military Health System (MHS) by DoD 6025.18-R, "DoD Healtli Information Privacy Regulation," January 24, 2003, and DoD 8580.02-R, "DoD Health Infonnation Security Regulation, July 12, 2007. The Contractor shall also comply with all applicable HIPAA-related rules and regulations as tliey are published and as fmther defined by later-occurring Government requirements and DoD guidance, including current and forthcoming DoD guidance implementing applicable amendments under the American Recovery and Reinvestment Act of2009 (ARRA). Any rules and regulations that are published, and/or requirements that are defined after the award date of this contract, and that require expenditure of additional Contractor resources for compliance, may be considered "changes" and will be subject to the "changes" clause under tbe contract.

3.3 Breach Response.

DoD 5400.11-R, "DoD Privacy Program," May 14, 2007, defines a breach as the "actual or possible loss of control, unauthorized disclosure, or unauthorized access of personal information where persons other than authorized users gain access or potential access to such information for other than authorized purposes where one or more individuals will be adversely affected." Within one hour of discove1y, the breach must be reported to the US Computer Emergency Readiness Team (US CERT) at https://forms.us-cert.gov/report/ and to the TMA Privacy Office at PrivacyOfficerMail@tma.osd.mil.

The Contractor shall adhere to the rep011ing and response requirements set forth in the Office of the Secretary of Defense (OSD) Memorandum 1504-07, "Safeguarding Against and Responding to the Breach of Personally Identifiable Information," June 5, 2009; DoD 5400.11-R, and applicable TMA Privacy Office guidance, including cmrnnt and fmihcoming DoD guidance on ARRA breach notification requirements, available at: http://www.tricare.mil/tma/privacy/breach.aspx.

mailto:PrivacyOfficerMail@tma.osd.mil http://www.tricare.mil/tma/privacy/breach.aspx