PWS-DRAFT_External Accreditation Services.pdf

Performance Work Statement (PWS)

External Accreditation Services

12/05/2019

Version 1.1

Vision Statement

1 Introduction

1.1 Mission

1.2 Scope

2 General Requirements

2.1 Non-Personal Services

2.2 Business Relations

2.3 Contract Administration and Management

2.3.1 Contract Management

2.3.2 Contract Administration

2.3.3 Personnel Administration

2.5 Contractor Personnel, Disciplines, and Specialties

2.6 Location and Hours of Work

3 Performance Requirements

3.1 Provide external accreditation for all CG clinics

3.2 Provide advice and expertise for CG clinics

3.3 Compose and deliver quarterly quality report on CG clinics for program office

4.1 Security and Safety

4.3 Government Furnished Materials

4.6 Quality

4.6.1 Quality Control Plan (QCP)

4.6.2 Quality Assurance Surveillance Plan (QASP)

5 Deliverables

6 Related Documents

Performance Work Statement (PWS)

External Accreditation

Vision Statement

87% of Coast Guard (CG) clinics are fully externally accredited per federal and civilian standards of practice. The lack of external accreditation can impede the delivery of high quality health care. The CG desires to have all 40 clinics (100%) receive full external accreditation resulting in 3 year certification for each site.

1 Introduction

Under the direction of United States Coast Guard (USCG) Health, Safety, and Work-Life Service Center (HSWL SC), the USCG ambulatory health care clinics are responsible for achieving external accreditation through a civilian accreditation agency with national and state recognition. The USCG operates forty-two (42) ambulatory health care clinics throughout the contiguous United States, as well as Alaska, Hawaii, and Puerto Rico, offering outpatient medical, dental, and vision care, as well as pharmacy, radiology and laboratory services.

Specifically, the types of care provided include outpatient medicine utilizing the patient centered wellness home model, aviation medicine, preventive medicine, physical therapy, optometry, dentistry, gynecology, occupational medicine and dental anesthesiology.

The number of medical professionals (e.g., doctors, dentists, pharmacists, optometrists, physician assistants, nurse practitioners, registered nurses) providing care and services at each clinic ranges from one (1) to thirty (30), with an average of five credentialed and/or privileged personnel at each location. The USCG operates one health care facility that provides overnight health care. The clinic at Training Center Cape May, New Jersey, includes a 25-bed ward for the recruits and active duty members with mild to moderate illnesses requiring overnight treatment.

1.1 Mission

In accordance with the Defense Health Agency (DHA) and the Department of Defense (DoD) Directives, health care clinics that provide care to Department of Defense (DoD) beneficiaries are required to be accredited. Additionally, to ensure continued participation in TRICARE, USCG clinics must be externally accredited. USCG Headquarters is responsible for maintaining a central repository for all credentials and privileges for USCG health care personnel and facilities. The HSWL SC is responsible for maintaining a central repository for all USCG health care facility accreditations. Approximately 9-16 accreditation surveys are required annually to ensure all Coast Guard clinics remain accredited. The next accreditation survey is due early 2020.

1.2 Scope

The purpose of this requirement is to obtain external accreditation services for the forty-two (42) Coast Guard ambulatory health care clinics located across the USCG enterprise in the United

States and applicable territories. This task is performance based and will be awarded on a Firm Fixed Price basis.

2 General Requirements

The USCG requires Contractor employees and surveyors be familiar with current Coast Guard Medical Manual (current version COMDTINST 6000.1F), HSWLSCTD 2018-018: External Accreditation Process, and all other instructions relating to credentialing and privileging, peer review process, etc. as carried out per USCG established policy and HSWL SC technical directives.

2.1 Non-Personal Services

The Government shall neither supervise contractor employees nor control the method by which the contractor performs the required tasks. Under no circumstances shall the Government assign tasks to, or prepare work schedules for, individual contractor employees. It shall be the responsibility of the contractor to manage its employees and to guard against any actions that are of the nature of personal services, or give the perception of personal services. If the contractor believes that any actions constitute, or are perceived to constitute personal services, it shall be the contractor's responsibility to notify the Procuring Contracting Officer (PCO) immediately.

2.2 Business Relations

The contractor shall successfully integrate and coordinate all activity needed to execute the requirement. The HSWL SC will be the primary point of contact for the contractor. Meetings will take place between 0900-1600 EST. Survey schedules are to be arranged with the HSWL SC at least 6 months in advance of a scheduled survey. The applications for survey will be the responsibility of the individual clinics. Should the clinic not complete the required application one month prior to survey, the HSWL SC shall be notified. The contractor shall manage the timeliness, completeness, and quality of survey. Should there be a concern, a grievance policy shall be available. All survey results will be remitted to the HSWL SC for review and dissemination to the individual clinics with the certificates and handbooks being forwarded directly to the individual clinics. The HSWL SC shall also access to or a copy of the current handbook. The contractor shall seek to ensure customer satisfaction and professional and ethical behavior of all contractor personnel.

2.3 Contract Administration and Management

The USCG requires Contractor support to complete the accreditation process. To remain current in standards, the USCG requires the Contractor to provide annual Accreditation Handbook to be distributed to each clinic, USCG Headquarters Medical and HSWL SC and training to ensure that clinics are successful in maintaining the standards which the Contractor uses to measure the clinics in the survey process.

The USCG requires Contractor employees and surveyors be/become familiar with current CG policy, instructions, technical directives (TD), and other requirements pertaining to medical care, credentialing and privileging, peer review process, etc.

2.3.1 Contract Management

The Contractor shall provide technical advice and feedback during and after each survey to assist the USCG in continuously improving health care for USCG personnel. The Contractor, however, has no authority to alter the current USCG policy, instructions, and directives.

2.3.2 Contract Administration

The contractor shall establish processes and assign appropriate resources to effectively administer the requirement based on a firm fixed price per clinic. The contractor shall respond to Government requests for contractual actions in a timely fashion. The contractor shall have a single point of contact between the Government and Contractor personnel assigned to support contracts or task orders. The contractor shall assign work effort of the personnel assigned to work on the requirement.

2.3.3 Personnel Administration

The contractor shall provide the following support as required. The contractor shall not conduct surveys during designated Government non-work days or other periods where Government offices are closed due to weather or security conditions. The contractor shall maintain the currency of their employees by providing initial and refresher training on CG policies and procedures as required to meet the PWS requirements. The contractor shall make necessary travel arrangements for employees. The contractor shall provide necessary infrastructure to support contract tasks and ensure that each surveyor has completed annual HIPAA training.

2.5 Contractor Personnel, Disciplines, and Specialties

The Contractor shall provide qualified personnel to perform all requirements specified under this contract. The Contractor shall not employ any person who is an employee of the United States Government if that employment would, or would appear to cause a conflict of interest. The Contractor shall provide surveyors who are trained and experienced in conducting surveys in small government health care facilities. Surveyors should be knowledgeable or familiar in accessing Coast Guard websites for documents including the Coast Guard Medical Manual, instructions and technical directives provided by the Coast Guard to its health care facilities in matters related to the survey process.

2.6 Location and Hours of Work

The Contractor shall conduct survey activities (e.g., interviews, site surveys) involving clinic staff members between the hours of 0800 and 1600 (local time) Monday through Friday, except Federal holidays or when the clinic is closed due to security or weather concerns. The Contractor shall coordinate all survey activities in advance with designated USCG personnel at each clinic locations.

3 Performance Requirements

To obtain external accreditation services for the forty-two (42) Coast Guard (CG) ambulatory health care clinics located across the USCG enterprise in the United States and applicable territories.

3.1 Provide external accreditation for all CG clinics.

3.1.1 The Contractor shall conduct accreditation surveys.

Deliverables

A001 Accreditation Survey

3.1.1.1 The Contractor shall be knowledgeable about the operation of small government run clinics.

3.1.1.2 The Contractor shall be able to provide services to clinics without an electronic medical record.

3.1.1.3 The Contractor shall provide survey reports to the program office for review.

A002 Individualized Survey Report

3.1.2 The Contractor shall provide access (either electronic or paper copy) to the organization's handbook to each clinic annually or as the handbook is updated.

Deliverables

A003 Accreditation Handbook

3.1.2.1 The Contractor shall have a grievance policy/protocol available.

3.1.3 The Contractor shall provide each clinic with an accreditation certificate for display and records upon successful completion of an accreditation survey.

Deliverables

A004 Accreditation Certificate

3.2 Provide advice and expertise for CG clinics.

3.2.1 The Contractor shall provide training for clinic personnel to be successful in external accreditation.

3.2.1.1 The Contractor shall conduct three (3) webinars or one live training annually as the discretion of the government.

A005 Webinar

A006 In-person training

3.2.2 The Contractor shall be available for communication with the government between the hours of 0800-1630 EST.

3.3 Compose and deliver quarterly quality report on CG clinics for program office.

Deliverables

A007 Quality Report

3.3.1 The fourth quarter quality report shall be a consolidated annual report to the program office.

4.1 Security and Safety

Contractor access to classified information is not currently required under this PWS. Therefore, at this time, Contractor employees are not required to have a Secret Clearance. However, the Contractor shall be knowledgeable on HIPAA Rules and Regulations and their employees (surveyors) are required to have completed all necessary training required under the HIPAA Rules and Regulations. Additionally, the Contractor shall not have unescorted or unaccompanied access into locked files or files requiring password access. Information review by the Contractor in these files shall not be shared with other than the Government, specifically the USCG HSWL SC.

4.3 Government Furnished Materials

The Government will make available the materials, office space, communications capability and information to complete the accreditation survey during the survey process for each clinic for use by the contractor in the performance of this contract.

4.6 Quality

This section describes the Quality Control components for this effort. The following sub-sections provide details of various considerations on this effort.

4.6.1 Quality Control Plan (QCP)

The Contractor shall develop a Task/Delivery Order QCP and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The Contractor's QCP is the means by which he assures himself that his work complies with the requirement of the contract.

The finalized QCP will be accepted by the Government at the time of the award of the

Task/Delivery Order. The Contracting Officer may notify the Contractor of required modifications to the plan during the period of performance. The Contractor then shall coordinate suggested modifications and obtain acceptance of the plan by the Contracting

Officer. Any modifications to the program during the period of performance shall be provided to the Contracting Officer for review no later than ten (10) working days prior to effective date of the change. The QCP shall be subject to the Government's review and approval. The

Government may find the QCP "unacceptable" whenever the Contractor's procedures do not accomplish quality control objective(s). The Contractor shall revise the QCP within ten (10) working days from receipt of notice that QCP is found "unacceptable."

4.6.2 Quality Assurance Surveillance Plan (QASP)

The Government shall monitor the Contractor's performance under this Task/Delivery Order in accordance with the Government's QASP.

5 Deliverables

The contractor shall provide deliverables as described in subsequent task orders. Deliverables shall be specified by the government. Format and delivery schedule for deliverables shall be outlined in Contract Data Requirements Lists.

Number Name Frequency Quantity

A001 Accreditation Survey every 3 years 42

Survey of CG clinics (see clinic roster

Appendix A) for accreditation.

A002 Individualized Survey Report every 3 years 1

A003 Accreditation Handbook annually or as updated

1 per clinic

A004 Accreditation Certificate every 3 years 2

Certification for display and one for records

A005 Webinar Annual 3

A006 In-person training As requested 1

Instead of annual webinar training at government's request.

A007 Quality Report quarterly

6 Related Documents

The following Documents are related to this project.

2020 Clinic Verification

COMDINST M6000.1F: Coast Guard Medical Manual

HSWLSCTD 2018-018: External Accreditation Process

HSWLSCTD 2018-013: Quality Improvement Focus Group (QIFG)