PWS Mock Survey - DRAFT.pdf

B.2 PERFOMANCE WORK STATEMENT

A. GENERAL INFORMATION

A.1. Title of Project:

Healthcare Accreditation Preparedness Mock Survey

A.2. General History:

The Department of Veterans Affairs (VA), Veterans Health Administration (VHA) has a requirement for non-personal services to provide Ongoing Preparedness Services, across the VA hospital enterprise.

Continuous Readiness Services has been provided by a contractor since 2013 to achieve continued compliance with the Joint Commission’s (TJC) healthcare accreditation processes and standards. TJC is an independent, not-for-profit organization, recognized by the Centers for Medicare and Medicaid Services (CMS) that accredits and certifies United States healthcare organizations, including all VHA Medical Centers/Facilities. To enable the ongoing improvement of health care services offered to Veterans, VHA requires services to accomplish ongoing preparedness and compliance with current TJC published standards and policies, accreditation processes and post-survey process completion.

The contractor shall focus on supporting VHA facilities, VISNs, and Program Offices with ongoing compliance with TJC accreditation standards/processes and enabling ongoing improvement of services provided to Veterans. The services provided through this national contract are intended as a national strategy to augment facility TJC ongoing compliance programs. Services are specific to the VHA Healthcare Accreditation Contract and associated manuals (Hospital, Ambulatory, Behavioral Health, and Home Care).

The contractor shall be responsible for coordinating a survey team to complete a 3-day Mock Survey to review all applicable organizational TJC Accreditation Manuals. At least one surveyor on each survey team shall be designated as lead.

The skill set required of the Mock Survey personnel surveying VHA Medical Centers (VHAMCs) includes experience with TJC Accreditation Manuals (Hospital, Ambulatory, Home Care, and Behavioral Health Care) and Policy: the ability to perform in-depth tracer activity: the ability to communicate, analyze and interpret findings into a functional report.

Experience: Proposals need to describe in detail staff experience, knowledge of current quality and safety demands in the healthcare industry, and an understanding of expectations of regulatory organizations. Vendor staff should demonstrate knowledge and expertise of consultants in applying TJC standards to complex and multi-healthcare organization when providing consultative services. All staff must be experienced with all TJC standards and accreditation processes for all applicable manuals (Hospital, Ambulatory, Behavioral Health and Human Services, and Home Care), including required post-survey activity.

Qualifications: Vendor leadership and staff credentials should show a minimum of five

(5) years or more experience with healthcare accreditation services, and modalities of

CONTINUATION PAGE 36C10GXXXXXXX Page 2 of 43 healthcare services and delivery. Vendor staff should hold at least a master’s degree in healthcare related fields or recognized occupational certifications related to consultative areas assigned (i.e. Occupational Safety, Life Safety, etc.). All licensed staff shall have current and unrestricted licensure.

A.3. Overall Desired Outcomes/Objectives:

On a national level, the Mock Survey process assures standards are being met and provides a proactive review of practice and systems for improvement. The accreditation process is a complex system of related and interdependent activities which enable the VHA to maintain a constant state of regulatory preparedness and maintain a safe healthcare environment.

B. SCOPE OF WORK

The contractor shall perform all services. The contractor shall provide all qualified personnel, equipment, supplies, facilities, transportation, travel, tools, materials, supervision, and other items and non-personal services necessary to successfully perform the services as defined in this Performance Work Statement (PWS) except for those items specified as Government furnished property and services. Contractor shall ensure requirements in PWS are accomplished in accordance with (IAW) the applicable documents list in Section D:

Contract Documents, Exhibits, Or Attachments. No Government employee shall be used for or perform any portion of the survey. Task Orders shall be placed during the current period of performance to indicate services required to be rendered.

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 sole responsibility of the contractor to manage its employees and to guard against any actions in the PWS 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 Contracting Officer (CO) immediately.

The purpose of this procurement action is to acquire Mock Survey services. These services will support 162 sites of care VA Medical Centers/Facilities across the United States; this includes all 50 states, territories, and possessions of the United States and the Commonwealth of Puerto Rico and identified VHA Headquarter Program Offices to enable an ongoing survey preparedness program to achieve and continue compliance with TJC accreditation standards and processes.

Veterans’ Health Administration (VHA) has a requirement for non-personal services to provide Ongoing Preparedness Services with the appropriate technical survey expertise. The purpose of these surveys is to:

a. Support the standardized approach for VHA national ongoing preparedness and compliance with TJC healthcare accreditation standards and processes.

b. Identify areas of concern with quality of care through direct observations and medical record reviews in person.

c. Enhance VHA staff knowledge of TJC accreditation survey process and standards.

d. Increase patient safety and improve patient outcomes by sharing best practices.

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e. Aggregate and analyze medical center and national level findings and trends for proactive process improvement.

B.1. Corrective Action Request (CAR):

When a concern with contractual compliance and/or performance is identified, the contractor will be notified via an email by the Contracting Officer (CO) in the form of an official cover letter and by Corrective Action Request (CAR) procedure and form (Attachment XX: Corrective Action Request Procedure and Form).

(1) Level I CAR is issued for nonconformity that can be corrected on the spot and where no further corrective action response is necessary.

Level I CARs shall be documented and issued to the contractor management level responsible for taking corrective actions. This may be at the lowest level of contractor management.

(2) Level II CAR is issued when contractual nonconformity cannot be corrected on the spot. At a minimum, nonconformity associated with Critical Safety Item (CSI) critical characteristics shall be issued at this level. Level II CARs should be directed to the contractor management level responsible for initiating corrective actions. This may be at mid-level contractor management.

(3) Level III CAR is issued to the supplier’s top management to call attention to serious contractual nonconformity. Repeat nonconformities found within one year for the same single point failure shall be issued as a Level III CAR. A Level III CAR may be coupled with contractual remedies. A Level I or II CAR need not be issued before a Level III CAR is generated. All Level III CARs shall be issued by the Contracting Officer to senior contractor management.

(4) Level IV CAR is issued to the contractor’s executive management when a Level III has been ineffective, or the contractual nonconformity is of such a serious nature to warrant contractual remedies.

(5) Level II - IV CARs shall, at a minimum, clearly state the request should be treated by the contractor as a customer complaint of nonconformance with the terms and conditions of the contract. These CARs shall be reviewed by the contractor as part of the corrective action system.

These CARs shall cite the following minimum requirements for contractor response:

i. Cause(s) of the nonconformity

ii. Actions taken or planned to eliminate the cause(s) and prevent recurrence of the nonconformity.

iii. Actions taken to correct the specific nonconformity.

iv. Whether other products are affected, including products already delivered to the customer.

v. Action taken to correct the weakness which allowed the deficient product to be presented to the government for acceptance.

vi. Target date(s) for implementation of planned actions

(6) Level II - IV CARs shall also, at a minimum, use the following seven steps associated with developing a CAR:

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i. Step 1: Define the problem and detail the corrective actions that need to take place to solve the problem.

ii. Step 2: Conduct a Root Cause Analysis

iii. Step 3: Define the appropriate CAR level.

iv. Step 4: Determine the appropriate time to issue CARs.

v. Step 5: Determine cost, schedule, and performance impacts of CAR.

vi. Step 6: Conduct CAR status checks

vii. Step 7: Determine when the problem has been solved.

B.2. Contract Information

B.2.1. Period of Performance:

The period of performance shall be a twelve (12) month base period and four

(4) twelve (12) month option periods. A continuation of performance of any services may be exercised more than once, but the total extension of performance hereunder shall not exceed 6 months beyond option period four.

Option periods are exercised as a required and are not guaranteed.

Base Year TBD

Option Year 1 TBD

Option Year 2 TBD

Option Year 3 TBD

Option Year 4 TBD

B.2.2. Type of Contract:

The Government will award a single Indefinite Delivery/Indefinite Quantity (ID/IQ) Fixed Price (FP) contract. Firm Fixed Price (FFP) Task Orders (TOs) will be placed during the period of performance for required services. Indefinite-Quantity Contract per the Federal Acquisition Regulation (FAR) 16.504.

B.2.3 Type of Orders

Task Orders shall be issued only by the Strategic Acquisition Center (SAC) Contracting Officer(s) as requirements for additional number of services are required within any current period of performance. No oral orders are authorized, and no other field units can place orders.

Not all Contract Line Items Number(s) (CLIN) are required to be ordered on any given Task Order. CLINs will be identified on every order and the quantity being ordered. For the minimum and maximum order limitations, reference Section C: Contract Clauses:

52.216-18 ORDERING

52.216-19 ORDER LIMITATIONS

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B.2.4. Place of Performance:

The work to be performed under the resulting contract will be performed at VA Medical Centers/Facilities throughout the United States and Puerto Rico.

A complete listing is provided (see Section XX).

B.2.5. Recognized Holidays:

The contractor shall not perform services on the following Federal holidays.

New Year’s Day Labor Day Martin Luther King Jr.’s Birthday Columbus Day President’s Day Veterans Day Memorial Day Thanksgiving Day Independence Day Christmas Day Juneteenth

B.2.6. Hours of Operation:

The contractor is responsible for conducting services between the hours of 7:30 am and 5:00pm per VA survey site local time zone Monday thru Friday except federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar

Government directed facility closings.

B.2.7. Business Day:

For purposes of communication with and submission of deliverables to the Program Office. The contractor is responsible for conducting services between the hours of 7:30am and 5:00pm per VA survey site Monday thru Friday except federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings.

B.3. Contract Terms & Conditions

B.3.1. Contractor Travel:

Contractor shall be authorized travel expenses in accordance with the Federal Travel Regulation (FTR).

B.3.2. Security Requirements:

The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract. For additional Information and requirements see Section G.

B.3.3. Physical Security:

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The Contractor shall be responsible for safeguarding government equipment, information, and property provided for contractor use. Any Government equipment provided to the contractor shall be handled and safeguarded per the Federal Acquisition Regulation (FAR) 45.104(a), Responsibility and Liability for Government Property and FAR 24.103 Procedures (Protection of Individual Privacy). Contractor will be always escorted during their site visit by a VA employee or designated Federally contracted employees with access badge, such as security.

B.3.4. Data Rights:

The Government has unlimited rights to all documents/material produced under this contract per FAR 27.409(b)(1). All documents and materials, to include the source codes of any software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership/copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the Contracting Officer. All materials, including, but not limited to, manuals, pamphlets, reports, training slides supplied to the Government shall be the sole property of the Government.

B.3.5. Confidentiality of Data and Privacy Act:

The contractor may, during performance, observe or handle information subject to the Privacy Act or other Federal regulations. Duplication or disclosure of data and other information to which the contractor will or may have access because of this contract is prohibited by law. It is understood that throughout the performance of the contract, the contractor may have access to confidential data that is either the sole property of VA or is the sole property of other than the contracting parties. The contractor hereby agrees to maintain the confidentiality of all such data to which access may be gained throughout contract performance, whether title thereto vests in VA or otherwise. The contractor hereby agrees not to disclose said data, any interpretation thereof, or data derivative thereto unauthorized parties in contravention of the provisions, without the written approval of the CO, or the party in which the title is wholly vested.

Also, FAR 52.224-1 Privacy Act Notification and FAR 52.224-2, Privacy Act, as stated in Section I, Contract Clauses, applies to this contract. All contract personnel performing on this contract will be required to sign a Certificate of Confidentiality and Non-Disclosure prior to commencing work. The Certificate will be provided and maintained by the COR and added to the contract file at any time during the performance of this contract. Any information systems involved with this contract are classified as systems of records subject to the Privacy Act of 1974 (Public Law 93-579) and all applicable Health Insurance Portability and Accountability Act (HIPAA) regulations. For additional requirements see Section G.

B.3.6. Definitions:

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The following definitions are used throughout the PWS and are to be construed as the statement of the meaning of a word, word group, a sign, or symbol; a statement expressing the essential nature of something; a product of defining; the action or the power of describing, explaining, or making definite.

For additional contractual definitions, see the Federal Acquisition Regulation (FAR) Subpart 2.101 – Definitions, The Department of Veteran’s Affairs Acquisition Regulations (VAAR) 802 - Definitions of Words and Terms.

These regulations parts define words and terms that are frequently used;

provide cross-references to other definitions in the regulations of the same word or term; and provides for the incorporation of these definitions in solicitations and contracts by reference.

These definitions have been derived by several sources, including but not limited to the FAR, VAAR, Law Insider Dictionary, Investopedia, Dictionary.com, Encyclopedia Britannica, and Black’s Law Dictionary.

Accurate: means free from error or defect; consistent with a standard, rule, or model.

Complete: Full; entire; Including every item or element of the thing spoken of, without omissions or deficiencies; as, a “complete” copy, record, schedule, or transcript.

Comprehensive: means complete; including all or nearly all elements or aspects of something.

Current: Whatever is at present in course of passage, present in its progress, the service rendered, and the compensation therefore measured by the time of the occurrence of the event. Passing in time or belonging to the time actually passing, now passing, present in its course, as the current month.

Deliverable: Used to describe the quantifiable goods or services that must be provided upon the completion of a project. Deliverables can be tangible or intangible in nature. A deliverable is a product or service created or performed in the completion of a project. When you consider a project, there are elements of input (what goes into the project such as time, resources, information, etc.) and elements of output - the deliverables. Key deliverables are the main outputs set and produced in the completion of a project.

Final: Last; conclusive.

Final Submission: Exists when nothing remains to be done to render submission complete.

Necessary: This word must be considered in the connection in which it is used, as it is a word susceptible of various meanings. It may import absolute physical necessity or inevitability, or it may import that which is only convenient, useful, appropriate, suitable, proper, or conducive to the end sought. It is an adjective expressing degrees and may express mere convenience or that which is indispensable or an absolute physical necessity.

It may mean something which in the accomplishment of a given object cannot

CONTINUATION PAGE 36C10GXXXXXXX Page 8 of 43 be dispensed with, or it may mean something reasonably useful and proper, and of greater or lesser benefit or convenience and its force and meaning must be determined with relation to the particular object sought.

Plan: A delineation; a design, a draft, a draft or form or representation; the representation of anything drawn on a plane, as a map or chart; a scheme; a sketch; also, a method of action, procedure, or arrangement.

Quantitative: The purpose is to explain, predict, and/or control phenomena through focused collection of numerical data. Test hypotheses, deductive.

Administration of tests and questionnaires (close ended). Conclusions and generalizations formulated at end of study, stated with predetermined degree of certainty. Inferences and /or generalizations are the researcher’s responsibility. Never 100% certain of findings.

Qualitative: The purpose is to explain and gain insight and understanding of phenomena through intensive collection of narrative data, generate hypothesis to be test inductive. Raw data are in words. Essentially ongoing, involves using the observations/comments to come to a conclusion.

Conclusions are tentative (conclusions can change), reviewed on an ongoing basis, conclusions are generalizations. The validity of the inferences/generalizations are the reader’s responsibility.

Sufficient: Adequate, enough, as much as may be necessary, equal, or fit for end proposed, and that which may be necessary to accomplish an object.

Timely or Reasonable Time: Such length of time as may fairly, properly, and reasonably be allowed or required, having regard to the nature of the act or duty, the subject matter, and to the attending circumstances.

Update: To change (something) by including the most recent information; to make (something) more modern; to give (someone) the most recent information about something.

B.3.7. Acronyms:

AQL Acceptable Quality Level(s)

ATO Authority to Operate

BAA Business Associate Agreement(s)

CAM Contractor Account Manager

CAP Corrective Action Plan(s)

CAR Corrective Action Request

CFR Code of Federal Regulations

CLIN Contract Line Items Number(s)

CO Contracting Officer

COR Contracting Officer Representative

CPARS Contractor Performance Assessment Reporting System

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FAR Federal Acquisition Regulation

FFP Firm Fixed Price

HIPAA Health Insurance Portability and Accountability Act of 1996

JTR Joint Travel Regulation

POC Point of Contact

PRS Performance Requirements Summary

PWS Performance Work Statement

QA Quality Assurance

QAP Quality Assurance Plan

QASP Quality Assurance Surveillance Plan

QM Quality Measures

TJC The Joint Commission

TO Task Order(s)

USC United States Code

VA Department of Veterans Affairs

VHA Veterans Health Administration

VHACO Veterans Health Administration Central Office

C. SPECIFIC MANDATORY ACTIVITIES, TASKS, and ASSOCIATED DELIVERABLES

C.1. General Requirements

All activities, tasks, and associated deliverables specified in this section shall be ordered by the Government via a TO. The Contract Line Item Number(s) (CLIN) shall be identify in the task via number and quantity required. All aspects of any task shall be performed as ordered on a TO. Any TO not indicating such required CLIN and quantity shall not be required to be provided by the contractor.

CLINs will be designated with either activity, task, and/or associated deliverables.

The activities are the overarching requirements which correlate to tasks and deliverables.

If for any reason the delivery date for a deliverable cannot be met, the contractor shall submit a written explanation to the CO and COR within three business days before the deliverable date. This notice to the CO and COR shall include the original deliverable due date, cite the reasons for the delay, describe the impact on the overall program, and include a firm commitment of when the work shall be completed. This is intended to be required as part of any deliverable requirement. The COR will then review the facts and discuss with the CO. The COR or CO shall respond to the contractor acknowledging receipt and communicating any additional concerns within two business days in accordance with applicable regulations.

C.2. Activity 1: Program Management:

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Program management is critical to effective program execution in the areas of risk management, quality assurance, and changing mission priorities. Good planning builds effective partnerships, establishes open communications, sets clear expectations, defines roles and responsibilities, and sets the framework for mission success. Contract management is a multi-disciplined process which encompasses technical, business, and procurement perspectives.

VA requires Program Management planning activities and materials, regular weekly meetings to ensure contract performance and define objectives, documentation of quality assurance processes, and documentation of key decisions made, the rationale for decisions, and tracking of required deliverables for each activity. One of the ways to ensure standards are met is an established Quality Assurance Program essential to detailing the procedures to verify services being performed to those Government standards according to the Acceptable Performance Objectives (APO) and Acceptable Quality Levels (AQLs).

Desired Outcome / Objective:

To focus on aligning project objectives to program objectives, identify interdependencies and triage any issues that occur, simplify resource allocation, accurately prevent risks, and expeditiously mitigate opportunities. Also, to improve communication, improve productivity and performance, achieve the program objectives within the given constraints, mitigate risks in advance, manage stakeholder expectations, and maximize results for all stakeholders. In turn, the Government can achieve its objectives while simultaneously reducing cost, technical and schedule risks, ultimately providing a framework to assist the VA and the Contractor’s project managers in improving contract oversight and strengthening performance accountability.

C.2.1. Task 1: Quality Assurance Plan (QAP):

The Quality Assurance Plan shall demonstrate effective measures of the accuracy, quality, and reliability of adherence to the requirements of this contract throughout the contract’s duration and be submitted per the solicitation. At a minimum, the QAP shall be based on the Performance Requirements Summary (PRS), outcomes, and identify how the Performance Objectives will be achieved.

It shall address all the personnel, specific tasks in the PWS, and remedial actions. The QAP is developed by the contractor and submitted to the Government in compliance with their contract deliverables. The Contractor, and not the Government, is responsible for management and quality control actions necessary to meet the quality standards set forth by the contract and Task Order performance. The QAP shall be used to guide and to comprehensively document the implementation of the required management and quality control actions to achieve the specified results/outcomes. The final version shall be submitted per the PRS to the CO and COR. After acceptance of the QAP the contractor shall receive the Contracting Officer’s acceptance in writing..

C.2.2. Task 2: Quality Assurance Surveillance Plan (QASP):

The Government shall utilize the contractor’s The Quality Assurance Surveillance Plan (QASP), which is part of the QAP, throughout the life of the contract to ensure the contractor is performing the services required by this PWS via the APOs and AQLs established. Performance shall be rated based on the

CONTINUATION PAGE 36C10GXXXXXXX Page 11 of 43 performance meeting the standards. The QASP is put in place to provide Government surveillance oversight of the Contractor’s quality control efforts to assure timely and effective delivery of the results specified in the contract and/or Task Order. The QASP shall reflect the Contractor’s responsibility to perform effective Quality Control. The QASP shall be developed concurrent with and traceable to PWS, Standards, and AQL. It shall be implemented as written to assure objectivity and consistency.

C.2.3. Task 3: Contractor Account Manager and Alternate:

Contractor shall assign a Contractor Account Manager (CAM) (and alternate), who shall have full authority to act for the contractor (i.e., resolve disputes, sign documents, etc.) on all matters relating to this acquisition. The name and contact information for the CAM (and alternate) shall be designated in writing to the CO and COR prior to contract award. The CAM shall be available during normal business hours.

Changes in the CAM, at any time, shall require the Contractor to notify the CO of the new representative at least five working days prior to the change. This notification shall be in writing and shall state the name and contact information for the new CAM and include the indication that the replacement holds equal or better education and experience.

C.2.4. Task 4: Business Associate Agreement (BAA):

The contractor shall sign and agree to the BAA to establish requirements for the

Department of Veterans Affairs (VA) Veterans Health Administration (VHA) and in accordance with the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health Act (HITECH) Act, and the HIPAA Privacy, Security, Breach Notification, and Enforcement Rules (“HIPAA Rules”), 45 C.F.R. Parts 160 and 164, for the Use and Disclosure of Protected Health Information (PHI) under the terms and conditions (See attachment XX)

Deliverable #1: Quality Assurance Plan

Deliverable #2: Quality Assurance Surveillance Plan Deliverable #3: Contract Account Manager and Alternate Deliverable #4: Business Associate Agreement

C.2.5. Task 5: Kick-Off Meeting:

The Kick-off meeting between the Program Office, Contracting, and the contractor shall be scheduled within 10 business days after Notice to Proceed is issued to the contractor. This shall be part of the base contract first TO requirement. Contracting shall coordinate the date, time, location (in person or virtual) of the meeting. The contractor shall attend meeting with the appropriate staff, prepare an agenda, presentation materials, and attendee list (with email addresses), which shall be provided to Contracting in PDF format and approved for distribution to all attendees at least five (5) business days prior to the meeting.

The contractor shall provide a final QAP and QASP (as described in B.XX and B.XX) to Contracting in PDF format for the first Kickoff meeting only.

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The contractor shall also provide meeting minutes in PDF format to all attendees within 15 business days following the meeting. This meeting shall occur at the beginning of every performance period; duration is estimated at two days for the base period and four hours per each subsequent option throughout the Period of Performance. This meeting duration is estimated at 2 hours per occurrence.

C.2.6. Task 6: Monthly Meeting:

The monthly meeting shall be attended by the contractor with the appropriate staff, prepare an agenda, presentation materials, and attendee list (with email addresses) provided by the contractor to facilitate discussion on status updates, schedule deviations or barriers, any areas of concern or of interest, introduction of new personnel and positions as well as staff losses, and feedback evaluations, monthly and quarterly data reports. The Government will provide their agenda topics so that the contractor can consolidate, in order to have a complete agenda. The contractor shall establish a MS Teams invitation for the monthly meeting calls.

The monthly meeting date and time shall be coordinated and established at the kickoff meeting. The contractor shall prepare and submit their agenda in PDF format to the CO and COR in PDF format at least five business days prior to the meeting. The contractor shall also provide meeting minutes in PDF format to all attendees within five business days following the meeting. This meeting duration is estimated at 1.5 hours per occurrence.

Deliverable #1: Quality Assurance Plan Deliverable #2: Quality Assurance Surveillance Plan Deliverable #3: Contract Account Manager and Alternate Deliverable #4: Business Associate Agreement Deliverable #5: Kick-Off Meeting Agenda Deliverable #6: Kick-Off Meeting Minutes Deliverable #7: Monthly Meeting Agenda

Deliverable #8: Monthly Meeting Minutes

C.3. Activity 2: Plans:

Plans provide a method of action, procedure, or description of the necessary information to describe how to meet the goals, scope of work, milestones, deliverables, and mitigate risks. Plans include Program Work Plan (PWP), Communication Plan, and Contractor Personnel Training Plan.

This information is essential in ensuring the Government and contractor have a mutual and bilateral understanding of the direction regarding methods, communication, and timelines for all types of plans.

C.3.1. Task 7: Program Work Plan (PWP):

Within 20 business days from the Notice to Proceed of the issuance of the contract, first TO, the contractor shall provide their official Program Work Plan (PWP) in PDF format to the COR The plan shall be consistent, with the plan submitted by

CONTINUATION PAGE 36C10GXXXXXXX Page 13 of 43 the contractor as part of the initial solicitation package, with only limited updates and changes from the original. The PWP shall describe how the contractor plans to address the following:

(1) Scheduling all necessary Mock surveys as specified in the contract by Task Order.

(2) Completing a comprehensive mock survey.

(3) Following process for appropriately identifying and communicating any

Immediate Jeopardy (IJ) situations encountered during survey. (A threat that represents immediate risk and has or may potentially have serious adverse effects on the health or safety of the patient, resident, or individual served. These threats are identified by the surveyor)

(4) Providing each facility with a feedback mechanism.

(5) Submitting final survey reports

(6) Submitting final Program Office report

(7) Providing monthly and quarterly data reports.

(8) Conducting National educational sessions.

C.3.2. Task 8: Communication Plan:

The contractor shall write a communications plan, submitted to the COR in PDF format, within 20 business days from the Notice to Proceed of the issuance of the contract first TO and implemented within 5 business days of notification by COR of approval. The Communication’s Plan shall describe how the contractor plans to address the following:

(1) Sharing of contractor’s key personnel names, titles/roles, preferred contact information and who from the contractor’s team should be contacted under which circumstances

(2) Scope of the communication plan, to include information such as:

i. Information needed to be shared

ii. Purpose of information sharing

iii. Who will provide the information

iv. To whom will the information be provided (COR, etc.)

v. When will the information be provided

vi. How will the information be provided

C.3.3. Task 9: Contractor Personnel Training Plan:

Within 20 business days from the Notice to Proceed, of the issuance of the contract first TO, the contractor shall provide to CO and COR their official training plan for training the current personnel and new personnel upon hire. The plan shall be consistent with the plan submitted by the contractor as part of the initial solicitation package, with only limited updates and changes from the original.

The plan shall detail the contractor’s utilization of the training strategies and activities required for all personnel to possess the necessary knowledge, skills, and abilities for performance on the contract.

In addition, within 20 business days from the Notice to Proceed of the issuance of the contract first TO, the contractor shall provide certificate and acknowledgment documentation to the COR and CO to substantiate that all

CONTINUATION PAGE 36C10GXXXXXXX Page 14 of 43 contractor personnel completed all the following listed items. The contractor shall also provide certificate and acknowledgment documentation to the COR and CO to substantiate to the COR and CO that any newly hired personnel completed all the following items prior to performance on the contract but no later than 20 business days from hire.

(1) Completion of VA Privacy/HIPPA regulations Talent

Management System (TMS) training (VA 10203)

(2) Completion of VA Privacy and Information Security Awareness and

Rules of Behavior TMS training (VA 10176)

(3) Signature on VA Handbook 6500.6 Appendix D Contractor Rules of

Behavior

(4) Certificate of Confidentiality and Non-Disclosure

Deliverable #9: Program Work Plan Deliverable #10: Communication Plan Deliverable #11: Contractor Personnel Training Plan

C.4. Activity 3: Mock Survey:

To enable the ongoing improvement of health care services offered to Veterans, VHA requires services to accomplish ongoing preparedness. Mock surveys evaluate compliance with current healthcare accreditation standards, policies, and processes.

Mock survey reports provide specific results. Customer Satisfaction survey provide facilities opportunity to give feedback on Mock Survey experience.

The objective of this task is to measure compliance and recommend actions to maintain compliance with The Joint Commission accreditation processes and standards.

C.4.1. Task 10: Facility Mock Survey:

The contractor shall conduct a 3-day Mock Survey to each of the identified VA hospitals via Task Order. Currently there are 159 VA sites to survey (see Attachment XX). Each site point of contact shall coordinate with the contractor for Ongoing Preparedness Services.

This Mock Survey shall require interpretation of TJC healthcare accreditation processes and standards under which the VA hospital currently holds accreditation. Applicable TJC programs for VHA facilities are Hospital, Ambulatory, Behavioral Health and Humans Services, and Home Care.

Mock Survey services require survey simulation with tracer no less than three

(3) days on site activity, and may include, but not limited to, organizational assessment of healthcare processes for standards compliance by a tracer activity, policy reviews, development of post-survey responses, review/evaluation of corrective action sustainment, and recommendations for correction of non-compliance. Services will include collaboration with VA staff, via, in person, electronic, and telephonic communications, and/or training sessions. Each episode of service will include a written report provided to the site POC and COR.

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Mock Surveys will be completed within the performance period with all scheduling dates identified within the first 10 months.

The contractor shall notify the COR of scheduling and rescheduling of mock surveys via modalities deemed by the government.

Following Mock Survey completion, the contractor shall be available to facility POC for 30 business days for any questions or clarifications.

C.4.2. Task 11: Facility Mock Survey Report:

The Contractor shall produce a written report for each Facility Mock Survey and submitted to the Facility POC and COR within 10 business days after completion of the survey. The survey report shall outlining the results of the mock survey to include at a minimum TJC standards, observations of non-compliance, and strategies for corrective actions. Any facility results with immediate threat to health and safety findings will be Identified and the findings forwarded to the COR via email within 1 hour of discovery..

C.4.3. Task 12: Facility Customer Satisfaction Survey:

The contractor shall provide a Customer Satisfaction Survey to Facility POC and cc: COR within 5 business days after each mock survey. At minimum questions shall include:

(1) Overall Mock Survey satisfaction rating Likert scale (1-5)

(2) What went well?

(3) What could have gone better?

Deliverables #12: Facility Mock Survey Report Deliverables #13: Facility Customer Satisfaction Survey

C.5. Activity 4: Ongoing Preparedness (Program Office):

To enable the ongoing improvement of health care services offered to Veterans, VHA requires services to accomplish ongoing preparedness. Program Office services support VHACO level office role in monitoring and supporting facility compliance with current TJC published standards and policies, accreditation processes and post-survey process completion. Program Office reports provide specific results.

Customer Satisfaction survey provide Program Offices opportunity to give feedback on services received.

The objective of this task is to provide services to VHA Program Offices in support alignment of Healthcare Accreditation standards. The desired outcome for each VHACO Program Office in support of TJC accreditation processes and ongoing standards compliance. The activity is to provide focused program level education on specific accreditation standards.

C.5.1. Task 13: Preparedness Analysis and Reporting:

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The contractor shall conduct four hours of preparedness analysis to VHA Central Office (VHACO) Program Offices. This task shall require overall trends of facility services including interpretation of TJC healthcare accreditation standards, , response to questions and providing informational feedback, education and training.

Designation of applicable VHACO Program Offices is determined by the COR and communicated upon initiation of each performance period. .

Each episode of preparedness analysis will include a written report provided to the Program Office and the COR, outlining the details of the tailored services provided.

30days following completion, contractor shall be available to Program Office POC for any questions or clarifications.

The contractor shall notify the COR of scheduling and rescheduling of

Program Office services via virtual modality within the period of performance

Program Office consultations will be completed within the performance period with all scheduling dates identified within the first 10 months.

C.5.2. Task 13: Program Office Report:

The contractor shall submit an episode of service written report provided to the COR, with 10 business days outlining the details of the tailored services provided to designated program office.

C.5.3. Task 14: Program Office Customer Satisfaction Survey:

The contractor shall submit a Customer Satisfaction Survey questionnaire to Program Office POC(s), cc: COR within 5 business days after each service. At minimum questions shall include:

(1) Overall Mock Survey satisfaction rating Likert scale (1-5)

(2) What went well?

(3) What could have gone better?

Deliverables #14: Program Office Report Deliverables #15: Program Office Customer Satisfaction Survey

C.6. Activity 5: Reporting:

The Facility Summary Mock Survey Report is intended to provide the Program Office standardized written accounting of noncompliance identified during mock survey.

The Customer Satisfaction survey is intended to provide feedback regarding their survey experience. The qualitative and quantitative data gleaned from this feedback mechanism allows the contractor an opportunity to gain a better understanding of the requirements and concerns so the contractor can improve, when applicable, the

CONTINUATION PAGE 36C10GXXXXXXX Page 17 of 43 service being provided.

The purpose of the activity is to provide a summary report of activities associated with the contract for purposes of tracking and trending for quality improvement.

Desired Outcome / Objective:

The objective of this task is to provide efficient communication of all service activities associated with the contract. The desired outcome is monthly communications of Customer Satisfaction, Facility Mock survey and Program Office services provided to each site.

C.6.1. Task 15: Facility Summary Mock Survey Reports:

The contractor shall provide a summary report to the COR of opportunities for improvement, cumulative for monthly, quarterly, and annual results. Format should be Microsoft Excel for ability to track, trend and search, sort, and filter opportunities for improvement.

C.6.2. Task 16: Customer Satisfaction Summary Reports:

The contractor shall provide a summary Facility and Program Office Customer Satisfaction report to the COR cumulative for monthly results.

Reports shall include all responses of satisfaction survey, facility program office location, consultant, survey beginning and end date, and date of feedback survey sent. Report format shall provide ability to search, sort and filter such as Microsoft Excel.

Deliverables #16: Aggregated Customer Satisfaction Reports Deliverables #17: Aggregated Facility Mock Survey Report

C.7. Activity 6: National Education:

The purpose of the activity is to provide virtual education to VHA staff to enhance understanding of accreditation standards, upcoming changes, and compliance strategies.

Desired Outcome / Objective:

The desired outcome is to enhance VHA staff knowledge of TJC accreditation standards and process.

C.7.1. Task XX: Training:

The contractor shall conduct (2-hour) national education (training specific to TJC accreditation standards, processes, and initiatives.

National Education topics will be selected by the Government. Scheduling shall be agreed upon by the COR and the contractor during each performance period. The Program Office shall send a meeting invitation to the contractor and participants in advance of each training. The COR will record all national education sessions and

CONTINUATION PAGE 36C10GXXXXXXX Page 18 of 43 make the recordings and presentation materials available to the VHA.

C.7.2. Task XX: National Education Presentation Materials:

The contractor shall provide all educational (training) materials via electronic means (PowerPoint, PDF, Excel, etc.) 10 business days prior to scheduled education to the

COR.

Deliverable #19: National Education Presentation Materials

D. DELIVERABLE SCHEDULE

The time of delivery or performance is an essential to contract performance. The following Deliverables Schedule Table identifies the deliverables, the quantity required per period of performance or as ordered via TO, and when the deliverables are due. The contractor has responsibility for the deliverables as they are necessary to achieve the desired objectives / outcomes of this program. As previously stated, anytime the delivery date for a deliverable cannot be met, the contractor shall submit a written explanation to the COR within three business days before the deliverable date.

Deliverable dates may be adjusted by mutual agreement via modification at the sole discretion of the Government. If the deliverable is due on a federal holiday, the next business day shall be recognized as the deliverable date.

Unless specified or otherwise mutually agreed to, all information, data, and reports used or produced for this contract shall be in an electronic format fully compatible with Microsoft Office or other commercial software approved prior to start of performance.

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DELIVERABLES SCHEDULE TABLE

DELIVERABLE # ITEM ESTIMATED

QUANTITY

PER

PERFORMANCE

PERIOD

DELIVERY DATE FORMAT

Deliverable #1 Quality Assurance Plan

1 Per Contract • Kickoff Meeting PDF

Deliverable #2 Quality Assurance Surveillance Plan

1 Per Contract • Kickoff Meeting PDF

Deliverable #3 Contract Account Manager and Alternate

1 • Kickoff Meeting PDF

Deliverable #4 Business Associate Agreement

1 • Kickoff Meeting PDF

Deliverable #5 Kick-Off Meeting Agenda

1 • Agenda 5 business days prior to the meeting

PDF

Deliverable #6 Kick-Off Meeting Minutes

1 • Minutes within 15 business days following the meeting to all attendees

Deliverable #7 Monthly Meeting Agenda

12 • All required materials & agenda 5 business days prior to the meeting

PDF

Deliverable #8 Monthly Meeting Minutes

12 • Minutes within 5 business days following the meeting

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PER

PERFORMANCE

PERIOD

DELIVERY DATE FORMAT

Deliverable #9 Program Work

1 per Contract • 20 business days from the Notice to Proceed of the issuance of the first TO to the COR and CO

Deliverable #10 Communication

1 per Contract • Within 20 from the Notice to Proceed of the issuance of the first TO to COR and CO

• Implemented within 5 business of notification by CO and COR of approval

Deliverable #11 Contractor Personnel Training Plan

1 per Employee • Kickoff Meeting

Attestation

Deliverable #12 Facility Mock Survey Report

159 • To facility POC(s) and COR within 10 days of completion of mock survey

• Any facility results with immediate threat to health and safety findings will be immediately forwarded to

COR

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PER

PERFORMANCE

PERIOD

DELIVERY DATE FORMAT

Deliverable #13 Facility Customer Satisfaction Survey

159 • COR (Copy Facility POC) within 10 days after each consultation

Electronic Survey Link

Deliverable #14

Program Office Report

7 • to Program Office POC(s) and COR within 5 days after each consultation

TBD

Deliverable #15 Program Office Customer

7 • to Program Office POC(s) and COR within 5 days

Electronic Survey Link

Deliverable #16 Aggregated Customer

Reports

Twelve (12) • to COR monthly

Excel

Deliverable #17 Aggregated Facility Mock

Twelve (12) • to COR monthly

Excel

Deliverable #19: Deliverable #19: National Education Presentation Materials

6 • By the 10th business day prior to the educational session presentation;

other materials in

E. PERFORMANCE METRICS & REQUIREMENTS SUMMARY

In order to achieve success, monitor and measure performance, the COR, in concert with the CO, will evaluate and assess the contractor’s performance on requirements of the PWS based on the following Performance Metrics Table, which identifies the Performance Objectives, Performance Standards, and Acceptable Quality Level (AQL) for “Satisfactory”

CONTINUATION PAGE 36C10GXXXXXXX Page 23 of 43 or “Higher Performance” throughout the performance period. The COR and CO will use the identified Methods of Surveillance to monitor and assess contractor performance to the achieved levels of the AQLs, measure the performance acceptability levels, and if necessary, use the remedies identified to ensure the contractor corrects deficiencies.

Evaluations will be discussed by the Government with the contractor on a quarterly basis in a forum which facilitates discourse and process improvement approaches. At the end of each assessment period, to include the quarterly assessments, the COR and CO will notify the contractor of the results of the assessment no later than 45 business days after the end of each quarter. These evaluations will be used to derive the ratings used on the Contractor Performance Assessment Reporting System (CPARS) to create and measure the quality and timely reporting of performance information per performance period of the contract.

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PERFORMANCE METRICS TABLE

Performance Objective

Performance Standard

(Task, Deliverable)

Acceptable Quality Level

(AQL) for Satisfactory or

Higher

Method of Surveillance

Remedies

1. Kick-Off Meeting

• The contractor shall attend the meeting with the appropriate staff with agenda, presentation materials, names of participants (with email addresses). The contractor shall provide agenda at least 5 business days prior to the meeting.

• The contractor shall provide meeting minutes…