PWS - National Nursing Quality Indicators Database Access and Reporting Services_DRAFT.pdf

ONS

Performance Work Statement [PWS]

National Nursing Quality Indicators Database Access and Reporting Services

DEPARTMENT OF VETERANS AFFAIRS [VA]

OFFICE OF NURSING SERVICE [ONS]

1. TITLE

2. BACKGROUND

The Veterans Health Administration [VHA], Office of Nursing Service [ONS] requires access to a nationally recognized nursing quality indicators database that provides an integrated data network allowing healthcare organizations to measure nurse-sensitive quality indicators. These indicators provide required data sets for national benchmarking against private and public healthcare facilities and support Magnet® and other nursing excellence programs. This benchmarking capability enables system-level reporting, centralized governance, and targeted workforce interventions that drive measurable patient safety and nurse retention improvements across VA Medical Centers.

Definitions and Acronyms [See Attachment A for complete list]:

a. CLABSI Central Line-Associated Bloodstream Infection

b. CAUTI Catheter-Associated Urinary Tract Infection

c. NDNQI National Database of Nursing Quality Indicators

d. ONS Office of Nursing Service

e. PHI Protected Health Information

f. VA Department of Veterans Affairs

g. VAHCS Veterans Affairs Health Care Systems [facilities]

3. OBJECTIVE AND SCOPE

The objective of this Firm Fixed Price [FFP] Blanket Purchase Agreement [BPA] is to obtain enterprise-wide access to a nursing quality indicators program that provides an integrated data network allowing healthcare organizations to measure nurse-sensitive quality indicators required for national benchmarking and Magnet Accreditation. The database shall enable real-time benchmarking, contributing to a high-reliability organization model across VHA facilities.

The Contractor shall provide access to quality metrics dashboards that will be utilized across the VA healthcare system to track and review nurse-sensitive indicators. The Contractor shall provide comparison capabilities among similar facilities for organizational awareness. The system shall accept data entry without requiring Protected Health Information [PHI].

Core indicators shall include at a minimum:

▪ Nursing care hours per patient day

▪ Patient days

▪ Hospital-acquired infections [including CLABSI and CAUTI]

▪ Falls data

▪ Pressure injury data

▪ Annual nurse satisfaction survey

▪ Nursing turnover rates

▪ Nurse education and certification tracking

The BPA will allow VA medical facilities to issue FFP Call Orders for consistent and repeatable services to support enterprise alignment, cost savings, and standardized system level visibility of nursing quality indicators.

4. ORDERING PERIOD

The ordering period for this BPA shall be five [5] years [60 month] from [insert start date] DD Month YYYY through [insert end date] DD Month YYYY.

The base and option periods of performance will be specified at the individual Call Order level.

Individual Call Orders shall define specific periods of performance based on facility needs, provided such periods do not extend beyond the BPA ordering period.

5. PLACE OF PERFORMANCE

The Contractor shall provide services at the Contractor's facilities [off-site] on behalf of participating VA facilities.

6. TYPE OF CONTRACT

Firm Fixed Price [FFP] Blanket Purchase Agreement [BPA] All work performed under this PWS shall be ordered via FFP Call Orders issued under this BPA.

7. GOVERNMENT FURNISHED EQUIPMENT [GFE]

No GFE is required under this BPA.

8. SPECIFIC TASKS AND DELIVERABLES

8.1 Database Access and Quality Metrics

The Contractor shall provide secure, web-based access to the nursing quality indicators database for authorized users at participating VA facilities.

Access shall include:

a. Data from facilities participating in the database program, aggregated in groups with comparable institutions [“Comparison Data”] in accordance with program procedures.

b. Clinical and Staffing Measure reports that include trends and Comparison Data for nurse sensitive quality measures.

c. The opportunity for participating facilities to conduct an annual Registered Nurse [RN] survey under established program guidelines, with appropriate coordination and timelines.

d. RN survey data reports that include Comparison Data.

e. Quality standards for data management through established standards of data collection, data reporting, and data security to ensure data integrity and security.

Schedule The Contractor shall provision platform access for authorized VA users within 15 calendar days after individual Call Order award and shall maintain such access throughout the Call Order period of performance unless otherwise directed by the Contracting Officer [CO] or COR.

Performance Standard

▪ 100 percent of ordered facilities receive initial access credentials within 15 calendar days of Call Order award.

▪ 99.5 percent monthly system uptime, excluding scheduled maintenance windows.

▪ User account/access issues corrected within two [2] business days of notification for at least 95 percent of cases.

8.2 Dashboard Access and Specific Indicators

The Contractor shall provide dashboard access for, at a minimum, the following quality indicators:

a. CLABSI

b. CAUTI

c. Falls

d. Pressure Injuries

e. Nursing Care Hours per patient day

Dashboards shall support trend analysis, peer comparison and unit-level drill down consistent with Attachment B – Sample Dashboard Requirements.

The Contractor shall provide operational dashboards with trend views, national and peer group comparison data, and unit-level detail for required nurse-sensitive indicators in accordance with program standards.

Performance Standard

▪ 100 percent of required dashboards are operational within 15 calendar days after access is established for each facility [Deliverable 9.2].

▪ Indicator data submitted by facilities are reflected in dashboards within 24 hours of successful submission for at least 95 percent of data loads.

▪ Comparison data and benchmark values are updated at least monthly in accordance with program schedules for 95 percent of cycles.

8.3 Survey and Tracking Tools

The Contractor shall provide:

a. Access to an annual nurse satisfaction survey and resulting aggregate and facility level reports with available comparison data.

b. Nursing turnover tracking capabilities, including monthly and annual turnover rates, voluntary versus involuntary separations, and, where available, new graduate RN turnover.

c. Nurse education and certification tracking capabilities, including degree mix, specialty certification rates, and trend analysis.

▪ Annual survey timeline and participation plan provided to the COR at least 30 calendar days before survey launch.

▪ Survey reports delivered within 30 calendar days after survey close for 95 percent of survey cycles [Deliverable 9.8].

▪ Turnover and education tracking tools accessible within 15 calendar days of Call

Order award for 100 percent of ordered facilities [Deliverable 9.4].

8.4 Training and Support

The Contractor shall provide:

a. Training in dashboard data entry, system navigation, and management. Training may include live webinars, recorded sessions, and written user guides.

b. Access to customer support related to dashboard management and database access during normal business hours [Monday–Friday, 8:00 AM to 5:00 PM Eastern Time, excluding Federal holidays].

▪ Initial training completed within 30 calendar days after Call Order award for designated facility personnel [Deliverable 9.6].

▪ Training materials and user documentation delivered within 15 calendar days after

Call Order award [Deliverable 9.5].

▪ Standard support requests acknowledged within one [1] business day for at least 95 percent of inquiries.

▪ Priority/access blocking issues acknowledged within four [4] business hours and resolved within two [2] business days for at least 90 percent of cases.

9. DELIVERABLES SCHEDULE

Ref. Deliverable Due Date Performance Standard

9.1 Access to quality metrics

database including custom dashboards for each facility

Within 15 calendar days after individual Call Order award

100% of ordered facilities receive access credentials and can log in successfully.

9.2 Dashboard access for CLABSI, CAUTI, Falls, Pressure Injuries, and Nursing Care Hours indicators

Within 15 calendar days after individual Call Order award

100% of required dashboards operational and viewable for authorized users.

9.3 Access to annual nurse

satisfaction/RN survey and survey data

Within 15 calendar days after individual Call Order award or survey cycle initiation

100% of ordered facilities receive survey access.

9.4 Nursing turnover and education

tracking tools

Within 15 calendar days after individual Call Order award

100% of ordered facilities receive tracking access.

9.5 Training materials and user

documentation

Within 15 calendar days after individual Call Order award

Complete training package delivered and accepted by COR.

9.6 Initial training session(s) Within 30 calendar days

after individual Call Order award

Training completed for 100% of designated facility personnel, or at least one session offered to each facility.

9.7 Monthly Clinical and Staffing

Measure reports

By the 10th calendar day of each month following data submission

95% of reports delivered on time; reports include trends and comparison data.

9.8 Quarterly RN Survey reports

(when applicable)

Within 30 calendar days after survey completion

Reports include comparison data; 95% delivered on time.

9.9 Annual performance summary

report

Within 30 calendar days after end of performance period

Report summarizes all key quality metrics and trends for the period.

10. PERFORMANCE REQUIREMENTS AND STANDARDS

The Government will evaluate Contractor performance against the following, objective, quantifiable performance standards:

Performance Requirement

Performance Standard

Acceptable Quality Level [AQL]

Method of Surveillance

Database system availability

Monthly uptime excluding scheduled maintenance

99.5% Random inspection of system logs, vendor reports

Timely delivery of monthly reports

Reports delivered by the 10th calendar day of each month

95% on time delivery 100% inspection of report delivery dates

Data accuracy Error free data processing and reporting

98% accuracy rate (no material errors)

Random sample review of selected reports vs.

source data

Customer support responsiveness

Response to support requests

95% of standard requests responded to within 4 business hours

Validated customer feedback and ticket system reports

Training completion

Facility personnel trained as agreed

100% of designated personnel attend or have access to training

100% inspection of training records

RN Survey administration

Survey availability during designated period

100% availability during survey window

100% inspection of survey access and logs

11. CONTRACTING OFFICER’S REPRESENTATIVE [COR] AUTHORITY

The COR is not authorized to make changes to the terms and conditions of this BPA or any Call Order. Only the Contracting Officer [CO] may authorize changes through written contract modifications.

The COR’s authority is limited to:

▪ Monitoring Contractor performance against technical requirements;

▪ Reviewing and accepting deliverables;

▪ Verifying performance for invoice approval; and

▪ Notifying the CO of any performance deficiencies.

The CO will issue a COR Appointment Memorandum to the COR, with a copy provided to the Contractor, describing the COR’s responsibilities and limitations.

12. CONTRACTOR PERSONNEL REQUIREMENTS

The Contractor shall provide personnel with appropriate skills in database administration, technical support, training, and data analysis necessary for successful performance under this

BPA.

Contractor employees shall not have access to VA sensitive information, VA production systems, or VA facilities under this PWS; therefore, no VA background investigations are required. The Contractor shall be US based and shall ensure that all VA data are maintained within the continental United States.

13. GOVERNMENT RESPONSIBILITIES

The Government will provide:

a. Designated facility points of contact for coordination.

b. Timely submission of nursing quality data per the Contractor’s established submission schedules [see Attachment C].

c. Identification of personnel requiring training.

d. Prompt notification of changes in facility participation or points of contact.

14. SECURITY REQUIREMENTS

Contractor employees shall not have access to VA sensitive or computer information and will not require access to VA facilities; no VA background investigations are required under this PWS.

The Contractor shall maintain all VA data within systems that comply with applicable federal security requirements for healthcare related data and shall not require or accept PHI as part of data submissions. Suspected security incidents affecting VA data or system access shall be reported to the CO and COR within one business day of discovery.

15. GOVERNMENT FURNISHED INFORMATION [GFI]

Only the minimum GFI necessary to establish user accounts, facility hierarchies, and data submission mapping [e.g., facility lists, unit identifiers] will be provided, if required.

16. QUALITY ASSURANCE SURVEILLANCE PLAN [QASP]

In accordance with VAAM Part M846, the Government will develop and maintain a QASP for this BPA and any resulting Call Orders, as applicable. The purpose of the QASP is to support Government contract quality assurance by ensuring that services acquired under this BPA conform to the requirements of the contract and this PWS.

The QASP will be maintained as a separate document in the official contract file and may be updated at the Government’s discretion throughout the period of performance. The CO is responsible for ensuring that a QASP is prepared and documented in the contract file, consistent with VAAM M846.401‑70.

The QASP will define the performance objectives, performance standards, acceptable quality levels [AQLs], surveillance methods, and frequency of surveillance, using the performance requirements and standards in Section 10 as a baseline.

Surveillance methods may include, but are not limited to:

a. Random sampling of Contractor performance, documentation, and system outputs.

b. Periodic inspections of system performance, report delivery timeliness, and data accuracy.

c. Review of validated customer complaints, user feedback, and ticketing system reports.

The COR will perform and document surveillance in accordance with the QASP and will notify the CO of any instances of nonconforming services. Surveillance intensity and frequency may be adjusted based on Contractor performance trends, with increased monitoring for critical performance standards or when performance issues are identified.

17. CONTRACT CLOSEOUT

The Government will retain ownership of all products, data outputs, reports, and materials developed by the Contractor and any subcontractors while performing work under this BPA.

Upon BPA or Call Order closeout, the Contractor shall provide all VA accessible data and reports in an exportable, commercially standard format ([e.g., CSV, Excel, PDF] within 30 calendar days of closeout notification.

18. CHANGES TO REQUIREMENTS

Only the Contracting Officer may approve changes to this PWS, the BPA, or any Call Order, through written modification. No other individual is authorized to modify deliverables, due dates, or performance requirements.

19. INVOICING AND PAYMENT

The Contractor shall submit invoices monthly in arrears for services provided under each Call Order.

Invoices shall:

▪ Reference the BPA number and specific Call Order number;

▪ Identify the period of performance; and

▪ Include sufficient backup documentation to support that required deliverables and performance standards were met.

Payment will be made in accordance with the Prompt Payment Act upon COR acceptance of services and approval of invoices

20. TRANSITION REQUIREMENTS

Upon expiration or termination of this BPA or any Call Order, the Contractor shall cooperate with the Government to ensure an orderly transition of services.

Transition support shall include:

▪ Providing data exports and system documentation as described in Section 17; and

▪ Reasonable technical assistance for a period not to exceed 60 calendar days following expiration or termination.

21. ADMINISTRATIVE INFORMATION

Questions regarding this PWS shall be directed to the Contracting Officer identified in the solicitation or award document.