PWS - Teleradiology Physician Services - NMVAHCS.pdf

Performance Work Statement for Teleradiology Physician Services

1. GENERAL:

1.1. Services Provided: The contractor shall furnish board certified or board eligible Radiology

Physician services in accordance with the specifications contained herein to the beneficiaries of the Department of Veterans Affairs (VA) and the New Mexico VA Health Care System

(NMVAHCS). The VA Radiology Services follow the standards & guidelines set forth by

American College of Radiology (ACR) Practice Parameters and Technical Standards |

American College of Radiology (acr.org). A contractor providing teleradiology services shall provide services consistent with The Joint Commission (TJC) and that meet or exceed

VA and the American College of Radiology Guidelines as defined in this document.

1.2. Place of Performance: Services shall be provided off-site at the Contractor’s location.

1.3. Authority: Title 38 United States Code (U.S.C.) § 8153 – Sharing of Health Care Resources

(HCR), Federal Acquisition Regulation (FAR) Part 12 - Acquisition of Commercial

Products and Commercial Services- in conjunction with FAR Part 15 – Contracting by

Negotiation.

1.4. Policy/Directives/Handbooks. The contractor shall be subject to the following policies, including any subsequent updates during the period of performance. The policies listed below can be accessed electronically at the following: VA Publications and VHA

Publications.

1.4.1. VA Directive 1663: Health Care Resources (HCR) Contracting – Buying Title 38

U.S.C. 8153

1.4.2. VHA Directive 1003.04: VHA Patient Advocacy

1.4.3. VHA Directive 1065(1): Productivity and Staffing Guidance for Specialty Provider

Group Practice

1.4.4. VHA Directive 1088(1): Communicating Test Results to Providers and Patients

1.4.5. VHA Directive 1100.18: Reporting and Responding to State Licensing Boards

1.4.6. VHA Directive 1100.20(2): Credentialing of Health Care Providers

1.4.7. VHA Directive 1100.21(1): Privileging

1.4.8. VHA Directive 1417: Lung Cancer Screening

1.4.9. VHA Directive 1605.01: Privacy and Release of Information

1.4.10. VHA Directive 1907.01(1): VHA Health Information Management and Health

Records

1.4.11. VHA Directive 1907.08: Health Care Information Security Policy and Requirements

1.4.12. VHA Handbook 1100.17: National Practitioner Data Bank (NPDB) Reports

1.4.13. Privacy Act of 1974 (5 U.S.C. 552a) as amended:

http://www.justice.gov/oip/foia_updates/Vol_XVII_4/page2.htm

1.4.14. 42 Code of Federal Regulations (CFR) Part 482 Conditions of Participation

Hospitals: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482

1.5. Acronyms/Definitions: Terms used in this contract shall be interpreted as follows unless the context expressly requires a different construction and/or interpretation. In case of a conflict https://www.acr.org/clinical-resources/clinical-tools-and-reference/practice-parameters-and-technical-standards https://www.acr.org/clinical-resources/clinical-tools-and-reference/practice-parameters-and-technical-standards https://www.va.gov/vapubs/ https://www.va.gov/vhapublications/index.cfm https://www.va.gov/vhapublications/index.cfm http://www.hpoe.org/resources https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482 in language between the Definitions and other sections of this contract, the language in this section shall govern.

1.5.1. ACGME: Accreditation Council for Graduate Medical Education

1.5.2. ACLS: Advanced Cardiac Life Support

1.5.3. BLS: Basic Life Support

1.5.4. CDC: Centers for Disease Control and Prevention

1.5.5. CEU: Certified Education Unit

1.5.6. Clinical Privileging: Clinical Privileging is the process by which a practitioner, licensed for independent practice; e.g., without supervision, direction, required sponsor, preceptor, mandatory collaboration, etc.; is permitted by law and the facility to practice independently, to provide specific medical or other patient care services within the scope of the individual’s license, based upon the individual’s clinical competence as determined by peer references, professional experience, health status, education, training and licensure. Clinical privileges must be facility-specific and provider-specific, and within available resources.

1.5.7. CME: Continuing Medical Education

1.5.8. CMS: Centers for Medicare and Medicaid Services

1.5.9. CO: Contracting Officer: The person executing this contract on behalf of the

Government with the authority to enter into and administer contracts and make related determinations and findings.

1.5.10. COR: Contracting Officer’s Representative: A person appointed by the CO to take necessary action to ensure the Contractor performs in accordance with and adheres to the specifications contained in the contract and to protect the interest of the

Government. The COR shall report to the CO promptly any indication of non-compliance in order that appropriate action can be taken.

1.5.11. COS: Chief of Staff

1.5.12. CPARS: Contractor Performance Assessment Reporting System

1.5.13. Credentialing: Credentialing is the process of obtaining, verifying, and assessing the qualifications of a health care provider to provide care or services in or for the

VA health care system. Credentials are documented evidence of licensure, education, training, experience, or other qualifications.

1.5.14. DEA: Drug Enforcement Agency

1.5.15. EHR: Electronic Health Record - electronic health record system used by the VA

1.5.16. FSMB: Federation of State Medical Boards

1.5.17. FTE: Full Time Equivalent. VA’s definition for full time-working the equivalent of

80 hours every two weeks, 2,080 hours per year. In calculating FTE, any hours not worked on national holidays shall not be included.

1.5.18. HHS: Department of Health and Human Services

1.5.19. HIPAA: Health Insurance Portability and Accountability Act

1.5.20. ISO: Information Security Officer

1.5.21. Key Personnel: The individuals specified in this contract who are essential to work performance.

1.5.22. NPI: National Provider Identifier. NPI is a standard, unique 10-digit numeric identifier required by HIPPA. The Veterans Health Administration must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical centers)

1.5.23. OPPE: Ongoing Provider Practice Evaluation

1.5.24. PACS: Picture Archival Communication System

1.5.25. POP: Period of Performance

1.5.26. PPD: Purified Protein Derivative

1.5.27. PWS: Performance Work Statement

1.5.28. QA/QI: Quality Assurance/Quality Improvement

1.5.29. QASP: Quality Assurance Surveillance Plan

1.5.30. QM/PI: Quality Management/Performance Improvement

1.5.31. VETPro: is VHA’s mandatory credentialing software platform to document the credentialing of VHA health care providers. This system facilitates completion of a uniform, accurate, and complete credentials file.

1.5.32. VHA: Veterans’ Health Administration

1.5.33. VISN: Veterans Integrated Services Network

1.5.34. VISTA: Veterans Information Systems Technology Architecture

2. QUALIFICATIONS:

2.1. Staff/Facility

2.1.1. License: Contract physician(s) assigned by the Contractor to perform the services covered by this contract shall have a current license to practice medicine in any

State Territory, or Commonwealth of the United States or the District of Columbia where services are being performed. All licenses held by the key personnel working on this contract shall be full and unrestricted licenses. Information on state licensing in tele-radiology may be found at this site: Teleradiology | American College of

Radiology (acr.org).Contract physician(s) who have current, full and unrestricted licenses in one or more states, but who have, or ever had, a license restricted, suspended, revoked, voluntarily revoked, voluntarily surrendered pending action or denied upon application may be considered for the purpose of this contract only if the provider is successfully credentialed and privileged by NMVAHCS

Credentialing and Privileging Office. Acceptance under this contract is contingent upon the provider meeting all clinical qualifications and being granted privileges by

NMVAHCS.

2.1.2. Board Certification: All contract physician(s) shall be board certified or board eligible in Diagnostic Radiology Medicine. All continuing education courses required for maintaining certification must be kept up to date. Documentation verifying current certification shall be provided by the Contractor to the VA COR on an annual basis for each year of contract performance.

https://www.acr.org/Advocacy/Issues/Legislative https://www.acr.org/Advocacy/Issues/Legislative

2.1.3. Credentialing and Privileging: Credentialing and privileging is to be done in accordance with the provisions of VHA Directive 1100.20(2) and VHA Directive

1100.21(1) referenced above. The Contractor is responsible to ensure that proposed physician(s) possesses the requisite credentials enabling the granting of privileges.

No services shall be provided by any contract physician(s) prior to obtaining approval by the NMVAHCS Professional Standards Board, Medical Executive

Board and Medical Center Director.

2.1.3.1. If a contract physician(s) is not credentialed and privileged or has credentials/privileges suspended or revoked, the Contractor shall furnish an acceptable substitute without any additional cost to the government.

2.1.3.2. When teleradiology services are being provided by contract physician(s) who direct, diagnose, or otherwise provide clinical treatment to a patient via a teleradiology link, the contract physician(s) must be appointed, credentialed, and privileged at the VA facility (facilities) which receive the teleradiology services (patient site), as well as at the site providing the services. The following requirements apply:

2.1.3.3. Contract licensed independent practitioners must be credentialed and privileged through the VA facility’s Medical Staff Office in accordance

Credentialing and Privileging Directives 1100.20(2) and 1100.21(1) and

VHA Directive 1914(1).

2.1.3.4. Separately delineated privileges for teleradiology services must be requested and assigned in this process.

2.1.3.5. In general, the credentialing process should be started at least 60-90 days in advance of estimated entry on duty. The time required for this process may be expedited when patient care needs are urgent.

2.1.3.6. The VA’s Medical Staff Office or Human Resources Management Service will provide an instruction packet containing forms and a detailed listing of required documentation, including curriculum vitae, current references, signed release of information from the candidate, and statement that the candidate does not have any physical or mental health condition that would adversely affect his/her ability to carry out the assigned duties, and additional credentialing forms. The candidate will also be required to make application through the VetPro internet-based process. The candidate will need to be enrolled in VetPro by the Credentialing Coordinator at the VA or by the Human Resources Management Service designee. The website address is: https://fcp.vetpro.org/Admin/Login/Index

2.1.3.7. It is the Contractor’s responsibility to contact the NMVAHCS Radiology

Department to request a package and instructions.

2.1.3.8. When contract physician(s) provide only teleconsultation by offering advice that supports care provided by VAs on site licensed independent providers, the Contractor must furnish VA with a copy of the contract physician(s) credentials, verification of credentials, and current clinical privileges. The contract physician(s) providing teleconsultation services do not have to be separately privileged at the VA facility.

2.1.3.9. The Contractor must furnish a copy of its policy and procedures for credentialing and privileging to the Contracting Officer and COR for review https://fcp.vetpro.org/Admin/Login/Index to ensure these meet the VA’s requirements for establishment of competence through these mechanisms.

2.1.4. Technical Proficiency - Contract physician(s) shall be technically proficient in the skills necessary to fulfill the government’s requirements, including the ability to speak, understand, read and write English fluently. Contractor shall provide documents upon request of the CO/COR to verify current and ongoing competency, skills, certification and/or licensure related to the provision of care, treatment and/or services performed. Contractor shall provide verifiable evidence of all educational and training experiences including any gaps in educational history for all contract physician(s) and contract physician(s) shall be responsible for abiding by the

Facility's Medical Staff By-Laws, rules, and regulations that govern medical staff behavior. See Section D - Attachments: D.1 – NMVAHCS Medical Staff By-Laws.

2.1.5. Continuing Medical Education (CME)/ Certified Education Unit (CEU)

Requirements: Contractor shall provide the COR copies of current CMEs as required or requested by the Facility. Contract physician(s) registered or certified by national/medical associations shall continue to meet the minimum standards for

CME to remain current. Contractor shall report CME hours to the credential’s office for tracking. These documents are required for both privileging and re-privileging.

Failure to provide shall result in loss of privileges for contract physician(s).

2.1.6. Training (VA MANDATORY): Contractor shall meet all VA educational requirements and mandatory course requirements defined herein; all training must be completed by the contract physician(s) as required by the VA.

Training Frequency Annual Hours

VA Privacy Policy and Security

Training Yearly 1 Hour

HIPAA Training Yearly 1 Hour

2.1.7. National Provider Identifier (NPI): NPI is a standard, unique 10-digit numeric identifier required by HIPAA. The Veterans Health Administration must use NPIs in all HIPAA-standard electronic transactions for individual (health care practitioners) and organizational entities (medical facilities). The Contractor shall have or obtain appropriate NPI and if pertinent the Taxonomy Code confirmation notice issued by the Centers for Medicare and Medicaid Services (CMS) National Plan and Provider

Enumeration System (NPPES) be provided to the Contracting Officer with the proposal.

2.1.8. Conflict of Interest: The Contractor and all contract physician(s) are responsible for identifying and communicating to the CO and COR conflicts of interest at the time of proposal and during the entirety of contract performance. At the time of proposal, the Contractor shall provide a statement which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided. The Contractor shall also provide statements containing the same information for any identified consultants or subcontractors who shall provide services. The Contractor must also provide relevant facts that show how it’s organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest. These statements shall be in response to the VAAR provision 852.209-70

Organizational Conflicts of Interest. See Section D - Attachments: D.2 – VAAR provision 852.209-70: Organizational Conflicts of Interest.

2.1.9. Citizenship related Requirements:

2.1.9.1. The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by

Homeland Security, Immigration and Customs Enforcement and the U.S

Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patient referrals.

2.1.9.2. While performing services for the Department of Veterans Affairs, the

Contractor shall not knowingly employ, contract, or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the

Contractor is required to comply with all “E-Verify” requirements consistent with “Executive Order 12989” and any related pertinent

Amendments, as well as applicable Federal Acquisition Regulations.

2.1.9.3. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of

Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by

Homeland Security, Immigration and Customs Enforcement and the U.S

Department of Labor, shall be prohibited from working at the Contractor’s place of business that services Department of Veterans Affairs patient referrals; or other place where the Contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach.

2.1.9.4. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under 18 U.S.C.

1001.

2.1.9.5. The Contractor agrees to obtain a similar certification from its subcontractors. The certification shall be made as part of the offerors response to the RFP using the subject attachment in Section D of the solicitation document. See Section D - Attachments: D.3 Contractor

Certification Immigration and Nationality Act of 1952, As Amended.

2.1.10. Annual Office of Inspector General (OIG) Statement: In accordance with HIPAA and the Balanced Budget Act (BBA) of 1977, the Department of Health and

Human Services (HHS) Office of Inspector General (OIG) has established a list of parties and entities excluded from Federal health care programs. Specifically, the listed parties and entities may not receive Federal Health Care program payments due to fraud and/or abuse of the Medicare and Medicaid programs.

2.1.10.1. Therefore, Contractor shall review the HHS OIG List of Excluded

Individuals/Entities on the HHS OIG web site at http://oig.hhs.gov/exclusions/index.asp to ensure that the proposed http://oig.hhs.gov/exclusions/index.asp contract physician(s) are not listed. Contractor should note that any excluded individual or entity that submits a claim for reimbursement to a

Federal health care program, or causes such a claim to be submitted, may be subject to a Civil Monetary Penalty (CMP) for each item or service furnished during a period that the person was excluded and may also be subject to treble damages for the amount claimed for each item or service. CMP’s may also be imposed against the Contractor that employ or enter into contracts with excluded individuals to provide items or services to Federal program beneficiaries.

2.1.10.2. By submitting their proposal, the Contractor certifies that the HHS OIG

List of Excluded Individuals/Entities has been reviewed and that the

Contractors are and/or firm is not listed as of the date the offer/bid was signed.

2.2. Clinical/Professional Direction: The qualifications of Contractor personnel are subject to review by VA Medical Facility COS or his/her clinical designee and approval by the

Medical Facility Director as provided in VHA Directive 1100.20(2) and VHA Directive

1100.21(1). Clinical/Professional direction of all clinical personnel covered by this contract for quality purposes will be provided by the Facility COS and/or the Chief of the Service or his designee. A clinical COR may be appointed, however, only the CO is authorized to consider any contract modification request and/or make changes to the contract during the administration of the resultant contract.

2.3. Non-Personal Healthcare Services: The parties agree that the Contractor and all contract physician(s) shall not be considered VA employees for any purpose.

2.4. Indemnification: The Contractor shall be liable for, and shall indemnify and hold harmless the Government against, all actions or claims for loss of or damage to property or the injury or death of persons, arising out of or resulting from the fault, negligence, or act or omission of the Contractor, its agents, or employees.

2.5. Prohibition Against Self-Referral: Contractor’s physicians are prohibited from referring VA patients to contractor’s or their own practice(s)

2.6. Inherent Government Functions: Contractor and Contract physician(s) shall not perform inherently governmental functions. This includes, but is not limited to, determination of agency policy, determination of Federal program priorities for budget requests, direction and control of government employees (outside a clinical context), selection or non-selection of individuals for Federal Government employment including the interviewing of individuals for employment, approval of position descriptions and performance standards for Federal employees, approving any contractual documents, approval of Federal licensing actions and inspections, and/or determination of budget policy, guidance, and strategy.

2.7. No Employee status: The Contractor shall be responsible for protecting Contract physician(s) furnishing services. To carry out this responsibility, the Contractor shall provide or certify that the following is provided for all their staff providing services under the resultant contract:

2.7.1. Workers’ compensation;

2.7.2. Professional liability insurance;

2.7.3. Health examinations;

2.7.4. Income tax withholding; and

2.7.5. Social security payments

2.8. Tort Liability: The Federal Tort Claims Act does not cover Contractor or contract physician(s). When a Contractor or contract physician(s) has been identified as a provider in a tort claim, the Contractor shall be responsible for notifying their legal counsel and/or insurance carrier. Any settlement or judgment arising from a Contractor’s (or contract physician(s)) action or non-action shall be the responsibility of the Contractor and/or insurance carrier.

2.9. Contingency Plan: Because continuity of care is an essential part of the Facility’s medical services, The Contractor shall have a contingency plan in place to be utilized if the contract physician(s) leaves Contractor’s employment or is unable to continue performance in accordance with the terms and conditions of the resulting contract.

2.9.1. Contractor shall submit a listing of proposed key personnel performing technical delivery of services in the following format:

Provider Name: (available when contract is awarded)

Title/Rank: (available when contract is awarded)

Curriculum Vitae and qualification documents of each key personnel shall be submitted with the proposal.

2.10. Emergency Substitutions: During the first ninety (90) calendar days of performance, the

Contractor shall make NO substitutions of key personnel unless the substitution is necessitated by illness, death or termination of employment. The Contractor shall notify the

CO, in writing, within fifteen (15) calendar day (s) after the occurrence of any of these events and provide the information required below. After 90 days, the Contractor shall submit the information required below to the CO at least fifteen (15) days calendar days prior to making any permanent substitutions.

2.10.1. The Contractor shall provide a detailed explanation of the circumstances necessitating the proposed substitutions, complete resumes for the proposed substitutes, and any additional information requested by the CO. Proposed substitutes shall have comparable qualifications to those of the persons being replaced. The CO will notify the Contractor within fifteen (15) calendar days after receipt of all required information of the decision on the proposed substitutes. The contract will be modified to reflect any approved changes of key personnel.

2.10.2. For temporary substitutions where the key person shall not be reporting to work for three (3) consecutive workdays or more, the Contractor shall provide a qualified replacement for the key person. The substitute shall have comparable qualifications to the key person. Any period exceeding two weeks will require the procedure as stated above.

3. VA HOURS OF OPERATION/SCHEDULING:

3.1. Business Hours: The contractor shall be available Monday through Friday from 16:00 PM to

08:00 AM, and 24 hours per day on Saturdays, Sundays, and all Federal holidays.

Transmission of images for interpretation may occur outside of these work schedule windows.

3.2. Contractor shall be available to the Facility for consultation and interpretation 24 hours a day, 7 days a week, 52 weeks a year for STAT, urgent, and routine exams as needed.

3.3. Federal Holidays: The following holidays are observed by the Department of Veterans

Affairs:

• New Year’s Day

• Martin Luther King’s Birthday

• President’s Day

• Memorial Day

• Juneteenth

• Independence Day

• Labor Day

• Columbus Day

• Veterans Day

• Thanksgiving Day

• Christmas Day

• Any day specifically declared to be a national holiday.

3.4. Continuity of services under contact:

3.4.1. Unless a state of emergency has been declared or clinics are otherwise cancelled by the NMVAHCS the Contractor shall provide the services specified under this contract.

3.4.2. Contractor is responsible for providing qualified personnel to read films. The VA must be informed at least fifteen (15) calendar days in advance if there will be a significant change in contractor’s ability to perform to allow for planning of service coverage and workload distribution. Requirements as noted in attachment B will be provided to all Facilities and maintained by the contractor. (D.4)

3.4.3. The contractor shall maintain open and professional communication with members of the VISN and Facility Diagnostic Imaging staff. The contractor shall provide up-to-date points of contact to facilitate communication on technical and administrative issues including review of quality measures and the VA OPPE process. The

Contractor will provide a schedule of radiologists with telephone numbers for consultation by VA technologists and referring physicians.

3.4.4. The contractor shall provide a single phone number with a list of individuals who could be contacted to immediately resolve any difficulties experienced of teleradiology services and STAT studies The COR will assure up-to-date rosters of staff are provided to the Contractor.

3.4.5. Tele-communications:

3.4.5.1. The contractor will secure and maintain its communications link between the contractor’s facility and the VAMCs’ facilities at the contractor’s expense. These expenses may be included in contractor’s proposal as a separate item. The cost to establish and maintain this communication link may be provided, if the Government deems it is more cost effective to the

Government.

3.4.5.2. In the event of telecommunications failure, the Government shall package, hard copy film or alternative media in Government-provided shipping containers, and ship to the contractor’s facility; using Government provided pre-paid shipping documentation. The contractor’s place of business must be within the confines of the continental United States.

3.4.5.3. The contractor shall make provisions for the proper maintenance and functioning of all teleradiology, and associated equipment, facilities and fixtures as may reasonably be required by Contract Physicians to perform services hereunder.

4. CONTRACTOR RESPONSIBILITIES:

4.1. Clinical Personnel Required: The Contractor shall provide contract physician(s) who are competent, qualified per this PWS and adequately trained to perform assigned duties.

4.2. Management and Supervision:

4.2.1. The Contractor shall be responsible for supervising the daily services provided under this contract by the Contractor’s staff.

4.2.2. The Contractor shall have written policies and procedures regarding staff credentials and privileging.

4.2.3. The Facility will provide to the Contractor policies, procedures and processes necessary to allow cooperative functioning between the agency and NMVAHCS.

Updates and refreshers will be provided to the Contractor upon request and when policy procedures or process changes.

4.2.4. The Contractor shall complete and maintain background investigations to insure that employees do not have a record of criminal offenses or substantiated incidents of patient abuse; and, if required to perform their duties, employees are properly licensed and insured to operate motor vehicles. A copy of the initiation of the background investigation as well as a completed background investigation shall be provided to the NMVAHCS.

4.3. Standards of Care: The contract physician(s)’ care shall cover the range of Radiology services as would be provided in a civilian medical treatment facility and the standard of care shall be of a quality, meeting or exceedingly currently recognized national standards as established by:

4.3.1. The American College of Radiology Guidelines: Practice Parameters and Technical

Standards | American College of Radiology (acr.org)

4.3.2. ACR Practice Parameter for Communication of Diagnostic Imaging Findings:

Practice Parameters and Technical Standards | American College of Radiology

(acr.org);

4.3.3. VA Standards: All teleradiology interpretation shall begin immediately upon receipt.

The contractor shall provide the VAMC with a final report of findings within sixty

(60) minutes of complete receipt of exam images for STAT, four (4) hours for urgent https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.acr.org%2FClinical-Resources%2FPractice-Parameters-and-Technical-Standards&data=05%7C02%7C%7C253687c82b95445e0e4e08dde4b066d9%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638918168474461721%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=XLQR8jU838AWHSM7qQI7jVekiUnhlRtFEyz7B%2FR%2BH84%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.acr.org%2FClinical-Resources%2FPractice-Parameters-and-Technical-Standards&data=05%7C02%7C%7C253687c82b95445e0e4e08dde4b066d9%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638918168474461721%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=XLQR8jU838AWHSM7qQI7jVekiUnhlRtFEyz7B%2FR%2BH84%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.acr.org%2FClinical-Resources%2FPractice-Parameters-and-Technical-Standards&data=05%7C02%7C%7C253687c82b95445e0e4e08dde4b066d9%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638918168474461721%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=XLQR8jU838AWHSM7qQI7jVekiUnhlRtFEyz7B%2FR%2BH84%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.acr.org%2FClinical-Resources%2FPractice-Parameters-and-Technical-Standards&data=05%7C02%7C%7C253687c82b95445e0e4e08dde4b066d9%7Ce95f1b23abaf45ee821db7ab251ab3bf%7C0%7C0%7C638918168474461721%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=XLQR8jU838AWHSM7qQI7jVekiUnhlRtFEyz7B%2FR%2BH84%3D&reserved=0 exams. Routine studies shall include a final report of findings and shall be provided to the VAMC by the Contractor within forty-eight (48) hours.

NMVAHCS Standards: See Section D – Attachments: D.5 – MCP 11-64(1):

Critical Test Results and D.6 – MCP 11-81: Ordering and Reporting Test

Results.

4.3.4. The professional standards of the Joint Commission (TJC):

http://www.jointcommission.org/standards_information/hap_requirements.aspx

4.3.5. The standards of the American Hospital Association (AHA):

http://www.hpoe.org/resources?show=100&type=8 and;

4.3.6. The requirements contained in this PWS.

4.4. MEDICAL RECORDS:

4.4.1. Authorities: Contractor’s physician(s) providing healthcare services to VA patients shall be considered as part of the Department Healthcare Activity and shall comply with the 5 U.S.C.552a (Privacy Act), 38 U.S.C. 5701 (Confidentiality of claimants records), 5 U.S.C. 552 (FOIA), 38 U.S.C. 5705 (Confidentiality of Medical Quality

Assurance Records) 38 U.S.C. 7332 (Confidentiality of certain medical records), Title 5 U.S.C. § 522a (Records Maintained on Individuals) as well as 45 C.F.R. Parts

160, 162, and 164 (HIPAA).

4.4.2. HIPAA: This contract and its requirements meet exception in 45 CFR 164.502(e), and do not require a BAA in order for Covered Entity to disclose Protected Health

Information to: a health care provider for treatment of VA patients. Based on this exception, a BAA is not required for this contract. Health records generated by this contract or provided to the Contractors by the VA are covered by the VA Privacy Act system of records entitled ‘Patient Medical Records-VA’ (24VA10A7). Contractor generated VA Patient records are the property of the VA and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that all records pertaining to medical care and services provided to VA patients are captured in the VA electronic health record system as required by VA policy as discussed in 4.4.4.

4.4.3. Disclosure: Contractor’s physician(s) may have access to patient medical records for the purpose of providing medical care and services to VA patients and performing services under the contract. VA authorizes the Contractor to discuss patient health information for coordination of care with community health care providers in compliance with VA regulations, HIPAA and VHA Directive 1605.01, Privacy and

Release of Information. The VA will provide the Contractor with a copy of VHA

Directive 1907.01(1), Health Information Management and Health Records and VHA

Directive 1605.1, Privacy and Release of Information. The penalties and liabilities for the unauthorized disclosure of VA patient information mandated by the statutes and regulations mentioned above, apply to the Contractor.

4.4.4. Professional Standards for Documenting Care: Care shall be appropriately documented in medical records in accordance with standard commercial practice and http://www.jointcommission.org/standards_information/hap_requirements.aspx http://www.hpoe.org/resources?show=100&type=8 guidelines established by VHA Directive 1907.01(1) Health Information

Management and Health Records:

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235 and all guidelines provided by the facility.

4.4.4.1. All film interpretations will either meet or exceed established VISN standards of timeliness, accuracy, content and signature. Only NMVAHCS approved abbreviations will be used for documentation of the patient health record. All imaging exam interpretations shall either meet or exceed established standards of timeliness, accuracy, content, and signature. Only medical abbreviations from The Joint Commission’s National Patient Safety

Goals, current edition, will be used for documentation of the patient health record. See Section D - Attachments: D.7 – MCP 136-11: Authorized and

Unauthorized Abbreviations

4.4.4.2. Interpretations shall include the following information:

4.4.4.2.1. Patient’s full name, Social Security Number (SSN), date of birth, clinical history, exam case number (accession number), date of interpretation, requesting physician, exam type, interpretation, diagnostic code, and signature of contract radiologist providing interpretation.

4.4.4.2.2. Contractor will provide interpretation per routine exam to the

NMVAHCS within forty-eight (48) hours after receipt of images.

All STAT exams, when properly identified, will be performed and the results communicated within one (1) hour of full receipt of images and appropriate patient information. Contractor will not be held responsible for late reports caused by delays in the respective transmission of images. All exam study interpretation reports shall be transmitted to the designated NMVAHCS system.

4.4.4.2.3. All emergency exams will take precedence over all routine exams.

4.4.5. Release of Information: The VA shall maintain control of releasing any copies of patient health information or health records and will follow policies and standards as defined, but not limited to Privacy Act requirements. Contractor will not release or disclose copies of records and will refer all such requests to the Release of

Information Department at the VA facility were assigned.

4.4.6. Management for Medical Records: National Archives and Records Administration record disposition requirements are found in RCS 10-1 Chapter 6, 6000 series.

4.4.7. MEDICAL RECORDS/COMPUTERIZED RECORD SYSTEMS/ DISCLOSURE/

RECORD RETENTION: All records created from these actions shall be managed per Record Control Schedule (RCS) 10-1. Close attention shall be given to disposition schedule found in RCS 10-1 Chapter 4, 4000 series (General Record

Schedule 1.1). Other records included but not limited to Chapter 1, 1180.15 and

1180.23 (GRS 1.1), Chapter 5, 5020.5 (GRS 5.4). There are some specific special contracting record schedules in RCS 10-1 for individual groups of records.

https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=9235

4.4.8. MEDICAL RECORDS REQUIREMENTS: Authorities: Contractor providing treatment and healthcare services to VHA patients in the community shall comply with 45 C.F.R. Parts 160, 162, and 164 (Health Insurance Portability and

Accountability Act’s Privacy Rule) and any other applicable law regarding health information, including contractual obligations as outlined in the Community Care

Network (CCN) contract.

4.4.9. Health records provided to the Contractor by the VA for the medical care and services to VA patients are covered by VHA Privacy Act system of records entitled

‘Patient Medical Records-VA’ 24VA10A7 at https://www.govinfo.gov/content/pkg/FR-2020-10-02/pdf/2020-21426.pdf Address and authority exist to disclosure these records to the Contractor for treatment purposes.

4.4.10. Contractor generated patient medical records are the property of the contractor and shall not be accessed, released, transferred, or destroyed except in accordance with applicable laws and regulations. Contractor shall ensure that copies of all health records pertaining to medical care and services provided to VHA patients are available for transmission and release when requested by VHA in accordance with the CCN contract, for treatment or payment purposes. As part of reimbursing the contractor for medical care and services provided to VHA patients, copies of health records may be required for payment and quality reviews.

4.5. Direct Patient Care: Estimated 95% the time involved in direct patient care. Contractor shall be responsible for:

4.5.1. Scope of Care: Contract physicians shall be responsible for providing including, but not limited to:

4.5.1.1. Contractor shall ensure that teleradiology equipment is maintained in good working order and in accordance with manufacturer’s specifications. Records of equipment, quality control and maintenance activities shall be provided to the COR on a quarterly basis. The reports shall be provided on or before the 10th day of the month starting, the new quarter.

4.5.1.2. Contractor shall perform and provide to the NMVAHCS Imaging

Department quarterly Peer Reviews of all interpreting Physicians.

4.5.1.3. Low Dose Computed Tomography (LDCT) Lung Cancer Screenings (LCS).

In accordance with VHA Directive 1417 “all radiologists responsible for reading lung cancer screening CTs will have competencies specific to LCS, including the requirements for specific Lung-RADS coding used in the interpretation of LDCT for LCS screening.” Documentation of this competency must be provided to the COR when a new provider enters on duty and at least annually thereafter.

4.5.1.4. Physicians provided in satisfaction of this contract shall be required to perform their assigned duties with regards to all admitted patients, outpatients, and eligible beneficiaries regardless of underlying disease process or physical condition of such patients or beneficiaries.

https://www.govinfo.gov/content/pkg/FR-2020-10-02/pdf/2020-21426.pdf

4.5.1.5. Contractor shall provide board certified or board eligible Radiologists to perform final teleradiology Interpretation services. Examination images captured by NMVAHCS will be transmitted to the contractor using the

Digital Imaging and Communications in Medicine (DICOM) protocol and the Federal Information Processing Standard (FIPS) compliant encryption.

Upon receipt of captured image and patient information from NMVAHCS the contractor shall provide an interpretation for studies. NMVAHCS personnel will inform the contractor once images are ready for viewing.

These procedures will be rendered in writing once the contract is awarded.

4.5.1.6. Contract physician(s) shall have control of the reporting process from dictation to report sign-off/electronic signature/approval/verification. The contract physician(s) dictates, self-edits, codes, and approves/signs/verifies their reports. No transcription services shall be provided by the VAMC.

Final reports are transmitted to the VA using secure HL7 messages. Report quality/content shall follow ACR standards of report structure and communication of results. Contract physician(s) shall notify clinicians of critical findings in accordance with American College of Radiology (ACR) standards, VHA and VISN alert notification policies and in a manner appropriate to the clinical urgency of the case.

4.5.1.7. If a serious medical condition is identified during the interpretation; the report shall be immediately called in telephonically and report to ordering physician or medical representative for their information and action.

Procedures outlined in Section D – Attachments: D.5 – MCP 11-64(1):

Critical Test Results and D.6 – MCP 11-81: Ordering and Reporting Test

Results will be followed.

4.5.1.8. All STAT exams, when properly identified, will be performed and the results communicated within one (1) hour of full receipt of images and appropriate patient information. STAT exams shall be identified by the technologist verifying the study. All STAT exams must be identified at receipt of the images and paperwork by contractor. VA will not need to guarantee any minimum study volume.

4.5.1.9. Finalized interpretation and official signature will be immediately electronically uploaded utilizing HL7 communication into the NMVAHCS database by an attending radiologist within 24 hours of the image being transmitted to the reading site.

4.5.1.10. Availability to consult with a radiologist to determine the most appropriate study for the clinical scenario involved; the VA has pre-defined protocols that would be used. Fees may be charged for such consults if the consult does not result in an imaging study being performed.

4.5.1.11. Mechanisms must be in-place to provide notification of test results for patients receiving care in accordance with VHA Directive 1088(1), Communicating Test Results to Providers and Patients.

4.6. ADMINISTRATIVE: Estimated 5% of time not involved in direct patient care.

4.6.1. Must take part in medical staff functions as required to meet the standards of the Joint

Commission on Accreditation of Health Care Organizations.

4.6.2. QA/QI documentation: The contract physician(s) shall complete the appropriate

QM/PI documentation pertaining to all procedures, complications and outcome of examinations.

4.6.3. Contractor will be responsible for performing peer reviews in support of Focused

Professional Practice Evaluations (FPPE) and Ongoing Professional Practice

Evaluations (OPPE) on all physicians providing services supporting this contract. A minimum of 50 peer reviews are required in a period of six months following the provider’s enter on duty date for the FPPE. If a provider receives an unsatisfactory result on a FPPE/OPPE by having 5% or greater 3a or 3b American College of

Radiology scores the FPPE may be extended by 6 months, the provider may be restricted from interpreting certain studies, or the provider may lose credential status at the NMVAHCS. This determination is made at the discretion of the Radiology

Service Chief and/or the Credentialing team. OPPEs are required on a yearly basis.

OPPEs cover a period from April 1 to March 31st of the following year and require a minimum of 50 peer reviews.

4.6.4. SYSTEM REQUIREMENTS:

4.6.4.1. The contractor must maintain a Teleradiology system that is reliable and functional to prevent any disruption in the delivery of services. Data transmission security must be maintained at all times. Facility personnel must be notified immediately of any equipment malfunctions that would hinder the transmission of images.

4.6.4.2. Contractor warrants that any data containing patient-specific identifiers will be handled in such a way as to prevent disclosure to unauthorized parties.

This includes transmission of the data (from the point at which the data leaves the VA network to the point at which the images are interpreted) as well as storage of the data by the Contractor. Contractor agrees to comply with all applicable data security laws and guidelines, as well as HIPAA and various JCAHO provisions. The contractor will provide utmost care and attention to patient data. All patients will be assured of their privacy and personal dignity in accordance with applicable laws, rules and regulations.

All patient information remains the sole property of the US Government and may not be used for any purpose other than those stipulated in this agreement.

4.6.4.3. VA will act as primary custodian of the patient information (including both the image data and the report) for all purposes related to VA and

Government records retention requirements.

4.6.4.4. Patient information, including images, will be retained by the Contractor only for the minimum period of time required to comply with any applicable laws, and should then be purged.

4.6.4.5. Upon request, Contractor will provide VA with access to information pertaining to the way in which the Contractor maintains VA patient data and the steps taken on an ongoing basis to assure the privacy and security thereof. This includes, but is not limited to, information regarding computer network architecture, configuration of firewall(s), routers, and other pieces of networking equipment, information about installed security software, and audits of patches of known security vulnerabilities. All relevant security-related patches and anti-virus updates must be installed within thirty (30) days of initial release.

4.6.4.6. Patient medical data transfer and storage complies with the American

College of Radiology (ACR) and Digital Imaging and Communication of

Medicine (DICOM) standards and meets and anticipates all current, known

CONFIDENTIALITY requirements and regulations.

4.6.4.7. Contractor radiologists shall be available to receive phone calls from the

NMVAHCS’s physicians (e.g., Emergency Room STAT requests after normal operating hours) in reference to the most appropriate study to perform in the given clinical situation. If an additional study is needed, the local VAMC referring provider will be contacted by the respective

Contractor’s staff to communicate the need for the study.

4.6.4.8. Contractor shall provide a transcribed final report, which will be uploaded to the respective VAMC's hospital information system(s) and electronically signed by the interpreting radiologists.

4.6.4.9. Contractor shall have ability to interpret images from commercial systems.

Contractor shall maintain its teleradiology equipment in good working order and in accordance with the specifications of the manufacturer. Equipment quality control shall be performed in accordance with manufacturer's specifications. Records of equipment quality control activities shall be made available to VA for review upon request.

4.7. PERFORMANCE STANDARDS, QUALITY ASSURANCE (QA) AND QUALITY

IMPROVEMENT(QI)

4.7.1. Quality Management/Quality Assurance Surveillance: Contract personnel shall be subject to Quality Management measures, such as patient satisfaction surveys, timely completion of medical records, and Peer Reviews. Methods of Surveillance:

VA Focused Provider Practice Evaluation (FPPE) and VA Ongoing Provider

Practice Evaluation (OPPE). Contractor performance will be monitored by the government using the standards as outlined in this Performance Work Statement

(PWS) and methods of surveillance detailed in the Quality Assurance Surveillance

Plan (QASP). The QASP shall be attached to the resultant contract and shall define the methods and frequency of surveillance conducted. See Section D – Attachments:

D.8 - Quality Assurance Surveillance Plan.

4.7.2. Patient Complaints: The CO will resolve complaints concerning Contractor relations with the Government employees or patients. The CO is final authority on validating complaints. In the event that The Contractor is involved and named in a validated patient complaint, the Government reserves the right to refuse acceptance of the services of such personnel. This does not preclude refusal in the event of incidents involving physical or verbal abuse.

4.7.3. Performance Standards:

4.7.3.1. Measure: Timeliness of Reports

Performance Requirement: Prompt delivery (timeliness) of interpretations and return routine, STAT and urgent exams.

Standard: Delivery 100% of the time. Sixty (60) minutes for STAT, four

(4) hours for urgent exams, forty-eight (48) hours for routine exams.

Acceptable Quality Level: 90% meet timeliness standards each month.

Surveillance Method: Review of computer logs.

Frequency: Monthly

4.7.3.2. Measure: Provider Quality Performance

Performance Requirement: All…