Tab 3 - Performance Work Statement - Medical Supply Technician 4.1.26.pdf

Attachment A – Performance Work Statement (

PERFORMANCE WORK STATEMENT (PWS)

NON-PERSONAL SERVICE – Medical Supply Technician

TABLE OF CONTENTS

Page

1.0 General 2

1.1 Background 2

2.0 Scope 2

3.0 Applicable Documents 2-3

4.0 Definitions 3-6

5.0 Government Furnished Information, Property & Services 6

6.0 Contractor Furnished Equipment 6-7

7.0 Performance Requirements Summary 7-9

7.1 Sterile Processing Duties

7.2 Work Schedule

7.3 Leave Requests

7.4 Timesheets

7.5 Ethics & Conduct

7.6 Performance Evaluation

7.7 Identification of Contractor

7.8 Management of Medical Information

7.9 IHS Information Technology Systems

8.0 Contractor Qualification Requirements 10-11

8.1 Experience

8.2 License/Registration Certifications

8.3 Motor Vehicle Operator’s License

8.4 Certifications

8.5 Health Requirements/Conditions of Employment

8.6 Immunization

8.7 Language Requirement and Cultural Awareness

8.8 Information Technology Skills

8.9 Orientation

8.10 Background Checks

9.0 Technical Direction 10

10.0 List of Attachments and Exhibits 11

11.0 Performance Requirements Summary 12

1. General: This Performance Work Statement (PWS) describes the requirements for a Non-Personal Service Contract for Medical Supply Technicians to support the mission of the Indian Health Service (IHS).

1.1. Background: IHS is an agency within the U.S. Department of Health and Human Services and is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally recognized tribes grew out of the special government to government relationship between the federal government and Indian tribes. The IHS is the principal federal health care provider and health advocate for the Indian people. The goal is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indians and Alaska Natives. The IHS currently provides health services to approximately 1.5 million American Indians and Alaska Natives who belong to more than 557 federally recognized tribes in 34 states.

1.2. Safe and effective sterile processing services are critical to infection prevention, patient safety, and regulatory compliance within IHS healthcare facilities. Due to staffing shortages and operational demands, IHS requires qualified contract personnel to support Sterile Processing Department operations. This performance work statement covers requirements for the Navajo Area and Shiprock Service Unit which includes Northern Navajo Medical Center (NNMC), Dzilth-Na-O-Dith-Hle Health Center (DZHC), and Four Corners Regional Health Center (FCRHC).

2. Scope: The Contractor shall perform all Sterile Processing Department (SPD) functions in accordance with

Section 8.0 of the Performance Work Statement.

2.1. Services shall encompass the performance of Medical Supply Technician (MST) services in support of outpatient and inpatient clinical services for IHS patients.

2.2. Place of Performance: Services are to be performed at hospitals, clinics and other healthcare facilities of the Navajo Area Indian Health Service within the Northern Navajo Medical Center.

2.2.1. Location: Northern Navajo Medical Center, US Hwy 491 North, Shiprock, NM 87420

2.3. Department: Sterile Processing Department (SPD)

2.4. Period of Performance: Shall be 1 Base Period + 4 Option Periods. Each contract period of performance shall contain a 6-month period of performance. The base period shall begin from the date of award.

Base Period 6 months Option Period 1 6 months Option Period 2 6 months Option Period 3 6 months Option Period 4 6 months

3. Applicable Documents: Please see the web link listed unless document is listed as an attachment.

3.1. The Joint Commission (TJC) http://www.jointcommission.org http://www.jointcommission.org/

3.2. Centers for Medicare and Medicaid Services (CMS) Standards http://www.cms.hhs.gov

3.3. Accreditation Association for Ambulatory Health Care(AAAHC) https://www.aaahc.org

3.4. Section 231 of Public Law 101-647, the Crime Control Act of 1990.

http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf

3.5. Section 4087 of Public Law 101-630, the Indian Child and Family Violence Act http://www.icctc.org/IHS-BIA%20CPT%Handbook/PL%201101-630.pdf

3.6. Health Insurance Portability and Accountability Act (HIPAA) of 1996.

http://www.cms.gov/HIPAAGeninfo/

3.7. Privacy Act of 1974. http://www.justice.gov/opcl.privacyact1974.htm

3.8. IHS Service Unit and Health Center Policies, Procedures and Protocols. (See section 11.0 for a list of attachments and exhibits)

3.9. Computer Security Act of 1980 http://security.ihs.gov/index.cfm

3.10. Federal Code of Conduct: Contractor Code of Business Ethics and Conduct eCFR :: 48 CFR 52.203-13 -- Contractor Code of Business Ethics and Conduct. (FAR 52.203-13)

3.11. IHS General Directives http://www.ihs.gov/index.cfm?module=AtoZ&option=index

3.12. IHS Computer Security Directives: http://security.ihs.gov/index.cfm

4. Definitions

4.1. Acceptance: Constitutes acknowledgement that the supplies or services conform to the applicable contract quality and quantity requirements, except as provided in FAR subpart 46.5 and subject to other terms and conditions of the contract.

4.2. Approval: Acknowledgment by the designated Government official that submittals, deliverables, or administrative documents (e.g., insurance certificates, installation schedules, planned utility interruptions, etc.) conform to the contractual requirements. Government approval does not relieve the Contractor from responsibility for compliance with contract requirements.

4.3. Area: A defined geographical region for Indian Health Service administrative purposes. Each Area

Office may administer several Service Units.

4.4. Business Associate: Any company or person that is exposed to, handles, or works with the data in medical records is a "Business Associate" of the medical entities they work for.

4.5. Business Associate Agreement {BAA): A business associate agreement (BAA) is a contract between a

HIPAA-covered entity and a HIPAA business associate (BA). The contract protects personal health information (PHI) in accordance with HIPAA guidelines.

http://www.cms.hhs.gov/ http://www.aaahc.org/ http://www.icctc.org/Crime%20Conrol%20Act%20of%201990.pdf http://www.icctc.org/IHS-BIA%20CPT%25Handbook/PL%201101-630.pdf http://www.cms.gov/HIPAAGeninfo/ http://www.justice.gov/opcl.privacyact1974.htm http://security.ihs.gov/index.cfm https://www.ecfr.gov/current/title-48/chapter-1/subchapter-H/part-52/subpart-52.2/section-52.203-13 http://www.ihs.gov/index.cfm?module=AtoZ&option=index http://security.ihs.gov/index.cfm

4.6. Code of Ethics: The Revised American Nurses Association Code of Ethics and Standards of Practice and Care, published in 1996 by the American Nurses Association which makes explicit primary goals, values and obligations of the nursing profession.

4.7. Contracting Officer {CO): A Government employee with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings.

4.8. Contractor: The individual awarded a legal binding contract to provide supplies and services.

4.9. Contracting Officer's Representative (COR): The COR is primarily responsible for the technical assistance and day-to-day program management of the contract.

4.10. Contractor Performance Assessment Report: A report that assesses a contractor's performance and provides a record, both positive and negative, on a given contract for specific period of time.

4.11. Cooperative Attitude: Behavior that is positive and displays a willingness to perform assigned sterile processing tasks and to be a team player.

4.12. Cultural Awareness: Realization and respect for American Indian and Alaska Native practices.

4.13. Customer: Patients, staff and visitors of an IHS service unit and health center.

4.14. Customer Evaluation/Input: Written comments made to the Contracting Officer regarding the

Contractors performance. This is one of the criteria used to evaluate the Contractor's performance.

4.15. Dependability: Qualities of being trusted and being able to repeat the same task to yield the same result.

4.16. Federal Acquisition Regulation (FAR): The FAR is the primary regulation for use by all Federal

Executive agencies in their acquisition of supplies and services with appropriated funds.

4.17. Federal Contract Disputes Act: The Contract Disputes Act (41 U.S.C. § 7101 et seq.) establishes the process for resolving claims and disputes between federal agencies and contractors, including requiring a Contracting Officer’s final decision and providing appeal rights.

4.18. Government Vehicle: An IHS owned motor vehicle or a vehicle leased by IHS through agreements with the General Services Administration (GSA) or through commercial rental agreements.

4.19. Health Center: A facility physically separated from a hospital, with a full range of ambulatory services including at least primary care providers, nursing, laboratory, and x-ray which are available at least 40 hours a week for outpatient care.

4.20. Health Insurance Portability and Accountability Act (HIPAA): A US law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

4.21. Key Personnel: Direct employee of the Contractor, or any subcontractor(s), affiliates, joint venture partners, or team members, and consultants engaged by any of those entities over which the Federal Government does not have direct supervisory control. These personnel are considered essential to the work being performed under the contract.

4.22. Non-Personal Services Contracts: means a contract under which the personnel rendering the services are not subject, either by the contract's terms or by the manner of its administration, to the supervision and control usually prevailing in relationships between the Government and its employees as defined in FAR 37.

4.23. Ordering Activity Contracting Officer: A Government employee of IHS authorized and warranted to issue task orders and to make subsequent task order modification(s) under this contract. The Ordering Activity CO has the authority to make initial determinations on all matters of dispute regarding task orders.

4.24. Orientation: An activity designed to provide basic familiarization with the facility, policies, and procedures, and to facilitate the transition of Sterile Processing Department (SPD) personnel into the IHS Service Unit and/or Health Center and assigned SPD functional areas.

4.25. Past Performance Information: Relevant information regarding a contractor's actions under previously awarded contracts. This includes the contractor's record of conformance to specifications and to standards of good workmanship; the contractor's record of containing and forecasting costs on any previously performed cost reimbursable contracts; the contractor's adherence to contract schedules, including the administrative aspects of performance; the contractor's history for reasonable and cooperative behavior and commitment to customer satisfaction; and generally, the contractor's business-like concern for the interest of the customer.

4.26. Patient Outcome: The end result of Sterile Processing Department (SPD) services as they relate to the safety, quality, and effectiveness of patient care.

4.27. Performance Requirements Summary: lists the services to be monitored and the standards to be applied.

4.28. Personal Protective Equipment (PPE): The equipment used to protect medical personnel from exposure to biological, chemical, and radioactive hazards.

4.29. Quality Control Plan (QCP): Those actions taken by the Contractor to control the quality of services provided. The Contractor's QCP must be equivalent to the Government's Quality Assurance plan.

4.30. Service Unit: The local administrative unit of IHS.

4.31. Standards of Practice and Standards of Care: Authoritative statements that define the responsibilities and professional accountability of Sterile Processing Department (SPD) personnel.

These standards guide SPD practice and provide a framework for evaluating quality, compliance, and performance across general and specialty sterile processing functions.

4.32. Tour of Duty: The time of day the SPD technician is scheduled to perform duties; also considered the shift of the day. The time can vary according to the needs of each facility and/or clinic, (e.g., 8-hour Tour of Duty or 10-hour Tour of Duty). May include weekends and holidays.

4.33. Valid Patient Complaint: Justifiable accusation made by a patient and supported by investigation.

4.34. Verifiable Emergency: An unexpected/unplanned absence by the contractor requiring valid documentation to confirm the occurrence.

5. Government Furnished Information, Property and Services

5.1. Information: Government unique information related to this requirement, which is necessary for Contractor performance, will be made available to the Contractor. The Contracting Officer or designee will be the point of contact for identification of any required information to be supplied by the Government.

5.2. Joint Use by the Government and the Contractor: The Government will provide, for joint use by the

Government and the Contractor, all necessary equipment, supplies, and clinic space to perform the services under this contract.

5.2.1. Government Vehicle: If required by the position, authorization shall be in accordance with IHS

Manual, Chapter 9, Part 1 - Motor Vehicle Safety.

5.3. Contractor Exclusive Use:

5.3.1. Personal Protective Equipment (PPE). The Government will furnish the Contractor with appropriate PPE other than specified in Section 6 of the contract. The Government will be responsible for any repair, cleaning, and inventory required for the PPE.

5.3.2. The Government will provide facility specific contractor identification badges for each contractor. A minimum fee of $20.00 will be charged for lost or destroyed badges.

5.4. Training: Facility-specific training necessary for the Contractor to perform required Sterile

Processing Department (SPD) functions, such as use of IHS IT systems and SPD-related operational procedures. Training will be provided only when required to improve or enhance the quality of SPD services or to meet Service Unit–mandated requirements during contract performance. Training will not be provided for continuing education, career development, or individual development purposes.

6. Contractor Furnished Property

6.1. Except for the property specified in section 5.0 as government furnished, the Contractor shall provide all uniforms and other personal medical instruments subject to the following:

6.1.1. Uniforms and Attire: Uniforms, including scrubs and jackets, for Sterile Processing Department (SPD) personnel shall be provided by the hospital and shall conform to the requirements of the Indian Health Service Manual, Part 3, Chapter 6. All uniforms and attire must meet the approval of facility leadership within the Shiprock Service Unit or Northern Navajo Medical Center.

6.1.2. Other Personal Work Equipment: N/A

7. Performance Requirement Summary

7.1. Sterile Processing Department (SPD) Duties

7.1.1. The Contractor shall perform Sterile Processing Department (SPD) duties and manage assigned sterile processing functions as described and in accordance with technical direction provided by NNMC's Clinical Nursing Supervisor otherwise known as Supervisory Clinical Nurse (SCN) herein this PWS.The Contractor shall perform in accordance with the following competency standards, as applicable to Sterile Processing Department (SPD) functions:

7.1.1.1. Written SPD Competency Standards

7.1.1.2. Confidentiality, HIPAA, and Patient Privacy Requirements

7.1.1.3. Infection Prevention and Control

7.1.1.4. Decontamination Procedures and Workflow

7.1.1.5. Instrument Inspection, Assembly, and Packaging

7.1.1.6. Sterilization Methods and Monitoring (e.g., steam, low-temperature systems, biological and chemical indicators)

7.1.1.7. Load Documentation and Recordkeeping

7.1.1.8. Case Cart Preparation and Distribution

7.1.1.9. Point-of-Use Cleaning Principles

7.1.1.10. Loaner Instrument Processing

7.1.1.11. Recall Procedures and Event Reporting

7.1.1.12. Use and Maintenance of SPD Equipment

7.1.1.13. Personal Protective Equipment (PPE) and Safety Practices

7.1.1.14. Standard Emergency Codes and Facility Safety Procedures

7.1.1.15. Hazardous Materials and Chemical Safety

7.1.1.16. Cultural Awareness and Sensitivity (as applicable to the NNMC Service Area)

7.1.1.17. Documentation and Tracking System Use (e.g., instrument tracking software)

7.1.1.18. Quality Assurance and Performance Improvement

7.1.1.19. Compliance with Applicable Standards (e.g., AAMI, CDC, The Joint Commission, IHS policies)

7.1.1.20. Standards of Sterile Processing Practice

7.2. Work Schedule

7.2.1. The Supervisory Clinical Nurse (SCN) for each department will provide technical direction on the specific tour of duty the contract Sterile Processing Technician will work. The time can vary according to the needs of each facility and/or clinic, (e.g., 8-hour Tour of Duty or 10-hour Tour of Duty). May include weekends and holidays.

7.2.2. The Contractor shall coordinate with the SCN to rotate into other duty sections as needed to support patient care (i.e., float to ER as sitter, go on transport, float to another department).

7.3. Leave Requests

7.3.1. The Contractor shall coordinate with the department SCN or designee prior to any absence from work. If the length of the absence exceeds eight (8) work hours and beyond, the Contractor shall coordinate and provide notification to the department SCN (the exception is verifiable emergencies) in advance of the desired absence.

7.3.2. Approval of leave is contingent upon availability of adequate staffing.

7.3.3. The Contractor shall provide written documentation from a qualified health care provider for absences of three (3) or more consecutive days, due to illness, stating:

7.3.3.1. The cause of the current illness or incapacitation AND

7.3.3.2. Indicating the Contractor as contagious or non-contagious.

7.4. Timesheets: The contractor shall track timesheets and ensure accurate tracking of hours worked to allow for correct billing. The government shall provide a blank timesheet template for use to track hours for billing. The contractor shall use blank template or provide the nursing contractor a blank timesheet copies for accurate tracking.

7.4.1. Timesheets shall be verified by SCN each week for correct billing purposes.

7.5. Ethics & Conduct: The Contractor shall meet standards as listed in the Federal Code of Conduct:

Contractor Code of Business Ethics and Conduct.

7.5.1. The Government reserves the right to examine and or re-examine any Contractor who meets the criteria of unplanned absences and does not meet performance standards as listed herein this

PWS.

7.6. Performance Evaluations:

7.6.1. The Contractor's performance will be evaluated in accordance with the standards set forth in the contract and Performance Requirements Summary on page 12.

7.6.2. The Government reserves the right to examine and or re-examine any Contractor who meets the criteria of unplanned absences and does not meet performance standards as listed herein this PWS

7.7. Identification of Contractor:

7.7.1. The Contractor shall ensure a government issued contractor wears identification badge during performance of duty. The identification badge, any other assigned keys or badges that are given upon starting the contract must be returned to the SCN upon completion of contract or service end date.

7.8. Management of Medical Information:

7.8.1. The Contractor shall manage all patient information in accordance with Health Insurance

Portability and Accountability Act (HIPAA) standards, Privacy Act, and IHS Service Unit and/or Health Center specific policies and protocols.

7.8.2. The Contractor shall ensure adherence to DHHS IT system security policies and procedures. The IT policies and procedures will be made available to the Contractor.

7.8.3. The Contractor shall immediately report to the Contracting Officer or COR any information or circumstances that may violate any statute, policy, or procedure.

7.9. IHS Information Technology Systems:

7.9.1. ln performance of this contract, the Contractor shall adapt to and successfully utilize IHS information technology systems that are deemed by the SCN as necessary for acceptable contractor performance.

7.9.2. The Contractor shall ensure that IHS information technology system security policies and procedures are adhered to. The IT policies and procedures will be made available to the Contractor at each IHS facility.

8. Contractor Qualification Requirements:

8.1. Experience: The Contractor shall have a minimum of twenty-four (24) months of sterile processing experience.

8.2. License/Registration: N/A

8.3. Motor Vehicle Operator's License. If required by the position, the Contractor shall possess a valid state driver's license throughout the term of this contract.

8.4. Certifications:

8.4.1. Current Basic Life Support (BLS) is mandatory for all specialties.

8.4.2. Certified Sterile Processing and Distribution Technician (CSPDT-CBSPD)

8.4.3. The contractor shall ensure that the contract MST technicians’ certifications remain active throughout the duration of the contract.

8.5. Immunization. The Contractor shall also provide the following documentation prior to RN Candidate selection:

8.5.1. Immunity to Rubella, Mumps, and Rubeola (Measles);

8.5.2. Proof of Hep B vaccination x3 OR positive titer OR a signed declination of the Hep B vaccinations will also be accepted;

8.5.3. Documented history of chicken pox OR varicella vaccination x2 OR positive varicella titer;

8.5.4. History of Tdap vaccination, with subsequent Td vaccination if older than 10 years;

8.5.5. Documentation of Tuberculosis testing (TB skin test or IGRA) within the past 12 months with documentation of chest x-ray and follow-up for a positive history;

8.5.6. 12 months with documentation of follow-up for a positive test.

8.5.7. Proof of influenza vaccination from October -1 thru March 31, per IHS Mandatory Influenza

Vaccination Policy.

8.6. Language Requirements and Cultural Awareness. The Contractor shall read, understand, speak, and write English to effectively communicate with patients and other health care workers, and shall be respectful of the local, American Indian and Alaska Native culture.

8.7. Information Technology Skills. The Contractor shall possess basic knowledge, skills, and abilities to use a computer.

8.8. Orientation. All Contractor personnel providing Sterile Processing Department (SPD) services under this contract shall attend mandatory orientations and training specified by the Government.

8.9. Background Checks: As directed by the Contracting Officer, the Contractor shall provide all requested information necessary to perform background checks. The Contractor shall comply with the requirement to obtain security investigations. The Contractor shall work with the IHS to ensure that the pre-employment screening process includes the appropriate investigation questionnaires and forms to be completed. All completed forms will be reviewed by the Contractor and forwarded to the Government Personnel. The Contractor will be immediately removed from the position if at any time the investigation receives unfavorable adjudication, or, if other unfavorable information that would affect the investigation becomes known.

8.9.1. e-App: Required Background Investigation Information:

8.9.2. Executive Orders 10450, 12968, and HSPD-12 require a background investigation as a condition of employment. This investigation will be processed utilizing the US Office of Personnel Management (OPM), Electronic Questionnaire for Investigation Processing (e-App) system.

8.9.3. FINGERPRINT CARD- FBI FD-258 (provided by the Federal Government)

8.9.4. Fingerprints MUST be cleared and approved prior to contract assignment. Contract assignment(s) are conditional on a cleared background check.

9. Technical Direction:

9.1.1. Performance of the work under this contract is subject to the technical direction of the SCN.

9.1.2. The SCN does not have the authority to, and shall not, issue any instructions outside the terms and conditions of this contract or technical direction that:

9.1.3. Constitutes an assignment of additional work outside the performance work statement;

9.1.4. Constitutes a change as defined in the changes;

9.1.5. In any manner causes an increase or decrease in the total estimated contract cost, fixed fee (if any), or the time required for contract performance;

9.1.6. Changes any of the expressed terms, conditions, or specifications of the contract; or the terms and conditions of the contract.

9.1.7. Technical direction shall be issued verbally or in writing by the SCN.

9.1.8. The Contractor shall proceed promptly with any challenges of performance or of technical direction duly issued by the SCN in the manner prescribed by this paragraph and within authority. If, in the Contractor's opinion, any instructions or direction by the SCN falls outside of the contract terms and conditions, the Contractor shall proceed with a written notice to the Contracting Officer in writing within 5 working days after receiving it and shall request the Contracting Officer to take action as described in this paragraph. Upon receiving this notification, the Contracting Officer shall provide guidance, clarify technical direction, execute an appropriate contract modification within a reasonable time or advise the Contractor in writing that the instruction or direction is within the requirements of the contract and does not constitute a change under the changes clause of the contract and that the contractor shall proceed promptly with its performance.

9.1.9. A failure of the Contractor and Contracting Officer to agree that the instruction or direction is both rescinded in its entirety; or within the requirements of the contract and does not constitute a change under the changes clause, or a failure to agree upon the contract action to be taken with respect to the instruction or direction shall be subject to the Disputes clause of this contract.

9.1.10. Any action taken by the Contractor in response to any direction given by any person other than the Contracting Officer or the SCN shall be at the Contractor's risk.

10. List of Attachments: The BAA will be provided to the Contractor upon award for their completion/signature. The signed BAA shall be returned to the Contracting Officer for internal filing.

10.1. Sterile Processing Department

10.1.1. Department specific competencies

10.1.2. Blank timesheet template

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Northern Navajo Medical Center: Sterile Processing Department-Orientation Competency

Employee Name/Title: ________________________________________ Date: _______________ Dept: ___________________

Permanent: __________ Contract: __________

Please consult provided Competency Book or PDF File to view/review each competency listed.

Competency Self Eval Validation

Type Experience

Level Validating

Initials Date

Equipment Competencies

1. ASP Sterrad 100 NX

2. Olympus MU-1 Maintenance Unit and Leakage Tester

3. Olympus Alt Pro Plus

4. Rennco Heat Sealing Machine

5. Steris Acu-SlnQ 2 Enzymatic Dosing System

6. Steris Amsco Century Steam Sterilizer V-120

7. Steris Amsco 400 Series Medium Steam Sterilizers

8. Steris Amsco 5000 Series Washer/Disinfector

9. Steris Cantel Scope Buddy Plus

10. Steris Caviwave Ultrasonic

11. Steris Innowave PCF Sonic Irrigator

12. Steris EndoDry Cabinets

13. Steris Medivator Advantage Plus AER

14. Steris Reliance Synergy Washer/Disinfector

15. Steris V-Pro Max 2 Low Temp Sterilization

Skills

16. Endoscopes-Precleaning

17. Endoscopes- Leak Testing

18. Endoscopes- Manual Cleaning

19. Endoscopes- Manual Flushing of Endoscope Channels

20. Endoscopes-AER Reprocessing

21. Endoscopes-Manual Disinfection

22. Endoscopes-Rinsing

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23. Endoscopes-Alcohol Flush (70% isopropyl or ethyl alcohol)

24. Endoscopes-Storage

25. Assembly – Environment

26. Instrument Inspection

27. Prep and Pack

28. Steam Sterilization

29. IUSS

30. Low Temperature Sterilization

31. Decontamination - Environment

32. Decontamination - Cleaning

33. Premixslip Lubricant

34. Resi-test Slide-Thru Cleaning Indicator

35. Revital-Ox Disinfection Solution

36. Revital-Ox Resert Test Strips

37. Sklar Polish

38. Integra Miltex Spray Lubricant for Instruments

39. MIFU

40. Transporting Instruments to and from SPD

Competency Self Eval Validation Type

Experience Level

Validating Initials

Date

Infection Control

41. Hand hygiene

42. PPE – Basic and COVID

Validating Initials & Signatures:

Initials Signature Initials Signature

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SELF EVALUATION HOW COMPETENCY/SKILL IS VALIDATED EXPERIENCE LEVEL

1. Have not experienced before

2. Know principle, but have not performed

3. Have performed but not recently, need review

4. Feel comfortable and competent in activity/skill

Competency will be validated by:

Direct observation (D) Simulation (S) Return Demonstration (RD) Test (T) Class (C ) Verbalize (V)

Use the appropriate letter in the column “How Validated”

1. Acquired some experience (may require practice, assistance) = Fail

2. Competent and/or can perform independently = Pass

3. Competent, performs independently, and is able to teach and/or assess the competency of others = Pass

Use the appropriate number in the column “Experience Level”

Employee Name: ________________________________

Employee Signature: _____________________________

Evaluator Signature: _____________________________

Clinical Coach or Supervisor signature: __________________________ Date: ____________________

Quizzes/tests can be added here and graded in addition to skill assessment. Duplicate as needed.

Knowledge Assessment

WEEKLY NURSING TIMESHEET

WEEK OF:

FACILITY NAME:

NORTHERN NAVAJO MEDICAL CENTER

EMPLOYEE NAME: CONTACT INFO:

PO NUMBER: PCN #:

DEPARTMENT: SUPERVISOR:

REGULAR HOURS

DATE DAY

START

TIME

LUNCH

(mins)

END

TIME

TOTAL

HOURS NOTES

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

WEEKLY

TOTALS

EMPLOYEE: I CERTIFY THAT THE HOURS SHOWN ABOVE REPRESENT MY TOTAL HOURS

WORKED AND THAT THEY ARE PROPERLY VERIFIED.

EMPLOYEE SIGNATURE: DATE:

SUPERVISOR SIGNATURE: DATE:

COMPANY NAME

Use increments of .25

Use increments of .25

BILL TO LINE:

PERFORMANCE REQUIREMENT SUMMARY

11. IDENTIFICATION OF REQUIRED PERFORMANCE STANDARD/QUALITY LEVELS

Performance standards define desired services. The Government performs surveillance to determine if the contractor exceeds, meets or does not meet these standards.

The Performance Requirements Summary Section 7.0 of the Performance Work Statement (Page 7-9) includes performance standards. The Government shall use these standards to determine contractor performance.

TASK ID INDICATOR STANDARD ACCEPTABLE

QUALITY LEVEL

METHOD OF

SURVEILLANCE

INCENTIVE

Contractor shall provide Sterile Processing services in accordance with this Performance Work Statement (PWS) in the Sterile Processing Department at the Northern Navajo Medical Center, Shiprock, New Mexico.

A Sterile Processing

Contractor services are “fully successful” or deemed “excellent” sterile processing must be attained. No reports of breached safety or other procedures that may have adversely affect patient outcomes.

A rating or “Fully Successfully or “Exceptional” must be attained

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract price for satisfactory service.

Favorable CPAR report

B Compliance No performance issues or violations of Policies; Procedures; Standards of Care or Hospital Protocols

A rating or “Fully Successful” or “Exceptional” must be attained

Periodic inspection, 100% inspection and analysis of contractor’s progress reports

Payment of contract

C Culturally Sensitivity

Contractors were compassionate and culturally sensitive

A rating or “Fully Successful” or “Exceptional” must be attained

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract

D Documentation Contractors completed require documentation in clear and legible form in a timely manner.

A rating or “Fully Successful” or “Exceptional” must be attained

Periodic inspection, 100% inspection and an analysis of contractor’s progress reports

Payment of contract

E Professionalism Contractors presented in professional appearance demonstrated exceptional ethical conduct with effective communication and exhibited exemplary attitude by being flexible and being adaptable.

A rating or “Fully Successful” or “Exceptional” must be attained

Direct observation, 100% inspection and an analysis of contractor’s progress reports.

Payment of contract

PERFORMANCE REQUIREMENT SUMMARY