ATTACHMENT 3 - Statement of Work - Trauma Registry Services.docx

Statement of Work Trauma Registry Backlog Services

BROOKE ARMY MEDICAL CENTER (BAMC)

PART 1

GENERAL INFORMATION

1..1 Description of Services/Introduction: This is a non-personal services requirement for Trauma Registry services in support of Trauma Program under the Department of Surgery (DOS), Brooke Army Medical Center (BAMC), Joint Base San Antonio – Fort Sam Houston, Texas. The purpose of this requirement is to obtain trauma registrar services to complete trauma registry charts that comprise the BAMC trauma registry backlog. The contractor will ensure accurate, timely, and complete abstraction, coding, and data entry of trauma patient information in compliance with all applicable accreditation, regulatory, and organizational requirements.

1.2 Background: As an American College of Surgeons (ACS) verified, state-designated Level I trauma center, BAMC must comply with data collection and reporting as set forth by local, state and federal regulations. Data from all BAMC trauma patients meeting inclusion criteria must be entered into the trauma registry within 60 days of patient discharge, in order to maintain compliance. Each record includes approximately 300 data elements. Data is also used to support performance improvement initiatives, conduct research and guide clinical practice guidelines.

1.3 Scope: The Contractor shall provide non-personal service(s). The Contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items necessary to perform services as described in the Statement of Work (SOW) and associated contract documents, except for those items specified in Part 3 Government Property & Services. The Contractor shall perform to the standards and acceptable quality levels identified in this SOW and associated contract documents.

1.4 Objective(s): The contractor shall complete open charts dating back to 2024. A list of incomplete records will be provided by BAMC to the contractor. The project must be complete by the end of the period of performance. The backlog is expected to be up to 2400 trauma records in various stages of completion. All information required to complete the records will be available in the electronic medical record Military Health System Genesis (MHSG). Government systems will be accessed using Application Virtual Hosting Environment (AVHE https://avhe.health.mil) which operates in a Citrix desktop environment and requires a Common Access Card (CAC) to access. In the event further information is needed, the contractor will reach out to the BAMC Point of Contact (POC).

1.5 Communication: The Contractor shall inform the COR of issues (or potential issues) that might affect the performance within 24 Hours of identifying those issues. Verbal reports shall be followed up by written reports within seven (7) calendar days (A.002).

1.6 Quality Assurance: The Government will evaluate the Contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government must do to ensure that the Contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the acceptable quality levels (performance thresholds).

1.7 Place of Performance: The work to be performed under this contract will be performed remotely.

1.8 Security Requirements: The following information is provided on security related matters.

1.8.1 Security Program: The Contractor shall have an active security clearance at the Tier 1 level at proposal submission and shall maintain this level of security for the life of the contract. The Tier 1 Investigation (T1), formerly National Agency Check and Inquiries (NACI), is the basic and minimum investigation required on all new Federal employees and many contractors. It consists of a national agency check with written inquiries and searches of records covering specific areas of an individual’s background within the previous five (5) years of submission. These inquiries are sent to current and past employers, schools attended, references, and local law enforcement authorities.

1.8.2 Contract Personnel Security Clearance Requirements: Contract personnel performing services under this contract must have an active T1 prior to the commencement of services and must maintain this level of security for the life of the contract. The Contractor shall coordinate and schedule all security requirements and appointments with the COR before contract personnel can provide services. The COR shall provide the Contractor with all required Security documentation, review all Security documentation submitted by the Contractor, and initiate the request for the contract personnel’s security action with the Security Manager. The Contractor is responsible for monitoring the coordination and completion of all Security requirements with the COR.

1.8.3 Individual Termination or Expiration of Employment: The Contractor shall collect all outstanding installation access passes and Common Access Cards (CACs) the same day employment of any contract personnel has expired or has been terminated and shall return them to the COR within seven (7) calendar days (A.003).

1.8.4 Contract Termination or Cancellation: Upon termination or cancellation of this contract, the Contractor shall collect all outstanding installation access passes and CACs and return them to the COR within seven (7) calendar days (A.004). Contract personnel that have agreed to continue providing services under the succeeding Contractor are exempted.

1.8.5 Common Access Cards (CACs): The Contractor shall provide the COR with any necessary information required to obtain a CAC or installation access card within seven (7) calendar days prior to contract personnel commencing services (A.005).

1.8.5 Background Checks: The Contractor shall consult with the COR applicable to the location(s) associated in this SOW, and identify the level of background check necessary, as supported by applicable regulation(s). The Contractor shall coordinate and schedule all background check requirements with the COR before contract personnel can provide services. The COR shall provide the Contractor with all required documentation, review all documentation submitted by the Contractor, and initiate the request for the contract personnel’s background check with the Security Manager and Provost Marshals Office (PMO). The Contractor is responsible for monitoring the coordination and completion of all background check requirements with the COR.

1.8.6 U.S. Citizen: U.S. Citizenship (copy of birth certificate or naturalization papers required). Contract personnel performing under this contract must be U.S. citizens. In addition, if any contract personnel fail to meet the citizenship requirements stated herein the Contractor shall not hold the government liable for not allowing performance under this contract.

1.9 Post-Award Conference/Periodic Progress Meetings: The Contractor shall attend any post-award conference convened by the contracting activity or contract administration office in accordance with FAR Subpart 42.5. The Contract Officer (KO), Contract Officer Representative (COR), and other Government personnel, as appropriate, shall meet periodically with the Contractor to review the Contractor's performance. At these meetings, the KO or will apprise the Contractor of how the Government views their performance and the Contractor shall apprise the Government of any problems experienced, if any. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the Government. The Contractor shall not make unplanned visits to the MTF without prior approval from either the KO or COR.

1.10 Contracting Officer’s Representative (COR): Refer to Part 2 of this SOW for the definition of a COR. As determined by the KO, a COR will be appointed and identified by letter of designation, a copy of which will be provided to the Contractor by the KO. The designation letter states the responsibilities and limitations of the COR, especially regarding changes in cost or price, estimates, or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting order. The COR monitors all technical aspects of the contract and assists in contract administration. The COR is not authorized to obligate the Government. If the work is not written in the contract, the COR is not authorized to request new work. The COR is authorized to perform the following functions: assure that the Contractor performs the technical requirements of the contract, perform inspections necessary in connection with contract performance, maintain written and oral communications with the Contractor concerning technical aspects of the contract, issue written interpretations of technical requirements, including Government drawings, designs, specifications, monitor Contractor's performance and notifies both the KO and Contractor of any deficiencies, coordinate availability of Government property, and coordinate site entry of contract personnel.

1.11 Key Personnel: The Contractor shall designate in writing both a Contract Manager and Alternate Contract Manager to the KO and COR at least seven (7) calendar days prior to the commencement of services. The Contract Manager and Alternate Contract Manager will coordinate the implementation of services and be responsible for the performance under this contract. Contract Managers shall have full authority to act on behalf of the Contractor on all contract matters relating to the daily operation of this contract, and the Alternate Contract Manager shall act on behalf of the Contractor should the Contract Manager be unavailable. The Contract Manager and/or Alternate Contract Manager shall be available via email. The Contractor shall immediately notify the KO and COR of any changes to the designated Contract Manager and/or Alternate Contract Manager and provide a designated replacement in writing within seven (7) calendar days after said change.

(a) Contract Manager & Alternate Contract Manager: The Contract Manager and/or Alternate Contract Manager shall submit to the COR for review a Profile Application Packet with a Curriculum Vitae (CV) for each contract candidate, prior to beginning services under this contract. Submitted Profile Application Packets with CVs shall detail each contract candidate’s years of experience, employment history, education, and associated certifications in relation to this requirement. The COR will then forward the Profile Application Packet to the Department for a final review. The Department will then approve or disapprove the submitted Profile Application Packet within seven (7) calendar days of receipt. No personal interviews shall be conducted by the Government.

(b) Special Qualifications: The Contractor shall ensure that all contract personnel are fully trained and qualified to provide a high level of quality services under this contract, as required for each position type. When hiring personnel, the Contractor shall keep in mind that the stability and continuity of the workforce is essential and shall maintain an adequate workforce for the uninterrupted performance of all tasks defined within the SOW.

(i) Experience: Contract personnel must have a minimum of 1 year of experience providing services as a Trauma registrar. While providing services under this contract, contract personnel are required to comply with any applicable state laws concerning their profession.

(ii) Education: Contract personnel must meet all the requirements in the most recent edition of the “Resources for Optimal Care of the Injured Patient” (ACS guidelines) and 75% of registrars working on the project must have successfully completed CAISS.

(iii) Certification: Details in Part 5

(iv) Licensure: Details in Part 5

1.12. Data Rights: The Government has unlimited rights to all documents and materials produced under this contract. All documents and materials, to include the source codes of software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership and copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the Contractor without written permission from the KO. All materials supplied to the Government shall be the sole property of the Government and may not be used for any other purpose. This right does not abrogate any other Government rights.

1.13. Non-Disclosure Requirements: Performance under this contract may require contract personnel to access data and information that is proprietary to a government agency, another Government Contractor, or of such nature that its dissemination or use other than as specified in this SOW would be adverse to the interests of the Government or others. The Contractor and contract personnel shall not divulge, or release data or information developed or obtained under the performance of this SOW, except to authorized Government personnel or upon written approval of the KO. The Contractor shall not use, disclose, or reproduce proprietary data, which bears a restrictive legend, other than as specified in this SOW. All documentation showing individual names or other personal information shall be controlled and protected under the provisions of the Privacy Act of 1974, Public Law 93-579, 5 United States Code (U.S.C.) Section 552a.

1.14 Non-Disclosure Statements: The Contractor shall provide a signed non-disclosure agreement to the Government within seven (7) days prior to commencement of services under this contract (A.008). Any unauthorized disclosure of information by contract personnel may result in the individual being removed from the contract. Standard non-disclosure statements shall be provided, as required, for personnel who may have access to Government data in the course of their duties.

1.15 Phase-In / Phase-Out Period: To minimize decreases in productivity and to prevent possible negative impacts on additional services, the Contractor shall have personnel on board, during the 30-day phase-in/phase-out periods. During the phase-in period, the Contractor shall become familiar with performance requirements to commence full performance of services on the contract start date.

1.16 Required Training

16.1 Anti-Terrorism (AT) Level I Training: All contract personnel, including subcontractor personnel, who are employed under the contract, shall complete AT Level I Training within 30 calendar days after contract start date or effective date of incorporation of this requirement into the contract, whichever applies, or within 30 calendar days after employment of new personnel. The Contractor shall submit certificates of completion (A.009) for each affected contract personnel and subcontractor personnel to the COR (or to the KO, if a COR is not assigned) within seven (7) calendar days after completion of this training by all contract personnel and subcontractor personnel. AT Level I awareness training is available at https://jkodirect.jten.mil. Contract personnel shall complete refresher training every 12 months except AOR specific AT Level I Training which shall be completed as required by local AT policies. Verification of the refresher training shall be provided to the COR within seven (7) calendar days after completion of the training (A.009).

16.2 Information Assurance (IA) Training: All contract personnel, including subcontract personnel, requiring access to Government information systems shall complete the DoD IA Cyber Awareness Training before the issuance of network access (A.012). Contract personnel must complete refresher training every 12 months. Verification of the refresher training shall be provided to the COR within seven (7) calendar days after completion of the training (A.012).

16.3 Protected Health Information (PHI): Contract personnel, including subcontract personnel, performing services under this contract with access to PHI and Government information shall complete “HIPAA & Privacy Act Training” per DoDI 5400.11-R, before the issuance of network access (A.013). Contract personnel must complete refresher training every 12 months. Verification of the refresher training shall be provided to the COR within seven (7) calendar days after completion of the training (A.013). Training is available at https://jkodirect.jten.mil.

16.4 MHS Genesis: The Government will provide training to contract personnel in MHS Genesis, at no additional expense to the Contractor. When directed by the KO, contract personnel shall attend this training in a paid status as part of the normal services required and billed under the contract. Access to such patient data systems is an "Automated Data Processing Sensitive" position requiring compliance with AR 380-19 and AR 380-67.

PART 2

DEFINITIONS & ACRONYMS

2 Definitions & Acronyms

2.1 Definitions: Although not inclusive of every term used within this SOW, the following provides a list of definitions used throughout this SOW and commonly used in the acquisition field.

Ancillary Personnel – This includes all HCPs except for Medical Doctors (MD) and Doctors of Osteopath (DO).

Backup Personnel – Pre-approved contract personnel designated to move into the position of the primary contract personnel to perform required services for the duration of his/her absence.

Beneficiaries of the Military Healthcare System – Those individuals entitled to care at the MTF in accordance with AR 40-3.

Clinical Privileges – Authorization by the government to provide specific patient care and treatment services in the organization, within well-defined limits, based on the individual’s license, education, training, experience, competence, judgment, and physical and mental health.

Continuing Education – Education beyond initial professional preparation relevant to the type of patient care delivered in the organization provides current knowledge relevant to the field of practice and is related to findings from quality assurance activities.

Contracting Officer (KO) – A person with the authority to enter, administer, and/or terminate contracts and make related determinations and findings on behalf of the Government. NOTE - The only individual who can legally bind the Government.

Contracting Officer's Representative (COR) – As defined in DFARS 202.101, means an individual designated and authorized in writing by the Contracting Officer to perform specific technical or administrative functions. DoD Instruction (DoDI) 5000.72, Part II Definitions states the following when defining a COR: “Defined in subpart 202.101 of Reference (f). Any individual delegated responsibilities pursuant to subpart 1.602-2 of Reference (e), regardless of local terminology, must be certified in accordance with this instruction. For example, local terminology can be COR, Contracting Officer’s Technical Representative (COTR), technical point of contact, technical representative, alternate COR, administrative COR, assistant COR, line-item manager, task order manager, quality assurance personnel, quality assurance evaluator, or COR management.” In addition, Army Regulation 70-13, Chapter 2, paragraph 2-2g, states, in part, the following when providing other surveillance support personnel to assist the COR when needed, “…These other surveillance support personnel may serve as on-site representatives of the COR in performance of actual contract surveillance if they meet all COR requirements and have been appointed by the KO as alternate CORs.”

Contractor – Supplier or vendor awarded a contract to provide specific supplies or service to the Government. The term used in this contract refers to the prime.

Contract Personnel – Individuals employed by the Contractor to perform services.

Contractor-acquired Property – Property acquired, fabricated, or otherwise provided by the Contractor for performing a contract and to which the Government has title.

Day – Unless otherwise specified, refers to a calendar day.

Deliverable – Anything that can be physically delivered but may include non-manufactured things such as meeting minutes or reports.

Facilities – Building, equipment and supplies necessary for the implementation of service by personnel.

Full-Time Equivalent (FTE) – The Contractor is required to provide 1,920 Regular Hours, which averages 160 Regular Hours per month or 40 Regular Hours per Work Week, for each FTE over a 12-month period. The following FTE determination can be used as a general reference:

1.00 FTE = Averages 40 Regular Hours per Work Week

0.75 FTE = Averages 30 Regular Hours per Work Week

0.50 FTE = Averages 20 Regular Hours per Work Week

0.25 FTE = Averages 10 Regular Hours per Work Week

Government-Furnished Property – As reflected in FAR 52.245-1, Government-furnished Property “means property in the possession of, or directly acquired by, the Government and subsequently furnished to contract personnel for performance of a contract. Government-furnished property includes, but is not limited to, spares and property furnished for repair, maintenance, overhaul, or modification. Government-furnished property also includes Contractor-acquired property if the Contractor-acquired property is a deliverable under a cost contract when accepted by the Government for continued use under the contract.

Government Property – All property owned or leased by the Government. Government property includes both Government-furnished and Contractor-acquired property. Government property includes material, equipment, special tooling, special test equipment, and real property. Government property does not include intellectual property and software.

Holiday Hours – Hours of service provided during Federal Holidays by contract personnel.

Military Health System (MHS) Genesis – An electronic health record for MHS and charting system for HCPs at the MTF. It provides enhanced, secure technology to manage health information; a single health record for service members, veterans, and their families; navigates the MTF’s appointment scheduling program, pharmacy, lab, and radiology ordering system and is interlinked with other departments within the MTF.

Military Time – On a 24-hour clock, will read as follows:

8:00 am = 0800 9:10 am = 0910 Noon = 1200 9:10 pm = 2110 Midnight = 2400 12:01 am = 0001

Overtime (OT) – Hours of service provided in excess of 40 Regular Hours within a Work Week by contract personnel.

Property Administrator – An authorized representative of the KO appointed in accordance with agency procedures, responsible for administering the contract requirements and obligations relating to Government property in the possession of contract personnel.

Physical Security – Part of security that is concerned with physical measures designed to safeguard personnel; to prevent unauthorized access to equipment, installations, material, and documents; and to safeguard against espionage, sabotage, damage, and theft.

Privileging Process – Process established by the MTF and AR 40-68 for granting clinical privileges to HCPs.

Quality Assessment & Improvement – Those actions taken by the Government to check services to determine if they meet the requirements of The Joint Commission (TJC), U.S. Army Medical Command, quality assurance and risk management program, and ensure that the contract personnel comply with the terms and conditions of the contract.

Quality Assurance – The various functions, including inspection, performed by the Government to determine whether a Contractor has fulfilled the contract obligations pertaining to quality and quantity.

Quality Assurance Surveillance Plan (QASP) – The key Government-developed surveillance process document and is applied to Performance-Based Service Contracting (PBSC). The QASP is used for managing Contractor performance assessment by ensuring that systematic quality assurance methods validate that Contractor quality control efforts are timely, effective, and are delivering the results specified in the contract or task order. The QASP directly corresponds to the performance objectives and standards (i.e., quality, quantity, timeliness) specified in the SOW. It provides specific details on how the Government will survey, observe, test, sample, evaluate, and document Contractor performance results to determine if the Contractor has met the required standards for each objective in the SOW. The QASP, with very few if any exceptions, is an internal Government document.

Quality Control – All necessary measures taken by the Contractor to assure that the quality of a product or service shall meet contract requirements.

Regular Hours – Up to 40 hours of service provided within a Work Week by contract personnel. Regular Hours do not include Federal Holidays worked.

Replacement Personnel – Contract personnel selected to fill a position for the duration of the contract period that was previously occupied by another contractor personnel.

Scheduled Absence – A prearranged absence from performance of contractual services by contract personnel. These absences are scheduled/arranged in advance.

Subcontractor – One that enters a contract with a prime Contractor. The Government does not have a contract with the subcontractor.

Subcontract Personnel – Individuals employed by the Subcontractor to perform services.

Tricare – A regionalized, tri-serviced, Contractor-supported, DoD-managed healthcare system.

Unscheduled Absence – Absences from performance of contractual services by contract personnel that are not scheduled/arrange in advance, regardless of whether the absences are caused by illness or for other reasons.

Workday – Hours of service provided in a single day by contract personnel.

Work Week – Sunday through Saturday, unless otherwise specified.

2.2 Acronyms: Although not inclusive of every term used within this SOW, or that may be included in an acquisition, the following provides a list of acronyms commonly used in the acquisition field.

PART 3

GOVERNMENT PROPERTY & SERVICES

3 Government Property & Services

3.1 Services: The Government shall provide administrative support required for contract performance (except as designated in the SOW), refuse collection, custodial services, and Government-related telephone service. Personal long-distance calls are not authorized.

3.2 Equipment: The Government will not provide use of Military Treatment Facility (MTF) equipment. All equipment, except for Common Access Card, will be provided by the Contractor as designated in the contract, section 4.3

3.3 Special Tooling & Test Equipment: Reserved

3.4 Materials: The Government will provide any available Standard Operating Procedures (SOPs), Local Instructions, and Policies as required for contract performance (except as designated in the contract). Contract personnel shall be responsible for safeguarding all government property provided for use. Neither the Contractor nor any of the contract personnel shall disclose or cause to be disseminated any information concerning the operation of the MTF that could result in or increase the likelihood of the possibility of breach of security or interrupt the continuity of operations or which breach the requirements of the Federal Privacy Act of 1974. However, the Contractor may be required to provide testimony or disposition in cases of due process action.

3.5 Training: In addition to the Required Training under paragraph 1.23, the Government may elect to provide unique training to contract personnel who are performing services under this contract. If the Government elects to provide such training, the Government will provide such training at no additional expense to the Contractor. When directed by the KO or COR, contract personnel shall attend all such training in a paid status as part of the normal services required and billed under the contract. If determined by the KO, such training may require a performance commitment by contractor personnel, in which the Contractor shall reimburse the government (by means of a reduction in an invoice) if contract personnel fail to satisfy the performance commitment after receiving the specified training. The amount of the reimbursement shall be the prorated cost of the training, calculated based on the total cost of the training and the number of months by which the individual contract personnel failed to complete the performance commitment. The length of the performance commitment shall be 12 months, or until the end of all performance under this contract, whichever occurs first.

3.6 Common Access Cards (CAC): The Government will provide Common Access Cards (CAC) via the MP ICAM system.

3.7 Data Dictionary: The BAMC Trauma Department will provide an electronic version of BAMC’s data dictionary.

PART 4

CONTRACTOR FURNISHED ITEMS & SERVICES

4 Contractor Furnished Property & Services

4.1 General: The Contractor shall provide all contract personnel necessary to perform services as described in the SOW and associated contract documents, except for those items specified in Part 3.

4.3 Materials: Common Access Card Reader and required computer hardware.

4.4 Background Checks: The Contractor shall provide Background Checks in accordance with this SOW and as determined by the Government.

4.5 Contractor Reports

4.5.1 Weekly Reports: The contractor shall provide a Weekly report to the COR as described in the SOW that identifies the following (A.018): reporting month in reference, Contract and/or Task Order number, awarded number of hours worked contract and total charts complete.

4.5.2 Quarterly Reports: The contractor shall provide a quarterly report (3-months) to the COR within the first seven (7) calendar days of the month immediately following the end of the fiscal quarter (i.e., January, April, July, October) that identifies the following requirements (A.019): each contract personnel’s compliance with annual, mandatory and/or unique training, licensure, and certifications. Quarterly reports shall also include expirations for the applicable items listed above.

4.6 Monthly Invoicing: The contractor shall submit monthly, in arrears, itemized invoices in accordance with DFARS 252.232-7003, for services rendered under this contract. Information regarding Wide Area Work Flow-RA is available on the Internet at https://wawf.eb.mil/.

PART 5

SPECIFIC TASKS

5 Specific Tasks

5.1 Basic Services: The purpose of this contract is to support the BAMC Trauma Program in the maintenance of the trauma registry. Contract Registrars will provide trauma registry data abstraction, entry and validation as well as conduct workload accuracy audits ensuring compliance, facilitate coding timeliness. They will prepare submissions to supervisor on coding and audit activities pending or completed. Contract Registrars will interface with other areas of the hospital and outside organizations to obtain the proper information needed to accomplish tasks (i.e. information management for computer support or questions, physicians to clarify patient care issues). They will perform and ensure uniform and consistent coding and reporting of all diagnoses according to program and regulatory requirements and guidelines. Contract registrars will ensure proper sequencing of injuries, assures accurate documentation of procedures, and provides sufficient text documentation to support the National Trauma Data Standards (NTDS), Trauma Quality Improvement Program (TQIP), State and Regional registries, BAMC data dictionary and any local requirements.

5.2 Tasks:

· Provide remote trauma registry services to abstract, transcribe, verify and enter trauma data from the electronic medical record (MHS Genesis) into the trauma registry.

· Access to government systems (AVHE, MHSG, and others as required) will be via government supplied Common Access Card (CAC) using a contractor supplied CAC reader and hardware.

· A minimum of 75% of trauma registrars are Certified Abbreviated Injury Scale Specialists (CAISS).

· 100% of trauma registrars have the following certifications/course completions: ICD-10 coding course within the last five years, AAAM AIS-15 course, American Trauma Society Trauma Registrar course (or equivalent per ACS guidelines). In addition, any other requirements outlined in the most current version of “Resources for Optimal Care of the Injured Patient” (https://www.facs.org/quality-programs/trauma/quality/verification-review-and-consultation-program/standards/) must be met.

· Registrars will maintain continuing education requirements per the ACS guidelines.

· All data entry must be entered in compliance with National Trauma Data Standard (NTDS), Trauma Quality Improvement Program (TQIP), State of Texas, and Brooke Army Medical Center standards and requirements in accordance with the BAMC data dictionary and the National Trauma Data Standard.

· Maintain compliance with all applicable federal, state, and local regulations.

· Registries used for this project are: ESO V5 (https://apps.stracdata.org (2024 records) and Image Trend Patient Registry (https://elite.stracdata.org/patientregistry ). Both are web-based platforms. ESO V5 requires a Citrix desktop environment.

· BAMC Trauma will provide remote training for the initial cadre of registrars (using Microsoft Teams), training of additional registrars will be the responsibility of the contractor.

· BAMC will provide an electronic copy of the BAMC data dictionary.

5.3 Requirements

As related to Trauma Registry support:

· The contract company will have no less than five years of documented experience providing trauma registry services to high volume trauma centers (Level I or II)

· Abstract, code, and enter trauma patient data into the registry IAW national, state, and organization data standards.

· Submit a data quality plan for approval to the BAMC Trauma Program Manager via email. This plan must include at a minimum: complete re-abstraction of no less than 10% of charts (must include all deaths), error rate broken down by registrar, indicate if changes to Injury Severity Score (ISS) and/or Trauma and Injury Severity Score (TRISS) resulted, what corrective action will be taken when discrepancies are found. All death charts will be reviewed for accuracy (can count towards the overall 10% requirement) with no more than 10% requiring significant adjustment to ISS (change in severity category) or TRISS (more than 10%) scores.

· All identified errors must be corrected.

· Ensure 10% of charts are reviewed (re-abstracted) for accuracy with a minimum accuracy rate of 90% (based upon contractor submitted and BAMC approved data quality plan).

· All records will undergo registry software validation (V5 or Image Trend) with all Level 1 and 2 errors corrected before marking the record as complete. All level 3 and 4 errors will be reviewed for validity before being closed.

· Appoint a project lead who will be the point of contact with the BAMC Trauma Program Manager and who will also be responsible for providing any deliverables and disseminating any information to the registrars working on the project. Project lead will attend all BAMC registry staff meetings remotely. In addition to the registrar qualifications, the project lead must be CAISS certified and have over five (5) years of experience in trauma registry data entry and be proficient in ESO V5 and Image Trend patient registries.

· Maintain confidentiality of written and verbal communication, autopsy reports, mortality and morbidity data, performance improvement activities and peer review data.

5.4 Delivery Requirements – See Deliverables Technical Exhibit 2

5.5 Reports:

5.5.1 Provide productivity reports no later than every Thursday for the prior week’s work. The productivity report will include the following (at a minimum): registrar name, number of records completed by registrar, time worked for the period being reported.

5.5..2 Provide QA reports by the tenth business day of the month for the previous month’s work.

5.6 Meeting: Project lead will meet at least monthly with BAMC trauma and contracting personnel.

5.7. Points of Contact (POC):

5.7.1 Primary:

Montaque Bussey Contact Officer Representative 210-916-8519 Montaque.m.bussey.civ@health.mil

5.7.2 Secondary:

Cesar Rocha Lead Contract Officer Representative 210-916-9415 Cesar.a.rocha2.civ@health.mil

6.0 Background Investigation

Background Investigation. The Contractor shall ensure all personnel performing under the contract are required to maintain a minimum of a favorably adjudicated Tier 1 (T1) formerly known as National Agency Check with written Inquires (NACI) for IT Level III access or Tier 3 formerly known as a National Agency Credit and Law Check (NACLC) for IT-II access. The contractor must coordinate with the Contracting Officer Representative (COR) to initiate the Request for Personnel Security Action prior to performance start date. U.S. Citizenship will be verified by presenting original or certified copy of birth certificate, certificate of citizenship/naturalization issued by INS, or born aboard certificate (Form FS-240 or DS-1350) or a valid U.S. Immigration Form 1-151 and Alien Registration Card ("Green Card") and is completed investigation document(s) to the BAMC Personnel Security Office at the time of in processing for all contract personnel assigned to the contract. In order to maintain the security requirements any derogatory information, to include law enforcement issues, mental health issues, or alcohol/drug related issues must be reported to the COR and to the BAMC Personnel Security Office.

6.1 Invoicing

Validation:

All invoices submitted through Wide Area Work Flow must include appropriate and/or sufficient documentation to validate the number of quantities billed. Reports for validation shall be emailed to the following:

Name: Jason Forcum Title: BAMC Trauma Program Manager E-mail Address: jason.e.forcum.civ@health.mil Office Phone: 210-916-1160

Name: Montaque Bussey Title: Contract Officer Representative E-mail Address: montaque.m.bussey.civ@health.mil Office Phone: 210-916-8519

PART 7

ATTACHMENT & TECHNICAL EXHIBIT LISTING

7 Attachment & Technical Exhibit List

7.1 Technical Exhibit A:

• Performance Requirements Summary (PRS)

7.2 Technical Exhibit B: Deliverables Schedule

TECHNICAL EXHIBIT A

PERFORMANCE REQUIREMENTS SUMMARY (PRS)

Turnover Rate of 20% 100% Inspection

TECHNICAL EXHIBIT B

DELIVERABLES SCHEDULE

A.001 – Data Quality Plan

A.002 – Report of Potential Issues

A.004 – Contract Termination or Cancellation

A.005 – CAC Info

A.006 – Favorable & Unfavorable Background Check

A.008 – Signed Non-Disclosure Agreement

A.009 – AT Level 1 Training Certificates

A.010 – AAAM AIS-15 Course Certificates

A.011 – ICD10 Course Training Certificate

A.012 – CAISS Training Certificate

A.013 – American Trauma Society Trauma Registrar Course Certificates

A.014 – DoD IA Cyber Awareness Training Certificates

A.015 – Protected Health Information

A.016 – Production Report

A.017 – Quality Assurance Report

BAMC (MAR23)