PWS_Certified_Tumor_Registrar.docx

DRAFT

PERFORMANCE WORK STATEMENT FOR CERTIFIED TUMOR REGISTRAR (CTR) AT MADIGAN ARMY MEDICAL CENTER

1.0 INTRODUCTION:

1.1 The contractor shall provide non-personal Certified Tumor Registrar (CTR) services at Madigan Army Medical Center (MAMC), Population Health Management Division; for the Period of Performance of; 01 September 2016 through 31 August 2017. This contract is to provide CTR functions to maintain and keep current MAMC’s abstraction, follow-up, case finding, as described below.

1.2 All services shall be provided in accordance with established standards, principles and ethics of the profession and applicable professional specialty organizations, The Joint Commission (JC) standards, applicable Department of Defense (DOD) and Army specific regulations, directives, and policies, and military treatment facilities (MTF) specific policies, procedures, and job descriptions. Contract health care providers (contract personnel) shall give the highest regard to patient dignity and observe the precepts of the American Hospital Association’s Bill of Rights for Patients. The Contractor shall provide non-personal services for varied ancillary healthcare specialties in accordance with established principles and ethics of the medical profession, the national standards established by the JC, the professional standards at the medical treatment facility (MTF), and the American Board of applicable specialty. The Contractor shall be held accountable for compliance to the standards listed in the Comprehensive Accreditation Manual for Hospitals (CAMH) dated January 2014 or current version.

1.3 The Contractor or contract employees shall provide services in conjunction with other non-contract providers to include physicians, nurse practitioners, physician assistants, registered and licensed practical nurses, and support personnel. All contract employees shall perform essentially the same functions, within the scope of acceptable practice for the specific specialty or position, as those required by Army or Government service health care professionals of similar experience and in similar duty assignments. The scope of services provided in military treatment facilities cover the same range of services as those that are provided in civilian treatment facilities of similar size and scope of services.

2.0 BACKGROUND:

2.1 The mission of the military healthcare system (MHS) is to ensure the nation has available at all times a healthy military force supported by a combat ready healthcare system. Health care services for eligible MHS beneficiaries are provided at military treatment facilities (MTFs) located on or near military installations or posts. The military treatment facility may be a clinic, Hospital, or Medical Center. Clinics are outpatient facilities offering primary care or simple specialty care (routine exams, tests, treatments). The Clinic may be a stand-alone site or a satellite of a larger Clinic, Hospital, or Medical Center. Army Community Hospitals (ACH) offers more complex, resource- intensive secondary care (e.g. inpatient care, surgery under anesthesia) and primary care at outpatient clinics inside and outside the hospital. Army Medical Centers (MEDCENs) offer tertiary (sophisticated diagnosis/treatment of any ailment), secondary, and primary care, hospital services, preventive services, blood bank, and other services. In addition, all MEDCENs offer graduate Medical

2.2 Madigan Army Medical Center (MAMC) is located on Joint Base Lewis McChord (JBLM) and is administered by the United States Army, Army Medical Department, in the State of Washington. During a single day of operations at Madigan Army Medical Center comprises a network of Army medical facilities located in Washington and California that serve more than 100,000 active duty service members, their families and retirees. As one of the U.S. Army’s largest medical treatment facilities and a state-of-the-art and technologically advanced medical center, Madigan maintains approximately 240 beds for inpatient care, and can expand to accommodate more than 300 inpatients during periods of urgent need including emergencies. Outpatients are seen at the hospital's medical mall complex handling nearly one million visits annually. Madigan performs more than 45 surgeries, fills nearly 4,000 prescriptions, and delivers eight babies daily.

3.0 SCOPE OF WORK:

3.1 The Contractor’s employee must have obtained certification through the National Cancer Registrars Association and have been at least one year of working as a Certified Tumor Registrar performing the following duties: Abstraction, Coding, Case Finding, Knowledge of Staging, patient follow-up, data submission, participation in the cancer committee, cancer conferences (aka Tumor Boards), Quality and Quality Improvements.. Certified Tumor Registrars (CTRs) are data information experts that capture a complete history, diagnosis, treatment, and health status for every eligible cancer patient according to program and regulatory requirements and guidelines. They ensure proper sequencing of primary tumors, assure accurate documentation of procedures, and provide sufficient text documentation to support the National Cancer Data Base (NCDB), Cancer Program Practice Profile Reports (CPPR), and Rapid Quality Reporting System (RQRS). All hospitals in Washington are legally required to provide their cancer data to the State Department of Health's Central Cancer Registry on a monthly basis. In addition, Madigan Army Medical Center (MAMC) is an accredited Academic Comprehensive Cancer Program established by the American College of Surgeons (ACoS) Commission on Cancer (CoC), therefore, MAMC is required to adhere to the CoC Cancer Program Standards which include uniform coding as specified in the Facility Oncology Registry Data Standards (FORDS). This data provides essential information to researchers, healthcare providers, and public health officials to better monitor and advance cancer treatments, conduct research and improve cancer prevention and screening programs. CTR's work with physicians, administrators, researchers and health care planners to provide support for cancer program development, ensure compliance of reporting standards, and serve as a valuable resource for cancer information with the ultimate goal of preventing and controlling cancer.

3.1.1 CTRs abstract a wide range of medical data from the EMR and code it in compliance with data standard and any history of a previous cancer, diagnostic findings, types, dates, and results of procedures used to diagnose cancer, cancer identification, primary site, cell type, extent of disease, cancer treatment, surgery, birthplace and residence, outcomes, annual follow-up information regarding patient status, recurrence and treatment. CTRs must maintain a thorough understanding of anatomy and physiology, medical terminology disease processes, surgical and radiation techniques, new chemotherapy and hormone drugs, through participation in continuing education programs to effectively apply International Classification of Diseases (ICD)-1O, Facility Oncology Registry Data Standards (FORDS), American Joint Committee on Cancer Tumor Nodes Metastasis (AJCC TNM), and Surveillance, Epidemiology, and End Results (SEER) coding guidelines to inpatient and outpatient diagnoses and procedures. All coding is correlated from supporting clinical documentation in the EMR. CTRs also participate in the development of coding policies and procedures as identified as well as independently research and solve complex coding problems and assist with special projects as required. In addition, to coding topography, morphology, and stage of disease, CTRs also ensure adherence to data management protocols as set forth in state and national requirements, departmental standards and guidelines set forth by the MAMC Cancer Committee. Perform other related duties incidental to the work described herein.

3.1.2 The MAMC Tumor Registry lost its CTR and will fall behind on case abstraction and follow-up. As of 25 January 2016 the case abstraction backlog is 58 patients with an expected 45 patients per month until contract is filled. The follow up backlog is 1300 patients with an average of 25 patients added daily. 60 cases require additional research regarding follow-on treatment information and the tumor registry is 4 months behind in case finding. The purpose of this contract is to remedy the backlog of abstracted cases, case finding and follow up through Contract CTRs completing abstracting, case finding and follow-up as well as Contract CTRs providing oversight of non-CTR abstractors and then keep the Registry current with regards for the same services. Contract CTR will perform analytical and evaluator reviews of medical record data, provide over site of data abstractors for QA, identify areas for coding/documentation improvement in all areas to enhance data quality and minimize patient risk, conduct workload accuracy audits ensuring compliance, facilitate coding timeliness and accuracy. They will prepare submissions to supervisor on coding and audit activities pending or complete. Provides in-house training to physicians, medical records technicians, and administrative personnel on issues concerning legislative requirements for cancer reporting, cancer program accreditation, AJCC staging, and cancer research opportunities. Contract CTR will serve on the Cancer Committee and assists with the preparation of, and participation in, the cancer program accreditation survey/prepares reports for cancer committee. Contract CTR 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, the CoC to discuss discrepancies in cancer program requirements, etc.). They will attend Tumor Board and maintain detailed records to include attendance, compliance rates, and other information relating to accreditation. Contract CTR will assists in planning and organization of the Tumor Board to include scheduling meetings, reviewing site setup, notifying participants, and taking minutes. They will tabulate review data and enter into the Commission on Cancer (CoC) Program Activity Report (PAR) or Survey Activity Report (SAR) databases for reporting to the Cancer Committee and other elements. They will perform and ensure uniform and consistent coding and reporting of all diagnoses according to program and regulatory requirements and guidelines. Contract CTR will ensure proper sequencing of primary tumors, assures accurate documentation of procedures, and provides sufficient text documentation to support the National Cancer Data Base (NCDB), Cancer Program Practice Profile Reports (CP3R), and Rapid Quality Reporting System (RQRS).

Administrative:

Contractor Representative; the Contractor shall designate in writing, a primary point of contact for contract coordination and implementation not later than five business days after receiving notice of contract award. Changes in the primary point of contact (POC), at any time, shall require the Contractor to notify the Contracting Officer (KO) of the new representative at least five working days prior to the change. This notification shall be in writing and shall state the name and contact information for the new point of contact.

The Contracting Officer’s Representative (COR) will be the KO’s authorized representative in administering the contract at the MTF level. The Contractor’s representative shall be available to discuss any problems that the Contractor’s personnel may be experiencing during the performance of this contract. Problems experienced by the Government with the Contractor’s performance will be discussed and resolved. Unresolved problems will be referred to the KO for resolution.

The Contractor and contract personnel shall abide by all MTF standards, rules, and procedures including requirements for any licensure, credentialing and quality assurance requirements. Such regulations include, but are not limited to, general safety, fire prevention, waste disposal, infection control, JC, and patient safety initiatives.

Media and Other Inquiries:

The Contractor shall not respond to any media inquiries. Any inquiries from the media, third parties, or public agencies shall be immediately relayed to the COR, who will relay them to the MTF Public Affairs Officer or, after duty hours, to the Administrative Officer of the Day (AOD). There shall be no interviews, comments, or any other response without the knowledge and approval of the MTF Commander. Other than routine inquiries from external agencies, all other inquiries and complaints shall be brought to the attention of the COR.

Emergency Health Care for Contract Personnel:

The MTF will provide emergency healthcare for injuries or life threatening medical emergencies occurring while on duty at the MTF. The Contractor shall reimburse the Government for such services as billed by the MTF.

Conflict of Interest:

The Contractor or contract personnel shall not bill the patient for services rendered under this contract. The Contractor or contract personnel shall not request or accept compensation of any kind for patients treated, procedures performed, or any other actions performed, except under the terms and conditions of this contract, at the rate specified.

The Contractor or contract personnel shall not, while performing services under this contract, advise, recommend, or suggest to persons eligible to receive medical care at Government expense that such persons should receive care from the Contractor or contract personnel or from any third party at any place other than as designated under this contract.

Confidentiality of Information:

Unless otherwise specified, all financial, statistical, personnel, and/or technical data which is furnished, produced or otherwise available to the Contractor during the performance of this contract are considered confidential business information and shall not be used for purposes other than performance of healthcare services under this contract. The Contractor shall not release any of the above information without prior written consent of the KO. The Contractor/contract personnel shall not use patient care rendered pursuant to this contract as part of a study, research project, or publication. The contract personnel shall prepare medical records, forms and documents as required, in accordance with the regulations and established guidelines listed in the contract.

The Contractor shall not employ active duty military or Government civilian employees to perform services under this contract.

The Contractor or contract personnel shall not use Government facilities, supplies, or equipment in private practice or for any purpose other than providing the healthcare services required under this contract.

Security:

Security Identification Badges. The Contractor and contract personnel shall comply with the local installation and MTF personnel identification and access requirements while on site. While on site, each contract personnel shall wear visible security badge identification, provided by the military installation or the MTF, on the front of his/her outer clothing. The badge must show the full name, title and if required by the Military the word “Contractor” in front. The COR will provide the paperwork to request identification badges.

The Contractor is responsible for absences of contract personnel due to expired identification and access documents. Such absences shall not relieve the Contractor of its obligation to perform the healthcare services required under this contract.

The contract personnel shall immediately report any lost or stolen badges to the COR.

The contract personnel shall turn in all identification badges to the COR, or his/her designated representative upon termination of their services under this contract.

RESERVED

Assignment of Government Keys:

The Contractor shall be responsible for any keys issued by the Government to contract personnel for use in the MTF. The keys shall not be duplicated. The Contractor shall be financially responsible for the replacement of any lost keys and any associated locks. Lost keys and/or locks shall be reported to the issuing party, Department Chief, or COR immediately upon recognition of the loss.

Safeguarding Material:

The contract personnel shall be responsible for safeguarding all Government property. The Contractor shall safeguard information of a confidential or sensitive nature. All patient related information is considered confidential and sensitive. If working remotely, Contractors are prohibited from reproducing patient information in any way. This includes printing. Neither the Contractor nor any of its contract personnel shall disclose or cause to be disseminated any information concerning the operation of the MTF that could result in or increase the possibility of a breach in 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.

Orientation and Training:

Military Treatment Facility, (MTF) in-processing checklist. When commencing work under this contract, the contract personnel shall obtain in-processing checklist(s) from the COR or designated office. All contract personnel are required to complete the applicable items on the checklist and turn it in to the designated office. Upon completion of the duty assignment, the contract personnel need to complete an out-processing checklist and return it to the designated office.

MTF and Unit Orientation:

The contract personnel shall be provided with a Government paid orientation to familiarize the contract personnel with the policies and procedures of the MTF, assigned department and specific unit.

3.5.2. Army Regulation (AR) 40-68 states orientation shall be completed within 45 days.

Annual Training Requirements:

The Contractor shall ensure that contract personnel complete any mandatory annual training requirements in accordance with MTF procedures.

Government Unique Training:

The Government may elect to provide unique Government 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 or to the contract personnel. When directed by the KO, contract personnel shall attend all such training in a paid status as part of the normal services required and billed under the contract. Such training shall require a performance commitment by the Contractor and the Contractor shall reimburse the Government (by means of a reduction in an invoice) if a contract personnel fails to satisfy the performance commitment after the contract personnel receives the unique Government training. The amount of the reimbursement shall be the prorated cost of training, calculated based on the total cost of the training and the number of months by which the contract personnel fails 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.

Computer Training:

Contract personnel who have any interaction with the MTF computer systems must receive training for the applicable system(s). The COR or designee will coordinate the necessary computer training. The training will be on-site and during normal duty hours. This training will be at no cost to the Contractor. These systems include but are not limited to:

Composite Healthcare Computer System (CHCS) is the military’s world-wide automated medical information system interfaces with 40 plus external clinical and administrative systems.

Armed Forces Health Longitudinal Technology Application (AHLTA) contains the MTF’s appointment scheduling program, pharmacy, lab, and radiology ordering system and is interlinked with other departments in the MTF. In addition, it contains the electronic medical records for MHS beneficiaries.

The Automated Central Tumor Registry (ACTUR) is the cancer registry system in use in the Department of Defense and must be used by the contractor.

JANUS is the Veteran’s Administration electronic medical record and must be used by the contractor.

AT Level I Training:

This provision/contract text is for contactor employees with an area of performance within an Army controlled installation, facility or area. All contractor employees, to include subcontractor employees, requiring access to Army installations, facilities and controlled access areas shall complete AT Level I awareness training within 30 calendar days after contract start date or effective date of incorporation of this requirement into the contract, whichever is applicable. The contractor shall submit certificates of completion for each affected contractor employee and subcontractor employee, to the COR or to the contracting officer, if a COR is not assigned, within 7 calendar days after completion of training by all employees and subcontractor personnel.

CAC Holders: AT Level I Training course (JS-US007-14) is now hosted on the Joint Knowledge online (JKO) Learning Management System (LMS) for CAC holders at https://jkodirect.jten.mil. Login and search for the course on the Course Catalog tab via the number or key word, enroll, and launch.

Non-CAC Holders: A standalone version of the course for Non-CAC holders (i.e. family member 14 years old and over, etc) is also available at the link http://jko.jten.mil/courses/at11/launch.html. An access link to this course is also located on the JKO login page. The standalone version is intended for Non- CAC users without a JKO account ONLY.

Access and General Protection/Security Policy and Procedures:

This standard language text is for contractor employees with an area of performance within an Army controlled installation, facility or area. Contractor and all associated sub-contractors employees shall comply with applicable installation, facility and area commander installation/facility access and local security policies and procedures (provided by government representative). The contractor shall also provide all information required for background checks to meet installation access requirements to be accomplished by installation Provost Marshal Office, Director of Emergency Services or Security Office. Contractor workforce must comply with all personal identity verification requirements as directed by DOD, HQDA and/or local policy. In addition to the changes otherwise authorized by the changes clause of this contract, should the Force Protection Condition (FPCON) at any individual facility or installation change, the Government may require changes in contractor security matters or processes.

Contractors Requiring Common Access Card (CAC):

Prior to issuance of a CAC Card; the contractor employee requires, at a minimum, a favorably adjudicated National Agency Check with Inquiries (NACI) or an equivalent or higher investigation in accordance with Army Directive 2014-05. The contractor employee will be issued a CAC only if duties involve one of the following: (1) Both physical access to a DoD facility and access, via logon, to DoD networks on-site or remotely; (2) Remote access, via logon, to a DoD network using DoD-approved remote access procedures; or (3) Physical access to multiple DoD facilities or multiple non-DoD federally controlled facilities on behalf of the DoD on a recurring basis for a period of 6 months or more. At the discretion of the sponsoring activity, an initial CAC may be issued based on a favorable review of the FBI fingerprint check and a successfully scheduled NACI at the Office of Personnel Management.

iWATCH Training:

This standard language is for contractor employees with an area of performance within an Army controlled installation, facility or area. The contractor and all associated sub-contractors shall brief all employees on the local iWATCH program (training standards provided by the requiring activity ATO). This local developed training will be used to inform employees of the types of behavior to watch for and instruct employees to report suspicious activity to the COR. This training shall be completed within 30 calendar days of new employees commencing performance with the results reported to the COR NLT 7 calendar days after completed training.

Contractor Employees Who Require Access to Government Information Systems:

All contractor employees with access to a government info system must be registered in the ATCTS (Army Training Certification Tracking System) at commencement of services, and must successfully complete the DOD Information Assurance Awareness prior to access to the information systems and then annually thereafter.

OPSEC Training:

Per AR 530-1, Operations Security, new contractor employees must complete Level I OPSEC training within 30 calendar days of their reporting for duty. All contractor employees must complete annual OPSEC awareness training.

For Information Assurance (IA)/information Technology (IT) Training:

All contractor employees and associated sub-contractor employees must complete the DoD IA awareness training before issuance of network access and annually thereafter. All contractor employees working IA/IT functions must comply with DoD and Army training requirements in DoD 8570.01, DoD 8570.01-M and AR 25-2 within six months of employment.

Threat Awareness Reporting Program:

Per AR 381-12 Threat Awareness and Reporting Program (TARP), contractor employees must receive annual TARP training by a CI agent or other trainer as specified in 2- 4b.

Sexual Harassment/Assault Response and Prevention (SHARP):

The contractor shall ensure all contract employee receive Sexual Harassment/Assault Response and Prevention (SHARP) training not later than 60 calendar days after the HCP begin performance under this contract. Training can be obtained either online or in person as offered at the installation where services are being provided. If the employee has an AKO account, they can access online the Team Bound Self Study course through Army Learning Management System (ALMS) at http://www.atsc.army.mil/tadlp/delivery/alms.asp

POLICY FOR REPORTING INCIDENTS OF SEXUAL ASSAULT AND SEXUAL HARRASSMENT UNDER SEXUAL ASSAULT PREVENTION AND RESPONSE PROGRAM (SHARP):

The contractor shall comply with OTSG/MEDCOM Policy Memo 13-062, Policy for Reporting Incidents of Sexual Assault and Sexual Harassment under the Sexual Assault Prevention and Response Program (SHARP), 12 Nov 2013. The SHARP reporting requirements apply only to knowledge obtained by contractor personnel while performing services under this contract.

The contractor shall require all contract employee with knowledge of an incident of sexual assault occurring on a Government facility, to include a Government leased facility, where the contractor is providing services under this contract, to report the incident to the contractor who shall immediately (within 24 hours) report the incident in writing to the government's COR. All incidents shall be reported whether they involve contractor personnel or Government personnel, or other individuals.

The contractor shall require all contract employee with knowledge of an incident of sexual harassment occurring on a Government facility, to include a Government leased facility, where the contractor is providing services under this contract, to report the incident to the contractor who shall immediately (within 24 hours) report the incident in writing to the government's COR. All incidents shall be reported whether they involve contractor personnel or Government personnel, or other individuals.

MTF HOURS OF OPERATION:

ACH’s and MEDCEN’s provide services 24 hours a day, 365 days a year (366 days during leap years) including holiday. Clinics have designated operating hours.

Hours of performance are Monday through Friday (excluding federal holidays), 0730 (7:30 am) to 1600 (4:00 pm), to include a thirty (30) minute lunch break and two (2) fifteen (15) minute breaks (morning, afternoon), which are not paid for by the government. Hours are subject to change as mutually agreed between the contractor and government.

Holidays:

The following is a list of legal federal holidays. Any of the federal holidays falling on a Saturday will be observed on the preceding Friday, holidays falling on a Sunday will be observed on the following Monday. Contract personnel may be required to work on legal holidays as determined by the COR.

New year’s Day, January 1st Martin Luther King’s Birthday, 3rd Monday in January President’s Day, 3rd Monday in February Memorial Day, Last Monday in May Independence Day, July 4th Labor Day, 1st Monday in September Columbus Day, 2nd Monday in October Veteran’s Day, November 11th Thanksgiving Day, 4th Thursday in November Christmas Day, December 25th

NOTE 1: Any holidays that are declared by Presidential Executive Order shall be observed in the same manner as the holidays listed above. If the area in which a contract employee is scheduled to work is closed due to the holiday and the employee is not required to report in, payment will not be made for those hours. Closures of the installation due to inclement weather or other such acts of God shall be handled in the same manner.

Contract personnel shall report to work as scheduled during emergencies, disasters or during adverse weather conditions. Contract services are still required during these situations.

Closures:

During anticipated closure of the facility due to Command declared training holidays or unplanned closure of the facility due to natural disasters, military emergencies, severe weather, or otherwise, the Contractors will only be paid for the actual hours that were worked.

Contractor Employee Hours of Performance:

Scheduling process: Hours of performance are Monday through Friday (excluding federal holidays), 0730 (7:30 am) to 1600 (4:00 pm), to include a thirty (30) minute lunch break and two (2) fifteen (15) minute breaks (morning, afternoon), which are not paid for by the government. Hours are subject to change as mutually agreed between the contractor and government.

There is no overtime rate for this contract. The normal hourly rate shall apply when the contract employee is required to remain on duty past their scheduled hours.

There are no on-call hours required for this contract.

The COR or their designee will be responsible for communicating with the contractor regarding scheduling issues. The supervisor may act as point of contact after normal duty hours, weekends and holidays. In such cases, the COR shall confirm all actions on the next normal working day.

Absences and Leave:

The contractor shall notify the COR or their designee when a scheduled contract personnel cannot fill a shift due to illness or emergency. Notification shall be as early as possible, but no later than 2 hours prior to start of scheduled shift.

The contractor shall have sufficient qualified personnel available so that all services are provided in the event a contract personnel scheduled to work becomes ill, resigns, is terminated, or is otherwise unavailable to work. The proposed substitutes shall have at least the minimum qualifications required for the position.

When the contractor cannot fill a position, the contractor shall notify the COR.

Scheduled absences of contract personnel shall be coordinated with the Department representative at least 30 calendar days in advance. Depending on how the hours are specified will determine whether or not the contractor supplies a substitute. Contractor will be paid for actual hours worked.

The Contractor is responsible for submitting an accurate invoice.

The Contractor may only invoice and be paid for the services actually rendered. If the Contractor performs fewer services than are provided in the contract schedule, the Government may, at the end of the applicable contract period, deobligate the excess quantities.

LICENSE VERIFICATION AND CREDENTIALS REVIEW OR PRIVILEGING:

RESERVED

RESERVED

RESERVED

Removal of Contract Personnel:

At any time during the performance of this contract, the Contracting Officer or COR may direct the contractor to immediately remove any contract provider whose actions or impaired state raises reasonable suspicion that clear and present danger of physical harm exists to a patient, other contract HCPs, government personnel or to the impaired individual. This provision will be used in emergency situations only and not for the purpose of bringing performance issues or other non-urgent concerns to the attention of the contractor.

If the need for a removal occurs, the COR will contact the contractor's point of contact and direct the contractor to remove that individual from the military facility and to not use that individual to perform any services required under this contract until the issue has been resolved by the Contracting Officer. The contractor shall formally meet with the COR to discuss further action in accordance with the MTF Quality Assurance and Inspection (QA&I) Plan and AR 40-68. A review of the basis for removal will be made by the Contracting Officer within 3 working days after the COR directed the removal.

If, after any investigation deemed necessary by the Contracting Officer and discussions with the contractor's representative, the Contracting Officer concludes that the contract provider’s impairment requires permanent removal from performance under the contract, the Contracting Officer will notify the contractor that permanent removal is required. In the event of disagreements between the government and the contractor's representative concerning matters of impaired contract provider’s, the decision of the Contracting Officer will be final. During the period of time between the removal and the final decision of the Contracting Officer, the contractor shall provide a backup/replacement contract provider in accordance with the terms and conditions of this contract.

RESERVED

Conduct:

Contract personnel shall comply with MTF policies regarding personal appearance and conduct.

Contract personnel shall abide by federal, state, and local MTF regulations and requirements concerning the nature of limited privileged communication between patients and the contract personnel as may be necessary for security and personnel reliability programs. They shall also abide by federal, state, and local MTF regulations concerning the confidentiality of patient records, as embodied in federal statutes including the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996. All medical records and reports will remain the property of the Government.

3.8.7. Contract personnel shall not introduce new procedures or services without prior approval of the Department Chief or representative. If disagreements or deviations from protocols or procedures occur, the Department Chief or representative shall be the deciding authority.

Health and Immunization Requirements:

All contract personnel performing services under this contract shall comply with the health and immunization requirements as stated in the MAMC Health Requirements clause. Backup/replacement contract personnel shall meet the same health and immunization requirements. The expense to comply with the health and immunization requirements shall be borne by the Contractor at no additional cost to the Government.

Criminal History Background Check Requirements:

Contract personnel determined by the MTF to be involved in the delivery of health care to children under the age of 18 on a frequent and regular basis must meet the requirements of the Crime Prevention Act of 1990, as specified in the Criminal History Background Check Requirements clause.

TRUSTED ASSOCIATED SPONSORSHIP SYSTEM (TASS):

The Contractor shall comply with agency personal identity verification procedures that implement Homeland Security Presidential Directive-12 (HSPD-12), Office of Management and Budget (OMB) guidance M- 05-24, and Federal Information Processing Standards Publication (FIPS PUB) Number 201.

The Contractor shall comply with agency personal identity verification procedures in all subcontracts when the subcontractor is required to have physical access to a federally controlled facility or access to a Federal information system.

The Contractor shall ensure compliance with the provisions set forth below. For purposes of the Federal Acquisition Regulation (FAR) Clause 52.204-9, the USG will designate a Trusted Agent (TA) for this contract. The USG reserves the right to amend or supplement these provisions pursuant to the Changes clause in the contract.

The Contractor is responsible for absences of contract employees due to expired identification and access documents. Such absences shall not relieve the Contractor of its obligation to perform the services required under this contract.

In-processing Requirements:

The HCPs are prohibited from performing services under this contract absent compliance with the in-processing requirements set forth below.

The USG will sponsor the contract employee for an Army Knowledge Online (AKO) account. All HCP e-mail addresses will identify them as a Contractor and use the format firstname.lastname.ctr@us.army.mil. The USG will discontinue the AKO when the Contract employee no longer requires access.

The USG TA will send a notice through the TASS to the AKO e-mail address provided IAW the above requirement. The HCP’s user ID and password will be provided in the e-mail and will be require a change at first login. In the event the e-mail message is not received, the Contractor may request the username and password from the TA and proceed to the website https://www.dmdc.osd.mil/tass to complete the process.

The HCP shall log into the TASS and complete the verification process by submitting the application back to the TA for approval.

The application will be accepted, returned, or rejected by the TA. Notice as to whether the application has been accepted, returned, or rejected will be provided to the HCP’s e-mail address within 48 hours after submission. If the application is returned or rejected, the HCP shall contact the TA and comply with the TA’s guidance to attempt to correct and resolve the issue(s).

Upon approval of the application, the HCP will receive an e-mail stating the CAC application was approved. The applicant must then go to a RAPIDS Issuing Facility to have the USG credential issued. To make an appointment, the HCP will follow the instructions provided by the TA and contact the COR for instructions. The HCP must present two acceptable forms of ID, which may include: Driver's License, Military ID, Contractor Company ID with picture and expiration date, charge card with picture imprinted, or passport.

Revalidation Requirements:

The TA is required to revalidate all HCPs, in the TASS, every 6 months. In the event revalidation is denied, the CAC credentials shall be revoked and the CAC will not be useable to log in.

Out-Processing Requirements:

When a HCP’s performance under this contract ceases, the HCP shall personally bring the CAC to the TA and complete the DA Form 2962. The TA will revoke the CAC from the TASS.

QUALITY MANAGEMENT:

3.13.1 The Contractor shall have a planned and systematic quality management process for monitoring and analyzing its contract performance.

3.13.2. The Contractor shall ensure that all contract employees comply with the MTF quality management/process improvement activities.

4.0 QUALITY ASSURANCE SURVEILLANCE PLAN:

4.1. Inspection. The inspection and acceptance point for all services rendered under this contract will be the COR. The performance by the contract personnel, the quality of services rendered, and any documentation or written material in support of same, shall be subject to continuous inspection, surveillance and review for acceptance by the KO or COR. Any services rendered by the contract personnel to patients or interaction with military/civilian personnel deemed unprofessional, threatening, or dangerous by the KO will be grounds for immediate termination for default or cause. Quality Assurance procedures established by the MTF shall be used for continuous monitoring. Other performance evaluation factors will be monitored that are not quantified by numerical measurements which include: Contractor providing personnel not meeting the minimum qualification standards; inappropriate prescriptions; patient customer service comments; Contractor relationship with hospital staff/Government contracting personnel; compliance with hospital healthcare policies and procedures.

5.0. POSITION DESCRIPTION (PD):

Position: Certified Tumor Registrar

Assigned to: Population Health Management Division, Madigan AMC, WA

Reports to: Administrative Officer, Population Health Management Division

Qualifications

Education: All contract personnel must be Certified Tumor Registrars which have minimum educational standards.

Licensure/Certification/Registration: All Certified Tumor Registrars providing services on this contract must be certified by the National Cancer Registrars Association.

Experience: Contract Certified Tumor Registrar (CTR) must have twelve (12) months experience (within 1 year of contract award) with FORDS coding, ICD-10 coding, American Joint Committee on Cancer TNM staging, Collaborative staging, Surveillance, Epidemiology, End Results (SEER) staging, multiple primary and histology coding.

Must have a working knowledge of Automated Cancer Tumor Registry (ACTUR) software, Windows-based software. Must be able to demonstrate a broad practical knowledge of accepted principles and procedures in medical records administration and standards of tumor registry operations. Must have excellent organizational skills with good follow through, investigative/analytic skills with detail orientation.

Must have excellent organizational skills with good follow through, investigative/analytic skills with detail orientation. Good verbal and written communication skills are essential.

After training on government unique systems has been provided, contract personnel must be able to utilize Armed Forces Health Longitudinal Technology Application (AHLTA), Essentris, Composite Healthcare Computer System (CHCS), and JANUS Electronic Medical Record (EMR) systems.

Specific Duties/Tasks: The contractor shall provide services of a Certified Tumor Registrar to include but not limited to:

Capture a complete history, diagnosis, treatment, and health status for every eligible cancer patient. All hospitals in Washington are legally required to provide their cancer data to the State Department of Health’s Central Cancer Registry on a monthly basis. MAMC is an accredited NCI-Designated Comprehensive Cancer Center Program established by the American College of Surgeons (ACoS), Commission on Cancer (CoC). MAMC is required to adhere to the CoC Cancer Programs Standards which include uniform coding as specified in the Facility Oncology Registry Data Standards (FORDS). These data provide essential information to researchers, healthcare providers, and public health officials to better monitor and advance cancer treatments, conduct research and improve cancer prevention and screening programs. Contract CTR will work with physicians, administrators, researchers, and health care planner to provide support for cancer program development, ensure compliance of reporting standards, and serve as a valuable resource for cancer information with the ultimate goal of preventing and controlling cancer.

Abstract a wide range of medical data from the EMR and code it in compliance with data standard sets established by the (ACoS) (CoC). This includes: medical history, physical findings, screening information, occupation and any history of a previous cancer, diagnostic findings, types, dates, and results of procedures used to diagnose cancer, cancer identification, primary site, cell type, extent of disease, cancer treatment, surgery, radiation therapy, chemotherapy, hormone therapy, immunotherapy, patient identification, age, gender, race, ethnicity, birthplace and residence, outcomes, annual follow-up information regarding patient status, recurrence and treatment.

All coding will be correlated from supporting clinical documentation in the EMR. CTRs will also participate in the development of coding policies and procedures as identified as well as independently research and solve complex coding problems and assist with special projects as required. In addition, to coding topography, morphology, and stage of disease, CTRs also ensure adherence to data management protocols as set forth in state and national requirements, departmental standards and guidelines set forth by the MAMC Cancer Committee. Perform other related duties incidental to the work described herein.

Requirements for all Positions:

The Contractor shall ensure that all contract personnel providing services under this contract shall be able to read, write, and speak English well enough to effectively communicate with all parties and other health care providers. In addition, if the position requires the use of computers, the contract personnel shall be computer literate.

The contract personnel shall possess sufficient initiative, interpersonal relationship skills and social sensitivity such that he/she can relate constructively to a variety of patients from diverse backgrounds.

5.2.3 The contract personnel shall have the required education, training, experience and documented current competence in the required specialty position description.

If services are provided remotely, the Contractor must adhere to all IT requirements for utilizing Government equipment and accessing Government systems. Supporting equipment will be at the vendor’s expense. I.e. interfaces, hardware, and software.

6.0 Performance Requirements Summary (PRS Table)

Performance Objective

Remedy

Satisfactory: All candidates meet all minimum qualifications.

Unsatisfactory: Candidates do not meet minimum qualifications.

Backlog is cleared by established date as stated in PWS Unsatisfactory: Backlog is not cleared by established date Paragraph 1.1 and 3.1.2

3.5.5.5 – 3.5.5.11 COR or designee will review SWANK account or DTMS Cure notice and document noncompliance in Monthly Status Report in VCE-COR.

50 and FAR 22.1703

COR

documentation and program review.

Immediately notify KO of any non-compliance Document compliance in CPARS. See FAR 52.222- 50 for KO remedies.

7.0 Contractor Manpower Reporting:

"ACCOUNTING FOR CONTRACT SERVICES-The Office of the Assistant Secretary of the Army (Manpower & Reserve Affairs) operates and maintains a secure Army data collection site where the contractor will report ALL contractor manpower (including subcontractor manpower) required for performance of this contract. The contractor is required to completely fill in all the information in the format using the following web address “https://cmra.army.mil. The required information includes: (1) Contracting Office, KO, KO’s Technical Representative; (2) Contract number, including task and delivery order number; (3) Beginning and ending dates covered by reporting period; (4) Contractor name, address, phone number, e-mail address, identity of contractor employee entering data; (5) Estimated direct labor hours (including sub-contractor); (6) Estimated direct labor dollars paid this reporting period (including sub-contractor); (7) Total payments (including sub-contractor); (8) Predominant Federal Service Code (FSC) reflecting services provided by contractor (and separate predominant FSC for each sub-contractor if different); (9) Organizational title associated with the Unit Identification Code (UIC) for the Army Requiring Activity (the Army Requiring Activity is responsible for providing the contractor with its UIC for the purposes of reporting this information); (10) Locations where contractor and sub-contractors perform the work (specified by zip code in the United States and nearest City, Country, when in an overseas location, using standardized nomenclature provided on website); (11) Presence of deployment or contingency contract…