SRCSGT | R | Joint Commission Review Consulting Contract.

FBO DAILY ISSUE OF DECEMBER 24, 2009 FBO #2952
SOURCES SOUGHT

R -- Joint Commission Review Consulting Contract.

Notice Date: 12/22/2009
Notice Type: Sources Sought
NAICS: 541611 — Administrative Management and General Management Consulting Services
Contracting Office: Department of Veterans Affairs;VA Medical Center;University & Woodland Aves;Philadelphia PA 19104
ZIP Code: 19104
Solicitation Number: VA-244-10-RP-0071
Response Due: 1/11/2010
Archive Date: 3/12/2010
Point of Contact: Ira S. Clavner215-823-5800 x7658
E-Mail Address: Contract Specialist
(Ira.Clavner@VA.gov)
Small Business Set-Aside: Total Small Business
Description: A.GENERAL OBJECTIVES AND REQUIREMENTS 1.TITLE OF PROJECT QUALITY MANAGEMENT DEVLOPMENT CONTRACT TO VALIDATE PHILADELPHIA VAMC JOINT COMMISSION, CARF, PATIENT SAFETY AND QUALITY, CONSULTATION, EDUCATION, AND TRAINING ACTIVITIES. 2.PURPOSE OF PROJECT Although this project is the continuation of the successful work of Joint Commission readiness, it is not just a Joint Commission readiness project. In order to successfully pass the Joint Commission, an organization cannot just do a last minute ramp up. It is imperative that organizations understand systems and processes. It is equally important to understand and operationalize a quality outcomes management philosophy and structure. This structure should be able to address both the outcomes of organizational processes but also address the individual outcomes of veterans receiving care. In addition patient safety initiatives must be integrated into all organizational systems. In order to do this multiple integrated systems must be evaluated and in some cases redesigned. Therefore the purpose of this project is to: analyze and evaluate current Joint Commission (JC) and CARF readiness, continue the evolution of the quality program in order to be one of proactive improvement rather than reactive quality assurance, provide staff development in the areas of systems and process re- design, work with leadership on critical care and other processes, facilitate the development of a comprehensive patient safety program. Emphasis will be placed on system design and compliance, performance improvement, quality outcomes management, tactical and operational planning and staff analysis and development. The end result would be the on-going state of Joint Commission and CARF readiness rather than a staff intensive, resource intensive, ramp up at the last minute. BACKGROUND Beginning in 2004, Joint Commission (JC) launched a comprehensive and far reaching new survey process. This process requires an accredited organization to submit self-assessments or periodic performance reviews for each of the JC functional chapters. After the completion of the self assessment, Philadelphia VAMC is required to submit corrective action identified through the self assessment process. Therefore the accuracy of the assessments and the ability to comply with corrective action is paramount to a successful survey. Additionally, the JC will do a systems analysis of key processes, so organizations must have effective systems in place. This approach requires that Philadelphia VAMC look at processes across its organizations and not just at a simple point in time. Finally, the JC will be evaluating critical processes that are specific to the Philadelphia VAMC relative to reported events, complaints, data base searches etc. A tracer methodology is used by Joint Commission. This system traces patients through care processes to identify strengths, weaknesses, vulnerabilities, trends and patterns. In addition the Community Living Center at Philadelphia VAMC requires intense focus on patient care process and systems particularly as they relate to CMS standards. At the current time it is critical that action plans for improvement be monitored for effective implementation. All of these factors necessitate the need for consultative service. This contract is an organizational development contract. The end result of contracted services would be a continued state of Joint Commission and CARF readiness, but more importantly, improved patient care and safety, as well as staff and leadership processes and outcomes. 3.SCOPE AND METHODOLOGY The contractor will provide comprehensive consulting activities and services to Philadelphia VAMC from October 1, 2009 through September 2012. This will include both at the Philadelphia facility as well as off site. The off site work will include review of policies, plans and other documents. The contractor will provide comprehensive on site assessment, education and consulting in Joint Commission readiness and CARF readiness, quality outcomes management, patient safety, quality improvement and organizational development. Additionally, the contractor will facilitate all performance reviews conducted by Philadelphia VAMC. This contractor will provide this service for all the Philadelphia VAMC clinical areas including: the methadone program, the in-patient behavioral health program, the out-patient addictions recovery program, the Community Living Center, the hospital and all the primary care ambulatory sites and the Home Based Primary Care program. Services provided will include but not limited to working with senior leadership, quality management, medical staff leadership, program mangers and line staff in the areas of: omedical staff credentialing opolicy and procedure development and updates oCARF accreditation oJoint Commission standards oCMS standards specifically for the Community Living Center ooutcomes management, operformance improvement, opatient safety including National Patient Safety Goals operiodic performance evaluations, ooperational planning, oprocess redesign. ostaff development and competency Additionally, this consultation will also include helping to manage the self- assessments, action plans and the documents required for Joint Commission. The scope of work will include on-going education for staff and written reports on a regular basis to Philadelphia VAMC leadership. B.TASKS AND ASSOCIATED DELIVERABLES 1.TERM OF THE CONTRACT October 1, 2009 thru September 30, 2012 2.DESCRIPTION OF TASKS AND ASSOCIATED DELIVERABLES Task #1:Initial meeting to provide Contractor all required documentation and determine specifics of all on-site visits- October 2009 Task #2:Site Visit / Consultations December 2009- September 2012 These tasks will be conducted on site and will include on-going assessment of JC readiness, patient safety, and CMS readiness for the Community Living Center. Contractors will work with key leadership staff including Medical Staff leadership as well as line staff. The projected accomplishments include: oReview and redesign of the current patient safety oFacilitation of four PPR completions annually and review of all PPR action plans and measures of success oFacilitation of CARF survey preparation and action plans oStaff preparation for any CMS related survey at the Community Living Center oSupport and guidance on any action plans generated from the Community Living Center oAttendance at any JC or CARF survey if possible oAssessment of medical staff credentialing compliance oAnnual review of Medical Staff bylaws, and Rules and Regulations with recommended revisions as necessary oAssistance in the development of a comprehensive on-going and focused physician evaluation program oAssistance with any sentinel event reported to the Joint Commission oAssistance with any complaint submitted to Joint Commission oPatient tracer activities oHuman resource competency oEducation regarding critical patient processes oRevisions to policies and procedures as required oEducation on all new JC and CARF standards oIntegration of quality and patient safety oPerformance improvement outcomes oCompletion of an annual mock survey oMonitoring of on-going compliance through the use of an electronic readiness tool oStaff development and education oOther tasks as assigned by the facility Director or the Quality Director oThese tasks will also include an intensive analysis of the recommendations made in the written report from each previous task. The contractor will work with all required staff however will work primarily with nursing, medical staff, quality and administrative leadership. Each task visit will include an oral report to senior management. Written Report: These tasks will include a comprehensive report of findings, action taken while on site and recommended actions for improvement. Task # 3: Off-site Consultation- On-going This task will include phone consultations, document review, policy reviews and other work assigned by Philadelphia VAMC that does not require a site visit. Deliverables will be the completion of the assigned work. 3.SCHEDULE FOR DELIVERABLES The following items shall be delivered in accordance with the schedule indicated. If the contractor believes that different dates should be established, these proposed dates will be indicated in the contractors technical proposal and the detailed work plan. All written deliverables will include one master plus the quantities shown below. Unless otherwise indicated Philadelphia VAMC will have 7 workdays in which to prepare and deliver consolidated comments to the contractor. The contractor will have 14 workdays in which to prepare and deliver a final product. Consultant staff will be available via telephone or email during interim periods for consultation and follow-up. The contractor's technical report shall contain a detailed work plan for accomplishment of the requirements of this task order, to include the methodology to be used for each aspect of the project and the proposed staffing to be used. ITEM Task #1. QUANTITY One (3 day visit) DELIVERY 14 Workdays FEES Up to $2300 per day per consultant. Maximum of two consultants for 3 days COST $13,800 ITEM Task #2. QUANTITY (a) 4 regular visits per year (3 day visit) QUANTITY (b) 1 mock survey per year (4-5 day visit) DELIVERY 14 Workdays FEES (a) Up to $2300 per day per consultant. FEES (b) Maximum of two consultants for 3-5 days COST (a) $55,200 COST (b) $23,000 ITEM Task #3. QUANTITY On-going/ up to 3 hours per month DELIVERY 14 Workdays FEES Up to $200/hour COST $7,200 Total $99,200* *Total of services not to exceed $99,200 per year. 4.REPORTING REQUIREMENTS The Contracting Officer in writing will issue any changes to this Tasks Order. No other party is authorized to make changes to the Task Order. In addition to the deliverables specified above, the Contractor is required to provide the Task Order Project Manager (TOPM) with written progress reports (original plus one copy). The frequency and due date of Progress Reports shall be established by the specific task order. The TOPM is required to provide monthly progress reports to the Contracting Officer by the fifth workday of the new calendar month. The progress report will cover all work completed during the preceding month and will present the work to be accomplished during the subsequent month. The report must identify any problems, which arose, and a statement explaining how the problem was resolved. This report must also identify any problems, which have arisen but have not been resolved. This report will be the basis for the Contracting Officer's authorization of payment of invoices. If for any reason a deliverable cannot be delivered as scheduled, the contractor is required to submit a request for a time extension to the Contracting Officer. This request will cite the reasons for the delay, the impact on the overall project, and the impact on the cost of this project. The Contracting Officer will consider each request on the basis of its merits and will, if appropriate, issue a modification to the task order. The contractor is required to proceed as originally scheduled until such modification is issued. 5. Completion of Mandatory VHS Training All contractor personnel assigned to work on this contract must complete VHA mandated training for contractors including but not limited to: oMandatory Annual Review oPrivacy Training oCyber Security Training 6.WORK HOURS Work hours shall be scheduled as needed for joint commission activities. Generally, work shall be performed during normal working hours (between 8:00 am and 4:30 pm, Monday through Friday). However, at times it may be necessary for the contractor to provide services outside of normal working hours due to an emergency or in order to complete necessary work. 7.SPECIAL CONTRACT REQUIREMENTS The services to be performed by the Contractor shall be performed within the VA policies and procedures and regulations of the Philadelphia VAMC. The services to be performed by the Contractor will be under the direction of the Quality Management Director. Quality Assessment reports (See attachment #1) and follow up reports are to be completed by the contractor and provided within fourteen days of a site visit. Contractor will do an oral exit briefing to the Medical Center Pentad and Quality Management Director after all site visits to the Medical Center. A written report will follow within fourteen days to include a comprehensive report of findings, action taken while onsite and recommended actions for improvement. 8.QUALIFICATIONS Contractor is required to have extensive experience in accreditation and joint commission standards and issues associated with the Hospital Accreditation Program (HAP), Long Term Care (LTC), Opioid Treatment Program (OTP), Behavioral Health Services (BHS), and Home Based Primary Care Programs. 9.PERSONEL POLICY The Contractor shall be responsible for protecting the personnel furnishing services under this contract. To carry out this responsibility, the Contractor shall provide the following for these personnel: *Workers compensation *Professional liability insurance *Health examinations *Income tax withholding, and *Social security payments Payments for any leave, including sick leave, holiday or vacation time, are the responsibility of the contractor. 10. MONITORING WORK HOURS Contractor shall report to the Director of Quality Management Service at the Philadelphia VAMC to sign in and out. Signature sheets to accomplish this process shall be made available by the QM Director. No payments shall be made to the contractor for any leave, including sick leave, holiday or vacation time as these payments are the responsibility of the contractor. 11. PROTECTION OF PROTECTED HEALTH INFORMATION The HIPPA Privacy Rule (Health Insurance Portability & Accountability Act) as provided under 45 CFR 164.503(e), 164.504(e), 164.532(d) and (e) requires that a Covered Entity obtain satisfactory assurances from its Business Associates that the business associate will appropriately safeguard the protected health information, within the meaning of HIPPA, that it receives or creates on behalf of the covered entity. The Contractor hereby covenants that it, its employees and its subcontractors shall not disclose or use any protected health care information except as such use or disclosure is required for treatment, payment or health care operations. Any breach of confidentiality and/or unauthorized release of information is subject to monetary penalty. Any individual making unauthorized disclosures may be criminally liable for violations of HIPPA. The contractor is responsible for training its employees with respect to required privacy rules and enforcing compliance. Contractor will have access to VA computerized record systems including Patient Medical Records. With respect to records that include drug or alcohol abuse data, sickle cell anemia treatment records, records of tests or treatment for or infection with HIV, medical quality assurance records, or any other sensitive information protected under 38 U.S.C. 4132 or 3305 only to the extent absolutely necessary to perform their contractual duties, contractor personnel shall access such records only to the extent absolutely necessary to perform their contractual duties and shall not disclose such data to anyone, including other employees of the contractor not involved in the performance of the particular contractual duty for which access was obtained. Violation of this provision may result in imposition of criminal penalties. 12. SECURITY REQUIREMENTS FOR CONTRACTOR EMPLOYEES Background Investigation The contractor working under this contract shall satisfy all requirements for appropriate security eligibility in dealing with access to sensitive information systems belonging to or being used on behalf of the Department of Veterans Affairs. To satisfy the requirements of the Department of Veterans Affairs, a Low Risk (NACI) Investigation shall be conducted on each Contractor employee proposed to provide services under this contract before such employee begins providing services to the Philadelphia VAMC under this contract. A higher level of investigation may be required if dictated by the level of access to VA systems required and type of work to be performed by a particular contractor employee. It is the responsibility of the contractor to: Prescreen all personnel requiring access to VA records to ensure that they maintain U.S. citizenship or a valid work VISA, and are able to read, write, speak and understand the English language; Submit to the VA Security and Investigation Center the following required forms within 30 days of the initiation of the investigation of each employee: -Standard Form 85, Questionnaire for Non-Sensitive Positions -Standard Form 85A, Continuation Sheet -FD 258, U.S. Department of Justice Fingerprint Applicant Chart -Optional Form 306, Declaration for Federal Employment -Option Form 612, Optional Application for Federal Employment; Withdraw an employee from consideration for working under this contract when notified of an unfavorable investigation determination by the Government; All costs associated with the background investigations will be paid by Philadelphia VAMC and then charged to the contractor by offsetting the actual costs against moneys due on the invoices received from the contractor.
Web Link: FBO.gov Permalink
(https://www.fbo.gov/spg/VA/PhVAMC642/PhVAMC642/VA-244-10-RP-0071/listing.html)
Place of Performance: Address: 3900 Woodland Avenue;Philadelphia, PA; Zip Code: 19104
Record: SN02029837-W 20091224/091222235536-3dbe8ed89c8b557c5a8e0868c7f55048 (fbodaily.com)
Source: FedBizOpps Link to This Notice
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R -- Joint Commission Review Consulting Contract.