R– VISN 17 Joint Commission Readiness
Notice Type: Sources Sought Notice
Posted Date:
Office Address:
Subject: R-- VISN 17 Joint Commission Readiness
Classification Code: R - Professional, administrative, and management support services
Solicitation Number: 36C25719Q0438
Contact:
Description:
This is a sources sought notice for market research purposes only to determine the availability of potential businesses with capabilities to provide the services described below. Potential offerors are invited to provide feedback via e-mail to [email protected]. Responses will be used to determine the appropriate acquisition strategy for a potential future acquisition.The intended contract period is one-year base period plus (4) four one-year option periods.
Potential contractors shall provide, at a minimum, the following:
1) Company name, address, point of contact, phone number, e-mail address, and DUNS.
2) Is your firm eligible for participation in one of the following small business programs If so, please indicate the program. Anticipated North American Industry Classification System (NAICS) code is 541611, small business size standard
[ ] yes [ ] no Small Business (SB)
[ ] yes [ ] no HUBZone
[ ] yes [ ] no Small Business 8(a)
[ ] yes [ ] no Small Disadvantaged Business (SDB)
[ ] yes [ ] no Women-Owned (WO) Small Business
[ ] yes [ ] no Service Disabled Veteran Owned Small Business (SDVOSB)
[ ] yes [ ] no Veteran Owned Small Business (VOSB)
[ ] yes [ ] no Other (please specify)
[ ] yes [ ] no
3) Provide a brief capability statement (Max 5 pages) with enough information to determine if your company can meet the requirement. The capabilities statement for this sources sought is not expected to be a Request for Quotation, Request for Proposal or Invitation for Bid, nor does it restrict the Government to an ultimate acquisition approach, but rather the Government is requesting a short statement regarding the company s ability to provide the services outlined in the draft SOW below. Any commercial brochures or currently existing marketing material may also be submitted with the capabilities statement. This synopsis is for information and planning purposes only and is not to be construed as a commitment by the Government. The Government will not pay for information solicited. Respondents will not be notified of the results of the evaluation.
1.0 GENERAL INFORMATION: This is a non-personnel services contract to provide Survey Readiness to all facilities within the VISN 17
1.1 Description of Services/Introduction: Perform Survey Readiness Service as defined in this Performance Work Statement except for those items specified as government furnished property and services. The contractor shall perform to the standards in this contract.
1.2 Background: An Accreditation Readiness (AR) review for Joint Commission (TJC) survey and
1.3 Objectives:
Joint Commission Standards Compliance including Environment of Care and Life Safety standards
Enhance staff accreditation survey process knowledge
Increase patient safety
1.4 Scope: The purpose of this procurement action is to acquire survey readiness services also known as continuous standards compliance. The
1.5 Quality Control: The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor s quality control program shall be the means by which it assures that their work complies with the requirement of the contract. A Quality Control Plan (QCP) shall be delivered within 30 days after contract award. Three copies of a comprehensive written QCP shall be submitted to the CO and COR within 5 working days when changes are made thereafter. After acceptance of the QCP the contractor shall receive the contracting officer s acceptance in writing of any proposed change to his quality control program.
1.6 Quality Assurance: The government will evaluate the contractor s performance under this contract in accordance with the Quality Assurance Surveillance Plan. 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 minimum acceptable defect rate(s).
1.7 Recognized Federal Holidays: The contractor shall not be required to perform services on national holidays.
Independence
Any other day deemed to be a national holiday by the President of
1.8 Hours of Operation: The contractor shall be responsible for conducting business,
1.9 Place of Performance: The work to be performed under this contract shall be performed at
Locations:
7400
5001
1.10 Type of Contract: The government will award a firm fixed price definite delivery contract.
1.11 Security Requirements: The contractor, their personnel, and their subcontractors shall be subject to the Federal laws, regulations, standards, and VA Directives and Handbooks regarding information and information system security as delineated in this contract. The position sensitivity for this effort has been designated as LOW.
1.12 Physical Security: The contractor shall be responsible for safeguarding all government equipment, information and property provided for contractor s use.
1.13 Operating Constraints: The contractor shall have a Business Associate Agreement (BAA) and safeguard Personal Health Information (PHI) agreements. The Contractor staff shall complete
1.14 Confidentiality of Data and Privacy Act: Any information systems involved with this contract are classified as systems of records subject to the Privacy Act of 1974 (Public Law 93-579) and all applicable Health Insurance Portability and Accountability Act (HIPAA) regulations.
The contractor may, during performance, observe or handle information subject to the Privacy Act or other Federal regulations. Duplication or disclosure of data and other information to which the contractor will or may have access because of this contract is prohibited by law. It is understood that throughout the performance of the contract, the contractor may have access to confidential data that is either the sole property of
1.15 Post Award Conference/Periodic Progress Meetings: The Contractor shall agree to attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. The contracting officer, Contracting Officers Representative (COR), and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor's performance. At these meetings the contracting officer will apprise the contractor of how the government views the contractor's performance and the contractor shall apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the government.
1.16 Contracting Officer Representative (COR): The (COR) will be identified by separate letter of delegation provided by the Contracting Officer (CO). The COR will monitor all technical aspects of the contract and assist in contract administration. The COR is not authorized to change any of the terms and conditions of the resulting contract.
1.17 Data Rights: The Government has unlimited rights to all documents/material produced under this contract. All documents and materials, to include the source codes of any software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership/copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the Contracting Officer. 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.
3.0 GOVERNMENT FURNISHED ITEMS AND SERVICES:
3.1. Materials: The Government will provide Joint Commission Standards policies and results of previous survey reports.
4.0 CONTRACTOR FURNISHED ITEMS AND RESPONSIBILITIES:
4.1 General: The Contractor shall furnish all supplies, equipment, facilities and services required to perform work under this contract that are not listed under Section 3 of this PWS.
5.0 SPECIFIC TASKS:
1. Conduct an Accreditation Readiness (AR) TJC and LTCI Review at each of the seven (7) VISN facilities. Each facility will be allowed 1 consultative visit (up to 5 consecutive days) for their accreditation readiness review.
2. Each consulting team must consist of comparable team credentials as a TJC team to include a physician consultant, a nurse consultant and/or an administrative/life safety consultant. The consultants will address Hospital, CLC,
3. Dates of the reviews are negotiated with the Quality Manager and Accreditation Coordinator at each facility in consultation with the VISN QMO. After all reviews are completed, the consultants will schedule an exit conference with the VISN Network Director, VISN QMO and other leadership staff to discuss findings and trends.
4. Consultants will use the most recent edition of Joint Commission Standards published in the Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH), and other appropriate standards for Nursing and Rehabilitation Centers, Ambulatory Care,
5. Each facility will supply the consultants with accurate information describing the scope of services provided. The facility will provide access to those staff members who would normally be involved in a
6. The organizational reviews will be coordinated with the local Quality Management or Accreditation staff at each site. It may be necessary for individual consultants to conduct their reviews separately, based on availability, but in all cases each component of the reviews will be completed prior to the end of the performance period. Each accreditation readiness review may include, but not be limited to; an opening conference, training, tracer activities, a
7. The consultants shall possess the appropriate qualifications of surveyor and consultant experience to include RN, MD, or Admin/life Safety Specialist with previous experience serving as TJC surveyors and credentials for conducting the surveys. They shall have surveyor and consultant experience and be knowledgeable of the unique challenges faced by VA Medical Centers. Consultant expertise in Hospital,
5.4. Deliverables/Reporting Requirements
The contractor shall submit reports to the COR or the Contracting Officer as requested for use in monitoring contractor performance. The complete lists of deliverables are provided below and shall be submitted in accordance with requirement. As a result of submissions additional information and/or clarification may be required and shall be provided upon request. All Tasks and Deliverables will be prioritized by the COR. Deliverable dates may be adjusted by mutual agreement.
As part of the contract the contractor shall provide:
a. Mock TJC surveys shall be conducted at each of the VISN 17 facilities during the contract period. The surveys shall include the development of a survey agenda, and a review of the TJC Program Manuals, TJC most challenging standards, TJC announced areas of focus, the seven (7) Management Plans, performance improvement activities, annual evaluations, Statement of Conditions, and other pertinent documents. The contractor shall coordinate the survey schedule with the Contracting Officer Representative (COR). The contractor shall assess the documentation covering items including, but not limited to, care delivery, fire safety, medical equipment, and utility systems. A review of related Environment of Care documentation from each facility s
(1) The contractor shall provide Contractor for 35 days of onsite consultation time (5 days X 7 facilities = 35 days) for the mock TJC surveys. (Actual dates to be mutually determined by contractor and each facilities Quality Manager.
(2) A brief needs assessment shall be conducted with each facility prior to the surveys to determine focus areas to include. This may include a review of hospital policies/procedures, staff training, performance improvement activities and goals, discussions with department heads, the building maintenance program, or any other area of weakness identified by the facility.
(3) The Contractor shall conduct a building tour, which will include visits to patient care settings and other areas likely to be visited by TJC. The Contractor shall provide consultation on the best methods to achieve the standards, and propose solutions to identified problems or issues.
(4) The Contractor shall conduct one or more informal on-site educational session(s) as needed, during scheduled survey dates, addressing shortcomings identified during the document review or building tour, or a general overview session for interested staff. These sessions shall be tailored to address the specific needs at each facility, and the background of those attending.
(5) The Contractor shall submit a written report by TJC standard within fifteen (15) working days after each site visit. The report shall cite the specific standard of noncompliance, a narrative assessment of noncompliance and specific recommendations for compliance. Any findings that may result in a finding of noncompliance must be clearly identified in the report, along with a recommendation on how best to resolve it. Findings of noncompliance and partial compliance shall be identified in the report. The report shall be submitted in an electronic format in Microsoft Word simultaneously to the Medical Center Director, and the VISN 17 Quality Management team.
(6) The contractor shall provide an aggregated VISN wide written report for VISN 17 Leadership at the time of the VISN summation session. The summary report shall include: facility findings, recommendations by facility, general strengths and weaknesses by facility, trends across the VISN and general and site-specific recommendations.
(7) The Contractor shall conduct a two-hour summation conference with VISN 17 Leadership at the VISN 17 Network Office,
3. The contractor shall provide deliverables as follows:
a. Mock TJC surveys at each of the seven (7) VISN 17 facilities and any CBOCs selected by the parent facility.
b. An electronic and hardcopy in a bound format (3-ring binder is acceptable), written report of findings provided to the facility within fifteen (15) working days of the survey citing the specific standard of noncompliance. Report shall be in Microsoft Word format submitted simultaneously to the Medical Center Director and VISN 17 Quality Management team.
c. An electronic and hardcopy in a bound format (3-ring binder is acceptable), aggregated VISN wide written report of findings provided to VISN prior to summation conference to include facility findings, recommendations by facility, general strengths and weaknesses by facility, trends across the VISN and general and site- specific recommendations. Reports shall be in Microsoft Work format submitted simultaneously to the VISN 17 Network Director and VISN 17 Quality Management team.
d. A two (2) hour summation presentation with VISN leadership at the VISN Office in
4. All surveys shall be coordinated with the VISN 17 Quality Management team who will be designated as the Contracting Officer s Representative (COR) for this contract.
a. Schedules for all contract services will be approved/finalized as soon as possible after contract award with a minimum of a two-week lead time from approval to scheduled task.
b. All contract services shall be completed within 180 days from award.
c. Each facility survey shall be completed on consecutive days in one week and not be continued over a weekend. No contract services shall be provided on weekends or federal holidays.
6.0 APPLICABLE PUBLICATIONS:
6.1. In the performance of the tasks associated with this Performance Work Statement (PWS), the Contractor shall comply with:
All applicable Health Insurance Portability and Accountability Act (HIPAA) Regulations
FAR 52.224-1 Privacy Act Notification and FAR 52.224-2, Privacy Act
BACKGROUND INVESTIGATION: The contractor will be required to complete a background investigation through Human Resources Management Service.
The Notice of Award letter shall instruct the successful offeror how to obtain the
CONTRACTOR TRAINING/INFORMATION SYSTEM
All
Prior to being able to gain access to the
Training must be successfully completed before each year of the contract and copies of the training certificates provided to the CO or COR
Other training may be required as determined by
This is a sources sought notice only. The information gathered from this request is for information and planning purposes only and will not be released. This does not constitute a solicitation. No solicitation is currently published, pending, or available. If a solicitation is issued, it will be issued at a later date. Responses to requests for information are not offers and cannot be accepted by the Government to form a binding contract. Vendor participation in this response or any informational session is not a promise of future business with the
Responses shall be submitted to [email protected] no later than
Link/URL: https://www.fbo.gov/spg/VA/VANTHCS/VANTHCS/36C25719Q0438/listing.html
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