650-23-4-420-0017: TJC Mock Survey FOR Joint COMMISSION

2 This is a sources sought announcement to be used for preliminary market research purposes only. No quotations are being requested or accepted with this synopsis. THIS IS NOT A SOLICITATION FOR QUOTATIONS AND NO CONTRACT SHALL BE AWARDED FROM THIS SYNOPSIS. No reimbursement will be made by the Government for any costs associated with providing information in response to this synopsis or any follow up information requests. The purpose of this synopsis is to gain knowledge of interest, capabilities and qualifications of various members of 8(a), HUBZone, Service-Disabled Veteran-Owned Small Business (SDVOSB), Women Owned Small Business (WOSB), Economically Disadvantaged Women Owned Small Business (EDWOSB), and Indian Small Business Economic Enterprises (ISBEE) to compete and perform a Firm Fixed Price Purchase Order. Statement of Work (SOW) Environment of Care/Life Safety Consultation Accreditation Survey for the Providence VA Medical Center Background Providence VA is looking for a specialized consultation survey to focus on the compliance of standards related to environment of care and life safety of the hospital of the Joint Commission Url: A Trusted Partner in Patient Care | The Joint Commission 80% of the top ten noncompliance findings for Hospitals were related to the Environment of Care and Life Safety. (The Joint Commission (2019). Perspectives. September 2019.39(9). Mock surveys foster staff engagement. As active participants in the process, participating staff become more engaged with the Joint Commission/CMS/state compliance requirements which helps healthcare organizations foster a culture of continuous improvement and create a sense of ownership over compliance and patient care. Objective and Specific Aims The mock survey will be conducted using the same methodology currently utilized by The Joint Commission. URL: Standards for Joint Commission Accreditation and Certification | The Joint Commission The environment of care and associated processes will be surveyed for compliance with the 2023 Joint Commission standards. Objective #1: Hospital to maintain accreditation by The Joint Commission Specific Aim #1: Assessment of standards compliance Specific Aim #2: Provide education on best practices, tools, and methods to make improvements. Objective #2: Improve the outcomes of accreditation surveys and the safety of the environment. Specific Aim #1: Provide support, coaching, and education to allow the Providence VAHCS to use the Joint Commission standards and accreditation process as a management tool to improve the safety of the environment and to objectively measure the quality of care against nationally recognized standards. Specific Aim #2: Goal of improving the safety of the environment of care is achieved, continuous accreditation readiness and improved accreditation outcomes. The ultimate purpose of the consultation survey is to meet compliance guidelines when the Joint Commission or other regulators conduct their survey. Creating a heightened awareness of regulations and better knowledge of standards leads to better compliance outcomes. Responsibilities Surveyor will provide three (3) day Joint Commission environment of care and Life Safety mock survey will include: Safety and Security (EC.01.01.01 and EC.02.01.03) Hazardous Materials and Waste (EC.02.02.01) Fire Safety (EC.02.03.01 and E.02.03.03) Medical Equipment (EC.02.04.01 and EC.02.04.03) Utilities (EC.02.05.01, EC.02.05.02, EC.02.05.03, EC.02.05.05, and EC.02.05.09) Environment of Care Management Plans Interim Life Safety Measures policy Review and provide corrective actions to inspection/testing/maintenance documentation and activities related to: Fire safety equipment and safety building features (EC.02.03 Emergency power systems (EC.02.05.07) Fire drills (EC.02.03.03) Medical equipment Interim Life Safety Measures Conduct a Life Safety Building tour consistent with The Joint Commission survey process. Reporting Initial findings and recommendations will be reported out during a leadership exit/closing conference, identifying the most significant trends and priorities for improvement. Comprehensive report will be provided electronically to the Providence VA including: An executive summary identifying the top priorities and recommended focus; The standard and element of performance; The level of compliance with each element of performance; Specific findings for each element of performance that the Providence VA is found to be in less than full compliance with during the mock survey; and A plan recommending corrective actions, practical implementation strategies, and appropriate educational efforts to focus the organization s survey preparation efforts. Following the survey, consultant will be accessible via telephone and e-mail for clarifications to the report, interpretation of Joint Commission standards, and to provide guidance on accreditation-related practices. Services will include guidance related to revisions to policies, procedures, plans, performance measurement tools, and other documents that will aid the Providence VAHCS in achieving and maintaining compliance with the Joint Commission standards.