Sources Sought Notice: Healthcare Leadership and Management Support Services
MARKET RESEARCH PURPOSES ONLY
NOT A REQUEST FOR QUOTE, PROPOSAL OR SOLICITATION
The Indian Health Service (IHS) is conducting market research to support the Office of Quality (OQ) to obtain expertise in the areas of hospital leadership mentoring, including the executive team (C-suite), support maintenance of The Joint Commission (TJC) accreditation standards and elements of performance (EPs) and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) within the Indian Health Service (IHS) system, and provide development of organizational gap analysis to improve and sustain hospital accreditation and compliance with CoPs, including, but not limited to leadership and governance, infection prevention and control, patient safety, plant facility safety (environment of care and life safety standards), credentialing and privileging, nursing, laboratory, radiology, dietary, and Quality Assessment and Performance Improvement (QAPI) functions, according to accreditation standards and EPs and CoPs (further referred to as accreditation support).
This is a Sources Sought notice to determine the availability of small businesses (inclusive of VOSB, SDVOSB, HUBZone SB, SDB, WOSB, LB), Indian Economic Enterprises (IEE) and Indian Small Business Economic Enterprises (ISBEE) capable of supplying the required solution and support services.
This notice is for planning purposes only, and does not constitute an invitation for Bids, Request for Proposal or Request for Quotation or an indication the Government to award a contract, nor does the Government intend to pay for any information submitted as a result of this notice. Your responses to the information requested will assist the Government in determining the appropriate acquisition method, including whether a set-aside is possible.
I. Background
The Indian Health Service (IHS) provides ambulatory health services to Tribal nations across the United States. The user population is approximately 2.56 million American Indians and Alaska Natives. These primary, specialty, oral health, and inpatient behavioral health services occur in approximately 24 hospitals, 51 ambulatory health care centers, and 13 Youth Regional Treatment Centers (YRTCs provide behavioral health inpatient services). IHS healthcare facilities are accredited and/or certified to incentivize delivering high-quality, safe, evidence-based care and support third-party billing for eligible patients. IHS’s mission is “to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.”
The IHS has experienced issues maintaining accreditation and quality of care at individual facilities, resulting in losing facility accreditation or the threat of loss. To address these issues, IHS has utilized site-by-site contract support and various strategies to support facility leadership in ensuring they can meet IHS’s mission. While positive results have been achieved, a more comprehensive approach that includes hospital leadership and management support services in advance of accreditation issues being identified is essential to more effectively addressing problems when identified and ensuring that a mechanism for ongoing support and engagement is available to ensure Facility, Area, and Headquarters (HQ) can maintain the highest medical quality standard.
II. Scope of Work / Capabilities Sought
The IHS is considering the establishment of a national contract vehicle to support facilities and address the challenges described above. This contract is expected to include the following task areas:
Task Area 1- Facility Support:
The Contractor shall be capable of providing customized support to individual Indian Health Service facilities as identified by IHS. The services within this anticipated task area consist of the following:
1. Conducting onsite validation of each facility’s compliance with the Centers for Medicare & Medicaid Services (CMS) or The Joint Commission (TJC), as appropriate, on an annual basis with a gap analysis of vulnerabilities and a corrective action plan (CAP) presented to facility, service area and HQ leadership, including trending issues/challenges across entities and providing a “roll-up” report to service areas and HQ - this will help the system understand where there may be systemic issues across the enterprise that shall enhance proactive responses.
2. Providing ongoing support for resolution of issues identified in the CAP, working with Facility, Area, and Headquarters staff to complete CAP items. These shall include, but are not limited to:
- Assessing survey readiness, conducting mock surveys, or preparing for review by other oversight organizations, including Occupational Safety and Health Administration (OSHA), National Fire Protection Association (NFPA), Centers for Disease Control and Prevention (CDC), American College of Obstetricians and Gynecologists (ACOG), Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), Association of periOperative Registered Nurses (AORN), The Association for the Advancement of Medical Instrumentation (AAMI), Institute for Safe Medication Practices (ISMP), etc.
- Providing facility leadership mentoring, including the Chief Executive Officers (CEO), Chief Medical Officers (CMO), Chief Operating Officers (COO), Chief Nursing Officer (CNO), Office of Environmental Health and Engineering, Life Safety Officers, laboratory and other hospital services as appropriate. This would include, but not be limited to, face-to-face provider education regarding the Restraint and Seclusion process and policy, nursing services, communications, and leadership issues.
- Conducting medical quality review, review of medical staff credentialing, and clinical documentation improvement. This shall include expert consultation to evaluate the quality and performance of the IHS and the facility’s ability to meet standards of care, including but not limited to review of credentialing-related documentation, and the production of written reports and other briefing materials, both for internal and external audiences.
- Any reviews require the contractor staff to ensure all IHS and patient data is confidential and complies with the Privacy Rule published to implement the Health Insurance Portability and Accountability Act of 1996 requirements and all other relevant patient privacy laws and regulations. IHS information is not subject to disclosure by contractor staff except as permitted or required by law or regulation.
- Providing specialized expert consultation in areas such as, but not limited to, infection prevention, central sterile processing, the environment of care, life safety, and ambulatory care.
- Helping establish and maintain a process for identifying and resolving adverse events, problems, and resolutions. This shall include a patient advocate program, a complaint and Grievance program, and conducting root cause analysis using IHS's established process.
- Reviewing facility communication, accountability, and processes. Support activities shall include, but are not limited to, project management, communication workshops, process redesign, and identifying accountability challenges.
- Reviewing facility-level policy and procedure reviews/revisions, including sustainability. Review and validate training and staff competencies.
- Supporting Quality Assessment/Performance Improvement (QA/PI) efforts, including quality team development and support, including the Quality Scorecard.
- Addressing specific Departmental or programmatic issues and assist the facility in addressing them as identified.
- Conducting transition planning activities following engagements to ensure Contractor efforts are integrated into federal operations.
Task Area 2- Facility Governance and Governing Body’s (GB) Support:
Under this anticipated task area, the contractor shall perform activities related to the following:
- Reviewing current GB practices at each level to develop a concrete understanding of GB operations, function, and, most importantly, value to attendees.
- Defining and educating on each level's core GB roles and responsibilities constructs.
- Determining what information is appropriate and necessary at the local level and what information is then required for communication to the service area and ultimately to the HQ level. This shall include, but is not limited to:
- Quality and safety information.
- Medical staff information, including credentialing/privileging.
- The level of detail should be appropriate to the level of review: details not necessary at the service and HQ level; however, anomalies or significant outliers should be discussed).
- Any policy or plan approval as necessary and required by regulatory agencies.
- Determining the best approaches and methodology for consistency and conciseness of required information.
- Ensure reporting is an impactful and appropriate reporting structure.
- Information sharing and direction vertically, responses to and from the board, and ensuring information is entirely shared bi-directionally.
- Define minimum expectations and performance metrics for each entity.
- Crafting appropriate, meaningful agendas.
- Understanding purposeful presentations that lead the board to informed decision-making.
- Simplifying minutes for ease of information capture and review.
- Improving board functioning to promote proactive board involvement and reduce reactive responses:
- Enhancing information flow and transparency.
- Focusing on communication and change management from the governance level.
- Enhance reporting and analysis at the governance level to better recognize systems/processes needing improvement and train the board to require analysis of direction, rate, variability, and magnitude of change.
Task Area 3-System-Wide Programmatic, Analytical, and Policy Support:
Under this anticipated task area, activities shall include assisting the IHS in the creation of system-wide programs or provide analytical or policy support for policy areas identified in this contract, such as:
- Assisting IHS in creating a system-wide quality program (as allowed by CMS and TJC)
- Assisting IHS in creating a system-wide patient safety program.
- Assisting IHS in creating a system-wide infection control and prevention program.
Providing policy and programmatic support. This shall require the production of any necessary analytical or other documents.
Task Area 4- Credentialing Support:
Under this anticipated task area, the contractor shall:
- Conduct ongoing credentialing specialist training to prepare IHS credentialing specialists for certification.
- Provide any requisite support for credentialing, including examining medical staff information provisioning, including credentialing/privileging.
III. Capability Statements:
To be considered as a potentially capable source for the purpose of making a small business set aside determination, respondents to this sources sought shall unequivocally demonstrate their capabilities to fulfill all the task areas described in Section II. Capability statements submitted in response to this notice should consist of the following:
1. Cover Page: Business name and bio, Unique Entity ID (UEI), business address, business website, business size status (i.e., SB, VOSB, SDVOSB, HUBZone SB, SDB, WOSB, IEE, or ISBEE), point of contact name, mailing address (if different from business address), phone number and email address. Provide this same information again if responding to provide a service offered by another firm.
2. Relevant Past Performance and Experience information inclusive of date of services, description, dollar value, client name, client address, client contact name, client point of contact mailing address (if different from that provided for client), client point of contact phone number, client point of contact email address, and name of company (to include UEI number and size status) if not the respondent. Information furnished in this section should be relevant to the work described in Section II on a national level. To be considered relevant, these past experiences should have been performed within the last five (5) years include/demonstrate the following:
a.) Experience performing onsite engagements at multiple facilities concurrently with a team of dedicated individuals. IHS estimates the likelihood the contractor would be required to resource 3-4 teams at 3-4 facilities at the same time, but this could vary based on need. Task Order Request for Proposals issued under an IDIQ will specify the location of facilities needing services and other details in order for the contractor to propose a team composition to meet the needs of each facility as well as the number of hours for each labor category needed. The Government anticipates most engagements would be nine to twelve months.
b.) Specialized experience to implement practical solutions to persistent clinical and compliance challenges, leveraging deep industry knowledge and subject matter expertise in all Joint Commission (TJC) accreditation standards/elements of performance (EPs), requirements of the Accreditation Association for Ambulatory Health Care (AAAHC), CMS Conditions of Participation (CoPs), and state agency regulations; this experience should include CMS EMTALA, CMS CoP, TJC Accreditation standards/EPs and Occupational Safety and Health Administration (OSHA) regulatory assessments
c.) Experiences resulting in documented results of successful coaching of AAAHC and TJC standards and CMS survey results at all levels within an organization, including, but not limited to
-
- Leadership/Governance
- Nursing
- Medical
- Environment of care/life safety
- Quality Assurance/Performance Improvement
- Credentialing
- Laboratory
- Sterilization/high level disinfection
- Risk Management
- Pharmacy (USP 797/800, Compounding sterile preparations, order management)
- Dental
- Water management plans
- Human Resources
- Nutrition (Dietary services)
d.) Experience in setting up systems and processes across the facility to drive compliance with operational efficiency and allow point-of-care providers to support the mission while maintaining compliance with accreditation and regulations.
e.) Experience aligning evidence-based best practices with regulatory requirements empowers leaders and point-of-care providers to drive operational efficiencies while achieving sustained compliance.
f.) Experience providing documented results of credible sustainment plans implemented in historic contracts, including transition plans.
g.) Experience providing documented results of leadership development and strategic processes.
h.) Experience providing project management for historical and newly developed corrective action plans.
i.) Experience in providing specialized experience to implement practical solutions to persistent clinical and compliance challenges, leveraging deep industry knowledge and expertise in CMS, AAAHC, The Joint Commission, and state agency regulations.
j.) Experience in providing expertise in implementing system-wide improvement efforts that strengthen decision-making skills, enhances critical thinking skills, empowering leaders to identify and address process gaps while fostering competent patient and workforce safety.
k.) Experience providing documented success in making improvements that last beyond the time period of the engagement.
IV. Response Instructions:
Interested parties shall respond with capability statements; no larger than 20 pages (not inclusive of the cover letter) via e-mail in PDF or Word format before 4:00 PM Eastern Time on March 29th, 2025 to Christopher.McGucken@ihs.gov.
In your response, please use " IHS-25-SS-HCLMSS” followed by your organizations name as the subject line.
Additionally, if your firm is an Indian Economic Enterprise (IEE) or Indian Small Business Economic Enterprise (ISBEE)- Please include a completed and signed copy of attached form “IHS IEE Form.pdf” with your response. This form will not be counted towards the total page limit.
Disclaimer and Important Notes: This notice does not obligate the Government to award a contract or otherwise pay for the information provided in response. The Government reserves the right to use information provided by respondents for any purpose deemed necessary and legally appropriate. Any organization responding to this notice should ensure that its response is complete and sufficiently detailed to allow the Government to determine the organization's qualifications to perform the work. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted. After a review of the responses received, a pre‐solicitation synopsis and solicitation may be published in the System for Award Management. However, responses to this notice will not be considered adequate responses to a solicitation.
Confidentiality: No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non‐proprietary technical information in any resultant solicitation(s).
