Health Services Accreditation

An advanced contract award notice (ACAN) is a public notice indicating to the supplier community that a department or agency intends to award a contract for goods, services or construction to a pre-identified supplier, thereby allowing other suppliers to signal their interest in bidding, by submitting a statement of capabilities. If no supplier submits a statement of capabilities that meets the requirements set out in the ACAN, on or before the closing date and time stated in the ACAN, the contracting officer may then proceed with the award to the pre-identified supplier.

1. Definition of the requirement:

The Correctional Service Canada (CSC) Health Services has a requirement to maintain its accreditation status to remain in compliance with its legislated mandate under section 86 of the Corrections and Conditional Release Act (CCRA). As well as to continue to strengthen support to address offender health needs with quality care reflective of evidence based best practice standards established by Accreditation Canada. CSC Health Services maintained its Accreditation Status in 2011, 2014 and 2018. The next Accreditation assessment will be conducted in 2023.

The work will involve the following:

1.1 Objectives:

1. Maintain relevant and current accreditation program and standards for CSC Health Services; provide ongoing technical advice and coordination to CSC Health Services in preparation for two formal assessments (2023 and ongoing between 2024 and 2027).

2. Prepare and conduct accreditation surveys at CSC National Headquarters (NHQ), Regional Headquarters (RHQ), Health Services Clinics, Regional Hospitals, Regional Pharmacies, Regional Treatment Centers and Community Mental Health.

3. Conduct on-site simulated surveys (mock tracers), facilitated by an Expert Advisor, in each of CSC’s five regions, to prepare CSC leaders, managers and front-line staff for the survey process.

1.2 Tasks:

The Contractor must:

Perform Simulated Surveys On-site:

1. Prepare CSC leaders and frontline staff for their survey by using the tracer methodology to assess critical areas and systems known to have a significant impact on the quality and safety of care.

2. Conduct an interview and discussion session with CSC Leaders at NHQ using the Leadership Standards as a guide and use the tracer methodology to virtually assess preselected priority processes;

3. Conduct an interview and discussion session with each of the regions using standards that will be determined in advance by the Regional Director Health Services;

4. Provide feedback in terms of staff preparation, areas of strength and opportunities for improvement that includes all participants from the tracers including the Leadership team

5. Provide a final summary report on the overall observations assessing the integration of related processes, consistency in the implementation of policies and procedures and communication within and between departments, programs, and services. 

6. The contractor must provide ongoing support to CSC Health Services that reinforces continuous quality improvement appropriate in the context of service delivery in a correctional setting and in keeping with CSC programs and policies

Accreditation program and standards for CSC Health Services:

1. Qmentum® Survey scheduled in 2023

1. The contractor must work with CSC Health Services (HS) on the following additional standards to determine whether they are required, and to adjust them to the CSC HS environment:

1. Leadership;

2. Infection Prevention and Control;

3. Medication Management;

4. CSC Health Services Standards

5. Mental Health Services;

6. Community-based Mental Health Services and Supports

7. Diagnostic Imaging (Ontario region only);

b. The Contractor must prepare and conduct accreditation surveys at CSC National and Regional Headquarters, Health Services Clinics including Mental Health in mainstream institutions, Regional Hospitals, Regional Pharmacies and Regional Treatment Centers and Community Mental Health using a health system approach and standards recognized by the International Society for Quality in Health Care under QMentum.

c. The Contractor must survey all 43 institutions as well as NHQ, each RHQ, Regional Hospitals, Regional Pharmacies and 1 Community Mental Health site per region (either in a CCC or Parole Office).

d. The Contractor must prepare a final consolidated report for CSC NHQ, aggregating the survey results within 45 days after the completion of surveys in each region and HQ.

2. For the QMentum Global™ Accreditation cycle the contractor must apply the standard commissioned by CSC to Health Standards Organization (HSO) for use in QMentum Global™.

3. The Contractor must provide ongoing support and coordination, including site preparation to ensure that CSC Health Services NHQ is adequately informed and is prepared for the Qmentum accreditation surveys for the 2023 accreditation process and QMentum Global™. This must include:

i. Providing an Accreditation Specialist to provide ongoing coaching for site preparation.

ii. Providing all required resource material for the accreditation process.

iii. Providing all site survey schedules and pre-survey meetings two months prior to the on site survey visits.

4. The Contractor must provide each CSC region and National Headquarters with a separate portal on the Contractor's website to enable CSC staff to keep track of the survey results and of any changes to the on-going requirements.

1.3 Expected results:

CSC will undertake its survey scheduled in 2023 under the Qmentum™ Program, after which CSC HS will transition to the new QMentum Global™ Program.

CSC will adhere to requirements for accreditation through the Qmentum™ and QMentum Global™ Programs as well as address any identified recommendations through the survey visits.

1.4 Performance standards:

The Contractor must complete the work in accordance with professional standards of practice.

1. The Contractor must provide a minimum of fifteen (15) surveyors and a minimum of two (2) surveyors must perform all work in both official languages English and French.

 1.1 A minimum of one (1) surveyor per Region must have been or be regulated by their relevant regulatory body as a medical doctor, dental practitioner, pharmacist or nurse.

2. The Contractor must use the Accreditation standards described below to review Health Services delivery in CSC.

1. Leadership Accreditation Standards addresses requirements for operational and performance management supports and decision-making structures across and throughout all levels of Health Services.

2. Infection Prevention and Control Accreditation Standards provide a framework to plan, implement, and evaluate an Infection Prevention and Control (IPAC) program suited to the needs of our CSC environment.

3. Medication Management Accreditation Standards review the complete medication process for a selection of medications including prescribing, administration, and monitoring patients from a Site, Regional and National perspective.

4. CSC Health Services Accreditation Standards examine the clinical services provided in a primary care setting.

5. The Mental Health Accreditation Standards review the overall for health care provided at the Regional Treatment Centres.

6. The Community-based Mental Health Services and Supports Accreditation Standards review the for mental health services delivered through the continuum of care from the institutions to the community.

7. The Diagnostic Imaging Accreditation Standards (Ontario Region only) review these for effective health services delivery.

1.5 Deliverables:

 The Contractor must provide the following deliverables:

1. Conduct six (6) simulated surveys, one in each of the five regions plus NHQ that must include a verbal and written post-session summary for each simulated survey.

2. Complete two-accreditation cycles, the Qmentum® Survey scheduled in 2023 followed by the new QMentum Global™ program that include ongoing support and coordination in preparation for the surveys as well as provide the final summary report on the overall results of the accreditation process with a decision of Accreditation for NHQ and each region.

3. Provide CSC National Headquarters and each region with a separate organizational portal on Accreditation Canada's website.

4. Work with CSC HSS to define the specific transition from the Qmentum® program to the new Qmentum Global™ program that includes a staged approach to its adoption and the new features as they become available.

5. Provide all deliverables in PDF format and in both official languages as requested by the Project Authority.

1.5.2 Paper consumption:

a. Should printed material be required, double sided printing in black and white format is the default unless otherwise specified by the Project Authority.

b. The Contractor must ensure printed material is on paper with a minimum recycled content of 30% and/or certified as originating from a sustainably managed forest.

c. The Contractor must recycle unneeded printed documents (in accordance with Security Requirements).

1.6 Constraints:

1.6.1 Location of work:

1. The Contractor must perform the work at different locations throughout Canada as determined by the Assistant Commissioner, Health Services.

2. Travel

   The Contractor must coordinate and arrange for all the travel, accommodation and meals for its surveyors, and must coordinate room reservations as well as videoconferencing and teleconferencing required for debriefing meetings outside of CSC institutions. Travel will only be required during the onsite portion of the survey, as the Accreditation Surveys must be conducted at sites across Canada.

1.6.2 Language of Work:

The contractor must perform all work in in both official languages, English and French.

 1.6.3 Security Requirements:

This contract includes the following security requirements:

 SECURITY REQUIREMENT FOR CANADIAN SUPPLIER:  

PWGSC FILE No. 21120-23-4152166

1. The Contractor/Offeror must, at all times during the performance of the Contract/Standing Offer, hold a valid Designated Organization Screening (DOS), issued by the Contract Security Program (CSP), Public Works and Government Services Canada (PWGSC).

2. The Contractor/Offeror personnel requiring access to PROTECTED information, assets or sensitive site(s) must EACH hold a valid RELIABILITY STATUS, granted or approved by the CSP, PWGSC.

3. The Contractor/Offeror MUST NOT remove any PROTECTED information or assets from the identified site(s), and the Contractor/Offeror must ensure that its personnel are made aware of and comply with this restriction.

4. Subcontracts which contain security requirements are NOT to be awarded without the prior written permission of the CSP, PWGSC.

5. The Contractor/Offeror must comply with the provisions of the:

a) Security Requirements Check List and security guide (if applicable), attached at Annex C;

b) Contract Security Manual (Latest Edition).

2. Criteria for assessment of the statement of capabilities (minimum essential requirements):

Any interested supplier must demonstrate by way of a statement of capabilities that it meets the following requirements:

Experience:

1. Must have experience in the last 7 years prior to the ACAN closing date in accrediting a minimum of ten (10) Health Service organizations in Canada;

2. Must have experience in the last 7 years prior to the ACAN closing date providing a health services accreditation program that is recognized by the International Society for Quality in Health Care and applied in all 10 Canadian provinces and three (3) territories.

3. The accreditation program much include a minimum of the following 7 standards that are relevant to primary health care, dental, or ancillary services:

• Leadership;

• Infection Prevention and Control;

• Medication Management;

• CSC Health Services Standards

• Mental Health Services;

• Community-based Mental Health Services and Supports

• Diagnostic Imaging

4. The Supplier must have performed at least 2 accreditations in both official languages, English and French

Professional designation, accreditation and/or certification:

1. Must provide proof of accreditation by the International Society for Quality in Health Care to accredit health service organizations in Canada.

3. Applicability of the trade agreement(s) to the procurement

This procurement is subject to the following trade agreement(s):

Canada Chile Free Trade Agreement (CCFTA);

Canadian Free Trade Agreement (CFTA);

The procedural requirements of the other international trade agreements will be fulfilled following compliance to the procedural requirements of CFTA, CCFTA, WTO-AGP and/or the CETA.

4. Set-aside under the Procurement Strategy for Indigenous Business

This procurement is not subject to any set-asides for Indigenous Suppliers.

5. Comprehensive Land Claims Agreement(s)

This procurement is not subject to a Comprehensive Land Claims Agreement.

6. Justification for the Pre-Identified Supplier

 The pre-identified supplier meets all of the minimum essential requirements described in this ACAN.

• Accreditation Canada is an Ottawa-based non-profit organization that works with a number of stakeholders including governments, regional health authorities, hospitals, national healthcare professional societies and community-based programs and services from both private and public sectors.

• Accreditation Canada specializes in the delivery of accreditation programs across a variety of healthcare settings in Canada and overseas, is accredited by the International Society for Quality in Health Care and is authorized by the National Standards of Canada.

• Accreditation Canada has extensive experience accrediting organizations across Canada including First Nations and Inuit communities.

• In 2008, Accreditation Canada launched its world-class Qmentum™ accreditation program, now implemented in more than 7,000 sites. The Canadian healthcare quality assessment model is built to accommodate 13 provincial and territorial healthcare jurisdictions and population needs, which provides a flexible and integrated model that covers the full spectrum of healthcare services from large networks and healthcare systems to small home care and primary care organizations, rural, urban, and aboriginal.

• Accreditation Canada has more than 500 surveyors which are a vital part of the accreditation program. They are senior professionals who work in accredited organizations in a variety of health and social services sectors. As peer reviewers and champions of quality and safety, they conduct the on-site survey, assessing the quality of programs and services against the standards, sharing their expertise, and providing guidance. These professionals bring valuable experience, knowledge, and insight to health care and social services organizations in Canada and internationally.

• Health Standards Organization is developing a new CSC Health Services standard as a National Standard of Canada that incorporates customized assessment areas including governance and leadership requirements regarding systemic racism and cultural safety and humility. 

7. Government Contracts Regulations Exception(s)

 The following exception to the Government Contracts Regulations is invoked for this procurement under subsection:

(d) only one person is capable of performing the contract.

8. Exclusions and/or Limited Tendering Reasons

The following exclusion(s) and/or limited tendering reasons are invoked under the section of the trade agreement(s) specified:

Canada Chile Free Trade Agreement (CCFTA) Article Kbis-09:

b. where, for works of art, or for reasons connected with the protection of patents, copyrights or other exclusive rights, or proprietary information or where there is an absence of competition for technical reasons, the goods or services can be supplied only by a particular supplier and no reasonable alternative or substitute exists;

 Canadian Free Trade Agreement (CFTA), Article 513

 (b) if the goods or services can be supplied only by a particular supplier and no reasonable alternative or substitute goods or services exist for any of the following reasons:

(iii) due to an absence of competition for technical reasons;

9. Ownership of Intellectual Property

Ownership of any foreground intellectual property arising out of the proposed contract will vest with the Contractor.

10. Period of the proposed contract or delivery date

The proposed contract is for a period of five years and seven months with an option to extend the contract for two additional one-year periods.

11. Cost estimate of the proposed contract

The estimated value of the contract, including option(s), is $1,047,329.00 (GST/HST extra).

12. Name and address of the pre-identified supplier

Name: Accreditation Canada

Address: 1159 Cyrville Road

Gloucester ON K1J 7S9

13. Suppliers' right to submit a statement of capabilities

Suppliers who consider themselves fully qualified and available to provide the goods, services or construction services described in the ACAN, may submit a statement of capabilities in writing to the contact person identified in this notice on or before the closing date and time of this notice. The statement of capabilities must clearly demonstrate how the supplier meets the advertised requirements.

14. Closing date and time for a submission of a statement of capabilities

The closing date and time for accepting statements of capabilities is September 20, 2022 at 2:00 PM EST.

15. Inquiries and submission of statements of capabilities

Inquiries and statement of capabilities are to be directed to:

Nadine Pike, Senior Procurement Officer

Telephone: (506) 378-1049

E-mail: nadine.pike@csc-scc.gc.ca