IHS FY 1999 Performance Plan


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Indian Health Service
FY 1999
Performance Plan
February 1, 1998

I. Overview of the Indian Health Service

The Indian Health Service (IHS), as the Operating Division (OPDIV) charged with administering the principal health program for American Indians and Alaska Natives (AI/AN), provides comprehensive health services through a system of IHS, tribal, and urban (I/T/U) operated facilities and programs. Many of the people served by the IHS live in some of the most remote and poverty stricken areas of the country and these health services represent the only source of health care. In terms of magnitude, the I/T/Us provide health services to 1.3 million AI/ANs through 144 service units composed of more than 500 direct health care delivery facilities, including 49 hospitals, 190 health centers, 7 school health centers, and 287 health stations, satellite clinics, and Alaska village clinics. Within this system, Indian tribes deliver IHS funded services to their own communities with about 35 percent of the IHS direct services budget in 11 hospitals, 129 health centers, 3 school health centers, and 240 health stations. Tribes who have elected to retain the Federal administration of their health services, or to defer tribal assumption of IHS programs until a later time receive services with about 65 percent of the IHS direct services budget in 38 hospitals, 61 health centers, 4 school health centers, and 47 health stations. The range of services includes inpatient and ambulatory care, and extensive preventive care, including focused efforts toward health promotion and disease prevention activities.

In addition, various health care and referral services are provided to Indian people away from the reservation settings through 34 urban programs. It is now estimated that approximately 60 percent of all AI/ANs now reside in or near urban centers rather than reservations and available evidence suggests they have considerable unmet health care needs. Another integral part of the program is the purchase of services from non-IHS providers to support, or in some cases in lieu of, direct care services. This Contract Health Services program represents about 18 percent of the IHS Budget and is distributed to IHS and Tribal programs at the same relative percentage as direct services funding (i.e., IHS = 65%, Tribal = 35%). In FY 1996, the IHS Fiscal Intermediary processed over 400,000 payment claims.

Since its inception in 1955, the IHS has demonstrated the ability to effectively utilize available resources to improve the health status of the AI/AN people including dramatic improvements in mortality rates between 1972 and 1993, including:

infant mortality reduced 54%
Years Potential Life increased 54%
overall mortality reduced 42%
maternal mortality reduced 65%
gastrointestinal disease mortality reduced 75%
TB mortality rate decreased 80%

The IHS achieved these improved outcomes despite a history of significantly lower health care resource levels and several complicating factors when compared with the U.S. population overall including:

per capita expenditures for health care (i.e., estimated to be about 2/3 national level when IHS and all other funding sources are combined for AI/ANs)
availability and access to facilities and providers (e.g., less than half the physicians and nurses per capita)
utilization of health care services (e.g., 25% annual utilization of dental service for AI/ANs compared to about 60% for US population overall)
significantly higher health care needs because of poor health status (significantly higher rates of diabetes, alcoholism, injuries, oral diseases, and overall death rate)
higher costs for providing health care in isolated rural setting (loss of economies of scale)
high unemployment, poverty, substandard housing, and other recognized contributing factors to reduced health status

It has been discouraging that despite having demonstrated significant results the funding pattern has been even less favorable in recent years. Since FY 1992, the IHS has had to absorb $323 million in unfunded fixed cost increases (inflation) that has resulted in a loss of per capita funding for services that now represents almost a 20 percent loss of spending power. As a result, while overall outpatient visits have steadily increased with the population growth (about 2.1 percent growth annually), decreases have occurred in important non-urgent primary services including:

23% decline in well child services between FY 1991 and FY 1996
14% decline in physical exams between FY 1994 and FY 1996
18% reduction in people receiving dental services since between FY 1994 and FY 1996
28% reduction in water fluoridation compliance between FY 1994 and FY 1996
38% increase in denials of health care referrals between FY 1995 and FY 1996

Thus, the increasing demand for urgent care in the face of reduced per capita funding has reduced the capacity of the IHS to provide the primary services that are critical to long-term health maintenance and improvement. If this trend continues, the long-term implications for the health status of AI/AN people are alarming.

During this same time period, and particularly since FY 1993, there has been a significant transition to tribal management of health programs under Title I and III of the Self-Determination legislation. This pattern, and the accompanying decentralization of many functions, has resulted in a loss of economies of scale, particularly for the public health infrastructure. This decentralizing trend is more costly in the short-term (loss of economies of scale) and in the opposite direction of trends in the health care industry for most of the country. However, it is essential to the Self-Determination process, local ownership of health problems and capability development, and in the long-term local program effectiveness.

In light of these trends and challenges, the IHS and its diverse stakeholders have been developing alternative methods to assure more efficient health programs and administrative support to Indian communities. In January of 1995, the Director convened the Indian Health Design Team (IHDT) which was composed of 29 representatives from the primary stakeholders in Indian health care and charged with reorganizing the IHS. The IHDT, which included 22 representatives of Indian tribes and communities, submitted a report making 50 recommendations for designing a new IHS. Under their guidance, the implementation of the recommendations will be accomplished in two phases by 1998. The IHS system is being redesigned to address an era of rising health care costs, a growing population, increasing tribal management of programs, and a changing health care industry. The redesign efforts emphasize patient care; strengthening government to government relations; streamlining administration and management; quality support services to field-based health care activities; diversification of operations; facilities staffing expansion; and fair treatment of employees.

Another product of the IHDT was the refinement of the IHS Mission, Goal, and Foundation that have been revised as follows:

MISSION:
The mission of the Indian Health Service, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

GOAL:
To assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people.

FOUNDATION:
To uphold the Federal Government�s obligation to promote healthy American Indian and Alaska Native people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes.

These three fundamental charges to the IHS were then integrated into the evolving IHS component of the DHHS Strategic Plan for the Government Performance and Results Act (GPRA) to yield the following four broad IHS Strategic Objectives to guide the Agency into the next millennium:

Strategic Objective 1: Improve Health Status
To reduce mortality and morbidity rates and enhance the quality of life for the eligible American Indian and Alaska Native population.
Strategic Objective 2: Provide Health Services
To assure access to high quality comprehensive public health services (i.e., clinical, preventive, community-based, educational, etc.) provided by qualified culturally sensitive health professionals with adequate support infrastructure (i.e., facilities, support staff, equipment, supplies, training, etc.)
Strategic Objective 3: Assure Partnerships and Consultation with I/T/Us
To assure that I/T/Us, and IHS Area Offices and Headquarters achieve a mutually acceptable partnership in addressing health problems:

providing adequate opportunities for I/T/Us and American Indian and Alaska Native organizations to participate in critical functions such as policy development and budget formulation, and

assuring that I/T/Us have adequate information to make informed decisions regarding options for receiving health services.

Strategic Objective 4: Perform Core Functions and Advocacy
Consistent with the IHS Mission, Goal and Foundation, to effectively and efficiently:

advocate for the health care needs of the American Indian and Alaska Native people, and

execute the core public health and inherent Federal functions.

These Strategic Objectives are essential for the realization of our Mission, Goal, and Foundation over the next 6 years by setting the programmatic, policy, and management course for the IHS. They are also consistent with the most recognized approach to evaluating health care organizations in that they address the structure, process, and outcomes of health care delivery and they provide the conceptual and philosophical framework for the performance indicators outlined in this annual performance plan.

II. IHS Approach to Developing Performance Indicators

This IHS Annual Performance Plan and its 25 performance indicators were developed in partnership with the critical stakeholders including Headquarters, Area Office, and I/T/U staff as well as tribal representatives. Much of this process occurred through Budget Formulation/GPRA workshops held in February and March in all 12 Area settings. In these sessions stakeholders were presented with an overview of the Agency�s new decentralized approach to budget formulation and its linkage to the implementation of the GPRA. In addition, Area specific health problems were reviewed as well as the recommendations of the Baseline Measures Workgroup* and potential performance indicators were then generated and prioritized along with funding recommendations. These 12 Area priority lists were then brought together and reviewed by a workgroup which identified a relatively high level of agreement across Areas on the most significant health problems and funding priorities. The greatest disparity existed regarding what specific indicators were most appropriate to assess progress relative to the identified health problems. Through a series of consultations with tribal groups and organization and I/T/U staff, the plan evolved and was most recently revised to its current form in response to even greater proposed budget restrictions.

*The Baseline Measures Workgroup was a group of IHS and tribal health professionals, including epidemiologists and statisticians, charged with identifying the most important health related data elements for all I/T/Us to continuously or periodically monitor. Their efforts included extensive analysis of existing data sources, the appropriateness of the HP2000 objectives, and the data needs for evaluation and accreditation.

The diagram that follows was used during these training sessions to clarify the GPRA process and show that it is essentially the same as the public health approach the IHS has long followed in health planning and evaluation. The logic of this model links resources to activities or "process" (both support and direct health services) which leads to reductions in risk factors for diseases and conditions (i.e., impact) and over time results in improved health outcomes. The model also depicts how external influences such as economic status, isolation, or social norms can have powerful effects on the success of interventions, particularly in addressing lifestyle related health outcomes.

The Public Health/GPRA Approach

In light of this conceptual model, three broad categories of indicators are of relevance.

Process Indicators:

Activities

Health Services

Impact Indicators:

Patient Impact

Outcome Indicators:

Health Outcome

It is appropriate to note that general workload types of indicators such as total outpatient visits and inpatient days are not included in this performance plan because any meaningful link to the budget or health outcomes is circuitous, at best. As noted earlier, outpatient visits have grown with population growth rather than varied with level of funding. Inpatient days have been declining across the country as well as in the IHS care systems to control costs and neither of these measures correlate in an interpretable way with improved health status. However, these data will continue to be monitored and presented to the Department as part of the IHS annual accountability report because they are of significance in the context of how successful we have been in achieving our performance indicators.

The performance indicators we have represent sentinel indicators for the IHS in that they are specifically focused on the 12 most significant health problems (i.e., as identified by the I/T/Us and the Baseline Measures Workgroup) affecting AI/ANs, and/or the essential services that address them. These problems include: diabetes, obesity, cancer, heart disease, alcohol and substance abuse, family abuse and violence, injuries, dental diseases, poor living environment, mental health, tobacco use, and maternal and child health. They all represent important links in the GPRA/Public Health process directed towards outcomes. Some represent primary prevention that attempts to prevent a disease or condition before it occurs (e.g., immunizations or controlling weight to prevent heart disease or diabetes). Others are "secondary preventive" in nature in that they attempt to reduce the morbidity and mortality associated with a disease or condition after it has occurred (e.g., reducing diabetic complications). Given that there will always be ten leading causes of death, our focus is to intervene early in the processes that contribute significantly to mortality and morbidity, rather than target end point problems such as heart attacks and stroke. This is the essence of the public health approach that has resulted in the improvements in health status of AI/AN people in the face of very limited resources over the last three decades.

We have also included indicators for assessing how our consumers perceive the quality of and access to services, and how our stakeholders perceive our performance in assuring adequate consultation and advocating for the needs of AI/AN people. In addition, we have developed indicators addressing our effectiveness in building collaborative relationships with other organizations to address cross-cutting issues and meeting our obligations as an Agency in the Department.

These 25 indicators do not represent the complete spectrum of activities and challenges the Agency and the I/T/Us address as part of a comprehensive public health organization. To do so would probably require several hundred indicators and require significant increases in resources just to collect the data. Consistent with the proposed GAO guidance, these indicators are limited to a vital few, represent multiple priorities, are linked to the responsible programs, and in many cases are measures we have used for many years for program evaluation. A few are focused primarily on better defining the magnitude of certain problems and to improve our evaluation capability. These efforts are essential because many of the data for the Healthy People 2000 initiative are dated and/or incomplete. A major challenge in selecting indicators for a one-year plan is that many of the processes necessary for intervening in complex chronic diseases require years or decades of focused efforts to realize significant progress, even with significant resource enhancements. Therefore, only a few of these indicators directly address health outcomes, while most are incremental activities that will lead to such outcomes over time. In addition, several directly embrace the principles and intent of the National Performance Review (NPR) and link directly with the Secretary�s Initiatives. Lastly, virtually all health problem related indicators support the Healthy People 2000 goals for the nation and all support the Department�s Strategic Plan.

However, it is important to acknowledge that these indicators were developed in partnership with Area and I/T/U staff and AI/AN tribal leaders with the first priority being the need to reflect the problems and strategic activities of the I/T/Us collectively. We believe this approach is essential to secure the high level of buy-in we will need with our diverse and decentralized programs. Because of the diversity across I/T/Us and the freedom of tribal programs to participate in GPRA activities at their discretion, not all indicators will be of priority to all I/T/Us. Furthermore, many activities that are not included in these indicators will continue to be priorities. These activities include implementation of an improvement plan based on the results of the Acquisition Balance Scorecard survey, implementation of the Department�s Quality of Work Life initiative, and locally, many other health problems unique to I/T/Us.

III. Data Collection, Validation, and Information Resource Management

The IHS utilizes outside (non-IHS) and IHS data sources to manage its diverse programs and assess Indian health status. The two principal outside data sources are the Bureau of the Census and the Centers for Disease Control and Prevention, in particular, the National Center for Health Statistics (NCHS). The Census Bureau is the source of Indian population counts and social and economic data. However, reliable Indian census data at the county level are only available from the decennial census, every 10 years.

The NCHS provides IHS with natality and mortality files that contain all births and deaths for U.S. residents, including those identified as American Indian or Alaska Native. The NCHS obtains birth and death records from the State departments of health, based on information reported on official State birth and death certificates. The IHS receives these records with essentially the same basic demographic information as the records maintained by NCHS, but with names, addresses, and record identification numbers deleted as required by the Privacy Act. It should also be noted that tribal identity is not recorded in these records by the states except for New Mexico. The data are subject to the degree of accuracy of reporting by the States to NCHS. The NCHS does perform numerous edit checks and imputes values for non-responses. The IHS assigns IHS organizational (Area and service unit) identifiers to the birth and death records in setting up its Indian database. The IHS computer routines for accomplishing this has been thoroughly checked out, and the results are continuously monitored.

Several studies have shown that there is considerable miscoding of Indian race on death certificates that understates Indian mortality especially in areas not associated with Indian reservations. While the IHS has developed some techniques for adjusting for miscoding the chief limitations of mortality data are associated with time lags, i.e., the data are not typically available from NCHS until three years after the events occur and mortality data are slow in showing the impact of health interventions. Due to these constraints, IHS has chosen not to use mortality data for annual performance plan indicators except in special circumstances. The IHS will continue to use mortality data for tracking long-term trends in Indian health status and to make comparisons with other population groups. However, having to wait three years to link activities in an annual performance plan with mortality findings is of limited value in the ongoing implementation and evaluation process.

The IHS has its own program information systems to collect data on the services provided by IHS and tribal direct and contract programs. The software used by IHS facilities and most tribal facilities is the Resource and Patient Management System (RPMS). Data are collected for each inpatient discharge, ambulatory medical visit, and dental visit (all patient specific) and for community health service programs including health education, community health representatives, environmental health, nutrition, public health nursing, mental health and social services, and substance abuse (all activities reporting systems). The patient-specific data are collected through the Patient Care Component (PCC) of the RPMS. These data are subject to recording, inputting, and transmitting errors. However, IHS software systems have extensive edits built in at the facility and central database levels to detect and correct a large part of the errors. Others that cannot be detected by computer are often discovered through the monitoring for reasonableness that is performed in the field and IHS headquarters.

Each facility that utilizes PCC has a facility-level database that contains the detailed PCC data collected at that site. A subset of the detailed PCC data (to meet the routine information needs of IHS Headquarters) is transmitted to the IHS central database. The PCC data are the source of most of IHS� GPRA measures since they reflect prevention activities and morbidity and do not have the time lags described previously for mortality data. However, many of IHS� proposed measures rely on detailed PCC data not currently transmitted to the IHS central database. The IHS is developing software to transmit some of these needed data items to the central database. In the meantime, IHS will need to use sampling routines to collect the required data from the individual facility-level databases. In some cases, the required data for a measure may not be part of PCC or, if it is, may not be coded at some facilities. Local surveys may need to be utilized in these areas to capture the required data. The degree to which these activities will be achieved is linked to available infrastructure to address these demands, which in turn is determined by budgets and the many competing priorities.

IV. Aggregation of Program Activities

Program activities within the IHS can be organized in several different ways. Since our goal in presenting our performance measures is to relate performance to our budget, we must communicate the way our programs are managed. The four categories we have chosen are Treatment, Prevention, Capital Programming/Infrastructure, and Consultation, Partnerships, Core Functions, and Advocacy. It is important to realize that there is no aggregation or disaggregation that allows mutually exclusive activities linked to mutually exclusive health problems. This conundrum exists because addressing most chronic diseases and problems such as injuries and family violence, require multidisciplinary interventions to successfully address. In such cases, there many be several health programs (and thus funding categories) simultaneously addressing the same problem (e.g., diabetes) and others (e.g., exercise, diet, tobacco use).

Thus, there is no aggregation of budget categories that can split out activities and funding sources that allow valid cost accounting linked to health outcomes for these. In such cases, the accounting link can go no farther than services. A manufacturing type of accounting mindset taken to an extreme simply does not fit well in the context of a comprehensive public health program. Therefore, the aggregations we have selected are reasonable given the limitations of any approach. There is no priority order to these categories and all are important in accomplishing the mission of the IHS. Table I that follows shows the relationship between the IHS Detail of Change Table, the appendix of the budget of the U.S., and our GPRA aggregation.

Table I

INDIAN HEALTH SERVICE Detail of Change Table		APPENDIX Budget of the United States		GPRA AGGREGATION Program Activities
SERVICES:		SERVICES:
1	Hospitals & Health Clinics
2	Dental Services			1	Treatment (1,2,3,4,5,10,11,12,14,15,24)
3	Mental Health
4	Alcohol & Substance Abuse			2	Prevention (6,7,8,9,21,22)
5	Contract Health Services
	Total, Clinical Services	1	Clinical Services (1-5)	3	Capital Programming/Infrastructure (16-23)
6	Public Health Nursing
7	Health Education			4	Partnerships, Consultation, Core Functions, and Advocacy (13,20,21,22)
8	Comm. Health Reps
9	Immunization AK
	Total, Prev Hlth	2	Preventive Health (6-9)
10	Urban Health	3	Urban Health (10)
11	Indian Health Professions	4	Indian Health Professions (11)
12	Tribal management	5	Tribal management (12)
13	Direct Operations	6	Direct Operations (13)
14	Self Governance	7	Self Governance (14)
15	Contract Support Costs	8	Contract Support Costs (15,24)
	Total, Services		Total, Services
FACILITIES:		FACILITIES:
16		9	Maint. & Improvement (16)
	Sanitation Facilities
17	New/Renovated
18	Existing
	Total, Sanitation
19	Hlth Care Facs. Constr.	10	Hlth Care Facs. Constr. (17-19)
	Facil. & Envir. Hlth Sup	11	Facil. & Envir. Hlth Sup (20-22)
20	Fac. Support
21	Env. Health Support
22	OEHE Support
	Total, F&EHS
23	Equipment	12	Equipment (23)
24	Contract Support Costs
	Total, Facilities		Total, Facilities
(24) Total, IHS		(12) Total, IHS		(4) Total, IHS

V. Effect of Budget Level on Performance Plan

This performance plan is based on the President�s budget request to Congress. At this funding level it is anticipated that the performance indicators can be accomplished with the existing IHS staffing level and without additional FTEs. Most of the program increases will be administered through grants to I/T/Us.

The ability of the IHS to achieve its performance indicators is linked to its capacity to provide clinical and preventive services as well as the infrastructure needed to support these services. However, the proposed President�s budget will not support the current level of services. In essence, this performance plan is a strategic attempt to minimize the impact of a continued loss of services that are unavoidable given the significant loss of spending power the IHS continues to experience. Therefore, many of the performance indicators are directed towards slowing the decline in services and minimizing the negative impact of this loss on health status. We are compelled to acknowledge that given this proposed budget, progress in many of the Healthy People 2000 objectives will be stalled and several health measures will likely worsen.

Thus, a budget below this proposed level will further weaken our public health infrastructure and diminish the level of achievement of many of these indicators related to providing services and/or health impact and outcome measures. The net result over time would be even greater increases in mortality and morbidity rates for the AI/AN people.

VI. Performance Indicators

A. Treatment Indicators:

Indicator 1: To establish Area age-specific diabetes prevalence rates for the AI/AN population by the end of FY 1999.

Rationale: Diabetes continues to be a growing problem in many AI/AN communities with rates increasing rapidly in several Areas and with no signs of decline in any Area. The impact of this disease in terms of individual and family suffering is immense as is the treatment costs to the Indian health delivery systems. Establishment of true prevalence indicators will allow the Agency and I/T/Us to target reductions of the prevalence particularly in younger age groups in future budget submissions. This indicator addresses HP 2000 objective 17.11 (diabetes: incidence and prevalence).

Approach: The IHS Office of Public Health is responsible for overall coordination of efforts to achieve this indicator. The IHS Diabetes Program estimates diabetes prevalence of diagnosed diabetes in Native Americans seeking care in I/T/U facilities. Rates are calculated based upon PCC/RPMS data, and are reported by geographic Area, gender, and age groups for adults. Longitudinal studies of diabetes conducted in Pima Indians since 1965 have provided extensive information on the prevalence and incidence of diabetes in this tribal community. There are several other tribal-specific diabetes epidemiological studies, none to the depth of the Pima studies, and covering fewer than 10% of tribes. There are no published studies on the growing problem of type II diabetes in American Indian youth, though there is extensive recognition by I/T/U providers that the age of diabetes onset is declining to younger adults and children.

Local/tribal facilities can assess diabetes prevalence by using PCC registries and /or diabetes case registries; deriving baseline measures for their tribal communities.

A recent Navajo Health and Nutrition Survey conducted in the Navajo Nation indicates significant underreporting of the prevalence of diabetes (personal communication, M. Glass, MD) indicating a need for aggressive community-wide diabetes screening to detect diabetes at earliest stages. The PCC underreports diabetes prevalence by using clinically diagnosed diabetes as the case definition.

To obtain accurate diabetes prevalence data on AI/AN by tribal group, geographic area, age groups, and gender, it will be necessary to systematically survey the extent and change in the diabetes epidemic, by adding periodic diabetes screenings of the population. Diabetes prevalence information will then be disseminated to I/T/U's , other DHHS agencies, Universities, and private foundations for use in identifying prevention strategies and resources.

Data Source: RPMS/PCC, Diabetes Registries, I/T/U National Diabetes Survey

Baseline: The IHS PCC and local diabetes registries are used now in all areas to determine clinically diagnosed diabetes prevalence rates. These rates will serve as the baseline and/or tribal-specific prevalence studies in selected tribes.

Type of Indicator: Process

Indicator 2: By the end of FY 1999, reduce the incidence of amputation and blindness associated with diabetic neuropathy and retinopathy by 5% in the AI/AN diabetic population from the FY 1996 rate.

Rationale: These two complications of diabetes represent considerable morbidity and compromises to the quality of life of the AI/AN population and require considerable resources to address when they occur. Diabetes case management to identify and track high-risk patients, reduce modifiable risk factors (such as protective footwear and laser treatment for diabetic retinopathy), provide culture specific client education, and improve access to care, have been proven to be effective in national studies. The IHS Diabetes Program's promotion efforts at I/T/U facilities to promote use of minimum standards of diabetes care, and Staged Diabetes Management guidelines for care have also demonstrated positive outcomes. This indicator specifically addresses HP 2000 objective 17.10 (diabetes related complications).

Approach: The IHS Diabetes Program systems interventions have been effective in significantly reducing the incidence of amputation in Chippewa Indians and Alaska Natives, using simple monofilament testing of sensation, culture sensitive diabetes self-management education, and foot checks by providers at each diabetes clinic visit. Resources needed to expand this successful work include the availability of staff with training to disseminate the methods/approaches to local I/T/U health providers nationwide. Resources include access to specialized tools such as monofilament screening devices and custom footwear.

Detailed studies of the incidence and risk factors for retinopathy have been reported for the Pima, the Sioux/Lakota, and several tribes in Oklahoma. The IHS Diabetes Program has assembled a Diabetes Eye Care Workgroup and funded a pilot study to develop a model for comprehensive risk management of diabetic retinopathy in FY 97 in AI/AN communities/facilities. Resources needed are access to routine retinal screening provided by trained optometric and opthalmologic providers, retinal cameras and laser equipment, epidemiology support, and training of primary care providers to refer all diabetic patients annually for a retinal exam for retinopathy screening. Aggressive glycemic and blood pressure control is urgently needed to reduce the high rates in the AI/AN population, and annual eye examinations to detect and treat diabetic retinopathy will be emphasized. Such interventions will allow early diagnosis and treatment, thereby preserving vision and preventing blindness.

Data Source: RPMS/PCC, Diabetes Registry, Contract Care Reports (external contractors providing laser treatments).

Baseline: Prevalence rates of diabetic retinopathy in type II diabetes populations range from 45% in Sioux, to 18% in Pima Indians.

Type of Indicator: Outcome

Indicator 3: Establish the incidence of cancer of the uterine cervix in AI/AN women for each Area by the end of FY 1999.

Definition: Invasive cancer of the uterine cervix, pathology confirmed, occurring in AI/AN women of any age, who reside in counties included in the IHS Area. Denominator: all AI/AN women who reside in counties included in that IHS Area, from U.S. census.

Rationale: This indicator is selected because cervical cancer occurs at much higher rates among AI/AN women than in the general U.S. population. Furthermore, this cancer is the cause of significant premature mortality, and is almost entirely preventable by thorough PAP screening and early treatment of pre-cancerous conditions. After systems are in place to accurately measure the incidence of cervical cancer, Area Directors will be able to establish reasonable and achievable goals for reduction in the incidence rate. The long-range goal should be to achieve parity with the U.S. all-races rate. This may be attainable within 10 years. This indicator directly supports the HP 2000 objective 16.4 (cervical cancer deaths).

Approach:The IHS Office of Public Health is responsible for overall coordination of efforts to achieve this indicator. The IHS Epidemiology Centers will be active participants in the process. Linkages with CDC, NCI, and some State and university sources are critical to success in meeting this indicator.

Some Areas have access to reliable cancer registries, which can supply the needed information. Most Areas will have to piece together their cancer cases from a combination of PCC/RPMS, CHS, and State Cancer Registry data. As the Women's Health Software component of the PCC becomes more universally available, this will provide easier access to this data from the IHS system. To obtain a complete count, it may be necessary to establish computer matches between State Cancer Registries and IHS Patient Registration tapes.

Cancer incidence information will then be disseminated to I/T/U�s, other DHHS components, universities, and private foundations for utilization in identifying prevention strategies and resources that can be employed most effectively to prevent and treat this disease.

The collaborative relationships and data systems that are established in meeting this indicator will be helpful for determining the incidence of other cancers, and could form the foundation for an aggregate Native Cancer Registry.

Data Source: RPMS/PCC; State and local Cancer Registries; NCI SEER data.

Baseline: Albuquerque, Alaska, Billings, and Navajo Areas have the capability to determine these rates now. The other Areas need to develop systems for getting this data.

Type of Indicator: Process

Indicator 4: By the end of FY 1999, assure that the proportion of the AI/AN female population over 40 years of age who have had screening mammography is no lower than the FY 1996 level.

Definition: The percentage of AI/AN women over age 40, registered for care with IHS, who have had a mammogram during the previous two years. Denominator: all AI/AN women over age 40, who are registered for care with IHS.

Rationale: Mammography has been associated with both reduced mortality and morbidity because breast cancer is identified at earlier stages. Early identification allows for early clinical intervention and secondary prevention of morbidity and mortality. This indicator directly supports HP 2000 objective 16.3 (female breast cancer deaths).

Approach: Local I/T/U service sites are responsible for delivering the screening. Regional coordination and assistance is the responsibility of the IHS Area offices. The overall coordination of this effort is performed by the IHS Office of Public Health. Linkages with NIH, CDC, and the American College of OB/GYN are critical to success. The number of women receiving mammograms will be a composite of CDC program mammograms, IHS direct services data, CHS figures, and Urban Clinic data. As the Women's Health Software component of the PCC is implemented, adequate data will be available from that source.

The strategic approach includes outreach to improve patient access and the availability of specialized staff and equipment to perform the screening. The staff required are public health nurses, Community Health Representatives, and health educators to improve outreach, and specialized clinical providers (nursing, physician, and imaging staff) to provide the actual clinical breast exams and mammograms. The availability of screening must also be associated with the capability to provide diagnostic studies such as ultrasound, biopsy, and fine needle aspiration, as well as treatment such as surgery and chemotherapy.

The successful reduction of premature deaths and morbidity among AI/AN women will depend on full implementation of effective screening and follow up clinical services. This indicator is linked to success in meeting Strategic Objectives one, two, and four of the Agency�s component of the DHHS Strategic Plan.

Data Sources: RPMS/ PCC/WHS (Women's Health Software), Assessment of IHS Diabetes Care (chart audit includes mammogram and CBE history), IHS Medical Imaging Program, and CDC NBCCEDP (National Breast and Cervical Cancer Early Detection Program).

Baseline: Based on FY 1996 Assessment of IHS Diabetes Care, 26% of the female diabetic user population met the ACS recommendation for Mammography (Areas ranged from 13-57%). 50% of the female diabetic population had ever had a Mammogram (Areas range from 34-80%). 25,590 mammograms were performed by IHS in FY 1995 (per IHS Medical Imaging Program).

Type of Indicator: Impact

Indicator 5: By the end of FY 1999, assure that the percentage of children age 0-5 receiving well child visits is no lower than the FY 1996 level.

Rationale: Well child visits have been associated with improved post-neonatal mortality and opportunities to improve family health and safety in the longer term. Of particular importance are the anticipatory educational interventions given to parents concerning diet and nutrition, injury prevention, and prevention of family violence. However, under the growing demands for urgent care and without expansion of service capacity, these services appear to have been in a gradual decline since 1991 despite an expansion in the service population. This indicator directly supports the Secretary�s Children�s Health Initiative in enhancing access to essential services and broadly supports the HP 2000 objectives addressing "Maternal and Child Health."

Approach: The responsible parties are the local I/T/U service sites. The IHS Area offices can provide assistance in development and coordination of media campaigns and analysis of information and they are responsible for regional coordination of this effort. The IHS Office of Public Health is responsible for overall coordination of the effort. Linkages with the USDA-WIC program and the DHHS Head Start program are also critical.

The strategies for success are rooted in effective outreach and management of clinic scheduling for service provision. The outreach activity is dependent upon parent education to assure their awareness of the importance of routine and periodic assessment of well children. Secondly, the effective identification of children in the targeted age groups is important. Public health nursing, Community Health Representatives, Head Start programs, and parent groups have important roles in identifying children and families who are the target of this intervention.

Clinical care is dependent upon the availability of trained nursing and physician staff with the time to address this objective. Scheduling and follow up of these children and their families is critical. The cooperation of medical records staff and others in the clinical environment is essential.

Achievement of effective well-child health care is critical to the prevention of childhood obesity, injuries, and family dysfunction. This objective is also consistent with the Secretary�s Initiative on Improving the Health of Children. Achievement of this indicator will significantly influence the Agency�s success in meeting Strategic Objectives one, two, and three of the Agency�s component of the DHHS Strategic Plan.

Data Source: RPMS/PCC

Baseline: Estimated to be (FY 1995) 606 out patient visits per 1000 user pop (0-5 years).

Type of Indicator: Process

Indicator 6: By the end of FY 1999, increase follow-up for youth discharged from adolescent Regional Treatment Centers (RTC) to 75%.

Rationale:Studies indicate that the longer individuals are engaged in treatment (including aftercare/continuing care) the better the prognosis. One RTC evaluation concluded "aftercare is the biggest problem" with limited coordination among RTC, service units and local aftercare programs retarding the effective and efficient delivery of treatment services. This indicator directly supports several HP 2000 "Substance Abuse: Alcohol and Other Drugs" objectives.

Approach:The Division of Clinical and Preventive Services, Office of Public Health will be responsible for coordinating data collection from the Adolescent Regional Treatment Centers who are the responsible parties.

The Alcoholism and Substance Abuse Program will develop an ongoing evaluation instrument in consultation with the RTC via a contract with FY 1997 resources. The evaluation process should be implemented in FY 1998. The evaluation will include follow-up information that will be reported to program staff and compiled for tracking this indicator.

In addition, those RTC utilizing the RPMS Chemical Dependency Management Information System (CDMIS) and the RPMS Mental Health/Social Service (MH/SS) packages, routinely collect follow-up information which can be exported for national reporting purposes. Aftercare services (for those utilizing CDMIS) occurring at local sites will also provide additional data to support tracking of this indicator.

Findings from the CATOR adolescent study indicate that youth engaged in aftercare/follow up activities had better sobriety rates than those who did not. Although one year follow-up information was limited in the IHS RTC Evaluation completed in FY 1997, data did suggest that youth who completed treatment and were involved in continuing care and follow up services maintained higher sobriety rates.

Data Source: CDMIS (IHS Alcoholism and Substance Abuse component of RPMS) and RTC Evaluation System to be implemented in Fiscal Year 1998.

Baseline: RTC Evaluation completed in 1997 indicated follow-up of only 50% of youth admitted between January 1993 and May 1995.

Type of Indicator: Process/Impact

Indicator 7: By the end of FY 1999, 75% of I/T/U prenatal clinics will be utilizing screening and case management protocols for pregnant substance using women.

Rationale: Surveillance conducted at 2 IHS Areas indicated Fetal Alcohol Syndrome (FAS) rates exceed general population rates (2.3 and 2.7/1000 live births vs. 0.6/1000 live births approximately). The Institute of Medicine 1996 report on FAS includes case identification and appropriate intervention and treatment of maternal alcohol abuse as a critical part of FAS prevention. This indicator directly supports HP 2000 objective 14.4.

Approach: The I/T/Us will be responsible for reporting via survey to be conducted by the Division of Clinical and Preventive Services implementation of protocols. Resources for analysis may be required from other divisions within the Office of Public Health.

The maternal Substance Abuse Questionnaire (SAQ), a screening instrument, was developed in the Aberdeen IHS Area with the Center for Disease Control and Prevention. A curriculum for utilizing the instrument in prenatal clinics and developing case management systems has been piloted in that Area and will in FY 1997 be piloted in four new Areas with IHS Headquarters resources. This screening instrument is one of several which are being encouraged for use in I/T/U to assure routine prenatal substance abuse screening and case management tailored to the resources of each site. A baseline will be established via survey in 1998 and repeated in 1999. A new prenatal package of PCC is being piloted in the Alaska Area; its ability to capture screening and case management information is still being explored.

Data Source: Survey and possibly RPMS Pre-natal application by 1998.

Baseline:To be defined in FY 1998.

Type of Indicator: Process

Indicator 8: Assure that during FY 1999, at least 22% of the AI/AN population obtain access to dental services.

Rationale: Available evidence supports that people who utilize dental services annually have improved oral health status compared to those who do not. Unfortunately, the growing AI/AN population has resulted in growing demands for dental care without growth in capacity to provide needed services. This problem has been compounded over the last two years with the enactment of two significant pay raises for Commissioned Corps dentists which the IHS has not received additional funding to support and has resulted in higher lapsed position rates for dental officers. As a result, since FY 1994 there has been a reduction in the percent of the AI/AN population annually receiving dental services and this trend may be irreversible for the near future. The long-term effects of this pattern are likely to be a worsening of the oral health status of AI/AN people, and significant personal suffering. Restoring access to both primary and secondary treatment and preventive services can lessen the disease progression. Improving access and thus increasing utilization of dental services can also result in less costly care, improved oral health status, and quality of life. However, funding constraints are at such a level that slowing the decline in utilization of dental services is the best that is possible. This indicator relates to the HP 2000 objectives 13.12 (oral screening, referral and follow-up: children) and 13.14 (regular dental visits: adults).

Approach: Providing access to care is directly dependent upon the dental care resources in a community which include adequate numbers of dental providers and facilities, and their efficiency in providing services. Strategies for increasing care and its effectiveness in light of fewer resources include improving access for targeted populations, (i.e., school-age children, diabetics or other special target groups), utilizing third party payers, and identifying Medicaid-eligible families which would result in increased resources to hire additional staff needed to provide direct services in local communities. The IHS Dental Program has also developed a training module for less experienced dental staff to enhance clinical efficiency. The dental program has been able to track patients who access the system through the dental exam and first visit codes through the RPMS as a valid proxy measure of utilization.

Data Source:IHS Dental Data System component of the RPMS.

Baseline: FY 1995 = 23%

Type of Indicator: Process

Indicator 9: By the end of FY 1999, assure that the percentage of AI/AN children 8-14 years who have received protective dental sealants on permanent molar teeth is no lower than 95% of the FY 1994 level.

Rationale: Dental sealants are an effective measure for reducing dental decay rates in children and can be effectively applied by dental auxiliaries at relatively low cost. Sealants and fluorides can prevent almost all tooth decay and play a role similar to vaccinations. Because surveys of AI/AN children�s oral health status have consistently identified significantly higher decay rates than the U.S. general population, sealants are essential to reducing the ravages and costs of treating dental decay. The IHS Dental Program is one of the few dental programs in the nation to have achieved the HP 1990 and 2000 dental sealant objectives, but sealant coverage has decline since FY 1994 because of resource constraints. Thus this indicator directly supports HP 2000 objective 13.8 (protective sealants: 14 year olds).

Approach: Local dental clinics are responsible for implementing/maintaining effective and efficient sealant programs that are either school-based or school-linked and targeted for children ages 6-14 years (to coincide with the eruption of first and second permanent molar teeth). Use of the 4373 procedure code, which was created specifically to measure use of sealants in school-age children, will enable local programs to track progress in meeting this objective. The Dental Data Software package in the RPMS environment can capture the number of children examined and the number of children who receive dental sealants on a quarterly and annual basis and document trends. Resources required to meet this objective include funding to purchase portable equipment for school-based sealant programs, materials for sealant application, and dental staff.

Data Source: IHS Dental Data System component of the RPMS.

Baseline: Estimates of FY 1994 sealant coverage are 60% for children 6-8 years and 65% for those 14-15 years.

Type of Indicator: Impact

Indicator 10: By the end of FY 1999, 70% of I/T/U medical facilities with Urgent Care or Emergency departments or services will have written policies and procedures for routinely identifying, treating and/or referring victims of family violence, abuse or neglect (i.e., child, spouse, and/or elderly).

Rationale: Family violence victims come to the health care system with a variety of physical injuries, illnesses or medical conditions directly related to abuse. The umbrella of family violence includes child, spouse or elder abuse and/or neglect. Experts in the field of family violence have identified an important link between violence against women and the abuse of their children. Research indicates that children who witness violence in the family are affected in the same way as children who are physically and sexually abused (Goodman and Rosenberg, 1987). The propensity for family violence can extend to older members of the family (parents, grandparents, aunts, uncles) living in the home. The consequences of family violence can be seen in physical, psychological and cognitive results such as intentional and unintentional injuries, detachment, avoidance, depression, and suicidal ideation. This indicator supports several of the HP 2000 "Violent and Abusive Behavior" objectives.

Approach:The Mental Health and Social Service program will work with IHS Area Offices to assure that staff are appropriately trained and local policies and procedures are established for these health concerns. Tribal and urban programs will also be encouraged to address these areas and IHS will respond to requests for assistance. Existing funds and staff will be utilized. Achievement of the indicator will assure local identification of family violence and that appropriate services for prevention and treatment of family violence, and its sequelae, are received by AI/AN victims, families and communities.

Data Source: Annual survey and/or progress review by IHS Area and Headquarters staff.

Baseline: To be determined in FY 1998.

Type of Indicator: Process

Indicator 11: By the end of FY 1999, 75% of the IHS programs will have implemented the use of the Mental Health/Social Services (MH/SS) data reporting system.

Rationale: The implementation of the MH/SS data reporting system will provide the vehicle for collection of baseline morbidity and services data for IHS. Audits of the existing I/T/U data systems have documented both under-reporting and lack of specificity of mental health related conditions reported and services provided.

Approach: Accomplishment of this indicator is contingent on several factors. The implementation of the RPMS data system should be mandatory and a priority within the IHS service system. Responsibility for the maintenance of the data system will be shared by the MH/SS program and Division of Information Resources, to assure clinical, technical and administrative viability. Achievement of the indicator will allow consistent reporting, data aggregation for planning, managed care, and more effective billing and collection for services. This objective is also essential for monitoring many of the HP 2000 objectives addressing "Mental Health and Mental Disorders."

Data Source: MH/SS component of RPMS.

Baseline: FY 1997 estimate of IHS program usage of MH/SS system is 35-40%.

Type of Indicator: Process

Indicator 12: By the end of FY 1999, develop and implement an information system which captures health status and patient care data for all Urban health care programs.

Rationale: Adequate health status and health services data are essential for the effective planning and management of any health care delivery system. Currently Urban Indian health programs capture data under the Urban Common Reporting Requirements (UCRR). These data are not currently compatible with other IHS health services data sets and only of limited use for the purpose of health systems management. Thus, the large urban AI/AN population has been minimally represented in AI/AN data sets. This indicator directly supports the HP 2000 objective 22.3 (comparable data collection procedures).

Approach: A workgroup has been formed, comprised of Urban Programs health directors to review and revise the UCRR. The revised UCRR will capture an expanded set of data which are compatible with the IHS RPMS System, as well as provide local urban program managers better information about the health status and health services provided to their clients. Until a comprehensive needs assessment is completed it is difficult to estimate the resource requirements of this project; however, attempts will be made to, where feasible, avail the IHS RPMS system to urban programs so that systems are not duplicated. This indicator was developed to help monitor successful development of thenupdated urban data reporting system.

Data Source: Self-report of Urban health programs.

Baseline: To be established by the end of FY 1999.

Type of Indicator: Process

Indicator 13: Maintain 100% accreditation of all IHS hospitals and outpatient clinics during FY 1999.

Rationale:The accreditation of IHS hospitals and clinics represents perhaps the most objective and respected measure of health care quality. In addition, accreditation is essential for maximizing third-party collections, and contributes directly and indirectly to many other indicators presented in this plan.

Approach: The local I/T/U multidisciplinary team approach to accreditation and ongoing quality management has been the mainstay of success in this important activity. Additional support and guidance from Areas and Headquarters staff will continue to support this indicator. This will be one of the most demanding indicators to meet given the proposed funding levels available to support the backlog of health facilities maintenance, improvement, and renovation that is critical to accreditation.

Data Source:IHS compiled database generated form accreditation reports.

Baseline: 100% accreditation of IHS hospitals and outpatient clinics for FY 1996-97.

Type of Indicator: Process

Indicator 14: Implement IHS-wide consumer satisfaction survey protocol to assess acceptability and accessibility of health care and establish baseline by the end of FY 1999.

Rationale: Assessing consumer satisfaction is fundamental to quality management and required for accreditation of hospitals and clinics. Furthermore, it is essential to meeting the President�s Executive Order on "Setting Customer Service Standards" and the Secretary�s initiative on improving the quality of health services. Securing OMB clearance for a comprehensive, pretested, culturally sensitive survey instrument will allow more frequent and sensitive assessments essential for improving services to AI/AN people.

Approach: The responsible parties are the local I/T/U service sites with assistance from the IHS Area office staff. In addition, IHS Office of Public Health will provide assistance in achieving OMB approval/clearance of a survey instrument (or instruments). The strategy will be to survey patients (clients) in a sampling format to assess their views on various aspects of the services delivered by the I/T/U�s, the manner in which the services were delivered, and provide the opportunity for offering suggestions for change or improvement. The information gathered will be analyzed and various local, Area-wide, or national policies or procedures will be considered for revision based on the findings.

There will be a need for staff to coordinate the development and implementation of such a survey both locally and, to a small degree, on an aggregate basis. The local staff would be part of the local quality assurance program and the aggregate staff would be part of the IHS epidemiology centers/program. Various other costs associated with this effort would include printing, software, and data processing services.

Continued responsiveness to the patients and the AI/AN communities will be dependent (in part) on the achievement of this target. This indicator is linked to the successful achievement of Strategic Objective number two in the Agency�s component of the DHHS Strategic Plan.

Data Source: IHS Consumer Satisfaction Survey.

Baseline: To be established by the end of FY 1999.

Type of Indicator: Process

B. Prevention Indicators:

Indicator 15: Assure overall childhood immunization rates of 80% complete and on time for children ages two and three, by the end of FY 1999.

Rationale: Immunizations are one of the most cost-effective public health measures available for improving health outcomes in children. In addition, vaccination coverage rates are a sensitive measure of the status of public health services and are essential in supporting the Secretary�s children�s initiative. This indicator also directly supports the HP 2000 "Immunizations and Infectious Disease" objectives.

Approach: Vaccination coverage rates will be calculated for a representative sample of IHS service population children who turned three years old during the fiscal year, and who have received the following immunizations:

Three polio vaccinations (IPV or OPV or a combination) by the second birthday

Four DTP or DTaP vaccinations (or an initial DTP or DTaP followed by at least three DTP, DTaP, and/or DT) by the second birthday

One MMR between the first and second birthdays

At least one Hemophilus influenzae type b (HIB) vaccination between the first and second birthdays

Three hepatitis B vaccinations by the second birthday

Two or three hepatitis A vaccinations (depending on the formulation) by the third birthday

A combined coverage rate including children who have received all of the immunizations listed above

These rates are to be collected and calculated by Service Unit, Area, and Headquarters personnel for a sample to be determined by the Epidemiology Program and the Immunization Program at Headquarters.

Data Source: IHS patient care records and public health nursing records.

Baseline: Varies by location, between 55% to 95%, no reliable national figure.

Type of Indicator: Impact

Indicator 16: By the end of FY 1999, reduce deaths by unintentional injuries for AI/AN people to no more than 110 per 100,000 people.

Rationale: Injuries are second only to childbirth as a leading cause of hospitalization for AI/AN people. Annually, forty six percent (46%) of the Years of Potential Life Lost (YPLL) for AI/AN people are the result of injuries. This objective specifically addresses the HP 2000 objective 9.1 (unintentional injury deaths).

Approach: The IHS has assigned a Principal Injury Prevention Consultant, in the Office of Public Health, at Headquarters who coordinates activities and resources with specially trained Injury Prevention Specialists at the Area and District level. This program employs a community empowerment model based upon Dr. John Farquar�s work at Stanford University (1985). Primary program emphasis is directed to building the capacity of tribes to recognize severe injury problems and employ multiple strategies to prevent or otherwise control injury outcomes. The Complete Injury Prevention Program model developed by IHS is the cornerstone of community-based intervention measures.

The IHS Five Year Injury Prevention Strategic Plan identified the need for tribal and Federal infrastructure in injury prevention. Since 1990, Congress has appropriated more than $3.5 million to injury prevention programs and competitively based intervention projects.

Most of the unintentional injury problem is related to motor vehicle crashes. Significant improvements can be made in these statistics with increase in use of occupant protection measures and decrease in use of alcohol. These injury measures are identified in the Year 2000 Objectives and are relatively easy to measure.

Data Source: Data systems that currently exist to track the identified objectives include hospital discharge and mortality statistics from the National Center for Health Statistics.

Baseline: Age-adjusted baseline: estimated to be 115 per 100,000 in 1992-1994 for AI/AN population on or near reservations. Note: This is significantly higher than the HP 2000 baseline which is based on all AI/AN rates.

Type of Indicator: Outcome

Indicator 17: By the end of FY 1999, halt the continued increase of obesity in AI/AN children age 0-4 at the FY 1998 rate.

Rationale: Obesity is prevalent among AI/AN people of all ages and is an important risk factor for cardiovascular disease and diabetes. Evidence supports that obese children are more likely to become obese adults and that obesity prevention programs may be more effective than weight-reduction programs. The effectiveness of nutritional counseling in changing the dietary habits of patients has been demonstrated. Well child visits including anticipatory guidance in maintaining breastfeeding and a healthy diet will have a positive impact on pre-school obesity rates. Pima Indian studies have shown that breastfeeding for at least two months is a diabetes prevention strategy for women and their infants. Ongoing periodic surveillance of school aged heights and weights will continue to monitor overweight prevalence in older children. The 6-year NIH-sponsored Pathways obesity prevention intervention in third and fifth grade students, which begins in FY 1997, may suggest large-scale interventions for school children. The recently released Surgeon General�s Report on Physical Fitness outlines additional intervention strategies for reducing obesity. This objective directly supports the HP 2000 objectives addressing "Nutrition" and "Physical Activity and Fitness."

Approach: The responsible parties are the local I/T/U and WIC service sites. The IHS Area and USDA Regional offices can provide assistance in development and coordination of media campaigns. The IHS Office of Public Health is responsible for overall coordination of the effort. The linkages with the USDA-WIC program, the USDA, the DHHS Head Start program, and CDC Nutrition and Physical Activity Division are critical. This objective is linked to Indicator 5, assurance of well child visits.

The strategies for success require effective outreach and management of clinic scheduling and coordination of WIC and well child care services and intensive medical nutrition therapy (MNT) for families of obese preschool children. Policies and procedures for referral from the brief WIC or well-child visit to the I/T/U registered dietitian for more frequent and long-term MNT visits are critical to achieve this objective. The outreach activity is dependent upon parent education to assure that they are aware of the importance of routine and periodic assessment of well children. Secondly, the effective identification of children in the targeted age groups is important. Public health nutrition, public health nursing, Community Health Representatives, WIC, and Head Start programs, and parent groups are important components in identifying children and families who are the target of this intervention. Coordination of maternal and child health clinical care, community activities, and community involvement are critical to prevent childhood obesity.

Providing MNT to prevent obesity is dependent upon the availability of trained nutrition staff with the time to address this objective. Scheduling and frequent follow up of these children and their families is critical. The cooperation of physicians, nursing, and medical records staff and others in the clinical environment is critical. Adequate funding to assure the availability of these staff in sufficient numbers is critical to assuring the desired outcome. Assurance of maximal enrollment of eligible children in third party insurance programs will also facilitate achievement of this target for this group.

Coordination between the Pediatric Surveillance System managers at the CDC Nutrition and Physical Activity Division and the IHS Office of Public Health is critical for data access and analysis of the IHS Service Area data subset. This objective is also consistent with the Secretary�s Initiative on Improving the Health of Children.

Data Source: CDC Pediatric Nutrition Surveillance System (PDNSS)

Baseline: To be determined in FY 1998.

Type of Indicator: Impact

Indicator 18: By the end of FY 1999, compile Area specific baseline databases for assessing substance abuse (particularly alcohol and tobacco), family abuse, and high-risk behaviors in AI/AN youth from Youth Risk Behavior Surveys (YRBS) collected by State education departments and the BIA.

Rationale: The abuse of substances in youth is associated with adverse impacts both during youth and in later adult life. This includes the association of alcohol abuse with motor vehicle accidents and other preventable deaths associated with injury (including self-inflicted) and the association of tobacco abuse in youth with early onset of heart disease, lung cancer and other preventable chronic diseases. Establishment of baselines will focus local and regional efforts to those problems of highest frequency in the youth of those locales.

Approach: The coordination of this effort will be managed nationally by the Office of Public Health. The implementation of the YRBS will be a joint effort involving, CDC, BIA, and the Department of Education nationally. At the regional level, coordination will be accomplished by the IHS Area Offices in partnership with tribes, urban organizations, and local school officials.

The strategy is to implement the YRBS on a routine and periodic basis in a representative sample of schools with significant AI/AN populations. This will involve outreach to local tribal and urban leadership (elected officials, health boards, governing boards, parents groups) and to local school districts to assure interest and participation. Local and Area IRB approval will be critical. The YRBS would be administered and data analysis conducted by IHS Epidemiology Centers, CDC, and other sources. This information will be disseminated back to the local and regional parties for development of appropriate policies and intervention programs.

Resources needed include the staff necessary to perform outreach and information sharing with the local leadership and schools. Specialized staff for analysis and organization of the findings will be necessary. Ultimately, staff for school health curriculum and other community based prevention efforts will be required to act on the findings.

The findings of this indicator are critical to the health of the youth of AI/AN communities both in the contemporary environment and in the future frequency of diseases that will affect the communities. Strategies number one and number four in the Agency�s component of the DHHS Strategic Plan will be impacted by this indicator, as will many of the HP 2000 objectives.

Baseline: To be established by the end of FY 1999 with comparative analyses with data collected in 1988.

Type of Indicator: Process

C. Capital Programming/Infrastructure Indicators:

Indicator 19: By the end of FY 1999, maintain the net backlog of maintenance, improvement, and renovation needs for health care facilities at the FY 1997 level.

Rationale: The provision of quality health services requires effective and efficient space, including reliable supporting building systems. This activity is also fundamental to maintaining hospital and clinic accreditation (see indicator 13). Given available funding, maintaining the status quo will be difficult but critical to work towards.

Approach: This initiative is part of an IHS effort to more accurately determine the resources and processes required to sustain physical surroundings which enhance the delivery of health care services. This includes maintaining both IHS and tribal health facilities in good working order, eliminating environmental and safety hazards, and modifying space as needed to facilitate changing service delivery practices.

The physical condition of IHS-operated, federally-owned and tribally owned health care facilities is evaluated continuously by local facility personnel and through annual general surveys conducted by local facility personnel and IHS Area Office engineers. In addition, comprehensive "Deep Look" surveys are conducted every five years by a team of specialists, which may include IHS and tribal engineers, architects, and operations experts, and occasionally technical specialists from private sector architectural/engineering firms.

A major facet of this initiative is an improvement of the data system in which identified facilities deficiencies are listed. The revised system will move input and querying of data to a lower level, Area Office and/or field sites, so the information may be used to support and improve decision making at those levels. Additional capabilities will be added to show the impact of new facilities on access to services. In a similar fashion, the IHS is seeking to determine the impact of new deficiencies that accrue normally in existing buildings. Another planned improvement would be a separate identification of space and renovation needs to adequately support and enhance delivery of health care services. Finally, capturing of expenditures for capital improvements for buildings, as promulgated by the Federal Accounting Standards Advisory Board will be enhanced.

Data Source: Identified deficiencies recorded in the Facilities Engineering Data System.

Baseline: Current backlog of identified deficiencies totaling $188 million.

Type of Indicator: Process/Impact

Indicator 20: Provide sanitation facilities to 4,300 new or like-new homes, and 8,730 existing Indian homes by the end of FY 1999.

Rationale: The IHS Sanitation Facilities Construction Program, an integral component of the IHS disease prevention activity, has carried out those authorities since 1960 using funds appropriated for Sanitation Facilities Construction to provide potable water and waste disposal facilities for AI/AN people. As a result, the rates for infant mortality, gastroenteritis morbidity, and other environmentally related diseases have been dramatically reduced, as much as 80 percent since 1973. Compelling evidence supports that many of these health status improvements are attributable to IHS' provision of water supplies, sewage disposal facilities, development of solid waste sites, and provision of technical assistance to Indian water and sewer utility organizations. Satisfactory environmental conditions (e.g., safe piped water and adequate sewage disposal) place fewer demands on IHS� primary health care delivery system. This indicator directly supports the HP 2000 objectives 11.3 (waterborne diseases) and 11.9 (people receiving safe drinking water).

Approach: The Indian Health Care Amendments (Title III, Section 302(g) 1 and 2 of P.L. 100-713) directed the IHS to identify the universe of Indian sanitation facilities deficiencies. As of the end of FY 1996, the backlog of feasible projects to address these needs totaled $716 million.

It is feasible to provide sanitation facilities for between 95 and 98 percent of all existing Indian homes. Also included in the backlog are projects intended to upgrade existing water supply and waste disposal facilities, and projects to improve sanitation facilities operation and maintenance capabilities in Indian country. Maximum health benefits will be realized by addressing needs identified and providing facilities for new/like-new homes when they are constructed.

Data Source: The Sanitation Facilities Deficiency System.

Baseline: Backlog of $716 million as of FY 1996.

Type of Indicator: Impact

Indicator 21: Improve access to health care by continuing construction of the Hopi (Polacca), Arizona Health Center and starting construction of the Ft. Defiance, Arizona Hospital by the end of FY 1999.

Rationale: The replacement Hopi health center has a projected workload for FY 2001 of 35,124 Provider Care Visits per year, which far exceeds current capacity. The replacement Ft. Defiance Hospital has a projected workload for FY 1997 of 69,198 Provider Care Visits per year that far exceeds current capacity.

Approach: The IHS developed the Health Facilities Construction Priority System (HFCPS) methodology in response to congressional directive to identify planning, design, construction, and renovation needs for the 10 top-priority inpatient care facilities and the 10 top-priority outpatient care facilities and to submit those needs through the President to the Congress. Under the three-phase HFCPS process, the IHS Headquarters solicits proposals for health facility construction from the Area Offices and ranks them according to their relative need for construction. Factors used to determine relative need are workload, age, isolation or alternatives to construction, and existing space data. The highest-ranking proposals are added to the Priority Lists.

When new projects are to be added to the Priority Lists, IHS Headquarters asks each IHS Area Office to submit proposals for Phase I consideration. The IHS uses the HFCPS methodology to review these proposals and to determine which will be considered during the more intensive Phase II review. A limited number of proposals that successfully complete Phase I are considered further during Phase II. The IHS examines these proposals in greater detail and applies the methodology to determine those proposals that will be considered during Phase III.

During Phase III, appropriate IHS Area Offices prepare a Program Justification Document (PJD) for each proposed project still being considered. IHS Headquarters reviews each PJD. If the PJD justifies construction, it is approved and the project is placed on the appropriate priority list below those already on the list. Proposed projects that have been approved and placed on a priority list remain on the list until they have been fully funded by congressional appropriations or other funding mechanism.

After projects are placed on the Priority Lists, IHS updates its 5-year planned construction budget. That budget is updated yearly and used as the basis for funding requests.

The HFCPS is generally applied using existing IHS resources (staff and equipment); however, some Area Offices have procured assistance in developing the PJD and POR.

Data Source: Health Care Facilities Priority System and Health Care Facilities Planned Construction Budget.

Baseline: Inpatient and Outpatient Facilities Priority List.

Type of Indicator: Process/Impact

D. Consultation, Partnerships, Core Functions, and Advocacy Indicators:

Indicator 22: By the end of FY 1999, the IHS will have implemented a formal policy for I/T/U consultation and participation, approved by I/T/U representatives, and a baseline survey of I/T/Us completed to assess the level of satisfaction with the implementation of the policy.

Rationale: It is fundamental to the intent of the NPR and the realization of the IHS Mission and Goal that I/T/Us increasingly become participating partners in the important processes which will guide the Agency into the next century. Given the number and diversity of I/T/Us, formal policies are essential to assure broad input, a rational and equitable approach to making timely decisions, and the highest possible buy-in across I/T/Us.

Approach: As the IHS continues to downsize in conformance with administration policies and in response to tribal governments taking their tribal shares due to compacting and/or contracting, it becomes critical that the IHS form a strong and effective partnership with its I/T/U constituents. This partnership is essential to ensure that resources are effectively and efficiently utilized to maximize the positive impact health programs have on the target I/T/U populations. Partnerships already exist with such tribal entities as the National Indian Health Board (NIHB), Regional Indian Health Boards, the Tribal Self-Governance Advisory Committee (TSGAC) and the National Congress of American Indians (NCAI). The starting point for this initiative will be to enlist the assistance of these entities in developing a culturally and politically sensitive consultation process as well as an implementation plan to ensure that this process is in operation by the end of FY 1999. This consultation process must provide equal access and opportunity to all I/T/U representatives.

Concurrent with the establishment of a consultation process, the IHS will work with key I/T/U representatives to develop evaluation criteria and a survey instrument. This activity will provide the IHS with a valid means to accurately assess the effectiveness of the consultation process and existing Agency consultation and participation policies in terms of I/T/U satisfaction with the consultation process. To establish credibility and trust with our I/T/Us in this process, the IHS will develop enabling policies expeditiously to facilitate and effect this consultation process.

Data Source: I/T/U survey instrument and protocol (to be developed).

Baseline: To be determined with baseline survey completed in FY 1998.

Type of Indicator: Process

Indicator 23: By the end of FY 1999, the IHS will have reduced its administrative infrastructure (Area and Headquarters) at least 10 % below the FY 1997 level while maintaining full compliance with major Federal requirements (i.e., GPRA, GMRA, ITMRA, etc.)

Rationale: A major recommendation in the IHDT�s plan for reorganizing the IHS was to downsize and streamline the IHS Headquarters and Area Offices and move from controlling and directing to consultation and support to I/T/Us. This recommendation supports the continued transition to local control, and the intent of the NPR, but represents a significant challenge because of the loss of economies of scale in the decentralization process.

Approach: As a growing number of tribes exercise their options for greater self-management under the Indian Self-Determination and Education Assistance Act, Areas and Headquarters are faced with meeting public health and administrative functions with significantly less resources (i.e., in excess of 50% reductions in some settings). To accomplish this the IHS is in the process of reorganizing Headquarters to a flatter and simpler structure and integrating the use of multi-disciplinary teams to address important functions, including the GPRA. Many Areas are likewise reorganizing to more efficient structures. As described in Performance Indicator 24, we are in the process of assessing our internal capabilities at Headquarters and Areas and looking to develop partnerships with outside organizations to bolster deficiencies identified. Doing more of what is important with less will require considerable training and improved technologies, as well as ceasing to expend resources on low value work. Assistance from the Department and OMB will be critical for both of these to occur.

The evaluation of our success in this attempt at "doing more with less" will come from the surveys of I/T/Us described in Performance Indicator 22. Feedback will come from the Department, OMB, and Congress relative to our level of compliance with the growing number of Federal requirements, particularly the GPRA, GMRA, and ITMRA, and audits of the resources expended. In the long run, our success in this effort will be reflected to a considerable degree in the level realization of our component of the DHHS Strategic Plan and the IHS Mission and Goal.

Data Source: Audits of Area and Headquarters, I/T/U Survey, and feedback from HHS, OMB, and Congress.

Baseline: To be determined with baseline survey completed in FY 1997.

Type of Indicator: Process

Indicator 24: By the end of FY 1999, the IHS will have increased the number of interagency agreements and cooperative agreements with agencies and organizations that are directed at improving the health status and/or the quality of life of AI/AN people by 20% over the FY 1996 level.

Rationale: Given the decreasing per capita funding the IHS is receiving for health services and the continued loss of public health infrastructure, it has become increasingly important to the IHS�s advocacy role to seek collaborative partnerships with other organizations which can assist in efforts to achieve the IHS Mission and Goal.

Approach: For many years the IHS has worked collaboratively with other organizations, particularly other department Agency�s (e.g., NIH, CDC, AHCPR), in efforts to improve the quantity and quality of services we provide. The IHS is currently in the process of proactively seeking additional and broader partnerships with organizations directed at setting in place long-term strategic approaches to addressing the interactive effects of health and social services, community empowerment, and economic development directed towards improved quality of life for AI/AN people.

Clearly opportunities exist for expanding agreements with existing organizations as well as developing new ones with other Federal, State and local agencies, as well as private sector organizations. In this light, our Director is currently spearheading a Domestic Policy Council multi-departmental initiative for AI/AN children and youth around two themes:

Ensuring a safe and healthy home and community
Ensuring personal development within the context of developing communities

Response thus far has encouraging with active participation from HUD, DOI, DOA, DOT, and several HHS OPTDIVs. The ultimate goal for the initiative is to improve the status of AI/AN children and youth relative to indicators reflecting the two themes. The approach is to collaborate with agencies that serve AI/AN people to improve coordination of services and increase access to services for AI/AN communities (including urban areas). Included in this effort is the drafting of and Executive Order to redirect policy and support needed legislative changes. In addition, the initial workgroup of this initiative embraced the importance of agencies documenting their commitment to the initiative through identifying appropriate specific GPRA performance indicators.

As encouraging as the this initiative appears at this time, it should be noted that given the flat or reduced funding of many of these Federal agencies, significant resources to assist in the large unmet need for health services is not expected from these efforts in the immediate future. This initiative is directed at long term activities and changes well in to the next century.

During the remainder of FY 1997 and throughout FY 1998, IHS Headquarters, in partnership with Areas and I/T/Us, will be surveying the public health capabilities and needs of all Areas. This effort will ascertain the capabilities within the IHS network and attempt to identify potential external partners to assist in meeting the identified needs. In the long run, assessing the utility of these collaborative partnerships in reaching the IHS Mission and Goal will be a more meaningful and valid performance indicator than the number of agreements.

Data Source: Audit of existing agreements.

Baseline: To be determined by FY 1998.

Type of Indicator: Process

Indicator 25: By the end of FY 1999, the IHS will begin implementing Managerial Cost Accounting (MCA) in accord with DHHS and OMB guidance.

Rationale and Approach: The Federal Financial Management Improvement Act of 1996 (The Brown Bill) requires IHS to achieve the linkage of resources to results through MCA. This bill requires each agency to maintain financial management systems that comply with Federal financial management systems requirements, applicable Federal accounting standards, and the U.S. Standard General Ledger at the transaction level. As mentioned in section IV, caution must be exercised in applying manufacturing accounting approaches to a comprehensive public health program. Attempting to cost account for outcomes for complex chronic disease processes (i.e., diabetes) addressed by many health disciplines in diverse settings, with long time lags in effect, is plagued with threats to validity, and would probably represent an exercise in futility.

The IHS has contracted with the Mitretek Systems to analyze technical alternatives for IHS cost reporting/cost accounting. This will be a detail analysis of technical alternatives and perform a cost benefit and trade off analysis of alternatives. The results will be provided to a steering committee to support strategic decision making regarding the implementation of cost reporting and cost accounting at IHS. This system is necessary to assist IHS leadership to maximize utility of diminishing resources, be cost effective, and ensure that patient care can be provided to its customers. Perhaps the most significant benefits or goals for establishing MCA is to an increase collections from private insurance, Medicare, and Medicaid.

Type of Indicator: Process

VII. Challenges, Concerns, and Conclusions

The IHS approaches the next millennium in the midst of the most profound changes in its history. We are simultaneously faced with the challenges of:

downsizing and restructuring our administrative infrastructure
decentralizing and providing for local control of resources to I/T/Us
reinventing ourselves through the directives of the Reinventing Government/National Performance Review process and demonstrating results based on the GPRA

On top of these changes, we have struggled to minimize the impact of absorbing almost a third of a billion dollars in cost increases since FY 1992. The impact of this shortfall on services has been discussed earlier, but the impact on staff and AI/AN consumers is probably more significant. For I/T/U staff, workloads have increased as a result of the growing consumer population and have been aggravated by higher rates of staff turnover and lapse positions. In addition, funding for training, equipment, and supplies has been cut to avoid deficit spending. People at Area Offices and Headquarters are similarly stressed having lost in excess of 60% of their staff in some cases. While no formal staff surveys have been run to assess morale, the informal communication known across the IHS as the "moccasin telegraph" supports that people are indeed struggling to cope with their work environment at levels not previously experienced. A recent and significant increase in EEO complaints also gives credence to this observation. The long-term impact of this work environment on recruitment and retention of well-qualified and committed staff is of increasing concern.

For consumers, the waiting times for appointments have increased and complaint rates are increasing. The backlog of needed but not urgent care (deferred services) under contract health services has almost double since 1993. Furthermore, the number of contract health care denials has increased 60 percent between FY 1994 and FY 1996. The IHS is in the process of assessing the factors contributing to these denials, but preliminary findings suggest it has been the result of both a decrease of local capacity to meet growing needs and diminishing spending power of contract funds to purchase services. The net effect is a loss of access to health services, which is becoming a painful reality for a growing number of AI/AN consumers.

These trends in diminished access to essential services are a bitter reality in light of the recently released findings of a Harvard School of Public Health /CDC national study of life expectancy. The study found that the lowest life expectancies in the country (including inner city ghettos) for both men and women exists in Indian populations, are similar to ones seen in sub-Saharan Africa, and are the lowest of any nation in this hemisphere except Haiti. It is perhaps not surprising that these Indian people have also been identified as living in the poorest counties in the entire country. To say we are serving the poorest of the poor and the sickest of the sick is supported by objective data.

For some consumers who participated in the budget formulation/GPRA process, the realization that IHS funding is not an entitled appropriation, despite what they thought were assured through treaty rights, was disconcerting. It appears that this lack of entitlement has been less of a point of contention for AI/AN people for much of the history of the IHS because of the steady program growth, that people were gaining access to needed services and they were becoming healthier. However, over the last several years, and probably for the first time in our Agency�s history, consumers are realizing that access to services is moving backwards. For a growing number of AI/AN people, the belief in the assurance of adequate health care is beginning to be perceived as another broken promise from the Federal government.

Despite our educational efforts, such growing mistrust has resulted in the GPRA being perceived by some AI/AN leaders as another unfunded bureaucratic mandate, or worse, a mechanism to further reduce funding for their health care. At several regional budget formulation/GPRA sessions people expressed deep concern that the GPRA could be used to justify reducing IHS funding for either poor performance, or high performance (i.e., if we are making such significant progress we can get by with less funding).

Despite these formidable challenges, the IHS has fully committed to the GPRA, in partnership with its stakeholders, as a means of restoring and eventually expanding the capacity to serve AI/AN people. The GPRA process has thus far proven useful, not only in focusing on results, but also in creating useful dialog between health program, administrative and budget staff that has rarely occurred previously. Recently, a few tribal representatives have voiced the opinion that active participation of tribal managed health programs in the GPRA is critical and should not be optional. While this recognition is encouraging, continuing to secure a high level of buy-in to the GPRA process from our diverse stakeholders in an increasingly decentralized organization will be demanding and will require continued dialog and flexibility by all parties at all levels.

One concern voiced by a growing number of IHS Area, Headquarters and I/T/U staff is worth noting to the readers of this plan. The concern is that the GPRA is at risk of being corrupted during the implementation process. While the intent of the GPRA, as well as the associated REGO and NPR initiatives, was to reduce red tape and low value process, increase flexibility, and to focus on customers and results, our experience is that the much anticipated reduction in low value process has not occurred. To the contrary, new reporting demands of the CFO, GMRA, ITMRA and growing list of requirements attached to the GPRA (e.g., acquisition management, debt management, etc.) have actually increased demands for process and with a growing redundancy. Hopefully some of this will be resolved as experience is gained by all in the GPRA process.

The IHS cautions that the simplicity and power of the GPRA can be diluted and the required administrative overhead significantly increased, while not supporting outcomes, if a reasonable balance between requiring highly detailed and incremental process accountability and allowing programs flexibility to creatively focus on and be accountable for outcomes. The emerging trend appears to be that "process accountability " will by default, displace the focus on outcomes. It is our contention that such an approach would be a disservice to the AI/AN people and the country�s taxpayers. We are compelled to acknowledge that any such nonessential but required activities will have serious consequences in the length and quality of our consumers� lives because resources critically needed to provide access to health care would be further diluted. We believe the effort and resources are better directed towards assuring access to health care and the complex and demanding iterative process of evaluating the link between activities and outcomes over time.

In conclusion, the IHS submits this performance plan in a spirit of commitment, a sense of challenge, but also with deep concern. We have outlined a very demanding set of performance goals for FY 1999 on the heels of a FY 1998 budget that for the sixth consecutive year fails to provide the inflationary cost increases necessary to maintain existing services. This plan is our best effort at minimizing the negative potential outcomes of this situation. We have a proud history of accomplishments that document our achievement of significant results long before it was required by law. With reasonable support, in partnership with our stakeholders, we will accomplish even more. Without adequate support, the AI/AN people could enter the next century with their health status actually declining for the first time since the inception of the IHS in 1955.

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This file last modified: Wednesday November 8, 2000 8:27 AM