Detailed Information on the
Tribally-Operated Health Programs Assessment

Collaborating with tribal programs to discuss appropriate means of gathering data on reimbursement from Medicare, Medicaid, and SCHIP to better understand the linkage between funding and performance. Recommendations to the IHS Director will be submitted in FY 2009.

Collaborate with tribal programs and other agencies to identify cost-effective ways to achieve facility accreditation for currently unaccredited programs to ensure access to quality health care.

Increase the reporting rate to at least 76% of the population. Beginning in FY 2007, reporting of health data was a standard negotiation item discussed and encouraged during Title I contract and Title V compact negotiations. The IHS will continue to raise this issue at subsequent negotiations as part of our ongoing negotiation objectives. Reporting of health data will also be incorporated into the FY 2009 IHS Area Lead Negotiator (ALN) curriculum training.

Work with the Tribal Self-Governance Advisory Committee (TSGAC) to assist IHS with a variety of performance measurement issues with the goal of increasing reporting of data from Tribally operated programs by creating a voluntary uniform data set that imposes minimal burdens on the Tribes.

In fiscal year 2007, the Tribal Self-Governance Advisory Committee (TSGAC) increased emphasis on federal accountability and performance management in carrying out the Indian Health Service's mission, specifically in regards to Tribally Operated Health Programs (TOHP). The TSGAC defined the need to create an advisory committee to centrally monitor and assist IHS with a variety of Agency performance measurements specific to TOHP. The IHS has embraced this concept and will collectively evaluate options to address this need in Q1-Q3 of FY 2008 by establishing a joint IHS/Tribal Workgroup to address issues related to performance reporting.

Measure: Percentage of AI/AN patients with diagnosed diabetes served by tribal health programs that achieve ideal blood sugar control.

Explanation:Blood sugar control is measures with a test called Hemoglobin A1C (HgbA1c) that measures the average blood sugar over the last 1-2 months. The ideal blood sugar level is set based on national diabetes care standards. Clinical studies have shown that a 1% decrease in absolute level of A1c for diabetics translates into a 14% decrease in total mortality, 21% in diabetes-related deaths, 43% decrease in amputations, and 24% decrease in kidney failure, among other positive outcomes. Historical trends for this measure are consistent with IHS-All rates. This is a treatment measure and results are highly dependent on patient compliance with dietary recommendations, medication management, and exercise. There has been a relative 21 percent increase in performance since baseline was established in 2003, with approximately the same increase required to meet the long term goal. This is an extremely ambitious target, given past performance.

Measure: Years of Potential Life Lost (YPLL) in the American Indian/Alaska Native (AI/AN) populations served by tribal health programs.

Explanation:YPLL measures the relative impact of various diseases and lethal forces on the AI/AN population served by TOHPs, and is computed by estimating the years that people would have lived if they had not died prematurely due to injury, cancer, heart disease, diabetes, or other causes.

Measure: Hospital admissions per 100,000 diabetics per year for long-term complications of diabetes.

Explanation:Assessing hospital admissions for complications of diabetes is a marker for diabetic standards of care which is provided to the diabetic population served. The goal is to reduce the number of hospital admissions through prevention of diabetes and delivery of appropriate care to diabetics that would improve management of the disease. Clinical studies have shown that a 1% decrease in absolute level of A1c for diabetics translates into a 14% decrease in total mortality, 21% in diabetes-related deaths, 43% decrease in amputations, and 24% decrease in kidney failure, among other positive outcomes. This measure is ambitious given the prevalence of diabetes in the AI/AN population.

Measure: Percentage of Tribally-Operated Health Programs' clinical user population included in GPRA data.

Explanation:TOHPs voluntarily report data which is included in national GPRA reporting for 17 clinical performance measures. This measure captures the percentage of the population included in clinical data reporting. Target decreases are due to funding-smaller TOHPs without IT infrastructure will not have the capacity to initiate electronic reporting, and therefore contribute an overall rate increase.

Measure: Number of designated annual clinical performance goals met.

Explanation:This composite measure includes: poor glycemic control, ideal glycemic control, controlled blood pressure, LDL assessed, nephropathy assessed, retinopathy exam, Pap smear rates, mammogram rates, colorectal cancer screening, tobacco cessation, FAS prevention, domestic violence screening, childhood immunizations, influenza vaccination, pneumococcal vaccination, depression screening, childhood weight control. These targets reflect success in meeting 88% of measure targets in FY 2007 and the goal of meeting 82% of targets in FY 2008 & 2009. These targets correspond to actual results for total measures met for IHS-All rates.

Is the program purpose clear?

Explanation: The purpose of Tribally-Operated Health Programs (TOHP) is to use tribal self-governance and self-determination as a means of achieving the Indian Health Service's mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives (AI/AN) to the highest level possible. The goal of TOHPs, which are carried out by Indian Tribes and Tribal Organizations (T/TO), is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to the service population. TOHPs substitute for the services formerly provided directly by IHS. IHS awards funding to tribes in an amount that corresponds to what IHS spent providing those services directly, plus overhead and a portion of headquarters and area office funding.

Evidence: The Snyder Act (PL 83-568) and the Indian Health Care Improvement Act (PL 94-437) authorized funding for clinical, preventive, and public health services for AI/ANs. The latter was enacted to "provide the quantity and quality of health services which will permit the health status of Indians to be raised to the highest possible level and to encourage the maximum participation of Indians in the planning and management of those services." The Indian Self-Determination and Education Assistance Act (PL 93-638) was enacted to "provide maximum participation in the government and education of the Indian people; to provide for the full participation on Indian tribes in programs and services conducted by the Federal Government for Indians and to encourage the development of human resources of the Indian People." The IHS mission statement also articulates the program's purpose.

Does the program address a specific and existing problem, interest, or need?

Explanation: In 2004, the Indian Health Service (IHS) served 1.4 million American Indians and Alaska Natives (AI/AN), including over 500,000 served by Tribally-Operated Health Programs (TOHPs). Many AI/ANs live in isolated communities; the average distance between an IHS facility and the nearest health care facility is 68 miles. There is a 23% poverty rate among AI/ANs, and 27.5% of AI/ANs are uninsured. There are significant disparities with regard to health outcomes and access to health services for AI/ANs compared to the US population in general. In 2000, the mortality rate in the AI/AN population exceeded the US all-races mortality rate for alcoholism (770%), tuberculosis (650%), diabetes (420%), unintentional injuries (280%), and pneumonia and flu (52%).

Evidence: Estimates are from Income, Poverty, and Health Insurance Coverage in the United States: 2003; and available at www.census.gov/hhes/www/income.html.

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The Indian Health Service (IHS) is the primary source of health care for the American Indian/Alaska Native (AI/AN) population. It is not likely that comprehensive health care services would be otherwise provided to this population by private or other public entities because of the high poverty and uninsured rates, and because many AI/AN communities are in rural, isolated areas where few or no alternative health care access points currently exist. Tribally-Operated Health Programs (TOHPs) substitute for the IHS-administered programs when the Tribe or Tribal Organization (T/TO) contracts with the federal government to provide health care to their communities. Tribes are authorized to bill third-party payors, such as Medicare, Medicaid, SCHIP, and private insurance, for eligible services provided to enrolled beneficiaries, and some tribes supplement IHS funding with other tribal revenues and grants from other public programs-such as Health Centers-or private entities.

Evidence: As mentioned in question 1.2, the poverty rate on reservations is 31%, the uninsured rate is 27.5%, and the average distance between an IHS facility and the nearest health care facility is 68 miles.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: Even though the program does not have the statutory authority to hold Tribally-Operated Health Programs (TOHPs) accountable for achieving the annual and long-term goals of the program, many TOHPs voluntarily provide performance data and other information illustrating their achievement of program goals and management standards, and the number of TOHPs doing this increases every year. There is no strong evidence that the operation and performance of TOHPs is ineffective. There are several examples of programs that have expanded the scope of health services and better targeted the services provided to tribal members after the program was contracted or compacted. Also, improved accountability procedures could work to better identify areas in need of improvement as well as best practices that other TOHPs can adapt for their unique circumstances.

Evidence: PL 93-638 and corresponding regulations at 25 CFR Part 900 and 42 CFR Part 136.

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: Funding for Tribally-Operated Health Programs (TOHPs) largely depends on the amount received in the previous year, and is not adjusted to most directly and efficiency support the program's annual and long-term goals. When a new health care facility comes on line, IHS provides a "staffing package", which is an amount of funding estimated to cover the costs of full staffing and is based on population size. Changes in funding levels are distrbuted according to changes in user population and estimates of inflationary costs. Funding for some activities, including the Special Diabetes Initiative, Injury Prevention, and Contract Health Services, are distributed based on need and/or performance, but this funding represents a small portion of funding available for TOHPs. Additionally, approximately $11 million of IHS services funding is included in the Indian Health Care Improvement Fund (IHCIF) in 2005 and is distributed primarily to areas with the lowest level of IHS funding per capita, with the goal of providing a more even distribution of funding across IHS service areas. However, the formula used to calculate this distribution does not take the entirety of third-party reimbursements (Medicare, Medicaid, SCHIP, and private insurance) into account when calculating how much is spent per user per area, because tribal programs are not required to report data on other revenues used for health care. As a result, this funding is often distributed to areas that have higher overall spending per capita, but lower IHS funding per capita, which perpetuates inequities between areas. Despite these issues regarding the optimal allocation of funding for TOHPs, funds are used to provide comprehensive health care for eligible AI/ANs, support the mission of the IHS, and do not supplant other funding sources or activities.

Evidence: Background on the calculation of the Federal Disparity Index (FDI), which is used to distribute funding for the IHCIF, can be found at www.ihs.gov/NonMedicalPrograms/Lnf/index.cfm. Additonal information can be found in the IHS Congressional Justification.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The program has two primary long-term performance measures, which are included in the IHS Strategic Plan and voluntarily reported on by 68% of contracting/compacting Tribes and Tribal Organizations (T/TOs) representing 85% of the population served by all contracting/compacting T/TOs. Reducing the Years of Potential Life Lost (YPLL) is a recognized mortality statistic that measures the total number of life years lost owing to premature death in a population. Improving blood sugar control among diabetics is also included in the IHS Strategic Plan and GPRA, and reflects progress towards the single most powerful intervention for reducing the morbidity and mortality associated with diabetes, as well as decreasing health care costs associated with this disease.

Evidence: The IHS Strategic Plan describes these two long-term goals and can be found at www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/index.asp. A discussion of the usefulness of YPLL can be found at www.cdc.gov/mmwr/preview/mmwrhtml/00001773.htm. Finally, a discussion of the importance of blood sugar control can be found in "Predictors of Health Care Costs in Adults With Diabetes", Diabetes Care Vol. 28, Number 1, Jan. 2005. This measure is particularly important because as mentioned in question 1.1, the prevalence of diabetes among AI/ANs is 310% of the U.S. all-races prevalence rate.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program's target of reducing Years of Potential Life Lost (YPLL) by 10% below the FY 2000-2002 baseline is ambitious for the given timeframe of ten years. This target is comparable to the actual performance achieved between 1992-1994 and 2000-2002, when YPLL declined by approximately 11% for IHS overall. Additionally, the program's target of increasing the percentage of diabetics with ideal blood sugar control to 40% over ten years from 28% in 2004 is ambitious given that the number of diabetics in the American Indian/Alaska Native (AI/AN) population increased by 45% between 1997 and 2002 and is expected to continue increasing.

Evidence: The IHS Strategic Plan discusses the program's long-term goals.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: Because the program is charged with improving the overall health of the American Indian and Alaska Native (AI/AN) population, Tribally-Operated Health Programs (TOHPs) that report GPRA data use 17 clinical performance indicators. For summary purposes, the program has consolidated these 17 performance goals into one composite measure-measuring the percentage of performance goals met-to illustrate overall progress toward achieving the program's targets. Progress on these indicators will result in greater progress toward achieving the program's long-term goal of reducing Years of Potential Life Lost (YPLL). Additionally, IHS has developed an annual performance measure to track the percentage of the TOHP clinical user population included in GPRA data submitted to IHS. Increasing the percentage of TOHPs providing GPRA data will provide IHS with a more complete picture of program performance.

Evidence: The IHS GPRA plan, included in the IHS Congressional Justification, describes each of the 17 performance indicators, including historical performance and targets. Beginning in FY 2007, the IHS Congressional Justification will describe in greater detail the link between these annual indicators and the agency's long-term goals as described in the IHS Strategic Plan.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: Based on performance on clinical measures through 2004, the targets for meeting annual clinical performance goals are realistic yet ambitious. Additionally, the target for increasing the percentage of the user population being served in tribal health programs that report GPRA data is ambitious and realistic, especially given that most of the programs that are not yet reporting data are smaller thus making progress on this measure will become more time- and resource-intensive.

Evidence: Evidence includes data on historic IHS performance and reporting status per user population for tribal health programs through 2004.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: The program does not formally link Tribally-Operated Health Programs' (TOHPs') activities to the program's overall goals. PL 93-638 prohibits IHS from requiring tribes to submit performance data, though 68% of TOHPs representing 85% of the overall TOHP user population voluntarily adopt and report on the program's performance goals. While IHS consults with TOHPs in the development of overall IHS performance indicators and goals, these goals are not included in contracts or compacts with T/TOs, so their commitment is not formalized.

Evidence: The IHS Strategic Plan includes a description of how its goals were determined in conjunction with TOHPs. Program data can be found in the GPRA section of the IHS Congressional Justification. Please see the evidence for question 1.4 for references to statute and regulation for specific details.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: Most hospitals are evaluated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Some ambulatory care centers are accredited through the Accreditation Association of Ambulatory Health Care, Inc. (AAAHC). These evaluations are the recognized benchmark of quality in the health care industry and are conducted through by external peer review teams using rigorous health care quality effectiveness criteria. Approximately 54% of tribally-run facilities serving 77% of the user population of tribal program are accredited by one of these two bodies.

Evidence: JCAHO evaluations are available by facility at www.jcaho.org/quality+check/index.asp. AAAHC evaluations are also available by facility at www.aaahc.org/eweb/StartPage.aspx.

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: The Indian Health Service (IHS) budget requests include a discussion of how inflationary costs, increasing disease prevalence, and population growth may affect demand for health services. However, funding provided to Tribally-Operated Health programs (TOHPs) may be reprogrammed for any purpose so long as it is an activity allowed in the TOHPs contract or compact. IHS may allocate services funding to target its performance goals, but TOHPs need not follow these same priorities. Therefore, it is difficult to know what impact a proposed funding or policy change will have on program performance. Additionally, as mentioned in question 1.5, funding for TOHPs largely depends on the amount received in the previous year, and is not adjusted to most directly and efficiency support achieving the program's annual and long-term goals.

Evidence: IHS Congressional Justifications provide information on proposed funding allocations and limited information on how this may impact program performance.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: Over the past several years, IHS staff have strongly encouraged tribes to voluntarily report GPRA data, and have provided resources, information technology solutions and technical assistance to assist Tribally-Operated Health Programs (TOHPs) in accomplishing this. The program recognizes the need to increase commitment to program goals and to tie budget requests to the accomplishment of these program goals. Ongoing support from the Office of Tribal Self Governance for GPRA, as well as the development of additional training and tribal mentoring opportunities, reflect the program's recognition of the deficiencies and the development of some tools to help overcome them. Additionally, IHS staff are in the process of developing marginal cost estimates for some GPRA measures. This work will help support future performance based budget requests.

Evidence: This information was provided through conversations with IHS staff.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The agency collects GPRA clinical data from 68% of Tribally-Operated Health Programs (TOHPs) representing 85% of the TOHP clinical user population, as described in Section II. IHS staff conduct conference calls with TOHP staff to discuss the findings in this data and address any concerns. The agency has responded to clinical and epidemiological data by creating competitive grant programs around immunizations, diabetes prevention, and injury prevention. Epidemiology centers provide data and technical assistance upon request. Additionally, IHS is required to provide technical assistance to tribes upon request. However, IHS could do more to use data to improve performance by being more pro-active with TOHPs in response to findings from GPRA data.

Evidence: GPRA data is available in IHS's Congressional Justification, applications and funding amounts for the competitive grants listed above can be found at grants.gov, and information about IHS's epidemiology centers are available at www.ihs.gov/MedicalPrograms/Epi/index.asp.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: PL 93-638 prohibits IHS from requiring tribes to submit performance data. While IHS consults with Tribally-Operated Health Programs (TOHPs) in the development of overall IHS performance indicators and goals, these goals are not included in contracts or compacts with Tribes and Tribal Organizations (T/TOs), so their commitment is not formalized. P.L. 93-638 includes a model contract format which includes a section that is intended to detail the performance goals negotiated between the TOHP and IHS. This section is often excluded from contracts. Additionally, there is no statutory mechanism for IHS to hold TOHPs accountable for achieving performance goals even if they are negotiated into contracts. One example of this is JCAHO accreditation (see Section II for more information on accreditation). Many contracts and compacts require accreditation or maintaining the standards of accreditation. However, only 57% of facilities are accredited, and there is no recourse against the TOHPs who fail to meet their contract requirement, and without accreditation, there is no mechanism for IHS to know whether TOHP facilities are meeting the standards of accreditation. PL 93-638 prevents IHS from holding TOHPs accountable for performance standards negotiated into contracts except under extreme circumstances (see question 1.4). The program has used a more cooperative approach in improving performance among TOHPs by strongly encouraging voluntary reporting of GPRA data and providing technical assistance to address performance issues. Additionally, in limited circumstances, IHS can sanction TOHPs for being noncompliant with the Single Audit Act. All TOHPs are governed by community-based boards or Councils that are made up of elected officials, which introduces an element of accountability to the community. Finally, IHS holds its Director and Area Directors accountable for achieving performance goals through their performance contracts.

Evidence: Supporting evidence includes performance contracts, PL 93-638 and its regulations, and conversations with IHS staff.

Are funds (Federal and partners') obligated in a timely manner and spent for the intended purpose?

Explanation: TOHPs receive their funding in an annual lump sum payment unless the Tribe or Tribal Organization (T/TO) and IHS agree to quarterly or other periodic payments. Funds are based on the activities and services documented in their funding agreement. Awards are made within ten days of apportionment. Annual audits and, for some TOHP contractors, quarterly financial liquidation reports are required to monitor the expenditure of Federal dollars.

Evidence: Tribal audits document the extent to which funds are obligated and spent appropriately.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The program has an efficiency measure to track the number of hospital admissions related to long-term complications of diabetes among diabetics. The goal is to reduce the number of hospital admissions through prevention of diabetes and delivery of appropriate care to diabetics that would improve their management of the disease. Improved management of diabetes leads to fewer complications and hospitalizations, which has been shown to reduce the cost of treating this disease. Diabetes is a leading cause of morbidity and mortality in the American Indian/Alaska Native population. Additionally, IHS has developed information technologies that improve clinical efficiencies and cost effectiveness. Over 95% of TOHPs use the Resource and Patient Management System (RPMS) to provide clinical and administrative data. Also, the IHS Electronic Health Record is a recently developed software application that works with RPMS and provides clinicians with immediate access to decision support tools and resources to determine the most effective course of action for a particular patient. Analysis of data at beta test sites has showed increased efficiency through a significant increase in the number of patient visits, decrease in medical error rates, and improved performance on selected GPRA clinical indicators. Tribal implementation of the Electronic Health Record is voluntary, but many TOHPs are expected to adopt the system. While this measure and these procedures are in place, the information IHS recieves regarding program efficiency is not complete. TOHPs need not provide information to IHS regarding their other sources of revenue for health services. Without this information, it is impossible to tell how much the TOHP is spending to achieve a given level of performance.

Evidence: Supporting information can be found in the IHS Congressional Justification. Additionally, further information on the impact of electronic health records can be found at www.gartnerg2.com/rpt/rpt-0902-0173.asp.

Does the program collaborate and coordinate effectively with related programs?

Explanation: Care agreements and pharmaceutical supply agreements with the Department of Veterans' Affairs have enabled IHS and Tribal Programs to increase and improve care to their clients. Tribal Programs have cooperated with the Bureau of Indian Affairs and the Administration for Children and Families on a number of initiatives addressing mental health, domestic violence, and child neglect. IHS works regularly with the Centers for Medicare and Medicaid Services regarding program guidance, regulations, and reimbursement rate setting.

Evidence: Supporting documentation includes memoranda of agreement and program announcements made by IHS and other related programs listed above.

Does the program use strong financial management practices?

Explanation: Tribally-Operated Health Programs (TOHPs) are required by regulation to maintain management systems for financial, procurement, and property management. TOHPs establish their own internal financial controls. The annual Single Agency Audit Report documents the extent to which the tribe is complying with its financial management procedures in the accounting for and expenditure of contract funds, and also whether the controls themselves are satisfactory. Where there are findings, the TOHP must formulate a Corrective Action Plan that will lay out the procedures by which the TOHP will correct the finding. The TOHP then works with IHS to clear the finding so that IHS can issue a management decision. If the TOHP fails to do this, IHS can impose sanctions on the program.

Evidence: Requirements are described in PL 93-638 and the corresponding regulations. Examples of follow-up Corrective Action Plans were also provided by IHS.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: The agency has provided incentives to address some of its highest priorities by creating competitive grant programs around immunizations, diabetes prevention, and injury prevention. Tribally-Operated Health Programs (TOHPs) are eligible to apply for these grants. Additionally, IHS has begun to collect and analyze GPRA data on a quarterly basis in order to more rapidly respond to performance issues. Finally, IHS provides TOHPs with an analysis of nationally aggregated data, a dashboard of high risk performance areas, and national recommendations regarding program performance.

Evidence: IHS grant announcements are available at grants.gov, and GPRA data is available in the IHS Congressional Justification.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: The program is limited by statute and regulations as to what information it can collect regarding activities by Tribally-Operated Health Programs (TOHPs). IHS can require no more than an annual audit and a narrative report or site visit, unless the TOHP agrees to more visits or oversight activities. Site visit reports (typically based on one-day long visits) and annual narrative reports provided by TOHPs in lieu of site visits reviewed for this analysis varied in the amount of detail they provided regarding grantee activities. These reports primarily focused on whether the program had particular personnel, financial management, and governance functions in place, but did not evaluate the adequacy of these items in providing quality health care.

Evidence: PL 93-638 includes details on reporting requirements and limitations. Site visit reports and annual narrative reports were also reviewed.

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The program provides annual Tribally-Operated Health Program (TOHP) performance data aggregated nationally for the TOHPs, and together with IHS direct data aggregated by the area level, in the IHS Congressional Justification. The TOHP data is based on voluntarily reporting by 68% of contracting/compacting Tribes and Tribal Organizations (T/TOs) representing 85% of the population served by all contracting/compacting T/TOs.

Evidence: Data are available in the IHS Congressional Justification.

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: Between 1992-1994 and 2000-2002, YPLL declined by approximately 11% for IHS overall and for Tribally-Operated Health Programs (TOHPs) in particular. The annual clinical goals tracked by TOHPs link to achievement of this long-term performance goal, suggesting that the program remains on track to achieve its target in 2012. The program's long-term goal of increasing the percentage of diabetics with ideal blood sugar control to 40% over ten years from 28% in 2004 is also an annual goal, and TOHPs and IHS programs overall continue to make progress toward the long-term target each year.

Evidence: The IHS Strategic Plan describes these two long-term goals and can be found at www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/index.asp.

Does the program (including program partners) achieve its annual performance goals?

Explanation: GPRA data reported by 68% of Tribally-Operated Health Programs (TOHPs) representing 85% of the user population indicate that most annual measure targets are met; however, the targets are not ambitious. During 2004, TOHPs that reported GPRA data met 12 of 15 GPRA indicators that comprise the composite measure used for the PART. The program merits a small extent on this question because partial reporting of partial success in meeting annual goals that do not have ambitious targets. Increasing the percentage of TOHPs providing GPRA data will provide IHS with a more complete picture of program performance.

Evidence: The IHS GPRA plan, included in the IHS Congressional Justification, describes each of the 17 performance indicators, including historical performance and targets.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: The Tribally-Operated Health Programs (TOHPs) have supported the development and deployment of appropriate information technology that improves the efficiency with which they can provide health care services. In 2003, the IHS Office of Information Technology supported the development of a new application for RPMS, called the Uniform Data Set Reporting System (UDS). This Tribally defined application is used to provide annual HRSA clinical data on users, encounters, and key prevention activities to Tribal programs receiving HRSA funds. In addition, the IHS Electronic Health Record (EHR) was released and deployed to 2 Tribal sites during FY 2004; it will be deployed at 9 tribal sites during FY 2005, with anticipated ongoing deployment at an additional 9 sites in FY 06 and FY 07. The hospitalization measure has established a baseline of hospitalizations for long term complications among persons with diabetes per 100,000 user population from the 2003 IHS database. Data will be available in early 2008 to determine to what extent tribal health programs are making progress on this measure.

Evidence: Information on EHR and UDS was provided in conversations with IHS staff. Hospitalization data is from the IHS National Patient Information Reporting System.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: Based on GPRA indicators reported on by IHS direct and tribal programs, TOHPs reported outcomes on performance measures similar to those of IHS overall in 2004. However, data used to make this comparison are based on 85% of the TOHP user population. Increasing the percentage of TOHPs providing GPRA data will provide IHS with a more complete picture of program performance. Comparisons with other public programs and private sector performance would be too difficult and costly to perform because of differing data collection methodologies and definitions.

Evidence: The IHS GPRA plan, included in the IHS Congressional Justification, describes each of the 17 performance indicators, including historical performance and targets.

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: Approximately 54% of TOHPs representing 77% of users served by tribal programs receive services in programs that are accredited by JCAHO, AAAHC, or other appropriate accrediting bodies. These evaluations are the recognized benchmark of quality in the health care industry and are conducted through by external peer review teams using rigorous health care quality effectiveness criteria.

Evidence: JCAHO evaluations are available by facility at www.jcaho.org/quality+check/index.asp. AAAHC evaluations are also available by facility at www.aaahc.org/eweb/StartPage.aspx.