Detailed Information on the
Indian Health Service Health Care Facilities Construction Assessment

Revised Health Care Priority System Methodology. The Health Care Priority System Methodology was completed in FY 2007. The IHS included tribal consultation during the revision process.

Complete a comparative analysis of IHS construction costs versus industry standards as part of the Post Occupancy Evaluations (POEs) of all facilities constructed by the Federal government and as many facilities constructed by Tribes as possible.

Measure: Percent reduction of the YPLL rate within 7 years of opening the new facility

Explanation:YPLL measures the relative impact of various diseases and lethal forces on the AI/AN population served by Indian Health Service facilities, 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. National trends demonstrate an increase in YPLL. The program will establish a baseline for newly constructed facilities. Results are a three-year aggregate based on the midyear for reporting. Letters represent a newly constructed facility.

Measure: Percent increase in the proportion of diagnosed diabetics demonstrating ideal blood sugar control within 7 years of opening the new facility

Explanation:This measure is a treatment measure and results are highly dependent on patient compliance with dietary recommendations, medication management, and exercise. National trends for this measure demonstrate a 1 percent increase between FY 2005-FY 2007. Therefore, a relative 10% improvement from baseline is an extremely ambitious target. Letters represent a newly constructed facility. Baselines for each facility will be established prior to reporting date.

Measure: Percent of scheduled construction projects completed on time

Explanation:Cost savings associated with Health Care Facilities Construction are complex and multi-factorial. The program renegotiates mobilization/demobilization of activities, revises project schedules, and may redesign current projects to current codes and standards. Timely completion of construction projects allow IHS to construct health care facilities that keep pace with innovations in medicine and to maintain staffing ratios that meet the needs of beneficiaries, which contribute to improved agency-wide operational performance and productivity.

Measure: Proportion of diagnosed diabetics demonstrating ideal blood sugar control (A1c<7.0)

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Proportion of eligible women who have had a pap screen within the previous three years.

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Proportion of eligible women who have had mammography screening within the previous two years.

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Alcohol-use screening (to prevent Fetal Alcohol Syndrome) among appropriate female patients.

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Combined*immunization rates for AI/AN children patients aged 19-35 months. (4:3:1:3:3 series). **Prior to 2006, vaccine rates reported using CRS Population, now using CRS Immunzation Package population.

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Influenza vaccination rates among adult patients aged 65 years and older.

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Pneumococcal vaccination rates among adult patients aged 65 years and older.

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Proportion of tobacco-using patients that receive tobacco cessation intervention.

Explanation:Measures 4-11 track the clinical performance of six recently constructed facilities (each labeled as letters A-F). The first number shows the rate achieved for the specific clinical measure; the second result shows the increase in access to care from a baseline in areas where facilities are constructed. These measures are rate based measures (consisting of a numerator and denominator). For most of the facilities the denominator has substantially increased due to growth in the patient population. These targets are ambitious because demand for services is increasing. For a complete display of data for each measure (FY 2004-2010), in addition to the footnotes which clarify specific issues for measures please go to: http://www.dfpc.ihs.gov/HCFC_Objectives.pdf

Measure: Energy consumption in Leadership in Energy and Environmental Design (LEED) certified IHS health care facilities compared to the industry energy consumption standard for comparable facilities.

Explanation:New IHS facilities are more energy efficient than the buildings they replace, reducing the operational cost of each new facility. The U.S. Green Building Council provides LEED standards for environmentally sustainable construction, which results in more efficient use of water and energy and reduced pollution and waste. The cost of designing and constructing LEED-certified buildings can be higher than the current industry standard. However, initial construction costs can be mitigated over time due to the lower energy consumption of "green" buildings as compared to the industry standard for energy consumption published by the American Society of Heating, Refrigerating and Air-Conditioning Engineers.

Is the program purpose clear?

Explanation: The purpose of the program is to ensure the optimum availability of functional, well-maintained health care facilities and staff housing. This purpose supports the overall mission of the Indian Health Service (IHS) which is to raise the physical, mental, social and spiritual health of the American Indian and Alaska Native (AI/AN population to the highest level. Without functional health care facilities, the efficient and effective delivery of preventative and curative services is not possible.

Evidence: The Snyder Act of 1921, 25 U.S.C. 13, authorized the Bureau of Indian Affairs (BIA) to provide health care services to the (AI/AN) population. The Transfer Act, P.L. 83-568, August 1954, transferred the authority for the maintenance and operation of heath care facilities to IHS. Title III, Health Facilities, of the Indian Health Care Improvement Act, P.L. 94-437, as amended, sets forth the statutory requirements for the program.

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

Explanation: Health care facilities are critical for meeting the health needs of the AI/AN population and are integral in IHS' achievement of its overall mission. The average age of an IHS health facility is 33 years. As existing health care facilities continue to age, the health care delivery system tends to become less efficient and the operational and maintenance costs for the facility increase. In many of the IHS facilities, costs for repair exceed the cost of replacment.

Evidence: There are over 500 health facility complexes serving more than 560 federally recognized tribes and 1.6 million AI/AN. The eligible AI/AN population is approximately 2.6 million. The total space of IHS and Tribal health care facilities is over 1.4 million square meters. Of this total space, the federal government owns 65 percent and tribes own 35 percent. IHS funding is being leveraged with Tribal funding. From 1996 to 2002, Tribal funding for new health care facilities totaled nearly $479 million; IHS funding was $218 million over the same period.

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

Explanation: The Transfer Act created IHS in HHS and transferred the authority to maintain and operate health care facilities for the benefit of the AI/AN population to it from the BIA in the Department of the Interior. For most AI/AN people, the IHS facilities construction program is the only legislative mandate for health care at the federal level. The provision of health care services to federally recognized AI/ANs grew out of a special relationship between the federal government and AI/AN Tribes. This government-to-government relationship is based on the unique constitutional status of AI/ANs in Article I, Section 8, of the United States Constitution. This relationship has been given form and substance by numerous treaties, laws, Supreme Court decisions and Executive Orders. Since states cannot enter into treaties, the responsibility to the AI/AN population is inherent to the federal government. Thus, the program is not redundant or duplicative of other federal, state, local or private efforts.

Evidence: Article I, Section 8, United States Constitution. Transfer Act, P.L. 83-568.

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

Explanation: The health care facilities program is free of major flaws that would limit the program's effectiveness or efficiency. In a study commissioned by the Federal Facilities Council of the National Research Council, IHS' processes for selecting projects and developing scopes of work is one of ten agencies highlighted as best practices in government. The program process includes a comprehensive priority list methodology. The program provides project design and construction management services for both federal and tribal projects. In addition, Congress has implicitly endorsed the priority list methodology by earmarking funds in accordance with the priority list.

Evidence: Gibson, G. Edward ,Jr. and Pappas, Michael P., Starting Smart: Key Practices for Developing Scopes of Work for Facility Projects, Federal Facilities Council Technical Report #146, The National Academies Press, Washington, DC (2003).

Is the program effectively targeted, so that resources will reach intended beneficiaries and/or otherwise address the program's purpose directly?

Explanation: The program uses a priority system that identifies locations that are determined to have the highest need for a new or replacement health care facility. The priority methodology takes into account facility age, condition and cost to repair, isolation, and user population. Space is provided to house authorized health care programs which are staffed accordingly. The IHS Construction Status Report tracks the phase of the project (i.e. planning, design, construction and completion). The IHS Budget Cost Estimating System is used to ensure that projects are completed within appropriations. Any remaining funds are re-programmed to fund other projects in accordance with the priority list.

Evidence: P.L. 100-713 directed that IHS submit a list of 10 highest priority inpatient and 10 highest priority outpatient facilities annually. Projects remain on the list until they are fully funded by Congressional appropriations. After Congress provides initial funding, the scope of work is updated for design since funding may occur years after the initial scope of work (size of the facilitity, medical services, cost estimate, etc.) was completed. See also, Gibson, G. Edward ,Jr. and Pappas, Michael P., Starting Smart: Key Practices for Developing Scopes of Work for Facility Projects, Federal Facilities Council Technical Report #146, The National Academies Press, Washington, DC (2003).

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: IHS has developed facility-specific long-term performance measures that will assess the role of new facilities in expanding access to critical health care services that impact heatlh outcomes.

Evidence: Within seven years of the completion of each facility , (1) Reduce the Years of Potential Life Lost (YPLL) and (2) Improve blood sugar control in diabetics. The following replacement facilities will be included in the initial cohort: St. Paul, Alaska; Metlakatla, Alaska; Sisseton, South Dakota; Red Mesa, Arizona; Clinton, Oklahoma; Eagle Butte, South Dakota; and Phoenix Indian Medical Center Southeast, Arizona. The measures will be applied to additional replacement facilities upon completion.

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

Explanation: The program has ambitious targets and timeframes for its long-term measures. The program will compare the three -year average of each performance measure at each facility prior to replacement with the three-year average of the fifth through seventh year after opening the replacement facility. The program analyzed performance data from facilities completed in the past in an effort to set its targets. The program found that performance varied widely at each facility. For instance, the YPLL ranged from a 4.9% reduction at one facility to a 19% reduction at another facility. Thus, for both the YPLL and diabetes outcome measures, the program has selected the mean of 10% for its targets (reduction and increase respectively) for each facility.

Evidence: By 2010, (1) Reduce the YPLL by 10% and (2) Improve blood sugar control in diabetics by 10% at the St. Paul, Alaska; Metlakatla, Alaska; Sisseton, South Dakota; Red Mesa, Arizona; Clinton, Oklahoma; Eagle Butte, South Dakota; and Phoenix Indian Medical Center Southeast, Arizona facilties. The timeframe may change based on the completion date of each facility since it will be necessary to evaluate data seven years after the completion of the facilities.

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: The program has a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals. The program has an efficiency measure to track progress toward completion of facilities in a timely manner within cost. In addition, the program tracks a number of annual performance measures that support YPLL, including improved diabetic blood sugar control for replacement facilities.

Evidence: (1) Percentage of projects completed on time within cost; (2) Improve diabetic blood sugar control; (3) Increase pap screening; (4) Increase mammography screening; (5) Increase alcohol screening for female patients of childbearing age; (6) Increase coverage of childhood immunications; (7) Increase coverage of flu vaccinations for adults; (8) Increase coverage of pneumococcal vaccinations for adults; and (9) Increase screening for tobacco usage.

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

Explanation: The program has established targets for its facility-specific annual clinical measures that support the long-term measures and has set annual performance targets in the IHS Government Performance Responsibility and Accountability (GPRA) Plan for its efficiency measure since FY 1999. The baseline will be established in FY 2005. As with the long-term measures, the facility-specific performance data show wide variance amongst the facilties analyzed. Thus, the program has selected an annual target of at least a 2% increase for each facility for each of the annual clinical measures.

Evidence: By the end of FY 2006: (1) complete 100% of phased construction on time and within costs; and (2) Improve diabetic blood sugar control by 2% over the FY 2005 rate; (3) Increase pap screening by 2% over the FY 2005 rate; (4) Increase mammography screening by 2% over the FY 2005 rate; (5) Increase alcohol screening for female patients of childbearing age by 2% over the FY 2005 rate; (6) Increase coverage of childhood immunications by 2% over the FY 2005 rate; (7) Increase coverage of flu vaccinations for adults by 2% over the FY 2005 rate; (8) Increase coverage of pneumococcal vaccinations for adults by 2% over the FY 2005 rate; and (9) Increase screening for tobacco usage by 2% over the FY 2005 rate.

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: All program partners commit to and work toward the annual and long-term goals of the program. Tribes are key partners and are involved in the planning, design and construction phases. In the planning phase, tribal resolutions are required for inclusion in the Program Justification Document (PJD). Tribal representatives are also involved annually with the IHS budget formulation process. This process includes consideration of specific projects from the priority lists for inclusion in the budget request. Tribes are also involved in the development of the annual performance plan.

Evidence: The Federal Appropriation Advisory Board (FAAB) is composed of twelve Tribal representatives and two IHS members to evaluate existing facilities policies, procedures and guidelines and recommend changes to the Director of the Office of Environmental Heath and Engineering (OEHE). If the Director of OEHE denies a recommendation of the FAAB, the FAAB may ask the Director of OEHE to defer the decision to the Director of IHS. See FAAB Charter. See also, Gibson, G. Edward ,Jr. and Pappas, Michael P., Starting Smart: Key Practices for Developing Scopes of Work for Facility Projects, Federal Facilities Council Technical Report #146, The National Academies Press, Washington, DC (2003), noting "charrette-type work sessions with stakeholders".

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: Regular evaluations are conducted through Post Occupancy Evaluation Surveys (POE). After more than one and a half years of operation, a POE survey is conducted for the new facility. The POE team for each survey is composed of three members: (1) program staff; (2) health care provider at the facility; and (3) independent consultant. The POE is a standardized, multifaceted evaluation tool for building improvement and includes the evaluations of the planning, design and construction processes followed in the project. Another regular evaluation for existing and replacement facilities is the Joint Commission of Accreditation Healthcare Organizations (JCAHO) evaluations. One of the functions evaluated by JCAHO is the Management of the Environment of Care which includes buildings and equipment. One of the processes evaluated is: "Performing strategic and on-going master planning by hospital leaders for the space, clear circulation of coccupants, equipment, supportive environment, and resources needed to safely and effectively support the services provided. . ." .

Evidence: Guidelines for the POE process are contained in Chapter 23-5 of the IHS Technical Handbook for Environmental Health and Engineering. The professional program staff representing architectural, engineering, and health planning on the POE survey team could not have been involved with the project surveyed. JCAHO Management of the Environment of Care standards, rationales, elements of performance and scoring guidelines effective January 1, 2004, Pre-publication Edition. IHS has maintained JCAHO accreditation for all of its facilities. The program has also sought independent evaulations as needed. One evaluation reviewed all issues that drive space requirements, updated design criteria and created an equipment planning process. This resulted in adoption of the Health Systems Planning Process in June 1999. The program also sought an independent evaluation of its staffing formulas for planning purposes (report issued in May 2000).

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 budget requests are explicitly tied to accomplishment of the annual and long-term performance goals and are presented in a complete and transparent manner in the program's budget. This linkage is futher enhanced with the adoption of facility-specific long-term outcome measures for YPLL and improved diabetic blood sugar control and the associated annual performance measures.

Evidence: Program goals for the construction of new health care facilities are listed in the priority listing and are updated annually after the completion of the current year budget cycle and an appropriation is realized. Updates are reflected in the annual issuance of the IHS Health Care Facilities Planned Construction Budget (5-Year Plan), Congressional Justifications and OMB Form 300 for active projects.

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

Explanation:  

Evidence:  

Has the agency/program conducted a recent, meaningful, credible analysis of alternatives that includes trade-offs between cost, schedule, risk, and performance goals and used the results to guide the resulting activity?

Explanation: For each approved new health care facility project an alternative analysis comparison is completed by the IHS and the Tribe to determine the level of need for the new health care facility and the best alternative to meet these needs. For inpatient projects, a cost analysis comparing direct services with contract services is prepared to determine whether to continue inpatient services or provide a health center with outpatient services. At least three sites are evaluated to determine the best site for the facility. During the early phases of the design stage, projects are subjected to an independent value engineering analysis to ensure life cycle and sustainability principles are considered in the construction and operational budgets.

Evidence: Cost Analysis Guidance, Direct vs. Private Contract for Inpatient Services, Technical Handbook Manual. The Department of Health and Human Services has encouraged the use of the Design-Build method of construction to save money and reduce the project schedule without compromising quality. The Design-Build approach begins construction early on in the design phase and reduces the number of change orders that can result in significant project cost overruns in traditional construction projects. The program has used the Design-Build method for construction of staff quarters. The estimated cost to build 193 staff quarters in Ft. Defiance, Arizona was $38 million with a completion date set for June 2004. Actual costs for the project were $28 million, a savings of $10 million, and was completed in February 2004, four months ahead of schedule. IHS is looking for opportunities to use Design-Build for construction of outpatient clinics.

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 program uses many nationally recognized guidelines and standards to define health care facility quality, capability and performance requirements. In addition, the program has produced the Architect/Engineer Guide and the Architect/Engineer Contractor Selection Guide. All contracts issued under the Federal Acquisition Requirements (FAR) include quality and performance requirements which serve as program management tools for Project Managers to utilize to keep the projects within budget and completed on time. A Post Occupancy Evaluation (POE) is conducted after a new facility has been in operation for 1.5 years to ascertain positive and negative features and characteristics to improve the planning and design process.

Evidence: American Institute of Architects Guidelines for Design and Construction for Hospitals and Clinics, NFPA Life Safety Codes, JCAHO Accreditation Manual for Hospitals, International Building Code. The current program process ensures that health care facility needs are evaluated and updated annually. Data from the Area Master Plans will facilitate the update of health care facility needs.

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: The IHS Director's Performance Contract with the Secretary of HHS includes the goals of the IHS GPRA plan. Each of the Area Director Annual Performance Contracts includes "Performance Objective B.4. The Area Director will facilitate and support activities that enhance the physical capacity of health care facilities in the Area." and lists program activities and the respective goals. The performance appraisal systems for the program managers includes an element "for staying within the approved program and project budgets" and specific, quantifiable goals for completion of construction projects. Program partners are held accountable by virtue of the contracting process. Once costs have been identified and funding is appropriated for the project, the budget amount is "locked". Federal and Tribal Project Officers insure the contractors meet quality levels and schedule requirements specified in the contract. Each contract is issued as a firm, fixed-price or a guaranteed maximum price not to exceed that can only be increased with the approval of the Contracting Officer.

Evidence: IHS Director Performance Contract. IHS Area Director Performance Contract. IHS Performance Appraisal System for Director and Deputy Director of Division of Engineering Services. Costs, schedule and performance results are achieved in accordance with contract requirements in most of the projects. Some projects, have remaining funds that are reprogrammed and used for other needed projects.

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

Explanation: Funding for new health care facilities are appropriated annually by Congress and the funding is obligated with contracts for the design and construction of the respective health care facility. The funds are appropriated as outlined in the approved PJD and Program of Requirements (POR). A limited amount of unobligated funds is available for repogramming for other construction projects, however the unobligated funds remain with the project until the project is completed.

Evidence: Funds are dispersed to IHS Area Offices or Engineering Services to initiate design and construction. These funds are dispersed using an Advice of Allowance document with notes indicating the purpose. The Real Property Reports provide a full accounting for all new health care facility project costs. A Construction in Progress report is completed upon approval of the first requisition obligating project funds. A Final Property Report, the total project financial accounting, is completed within 30 days of completion of all construction and final acceptance being issued by the government to the contractor.

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 application of FAR requirements for direct federal construction contracts provides for competition. A Tribal contract issued under the Indian Self Determination and Education Act (ISDEA) uses similar competition requirements. Cost estimates are determined through extensive experience and the use of an automated health care facility estimating system developed specifically for the IHS health care facilities program.

Evidence: PL. 93-638 Construction Contract Information Packet. The program also utiIizes a number of project management computer applications including time reporting, scheduling, etc.

Does the program collaborate and coordinate effectively with related programs?

Explanation: IHS is a member of the Federal Facilities Council which produces practices documents for agencies to consider for their facilities program. IHS also has a number of staff who participate as members of various national code committees that review proposed code changes related to hospital and clinic construction. In addition, the IHS technical staff participate with the American Institute of Architects in the development and update of the Guidelines for Design and Construction of Hospital and Health Care Facilities.

Evidence: Under the requirements of Executive Order 12941, Seismic Safety of Existing Federally Owned or Lease Buildings, the IHS entered into an Interagency Agreement with the Bureau of Reclamation (BoR) to conduct a structural analysis/evaluation with cost estimates for for three IHS owned buildings.

Does the program use strong financial management practices?

Explanation: Funds are dispersed to IHS Area Offices or Engineering Services using an Advice of Allowance document with notes indicating the purpose. The Real Property Reports provide a full accounting for all new health care facility project costs. A Construction in Progress report is completed upon approval of the first requisition obligating project funds. The Final Property Report, the total project financial accounting, documents all financial transactions for the design and construction of the health care facility project within 30 days of completion of all construction and final acceptance being issued by the government to the contractor.

Evidence: The health care facility cost estimating application is continually updated and improved as deficiencies and updated cost information becomes available. All payments are certified by the respective Project Officer to ensure accuracy and to minimize errors. Audits of financial statements on new and replacement health care facility projects have received no material weaknesses.

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

Explanation:  

Evidence:  

Is the program managed by maintaining clearly defined deliverables, capability/performance characteristics, and appropriate, credible cost and schedule goals?

Explanation: The program has three phases of preliminary planning to establish clearly defined deliverables, performance characteristics, and credible cost and schedule goals. Phase I consists of a preliminary screening of needs by headquarters. Phase II involves headquarters validation of needs based on population and facility requirements. Phase III is the development of the project scope of work. The POR results from the enhancement of the PJD with architectural templates and layouts from each functional area. The POR is updated and revised after initial funding is provided by Congress and becomes the basis for the scope of work for design and, consequently, construction.

Evidence: IHS Health Systems Planning Process. See also, Gibson, G. Edward ,Jr. and Pappas, Michael P., Starting Smart: Key Practices for Developing Scopes of Work for Facility Projects, Federal Facilities Council Technical Report #146, The National Academies Press, Washington, DC (2003).

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

Explanation: The program is able to demonstrate progress in achieving its long-term performance goals. The program sampled replacement facilities to conduct a statistical analysis of facility-specific performance data for YPLL and blood sugar control. The data analyses generally documented improvement, though with a wide variance of achievement. In addition, previous PART analyses have noted that YPLL has been reduced and blood sugar control has increased overall for IHS.

Evidence: The increase in pre-construction and post-construction rates for YPLL at new facilities ranged from 4.9% to 19%. Similar performance and variance was identified with blood sugar control. The YPLL rate has been reduced approximately 50% between 1972-1974 and 1996-1998, and blood sugar control amongst diabetics has been increased from 22% in 1998 to 30% in 2002 overall for IHS.

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

Explanation: The program does achieve its annual performance goals. The program has performed well on its efficiency measure completing 100% of its projects on schedule and within costs in FY 2002 and FY 2003. IHS' documented performance overall on the annual goals measures can be partly attributed to program activities. However, there is limited information in terms of the clinical services measures for recently built facilities. The limitation is the result of not having the information technology capacity prior to FY 2003 to reliably measure changes in all of these clinical measures before and after facilities were completed. The new facility-specific annual performance goals will directly link the program to these outcomes once the 2005 rate is established for each facility.

Evidence: IHS FY 2005 Performance Plan, FY 2004 Revised Final Performance Plan, and FY 2003 Performance Report.

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

Explanation: The program has achieved program goals and demonstrates improved efficiencies and cost effectiveness. The program uses its licensed professional engineer and architects as Program Managers for the construction projects. The program has also used new contracting processes, design-build, for cost-effectiveness. The program has also automated its facilities planning and construction process and improved its staffing level planning methodology for more efficient and accurate planning outcomes.

Evidence: The program has reduced its staff by 58% between 1995 to 2004. As mentioned above, the program achieved savings of $10 million and completed 193 housing units over 7 months ahead of schedule in the Fort Defiance, Arizona project in 2002 using the design-build process. In May 2004, the program issued a design-build contract for 155 housing units in two locations (62 in Pinon, Arizona and 93 in Red Mesa, Arizona) which will result in savings of $11 million and completion 5 months ahead of schedule.

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

Explanation: The program compares favorably to other programs in the government and in the private sector. As mentioned above, IHS' processes for selecting projects and developing scopes of work is one of ten agencies highlighted as best practices in government in a study commissioned by the Federal Facilities Council. Like private sector health care facilities, IHS health care facilities are subjected to evaluations to secure JCAHO accreditation.

Evidence: Gibson, G. Edward ,Jr. and Pappas, Michael P., Starting Smart: Key Practices for Developing Scopes of Work for Facility Projects, Federal Facilities Council Technical Report #146, The National Academies Press, Washington, DC (2003).

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

Explanation: As mentioned above, the program is subjected to a number of independent evaulations that demonstrate it is effective and achieving results. The POE survey is utilized to validate the IHS planning methodology for health care facilities and has been used to upgrade the design criteria and construction methods for future projects. JCAHO accreditation for new health care facilities within two years of opening has found all new facilities to meet their standards.

Evidence: Guidelines for the POE process are contained in Chapter 23-5 of the HIS Technical Handbook for Environmental Health and Engineering. The professional program staff representing architectural, engineering, and health planning on the POE survey team could not have been involved with the project surveyed. JCAHO Management of the Environment of Care standards, rationales, elements of performance and scoring guidelines effective January 1, 2004, Pre-publication Edition.

Were program goals achieved within budgeted costs and established schedules?

Explanation: Program goals have been achieved within budgeted costs and established schedules. As mentioned above, the program has completed its phases of construction projects on time and within cost. In the three instances, where the program has failed to meet the established schedule, the failure can be attributed to external administrative factors. Phases of construction projects are completed within budgeted costs and increased savings have been achieved with the use of the design-build contracting process.

Evidence: The program has performed well on its efficiency measure completing 100% of its projects on schedule and within costs in 2002 and FY 2003. The program completed 71% (5 of 7 phases) and 83% (5 of 6 phases) of phases of projects on time and within costs in 2001 and 2000, respectively. The incomplete phases were completed in the subsequent year (2001 and 2002, respectively). The three projects were not completed on schedule, but within costs, and the delays were attributed to external administrative factors. In 2000, the addition of a ISDEA negotiated construction contract transferred the scheduling responsibilities to the Tribe which resulted in delays from orignial plans. In 2001, the projects not completed on schedule were the result of the implementation of two new construction processes: Joint Venture Construction Program and the Small Ambulatory Program. The program achieved savings of $10 million and completed 193 housing units in a little over 7 months ahead of schedule in the Fort Defiance, Arizona project in 2002 using the design-build process. In May 2004, the program has issued a design-build contract for 155 housing units in two locations (62 in Pinon, Arizona and 93 in Red Mesa, Arizona) which will result in savings of $11 million and completion 5 months ahead of schedule.