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About the Performance Evaluation System (PES)
The Indian Health Performance Evaluation System was developed to
provide a mechanism within Indian Health to meet the Joint Commission
ORYX ® initiative.
The system is planned to also be utilized for the collection and
measurement of indicators to meet the requirements of the Government
Performance Results Act (GPRA). The measures within the system were
developed to be specific to Indian Health populations. Performance
measures will continue to be developed through an annual call for new
indicators from user members, clinical advisors and quality managers.
The PES will appraise the quality of care and/or services provided
by each participating facility by employing defined and measurable
indicators. The PES will be administered by the Indian Health
Service, and agency within the Department of Health and Human
Services (DHHS). The system was internally engineered by Indian
Health Service staff consisting of health providers, computer
systems analysts/programmers, statistical, epidemiology and other
health provider support.
The PES is based on the hospital, ambulatory and demographic
information being collected and entered into the IHS Resource
Patient Management System (RPMS), a full suite of software
applications for patient care at the local health facility level.
Aggregate data for the IHS will be accessed from the National
Patient Information Resource System (NPIRS) located in
Albuquerque, New Mexico. Utilizing the Statistical Analysis
System (SAS), program will be developed (1) to calculate
measurable indicators, (2) to ensure data quality and completeness,
(3) to determine statistical reliability and (4) to generated
tracking reports. Indicator rates will be calculated using defined
data elements contained in the above data source. Risk analysis
will be used, where appropriate, to ensure statistical reliability
of the outcome indicators. Results will be adjusted, where
appropriate for comparative purposes.
Reports will be electronically transmitted on a quarterly basis to
all participating facilities for comparative analysis and to the Joint
Commission for surveyor review. The information returned to the hospital
will be tracked through the Quality Council. Should results indicate
an opportunity for improvement, intensive review will be implemented
and an improvement process will be implemented. The information may
also be used to assess the education and training needs of patients and
staff, as well as to determine the accuracy and dependability of the
data system.
Data quality, including accuracy and completeness of measurement data,
is monitored at the enrolled organization by random sampling of chart
review comparing medical record documentation to data furnished by the
system. The RPMS data my be monitored by the IHS by coding audit with
an option to random sample ICD-9-CM diagnosis code or visits. This audit
searches the Patient Care Component (PCC) database for visits matching
user criteria and will select omission errors.
Education and training is provided by the PES Education Specialists.
These specialists provide initial on site training to key area staff.
The enrolled organization quality managers provide in service educations
as needed within their respective facilities.
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