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.

Costs What I Get Your facility's participation fee of $4,000.00 is used to directly support the Indian Health Performance Evaluation System. This is a "cost sharing" program with each facility's fee being used to provide oversight, reporting, software development and coordination with Joint Commission ORYX ® requirements, IHS areas and tribes. The PES will provide the following activities: Program Management through a full time Program Manager for the PES Reporting of Indicators to Joint Commission ORYX ® and your health facility Indicators specific to Indian Health All technical matters related to software development, transmitting, receiving and reporting of data Coordination of new or revised indicators Provide the framework for a Quality Improvement Plan through indicators reported Improved patient reporting and reliability of data Better utilization of local staff, no additional staff needed Services Breakdown Estimated Hours Estimated Cost Initial ORYX Indicator Set-up, training, on-site 16 hours travel 40 $1385 Training, set-up on-site 24 $0 Phone support estimate 20 $692 Follow-up training, data interpretation support, on-site 40 $1385 National Users meeting 0 $0 ORYX Reporting Requirements 0 $0 Estimated total number hours to provide service 100 $3462 Travel and Per Diem Cost ? * Other Expenses Supplies $200 Sub-total 100 $3662 Administrative charge 8.26% $315 Total Participation Cost (rounded up) 100 $4000 * = Facility Responsibility

Requirements To use the Indian Health Performance Evaluation System, your health facility must be running the Resource Patient Management System (RPMS). The following software versions MUST be in place to properly report data for the PES. FileMan V21 or higher Kernel V 8 or higher PCC Management Reports V 3.0 (APCL), through patch 2 APCP V.2.0 (PCC Data Transmission) XB V 3.0 through patch 5 AIB V 3.0 must be running in the Area