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####### 

####### Indian Health Service

FY 2004 Performance Plan

FY 2003 Revised Final Performance Plan

and FY 2002 Performance Report

####### 

*January 29, 2003*

*Congressional Justification Submission*

# TABLE OF CONTENTS {#table-of-contents .Style-Heading-1Section-Title-+-Centered-Left:--0\"-First-line:--0\" .unnumbered}

[Executive Summary iii](#executive-summary)

[Table 1: Mortality Rate Disparities Continue Among AI/AN and All Races
in the IHS Service Area vii](#__RefHeading___Toc31535836)

[1.0 plan and Performance Report overview
1-1](#plan-and-performance-report-overview)

[Table 2: Performance Summary Table 1-2](#__RefHeading___Toc31535838)

[1.1 Treatment Performance Measures
1-3](#treatment-performance-measures)

[1.1.1 Diabetes Group 1-3](#diabetes-group)

[1.1.2 Oral Health Group 1-3](#oral-health-group)

[1.2 Prevention Performance Measures
1-4](#prevention-performance-measures)

[1.2.1 Developmental Prevention Group
1-4](#developmental-prevention-group)

[1.3 Consultation, Partnerships, Core Functions, and Advocacy
Performance Measures
1-4](#consultation-partnerships-core-functions-and-advocacy-performance-measures)

[1.4 Information Technology Development and GPRA
1-4](#information-technology-development-and-gpra)

[1.5 Key External Factors Influencing Success
1-5](#key-external-factors-influencing-success)

[2.0 OVERVIEW OF PERFORMANCE MEASUREMENT
2-1](#overview-of-performance-measurement)

[Table 3: Roadmap of Relationship of IHS Strategic Goals, Long Term
Outcome Goals, and Annual Performance Indicators
2-1](#__RefHeading___Toc31535852)

[2.1 Budget and Program Aggregation
2-3](#budget-and-program-aggregation)

[Table 4: Budget Category Aggregation 2-5](#__RefHeading___Toc31535854)

[2.2 Budget Category Aggregation 2-6](#budget-category-aggregation)

[Table 5: Crosswalk to FY 2004 Budget Request
2-6](#__RefHeading___Toc31535856)

[3.0 GOAL-BY-GOAL PERFORMANCE MEASUREMENT
3-1](#goal-by-goal-performance-measurement)

[3.1 Treatment and Prevention Categories
3-1](#treatment-and-prevention-categories)

[3.1.1 Program Description and Context
3-1](#program-description-and-context)

[3.1.2 Treatment Aggregation 3-1](#treatment-aggregation)

[3.1.3 Prevention Aggregation 3-2](#prevention-aggregation)

[3.1.4 Treatment Indicators 3-3](#treatment-indicators)

[Table 6: Treatment Indicators Performance Summary
3-3](#__RefHeading___Toc31535863)

[3.1.4.1 Diabetes Group: 3-10](#diabetes-group-1)

[3.1.4.2 Cancer Screening Group: 3-18](#cancer-screening-group)

[3.1.4.3 Well Child Care Indicator: 3-21](#well-child-care-indicator)

[3.1.4.4 Substance Abuse Treatment Group:
3-23](#substance-abuse-treatment-group)

[3.1.4.5 Oral Health Group: 3-26](#oral-health-group-1)

[3.1.4.6 Family Violence, Abuse, or Neglect Indicator:
3-32](#family-violence-abuse-or-neglect-indicator)

[3.1.4.7 Information Technology Development Group:
3-34](#information-technology-development-group)

[3.1.4.8 Quality of Care Indicator Group:
3-38](#quality-of-care-indicator-group)

[3.1.5 Prevention Indicators 3-41](#prevention-indicators)

[Table 7: Prevention Indicators Performance Summary
3-41](#__RefHeading___Toc31535873)

[3.1.5.1 Public Health Nursing Indicator:
3-46](#public-health-nursing-indicator)

[3.1.5.2 Immunization Group: 3-47](#immunization-group)

[3.1.5.3 Injury Prevention Group: 3-50](#injury-prevention-group-1)

[3.1.5.4 Suicide Prevention Indicator:
3-52](#suicide-prevention-indicator-1)

[3.1.5.5 Developmental Prevention and Treatment Group:
3-53](#developmental-prevention-and-treatment-group)

[3.1.5.6 HIV/AIDS Indicator: 3-56](#hivaids-indicator)

[3.1.5.7 Environmental Surveillance Indicator:
3-57](#environmental-surveillance-indicator-1)

[3.2 Capital Programming/Infrastructure Category
3-58](#capital-programminginfrastructure-category)

[3.2.1 Program Description and Context
3-58](#program-description-and-context-1)

[3.2.2 Capital Programming /Infrastructure: Performance Indicators
3-58](#capital-programming-infrastructure-performance-indicators)

[3.2.3 Capital Programming/Infrastructure Indicators
3-59](#capital-programminginfrastructure-indicators)

[Table 8: Capital Programming/Infrastructure Performance Summary
3-59](#__RefHeading___Toc31535885)

[3.2.3.1 Capital Programming /Infrastructure Group:
3-60](#capital-programming-infrastructure-group)

[3.3 Partnerships, Consultation, Core Functions, and Advocacy Category
3-65](#partnerships-consultation-core-functions-and-advocacy-category)

[3.3.1 Program Description and Context
3-65](#program-description-and-context-2)

[3.3.2 Performance Indicators 3-65](#performance-indicators)

[3.3.3 Partnerships, Consultation, Core Functions, and Advocacy
Indicators
3-66](#partnerships-consultation-core-functions-and-advocacy-indicators)

[Table 9: Consultation, Partnerships, Core Functions, and Advocacy
Indicators Performance Summary 3-66](#__RefHeading___Toc31535891)

[3.3.3.1 Consultation Improvement Indicator:
3-69](#consultation-improvement-indicator)

[3.3.3.2 Administrative Efficiency, Effectiveness, and Accountability
Group:
3-70](#administrative-efficiency-effectiveness-and-accountability-group)

[3.3.3.3 Quality of Work Life and Staff Retention Group:
3-75](#quality-of-work-life-and-staff-retention-group)

[4.0 APPENDIX 1: Linkage to HHS and Agency Strategic PlanS
4-1](#appendix-1-linkage-to-hhs-and-agency-strategic-plans)

[5.0 Appendix 2: Changes and Improvements
5-1](#appendix-2-changes-and-improvements)

[5.1 FY 2004 Performance Plan 5-1](#fy-2004-performance-plan)

[5.2 Revisions to FY 2003 Performance Plan
5-1](#revisions-to-fy-2003-performance-plan)

[Table 10: Summary of Changes to the FY 2003 IHS Performance Indicators
5-1](#__RefHeading___Toc31535899)

[6.0 APPENDIX 3: PARTNERSHIPS AND COORDINATION
6-1](#appendix-3-partnerships-and-coordination)

[6.1 Program Coordination By Partners Within DHHS
6-1](#program-coordination-by-partners-within-dhhs)

[6.2 Collaboration With Other Federal Agencies
6-5](#collaboration-with-other-federal-agencies)

[6.3 Injury Prevention 6-5](#injury-prevention)

[7.0 Appendix 4: Data Verification and Validation
7-1](#appendix-4-data-verification-and-validation)

[7.1 Data Sources to Describe the American Indian and Alaska Native
Population
7-1](#data-sources-to-describe-the-american-indian-and-alaska-native-population)

[7.2 IHS Automated Data Systems 7-2](#ihs-automated-data-systems)

[7.3 IHS Diabetes Care and Outcomes Audit
7-3](#ihs-diabetes-care-and-outcomes-audit)

[8.0 Appendix 5: Performance Measurement Linkages
8-1](#appendix-5-performance-measurement-linkages)

[8.1 Performance Measurement Linkages with Budget
8-1](#performance-measurement-linkages-with-budget)

[8.2 Cost Accounting 8-1](#cost-accounting)

[8.3 Human Resources 8-2](#human-resources)

[8.4 Capital Planning 8-3](#capital-planning)

[8.5 Program Evaluation 8-3](#program-evaluation)

[8.6 Summary of Select Evaluations Activities
8-4](#summary-of-select-evaluations-activities)

[8.7 New Directions for Evaluation 8-5](#new-directions-for-evaluation)

#   {#section-2 .unnumbered}

# Executive Summary

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.*

The Indian Health Service (IHS) is the Operating Division (OPDIV) within
the Department of Health and Human Services (HHS) that carries out the
federal government's trust responsibility to provide health care
services to eligible American Indian and Alaska Native people. IHS
provides these health services through a network of 594 healthcare
facilities, including 49 hospitals, 219 ambulatory clinics, 309 health
stations, 15 school-based clinics and numerous Alaskan village clinics.
These facilities provide direct health care services to over 1.4 million
American Indian and Alaska Native people; many of these people live in
isolated areas where there is no access to health services other than
those offered by IHS or tribally operated programs. Until the mid 1990s,
IHS operated most of these facilities and programs as federal programs.
However, IHS has long advocated for and supported the federal policy of
Indian self-determination. Because of this commitment, currently over
50% of the Indian health system is operated directly by tribal
governments. In addition to these tribally operated programs, IHS has
contracts with 34 urban Indian organizations to provide services to
eligible Indian people who reside in large metropolitan areas.

IHS, tribal and urban (I/T/U) programs offer comprehensive in-hospital
and ambulatory services for Indian people. However, there are many
occasions where patients must be referred to hospitals or specialists
who are not part of the I/T/U system. The costs for these services are
covered through the Contract Health Services (CHS) appropriation,
representing approximately 17% of the IHS budget in FY 2003. These
services are available to the IHS and tribal programs, but not to the
urban programs. The IHS and tribal programs utilize negotiated contracts
with these hospitals and specialists in an attempt to provide the most
efficient use of these limited funds. However, most of the health
programs deplete their CHS funds prior to the end of the fiscal year.

Since 1955, the IHS has demonstrated the ability to utilize limited
resources to improve the health status of the American Indian and Alaska
Native people by focusing on preventive and primary care services. The
development and implementation of a community-based, public health model
has lead to significant improvements in the health status of American
Indian and Alaska Native people. Examples can be seen in the dramatic
decreases in mortality rates for certain health problems between 1972-74
and 1997-99:

-   Maternal mortality reduced 79% (31.6 to 6.7 per 100,000);

-   Tuberculosis mortality reduced 86% (10.7 to 1.5 per 100,000);

-   Gastrointestinal disease mortality reduced 72% (6.7 to 1.9 per
    100,000);

-   Infant mortality reduced 65% (25.0 to 8.8 per 1,000 live births);
    and

-   Unintentional injuries mortality reduced 54% (206.7 to 95.1 per
    100,000).

These changes are even more significant when one considers that IHS
achieved these improved outcomes despite the following:

-   IHS receives lower per capita funding than the average Medicaid
    patient;

-   IHS has higher costs for health care due to increased disease burden
    and lack of access;

-   Provider recruitment and retention problems limit the availability
    of providers (e.g., half the physicians and nurses per capita as the
    general population);

-   Facilities are lacking or inadequate in numerous locations (i.e.,
    the average age of IHS facilities is 32 years in comparison to 9
    years for the private sector); and

-   High unemployment, poverty, lack of education, substandard housing,
    and other social determinants of health lead to poor health status.

However, an increasing demand for urgent care services, coupled with a
consistent 1.7% increase in user population, has resulted in a decreased
ability to provide comprehensive preventive and clinical services to the
American Indian and Alaska Native population. The overall outpatient
visits steadily increased until 1999 when the limits in our ability to
serve more patients appear to have been met as evident in the following
chart:

![](media/image3.wmf){width="5.524305555555555in" height="2.875in"}

While the IHS public health model has been effective in eliminating
certain infectious diseases, improving maternal and child health and
increasing access to clean water and sanitation, the problems facing
Indian people and communities today are very different from those that
existed historically. The health problems in American Indian and Alaska
Native communities today mirror the health problems confronting U.S.All
Races. These problems include obesity, substance abuse, lack of
exercise, tobacco dependence, and violence. The impact of these
conditions in American Indian and Alaska Native populations is reflected
in increased disease burden and decreased life expectancy. These often
lead to the development of chronic diseases that require costly
long-term treatment such as cardiovascular disease, diabetes (including
kidney disease, dialysis, and blindness), liver disease, cancer, and
injuries.

In addition, the recent fully analyzed and racially adjusted mortality
data (FY 1999) available from the National Center for Health Statistics
documents an overall 4.5% increase in death rate for American Indian and
Alaska Native people from 698.4 per 100,000 population for the period
1994 to 1996 to 730.1 per 100,000 population for the period 1997 to
1999. See Table 1 on pages viii and ix for disease specific information.

While a community based, public health oriented program provided a cost
effective positive impact on health status when the health problems were
more clearly linked to disease processes prevalent many years ago, this
model has yet to be adapted to the more recent behavioral and lifestyle
issues, which face IHS today. Implementing the types of prevention and
patient education programs that are needed, while continuing to provide
high quality medical services to a population that has a
disproportionate amount of chronic medical diseases, will require
additional resources that are not currently available to IHS.

Despite these challenges, IHS has shown that, with additional resources,
the I/T/U system can produce measurable improvements in the health
status of the American Indian and Alaska Native population. An excellent
example of this is the current Special Diabetes Program for Indians
(SDPI). There has been a clear trend in improvement in the services that
are provided to the diabetic patients. In fact, the I/T/U system has
already far exceeded the Healthy People 2010 target of 50% for annual
HgbA1c screening. In addition, there has been a steady increase in the
percent of American Indian and Alaska Native diabetic patients whose
HgbA1c is less than 7.0. (reflecting ideal blood sugar control) See
graphs below.

![](media/image4.wmf){width="2.8541666666666665in"
height="1.8958333333333333in"}

This is significant because current literature states that a decrease of
1.0 in HgbA1c levels achieves the following:

-   14% decrease in mortality;

-   43% decrease in amputations;

-   24% decrease in renal failure; and

-   \$800 decrease in annual health care costs.

These data show that the ITU system can be effective when new funding is
available and targeted to specific health problems.

Within this document, the initial FY 2004 and revised final FY 2003
Performance Plans have merged with the FY 2002 Performance Report
consistent with the required format developed with the Department of
Health and Human Services. It presents a strategic set of performance
indicators intended to approach the growing health disparities between
the American Indian and Alaska Native population and the rest of the US
population (see chart below). However, achieving these performance
targets will be insufficient in reversing the worsening health status of
American Indian and Alaska Native people. Health disparities between
American Indian and Alaska Native's and the US population in general are
unlikely to improve unless additional resources become available to
target these ongoing disparities.

[IHS GPRA Contact:]{.underline}

Theresa Cullen, MD, MS

Planning and Evaluation

Office of Program Support/Office of Public Health

Phone: (301) 443-1549

Fax: (301) 443-0114

[]{#__RefHeading___Toc31535836 .anchor}Table 1: Mortality Rate
Disparities Continue Among AI/AN and All Races\
in the IHS Service Area

![](media/image6.wmf) ![](media/image7.wmf)

![](media/image8.wmf) ![](media/image9.wmf)

![](media/image10.wmf) ![](media/image11.wmf)

# plan and Performance Report overview

This performance plan outlines the incremental steps necessary to
achieve our Strategic Goals and our Mission. The Strategic Goals provide
the framework for key long-term outcome goals that are addressed through
the performance indicators in this plan. The performance indicators in
turn address the most significant health problems facing the American
Indian and Alaska Native population as identified by representatives of
the local I/T/U programs as well as management areas of the President\'s
Management Agenda.

**Strategic Goal 1 is to Build Healthy Communities.** Health care is
significantly determined at the community level; lifestyles established
at that level profoundly influence health. The application of
collaborative public health models remains critical to the development
of healthy communities. These public health models can help empower
communities to identify their own health problems as well as actively
involve them in developing the solutions.

**Strategic Goal 2 is to Achieve Parity in Access by 2010.** Achieving
parity in access to essential health care services is essential. This
requires a focused advocacy effort coordinated across an expanded Indian
health network. It also requires improving efficiencies, increasing
collections, and tapping alternative revenue streams across I/T/Us. It
requires appropriate organizational capacity and expertise within the
Indian Health System.

**Strategic Goal 3 is to Provide Compassionate, Quality Health Care.**
Improving the quality, safety, effectiveness, and acceptability of
comprehensive, culturally appropriate health care for American Indian
and Alaska Natives remains a management priority. An adequate
information technology infrastructure helps ensure access to safe,
evidence-based standards of care as well as health information to
providers and consumers.

**Strategic Goal 4 is to Embrace Innovation.** The IHS can only achieve
the previous three goals by embracing innovation. The IHS must develop a
more a proactive and entrepreneurial corporate culture, and expand
partnerships and coalitions to expand the Indian health network. This
requires the IHS to improve its coordination and communications capacity
and support the development of new structures, which can assist the
Indian health network advocacy efforts in multiple dimensions.

Each of these Goals has one or more long-term outcomes identified with
specific targets for specific timeframes; the funding resources
necessary to achieve these goals are described in the budget request.
This current budget request allows for continued access to basic health
services as well as prevention activities. Indicators addressing
prevention activities and pilot projects offer the potential to reduce
American Indian and Alaska Native health disparities.

[]{#__RefHeading___Toc31535838 .anchor}**Table 2: Performance Summary
Table**

+-----+---------------------+-------------+-------------+-----------+
| FY  | Measures in Plan by | Results     | Results Met | U         |
|     | Budget Category     | Reported    |             | nreported |
|     |                     |             | Completely  |           |
+-----+---------------------+-------------+-------------+-----------+
| 1   | Treatment - 17      | 17          | 12          |           |
| 999 |                     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Prevention - 3      | 3           | 1           |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Capital             | 3           | 2           |           |
|     | Programming/        |             |             |           |
|     | Infrastructure - 3  |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Consultation,       | 4           | 3           |           |
|     | Partnerships, Core  |             |             |           |
|     | Functions,          |             |             |           |
|     | Advocacy - 4        |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Total - 27          | 27          | 18          | 0         |
+-----+---------------------+-------------+-------------+-----------+
| 2   | Treatment - 18      | 18          | 13          |           |
| 000 |                     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Prevention - 8      | 7           | 4           | 1         |
+-----+---------------------+-------------+-------------+-----------+
|     | Capital             | 3           | 2           |           |
|     | Programming/        |             |             |           |
|     | Infrastructure - 3  |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Consultation,       | 5           | 4           |           |
|     | Partnerships, Core  |             |             |           |
|     | Functions,          |             |             |           |
|     | Advocacy - 5        |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Total - 34          | 33          | 23          | 1         |
+-----+---------------------+-------------+-------------+-----------+
| 2   | Treatment - 19      | 19          | 13          |           |
| 001 |                     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Prevention - 11     | 10          | 6           | 1         |
+-----+---------------------+-------------+-------------+-----------+
|     | Capital             | 3           | 2           |           |
|     | Programming/        |             |             |           |
|     | Infrastructure - 3  |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Consultation,       | 4           | 3           | 1         |
|     | Partnerships, Core  |             |             |           |
|     | Functions,          |             |             |           |
|     | Advocacy - 5        |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Total - 38          | 36          | 24          | 2         |
+-----+---------------------+-------------+-------------+-----------+
| 2   | Treatment - 21      | 15          | 13          | 6         |
| 002 |                     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Prevention - 12     | 11          | 9           | 1         |
+-----+---------------------+-------------+-------------+-----------+
|     | Capital             | 2           | 2           | 0         |
|     | Programming/        |             |             |           |
|     | Infrastructure - 2  |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Consultation,       | 4           | 2           | 1         |
|     | Partnerships, Core  |             |             |           |
|     | Functions,          |             |             |           |
|     | Advocacy - 5        |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Total - 40          | 32          | 25          | 9         |
+-----+---------------------+-------------+-------------+-----------+
| 2   | Treatment - 21      |             |             |           |
| 003 |                     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Prevention - 12     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Capital             |             |             |           |
|     | Programming/        |             |             |           |
|     | Infrastructure - 2  |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Consultation,       |             |             |           |
|     | Partnerships, Core  |             |             |           |
|     | Functions,          |             |             |           |
|     | Advocacy - 6        |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Total - 41          |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
| 2   | Treatment -- 20     |             |             |           |
| 004 |                     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Prevention - 12     |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Capital             |             |             |           |
|     | Programming/        |             |             |           |
|     | Infrastructure - 2  |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Consultation,       |             |             |           |
|     | Partnerships, Core  |             |             |           |
|     | Functions,          |             |             |           |
|     | Advocacy - 6        |             |             |           |
+-----+---------------------+-------------+-------------+-----------+
|     | Total - 40          |             |             |           |
+-----+---------------------+-------------+-------------+-----------+

The FY 2002 performance report highlights several noteworthy
accomplishments as well as conveys the challenges and difficulties faced
by the I/T/U programs in achieving these measures. A few are presented
here as representative of the overall report.

## Treatment Performance Measures

### Diabetes Group

IHS has been cited as a model of community involvement and program
effectiveness for the use of the IHS *Diabetes Care and Outcome Audit*
to measure diabetes care in American Indian and Alaska Native
communities. The Diabetes Care Audit assesses diabetes care and
education for approximately 85,000 IHS diabetes patients. These measures
are incorporated into the National Council on Quality Assurance/American
Diabetes Association proposal for national performance benchmarks for
diabetes care.

IHS chose four of these audit measures as GPRA performance goals; all
four clinical measures were met in 2001. Trends from the 2001 audit data
indicate a continued improvement in these indicators including blood
sugar control, assessment for early diabetic kidney disease, LDL
cholesterol evaluation and diabetic blood pressure control.

The IHS National Diabetes Program attributes these clinical improvements
to the extensive commitment that IHS and local communities have made to
improve diabetes control. Blood sugar control, in particular, has been
shown in large clinical trials to reduce the complications of diabetes
over time and to save money. The IHS National Diabetes Program is
encouraging programs to use the new diabetes funding to continue to
enhance their clinical care programs as well as their prevention
projects.

### Oral Health Group

Indicators #12, 13, and 14 provide a measure of three aspects of the
dental program that collectively have the potential to affect oral
health outcomes. Access to dental care (Indicator #13) is strongly
associated with oral health. Periodic examinations allow for the
detection and treatment of dental disease. Addressing overall access to
dental care remains the dental programs greatest challenge. It is worth
noting that the national average for access to dental has stood at just
over 60% for several years. Access to dental care within IHS increased
to 27% in 2002, enabling us to meet our GPRA indicator. Access remains a
continued priority for the IHS.

The benefits of water fluoridation and dental sealants (Indicators #12
and #14) are well documented. Both are proven to prevent dental decay
and are associated with significant decreases in individual disease.
These indicators provide a valid estimate of the effectiveness of a
dental public health program. In 2002, there was an increase of 7.2% in
dental sealants -- meeting our GPRA goal. However, access to
fluoridation only increased by 1%; we had hoped for a 5% increase. As a
result, the Office of Environmental Health and the Headquarters Division
of Oral Health are developing a new centralized effort to promote
fluoridation in Indian communities.

## Prevention Performance Measures

### Developmental Prevention Group

Indicators 30-32 are collaborative pilot projects with tribes and
outside organizations to address cardiovascular disease, obesity, and
tobacco control respectively. All 2002 targets were achieved. For FY
2002 and beyond, the indicators addressing obesity and tobacco control
have evolved into global IHS-wide efforts. Effective programs that
address these problems are critical to effective prevention and improved
health status in American Indian and Alaska Native communities.

## Consultation, Partnerships, Core Functions, and Advocacy Performance Measures

For FY 2002, two of these five indicators were fully accomplished and
one was partially accomplished. In addition, one indicator was not met
and one will not be reported until later this fiscal year. The partially
achieved indicator addressed improving tribal consultation (Indicator
39) and the completely achieved indicators addressed developing cost
accounting capacity (Indicator 42), and developing protocols to support
the efficient, effective and equitable transfer of management of health
programs to tribes submitting proposals or letters of intent to contract
or compact IHS programs under the Indian Self-Determination Act
(Indicator 44). These all represent critical internal management
functions that significantly contribute to our Mission.

The single unachieved indicator for FY 2002 was improving our Human
Resource Management (HRM) Index employee survey score by one point to
97. This goal was not met with a FY 2002 score remaining at 96 as has
since 2000. This lack of progress is attributed to continued recruitment
issues for health care providers in many clinical settings, putting
considerable strain on current IHS staff.

## Information Technology Development and GPRA

The IHS health information system provides user-friendly tools to
facilitate tracking and improving direct patient care at the local
sites; they also facilitate health data aggregation that is transparent
to the end user. Reporting on GPRA indicators is dependent upon this
reliable health information system. This system, RPMS (Resource Patient
Management System), supports and facilitates the integration of
clinical, administrative, and financial data at more than 80% of Indian
health system healthcare facilities. The Patient Care Component of the
RPMS is an automated system for the collection, storage, and output of
data gathered at the point of patient contact in the outpatient,
inpatient, and field visit settings. The National Patient Information
Resource System (NPIRS) database includes data from both facilities
using RPMS as well as those using other Health Information systems. This
national data is used to generate data for many of the IHS GPRA clinical
indicators. Ongoing improvements include additional software
development, as well as the development and deployment of a graphical
user interface system.

Indian Health Service has developed and deployed a new software
application (GPRA+ Clinical Performance Indicator System) that is
designed to extract GPRA clinical indicator information from the RPMS
system. This application facilitates local, as well as regional,
compilation of clinical GPRA indicator results. The application allows a
provider to track their own performance based upon the GPRA clinical
indicators (similar to the use of HEDIS by individual providers). In
addition, this application allows the local site to do facility and area
data aggregation using a site-specified time period.

IHS obtains data for most clinical indicators using electronic queries
on current FY 2002 data. Automating extraction of data in this way
allows IHS to add new performance measures in the most cost-effective
way, without imposing additional data collection burdens on health care
staff. A data warehouse is being implemented to ensure accurate user
population information as well as clinical data.

## Key External Factors Influencing Success

A variety of external factors continue to influence our success in
achieving our performance goals. Both external and internal factors
affect our outcomes.

### The Role of Poverty

Socioeconomic determinants of health for both acute and chronic
conditions have been documented worldwide. In fact, many of the racial
and ethnic disparities in health status disappear when analyses control
for education and socioeconomic status. While increasing access to
comprehensive health services over time will reduce both mortality and
morbidity to some degree in American Indian and Alaska Native
communities, health services alone are not likely to eliminate the huge
health disparity gap that now exists, unless the other complex factors
contributing to poverty are also addressed. Poor health status should be
viewed as both a cause and an effect of poverty.

### A Lack of Cost-Effective Interventions for Chronic Diseases 

Prevention, diagnosis and treatment of diseases such as obesity,
alcoholism, diabetes, and cancer are extremely costly. The IHS is funded
at approximately \$1400 per person per year with Medicare/Medicaid,
private insurance collections and out of pocket expenditures adding an
estimated \$500-700 more. Thus, American Indian and Alaska Native people
are funded at approximately \$2000 per person annually compared to
almost \$4000 for the U.S.general population. In communities where the
diabetes prevalence is approaching 40-50 percent, the entire available
per capita funding could be completely consumed in treating diabetes,
leaving no resources for clinical management of alcoholism, cancer,
injuries, oral health, prenatal care, and well-baby/immunizations to
name only a few.

### Third Party Collections

The IHS is committed to the identification of available alternate
resources and full optimization of third party collections for delivery
of health care services. IHS has significantly increased its third party
collections, because of higher negotiated Medicare and Medicaid rates,
new authority to bill under CHIP and more efficient business management
practices involving patient eligibility determination, documentation of
services and processing of claims. These increases have been critical to
the I/T/Us ability to meet increasingly demanding accreditation and
quality standards and maintain access to services in the face of growing
health demands driven by population growth and increasing health
disparities. Third-party collections contribute to many performance
measures and are considered in a general way in setting performance
targets.

### Recruitment and Retention of Health Care Providers

Vacancy rates for some health care providers are at the highest level in
IHS history and are directly related to difficulties in recruitment and
retention of these providers. External factors include the growing debt
levels for health professionals leaving school, and relative shortages
of certain health professionals. Internal factors include isolation,
lack of amenities in many reservation settings, limited spousal
employment opportunities, as well as limited access to consultants and
diminished professional support from IHS Headquarters.

Collectively these trends and associated reductions in career
development and training opportunities appear to have resulted in
ongoing issues with recruitment and retention.

# OVERVIEW OF PERFORMANCE MEASUREMENT

Table 3 outlines the relationship between the IHS Strategic Plan's four
broad Strategic Goals, their supporting long-term outcome goals, and the
FY 2004 performance indicators. Annual performance indicators contribute
to the realization of the long-term outcome goals that serve as the
progress measures for the IHS Strategic Goals.

[]{#__RefHeading___Toc31535852 .anchor}Table 3:\
Roadmap of Relationship of IHS Strategic Goals, Long Term Outcome
Goals,\
and Annual Performance Indicators

+-----------------+-----------------+---------------------+-----------+
| IHS Strategic   | Long Term       | Annual Performance  | Budget    |
| Goals           | Outcome Goals   | Indicators          | Category  |
+=================+=================+=====================+===========+
| GOAL 1: BUILD   | By 2010 we will | -   Indicator 3:    | Treatment |
| HEALTHY         | decrease years  |     Diabetic Blood  |           |
| COMMUNITIES     | of productive   |     Pressure        |           |
|                 | life lost       |     Control         |           |
|                 | (YPLL) by 20%   |                     |           |
|                 | over the 2002   | -   Indicator 4:    |           |
|                 | level.          |     Diabetic Lipid  |           |
|                 |                 |     Screening       |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 5:    |           |
|                 |                 |     Diabetic Kidney |           |
|                 |                 |     Disease         |           |
|                 |                 |     Screening       |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 7:    |           |
|                 |                 |     Pap Screening   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 8:    |           |
|                 |                 |     Mammography     |           |
|                 |                 |     Screening       |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 16:   |           |
|                 |                 |     Domestic        |           |
|                 |                 |     Violence        |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 23:   | P         |
|                 |                 |     Public Health   | revention |
|                 |                 |     Nursing visits  |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 24:   |           |
|                 |                 |     Children's      |           |
|                 |                 |     Immunizations   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 25:   |           |
|                 |                 |     Adult Influenza |           |
|                 |                 |     Immunizations   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 26:   |           |
|                 |                 |     Adult           |           |
|                 |                 |     Pneumococcal    |           |
|                 |                 |     Immunizations   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 27:   |           |
|                 |                 |     Injury          |           |
|                 |                 |     Prevention      |           |
|                 |                 |     Projects        |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 28:   |           |
|                 |                 |     Reduce          |           |
|                 |                 |     Unintentional   |           |
|                 |                 |     Injury          |           |
|                 |                 |     Mortality Rates |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 29:   |           |
|                 |                 |     Suicide         |           |
|                 |                 |     Surveillance    |           |
|                 |                 |     System          |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 30:   |           |
|                 |                 |     Cardiovascular  |           |
|                 |                 |     Disease         |           |
|                 |                 |     Prevention      |           |
|                 |                 |     Programs        |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 32:   |           |
|                 |                 |     Tobacco Control |           |
|                 |                 |     Plan            |           |
+-----------------+-----------------+---------------------+-----------+
|                 | By 2010 we will | -   Indicator 31:   | P         |
|                 | decrease        |     Obesity         | revention |
|                 | obesity rates   |     Prevention and  |           |
|                 | for children by |     Control Plan    |           |
|                 | 10% over the    |                     |           |
|                 | 2002 rate.      |                     |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | Other Annual        | Treatment |
|                 |                 | Milestones for      |           |
|                 |                 | Strategic Goal 1:   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 1:    |           |
|                 |                 |     Diabetes        |           |
|                 |                 |     Prevalence      |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 10:   |           |
|                 |                 |     Youth Regional  |           |
|                 |                 |     Treatment       |           |
|                 |                 |     Centers         |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 11:   |           |
|                 |                 |     FAS Protocols   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 12:   |           |
|                 |                 |     Water           |           |
|                 |                 |     Fluoridation    |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 16:   |           |
|                 |                 |     Domestic        |           |
|                 |                 |     Violence        |           |
|                 |                 |                     |           |
|                 |                 |   Training/Policies |           |
|                 |                 |     and Procedures  |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 35:   | P         |
|                 |                 |     Environmental   | revention |
|                 |                 |     Health Systems  |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 41:   | Cons      |
|                 |                 |     Assess Public   | ultation, |
|                 |                 |     Health          | Part      |
|                 |                 |     Infrastructure  | nerships, |
|                 |                 |                     | Core      |
|                 |                 |                     | F         |
|                 |                 |                     | unctions, |
|                 |                 |                     | and       |
|                 |                 |                     | Advocacy  |
+-----------------+-----------------+---------------------+-----------+
| GOAL 2: ACHIEVE | By 2010 we will | -   Indicator 14:   | Treatment |
| PARITY IN       | assure 70% of   |     Dental Sealants |           |
| ACCESS BY 2010  | AI/AN children  |                     |           |
|                 | receive dental  |                     |           |
|                 | sealants.       |                     |           |
+-----------------+-----------------+---------------------+-----------+
|                 | By 2010 we will | -   Indicator 24:   | P         |
|                 | increase        |     Childhood       | revention |
|                 | childhood       |     Immunizations   |           |
|                 | immunization    |                     |           |
|                 | rates to 95%.   |                     |           |
+-----------------+-----------------+---------------------+-----------+
|                 | By 2010 we will | -   Indicator 2:    | Treatment |
|                 | assure that 40% |     Diabetic Blood  |           |
|                 | of AI/AN        |     Sugar Control   |           |
|                 | diabetics       |                     |           |
|                 | achieve         |                     |           |
|                 | \"ideal\" blood |                     |           |
|                 | sugar control.  |                     |           |
+-----------------+-----------------+---------------------+-----------+
|                 | By 2010 we will | -   Indicator 37:   | Capital   |
|                 | assure that 94% |     Sanitation      | Pro       |
|                 | of AI/AN homes  |     Facilities      | gramming/ |
|                 | have safe and   |                     | Infra     |
|                 | adequate        |                     | structure |
|                 | sanitation      |                     |           |
|                 | facilities.     |                     |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | Other Annual        | Treatment |
|                 |                 | Milestones for      |           |
|                 |                 | Strategic Goal 2:   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 13:   |           |
|                 |                 |     Access to       |           |
|                 |                 |     Dental Services |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 15:   |           |
|                 |                 |     Diabetic Access |           |
|                 |                 |     to Dental       |           |
|                 |                 |     Services        |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 23:   | P         |
|                 |                 |     Public Health   | revention |
|                 |                 |     Nursing         |           |
|                 |                 |     Services        |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 38:   | Capital   |
|                 |                 |     Construction of | Pro       |
|                 |                 |     Health Care     | gramming/ |
|                 |                 |     Facilities      | Infra     |
|                 |                 |                     | structure |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 40:   | Cons      |
|                 |                 |     CHS Rate        | ultation, |
|                 |                 |     Agreements      | Part      |
|                 |                 |                     | nerships, |
|                 |                 | -   Indicator 43:   | Core      |
|                 |                 |     M/M Compliance  | F         |
|                 |                 |     Plans           | unctions, |
|                 |                 |                     | and       |
|                 |                 | -   Indicator 46:   | Advocacy  |
|                 |                 |     Nurse Retention |           |
+-----------------+-----------------+---------------------+-----------+
| GOAL 3: PROVIDE | By 2010 we will | -   Indicator 20:   | Treatment |
| COMPASSIONATE,  | assure that at  |     Accreditation   |           |
| QUALITY HEALTH  | least 90% of    |     of Facilities   |           |
| CARE            | the AI/AN       |                     |           |
|                 | consumers       | -   Indicator 22:   |           |
|                 | receiving       |     Consumer        |           |
|                 | health care in  |     Satisfaction    |           |
|                 | IHS facilities  |                     |           |
|                 | perceive it to  |                     |           |
|                 | be good, very   |                     |           |
|                 | good, or        |                     |           |
|                 | excellent while |                     |           |
|                 | maintaining     |                     |           |
|                 | 100%            |                     |           |
|                 | accreditation.  |                     |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | Other Annual        | Treatment |
|                 |                 | Milestones for      |           |
|                 |                 | Strategic Goal 3:   |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 6:    |           |
|                 |                 |     Diabetic        |           |
|                 |                 |     Retinopathy     |           |
|                 |                 |     Screening       |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 17:   |           |
|                 |                 |     Local Data      |           |
|                 |                 |     Quality         |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 18:   |           |
|                 |                 |     Expand Use of   |           |
|                 |                 |     Behavioral      |           |
|                 |                 |     Health Data     |           |
|                 |                 |     System          |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 19:   |           |
|                 |                 |     Expand I/T/U    |           |
|                 |                 |     use of          |           |
|                 |                 |     RPMS-Compatible |           |
|                 |                 |     Systems         |           |
|                 |                 |                     |           |
|                 |                 | -   Indicator 21:   |           |
|                 |                 |     Implement       |           |
|                 |                 |     Medication      |           |
|                 |                 |     Error Reporting |           |
|                 |                 |     System          |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 34:   | P         |
|                 |                 |     HIV/AIDS        | revention |
|                 |                 |     Prevention      |           |
|                 |                 |     Education at    |           |
|                 |                 |     Prenatal        |           |
|                 |                 |     Evaluations     |           |
+-----------------+-----------------+---------------------+-----------+
|                 |                 | -   Indicator 44:   | Cons      |
|                 |                 |     Contract        | ultation, |
|                 |                 |     Support Cost    | Part      |
|                 |                 |     Protocols       | nerships, |
|                 |                 |                     | Core      |
|                 |                 |                     | F         |
|                 |                 |                     | unctions, |
|                 |                 |                     | and       |
|                 |                 |                     | Advocacy  |
+-----------------+-----------------+---------------------+-----------+
| GOAL 4: EMBRACE | By 2010, the    | -   Indicator 39:   | Cons      |
| INNOVATION      | work of the     |     I/T/U           | ultation, |
|                 | Indian health   |     Satisfaction    | Part      |
|                 | network will    |     with            | nerships, |
|                 | result in the   |     Consultation    | Core      |
|                 | per capita      |     Policy          | F         |
|                 | funding         |                     | unctions, |
|                 | available for   |                     | and       |
|                 | health care for |                     | Advocacy  |
|                 | AI/AN people to |                     |           |
|                 | be comparable   |                     |           |
|                 | to the US All   |                     |           |
|                 | Races level.    |                     |           |
+-----------------+-----------------+---------------------+-----------+

*NOTE: Indicators 9, 33, 36, 42, and 45 have been discontinued for FY
2004.*

## Budget and Program Aggregation

Table 3 above relates our performance measures to our budget. We have
selected four functional areas for the aggregation of the 24 budget
categories identified in the IHS Detail of Changes Table: 1) Treatment,
2) Prevention, 3) Capital Programming/Infrastructure, and 4)
Consultation, Partnerships, Core Functions, and Advocacy.

Most chronic diseases such as diabetes, obesity, injuries, and family
violence, require multidisciplinary interventions to be successful. In
such cases, there may be several providers, as well as health programs
and funding categories, simultaneously addressing these health problems.
Moreover, tribal programs, which now manage over 50% of the total IHS
budget, have the legal flexibility to reprogram funding categories to
meet their identified health priorities and likewise use an accounting
tailored to their needs and preferences. As a result, with the exception
of the facilities construction category, tribes tend to use resources
based on individual tribal priorities; consequently, the link between
named categories in the IHS budget and how the funds actually are used
in tribal programs may not be highly correlated.

Thus, for tribal programs, the aggregation issue is probably moot. For
IHS managed programs, aggregation of budget categories that not only
splits out activities and funding sources but also allows a valid cost
accounting link to health outcomes cannot be provided. In such cases,
the accounting link can go no farther than services.

All of these categories are important in accomplishing the mission of
the IHS. Table 4 below shows the relationship between the funding
categories in IHS Detail of Changes Table and the appendix of the
"Budget of the United States" and our GPRA aggregation. A brief
explanation of the components of each aggregation category precedes each
set of performance indicators.

[]{#__RefHeading___Toc31535854 .anchor}Table 4:\
Budget Category Aggregation

+---+---+--------------+---+---+----------------+---+---+------------------------+
| [ |   |              |   | [ |                |   | [ |                        |
| I |   |              |   | A |                |   | G |                        |
| N |   |              |   | P |                |   | P |                        |
| D |   |              |   | P |                |   | R |                        |
| I |   |              |   | E |                |   | A |                        |
| A |   |              |   | N |                |   | A |                        |
| N |   |              |   | D |                |   | G |                        |
| H |   |              |   | I |                |   | G |                        |
| E |   |              |   | X |                |   | R |                        |
| A |   |              |   | ] |                |   | E |                        |
| L |   |              |   | { |                |   | G |                        |
| T |   |              |   | . |                |   | A |                        |
| H |   |              |   | u |                |   | T |                        |
| S |   |              |   | n |                |   | I |                        |
| E |   |              |   | d |                |   | O |                        |
| R |   |              |   | e |                |   | N |                        |
| V |   |              |   | r |                |   | ] |                        |
| I |   |              |   | l |                |   | { |                        |
| C |   |              |   | i |                |   | . |                        |
| E |   |              |   | n |                |   | u |                        |
| ] |   |              |   | e |                |   | n |                        |
| { |   |              |   | } |                |   | d |                        |
| . |   |              |   | \ |                |   | e |                        |
| u |   |              |   | B |                |   | r |                        |
| n |   |              |   | u |                |   | l |                        |
| d |   |              |   | d |                |   | i |                        |
| e |   |              |   | g |                |   | n |                        |
| r |   |              |   | e |                |   | e |                        |
| l |   |              |   | t |                |   | } |                        |
| i |   |              |   | o |                |   | \ |                        |
| n |   |              |   | f |                |   | i |                        |
| e |   |              |   | t |                |   | t |                        |
| } |   |              |   | h |                |   | e |                        |
| \ |   |              |   | e |                |   | m |                        |
| D |   |              |   | U |                |   | s |                        |
| e |   |              |   | n |                |   | f |                        |
| t |   |              |   | i |                |   | r |                        |
| a |   |              |   | t |                |   | o |                        |
| i |   |              |   | e |                |   | m |                        |
| l |   |              |   | d |                |   | l |                        |
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| f |   |              |   | t |                |   | f |                        |
| C |   |              |   | a |                |   | t |                        |
| h |   |              |   | t |                |   | c |                        |
| a |   |              |   | e |                |   | o |                        |
| n |   |              |   | s |                |   | l |                        |
| g |   |              |   |   |                |   | u |                        |
| e |   |              |   | i |                |   | m |                        |
| T |   |              |   | t |                |   | n |                        |
| a |   |              |   | e |                |   |   |                        |
| b |   |              |   | m |                |   |   |                        |
| l |   |              |   | s |                |   |   |                        |
| e |   |              |   | f |                |   |   |                        |
|   |   |              |   | r |                |   |   |                        |
|   |   |              |   | o |                |   |   |                        |
|   |   |              |   | m |                |   |   |                        |
|   |   |              |   | l |                |   |   |                        |
|   |   |              |   | e |                |   |   |                        |
|   |   |              |   | f |                |   |   |                        |
|   |   |              |   | t |                |   |   |                        |
|   |   |              |   | c |                |   |   |                        |
|   |   |              |   | o |                |   |   |                        |
|   |   |              |   | l |                |   |   |                        |
|   |   |              |   | u |                |   |   |                        |
|   |   |              |   | m |                |   |   |                        |
|   |   |              |   | n |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| [ |   |              |   | [ |                |   |   |                        |
| S |   |              |   | S |                |   |   |                        |
| E |   |              |   | E |                |   |   |                        |
| R |   |              |   | R |                |   |   |                        |
| V |   |              |   | V |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| C |   |              |   | C |                |   |   |                        |
| E |   |              |   | E |                |   |   |                        |
| S |   |              |   | S |                |   |   |                        |
| : |   |              |   | : |                |   |   |                        |
| ] |   |              |   | ] |                |   |   |                        |
| { |   |              |   | { |                |   |   |                        |
| . |   |              |   | . |                |   |   |                        |
| u |   |              |   | u |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| d |   |              |   | d |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| r |   |              |   | r |                |   |   |                        |
| l |   |              |   | l |                |   |   |                        |
| i |   |              |   | i |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| } |   |              |   | } |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | H |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | & |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | C |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 2 | D |              |   |   |                |   | 1 | Treatment              |
|   | e |              |   |   |                |   | \ | (1,2                   |
|   | n |              |   |   |                |   | . | ,3,4,5,10,11,12,14,15) |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 3 | M |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 4 | A |              |   |   |                |   | 2 | Prevention             |
|   | l |              |   |   |                |   | \ | (6,7,8,9,19b)\*        |
|   | c |              |   |   |                |   | . |                        |
|   | o |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | & |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | A |              |   |   |                |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 5 | C |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   | T |              |   | 1 | Clinical       |   | 3 | Capital Programming/\  |
|   | o |              |   |   | Services (1-5) |   | \ | Infrastructure         |
|   | t |              |   |   |                |   | . | (16-20)\*\*            |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | , |              |   |   |                |   |   |                        |
|   | C |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 6 | P |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | N |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | g |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 7 | H |              |   |   |                |   | 4 | Partnerships,          |
|   | e |              |   |   |                |   | \ | Consultation,\         |
|   | a |              |   |   |                |   | . | Core Functions, and    |
|   | l |              |   |   |                |   |   | Advocacy               |
|   | t |              |   |   |                |   |   | (13,19a-c)\*\*\*       |
|   | h |              |   |   |                |   |   |                        |
|   | E |              |   |   |                |   |   |                        |
|   | d |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 8 | C |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | . |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | R |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 9 | I |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | z |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | A |              |   |   |                |   |   |                        |
|   | K |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   | T |              |   | 2 | Preventive     |   |   | \*The Prevention       |
|   | o |              |   |   | Health (6-9)   |   |   | category includes 35%  |
|   | t |              |   |   |                |   |   | of Environmental       |
|   | a |              |   |   |                |   |   | Health Support (19b)   |
|   | l |              |   |   |                |   |   | activities.            |
|   | , |              |   |   |                |   |   |                        |
|   | P |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | U |              |   | 3 | Urban Health   |   |   |                        |
| 0 | r |              |   |   | (10)           |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | H |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | I |              |   | 4 | Indian Health  |   |   | \*\*The Capital        |
| 1 | n |              |   |   | Professions    |   |   | Prog                   |
|   | d |              |   |   | (11)           |   |   | ramming/Infrastructure |
|   | i |              |   |   |                |   |   | category includes 80%  |
|   | a |              |   |   |                |   |   | of Facilities Support  |
|   | n |              |   |   |                |   |   | (19a), 60% of          |
|   | H |              |   |   |                |   |   | Environmental Health   |
|   | e |              |   |   |                |   |   | Support (19b), and 20% |
|   | a |              |   |   |                |   |   | of OEHE Support (19c)  |
|   | l |              |   |   |                |   |   | activities.            |
|   | t |              |   |   |                |   |   |                        |
|   | h |              |   |   |                |   |   |                        |
|   | P |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | f |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | T |              |   | 5 | Tribal         |   |   |                        |
| 2 | r |              |   |   | Management     |   |   |                        |
|   | i |              |   |   | (12)           |   |   |                        |
|   | b |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | M |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | g |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | m |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | D |              |   | 6 | Direct         |   |   |                        |
| 3 | i |              |   |   | Operations     |   |   |                        |
|   | r |              |   |   | (13)           |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | O |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | n |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | S |              |   | 7 | Self           |   |   | \*\*\*The              |
| 4 | e |              |   |   | Governance     |   |   | Partnerships,          |
|   | l |              |   |   | (14)           |   |   | Consultation, Core     |
|   | f |              |   |   |                |   |   | Functions, and         |
|   | G |              |   |   |                |   |   | Advocacy category      |
|   | o |              |   |   |                |   |   | includes 20% of        |
|   | v |              |   |   |                |   |   | Facilities Support     |
|   | e |              |   |   |                |   |   | (19a), 5% of           |
|   | r |              |   |   |                |   |   | Environmental Health   |
|   | n |              |   |   |                |   |   | Support (19b), and 80% |
|   | a |              |   |   |                |   |   | of OEHE Support (19c)  |
|   | n |              |   |   |                |   |   | activities.            |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 | C |              |   | 8 | Contract       |   |   |                        |
| 5 | o |              |   |   | Support Costs  |   |   |                        |
|   | n |              |   |   | (15)           |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | u |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | p |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | C |              |   |   |                |   |   |                        |
|   | o |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   | T |              |   |   | Total,         |   |   |                        |
|   | o |              |   |   | Services       |   |   |                        |
|   | t |              |   |   |                |   |   |                        |
|   | a |              |   |   |                |   |   |                        |
|   | l |              |   |   |                |   |   |                        |
|   | , |              |   |   |                |   |   |                        |
|   | S |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | r |              |   |   |                |   |   |                        |
|   | v |              |   |   |                |   |   |                        |
|   | i |              |   |   |                |   |   |                        |
|   | c |              |   |   |                |   |   |                        |
|   | e |              |   |   |                |   |   |                        |
|   | s |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| [ |   |              |   | [ |                |   |   |                        |
| F |   |              |   | F |                |   |   |                        |
| A |   |              |   | A |                |   |   |                        |
| C |   |              |   | C |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| L |   |              |   | L |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| T |   |              |   | T |                |   |   |                        |
| I |   |              |   | I |                |   |   |                        |
| E |   |              |   | E |                |   |   |                        |
| S |   |              |   | S |                |   |   |                        |
| : |   |              |   | : |                |   |   |                        |
| ] |   |              |   | ] |                |   |   |                        |
| { |   |              |   | { |                |   |   |                        |
| . |   |              |   | . |                |   |   |                        |
| u |   |              |   | u |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| d |   |              |   | d |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| r |   |              |   | r |                |   |   |                        |
| l |   |              |   | l |                |   |   |                        |
| i |   |              |   | i |                |   |   |                        |
| n |   |              |   | n |                |   |   |                        |
| e |   |              |   | e |                |   |   |                        |
| } |   |              |   | } |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Maint. &     |   | 9 | Maint. &       |   |   |                        |
| 6 |   | Improvement  |   |   | Improvement    |   |   |                        |
|   |   |              |   |   | (16)           |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Sanit.       |   |   |                |   |   |                        |
| 7 |   | Facil.       |   |   |                |   |   |                        |
|   |   | Constr.      |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Hlth Care    |   | 1 | Hlth Care      |   |   |                        |
| 8 |   | Facs.        |   | 0 | Facs. Constr.  |   |   |                        |
|   |   | Constr.      |   |   | (17-18)        |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Facility &   |   | 1 | Facil. &       |   |   |                        |
| 9 |   | Envir. Hlth  |   | 1 | Envir. Hlth    |   |   |                        |
|   |   | Support      |   |   | Sup (19a-c)    |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Facility     |   |   |                |   |   |                        |
| 9 |   | Support      |   |   |                |   |   |                        |
| a |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | Env. Health  |   |   |                |   |   |                        |
| 9 |   | Support      |   |   |                |   |   |                        |
| b |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 1 |   | OEHE Support |   |   |                |   |   |                        |
| 9 |   |              |   |   |                |   |   |                        |
| c |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| 2 |   | Equipment    |   | 1 | Equipment (20) |   |   |                        |
| 0 |   |              |   | 2 |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   |   |              |   |   |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
|   |   | Total,       |   |   | Total,         |   |   |                        |
|   |   | Facilities   |   |   | Facilities     |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+
| \ |   |              |   | \ |                |   | \ |                        |
| ( |   |              |   | ( |                |   | ( |                        |
| 2 |   |              |   | 1 |                |   | 4 |                        |
| 0 |   |              |   | 2 |                |   | \ |                        |
| \ |   |              |   | \ |                |   | ) |                        |
| ) |   |              |   | ) |                |   | T |                        |
| T |   |              |   | T |                |   | o |                        |
| o |   |              |   | o |                |   | t |                        |
| t |   |              |   | t |                |   | a |                        |
| a |   |              |   | a |                |   | l |                        |
| l |   |              |   | l |                |   | , |                        |
| , |   |              |   | , |                |   | I |                        |
| I |   |              |   | I |                |   | H |                        |
| H |   |              |   | H |                |   | S |                        |
| S |   |              |   | S |                |   |   |                        |
+---+---+--------------+---+---+----------------+---+---+------------------------+

## Budget Category Aggregation

[]{#__RefHeading___Toc31535856 .anchor}Table 5: Crosswalk to FY 2004
Budget Request

  ----------------------------------------------------------------------------------------
                       Category/Sub-sub activity                         FY 2004 Request
  -------------------- ------------------------------------------------- -----------------
                       TREATMENT                                         

  1                    Hospitals & Health Clinics                        \$1,194,600,000

  2                    Dental Services \*                                105,566,000

  3                    Mental Health                                     53,959,000

  4                    Alcohol and Substance Abuse                       139,975,000

  5                    Contract Health Services                          493,046,000

  10                   Urban Health                                      31,568,000

  11                   Indian Health Professions                         35,417,000

  12                   Tribal Management                                 2,406,000

  14                   Self-Governance                                   10,250,000

  15                   Contract Support Costs                            270,734,000

                       M/M and PI Collections (85%)                      477,462,000

                       Diabetes                                          150,000,000

                       Total                                             \$2,964,983,000

                                                                         

                       PREVENTION                                        

  6                    Public Health Nursing \*                          \$ 43,112,000

  7                    Health Education                                  11,940,000

  8                    Community Health Representatives                  51,633,000

  9                    Immunization AK                                   1,580,000

  19b                  Environmental Health Support (35%)                19,818,000

                       Total                                             \$128,083,000

                                                                         

                       CAPITAL PROGRAMMING/INFRASTRUCTURE                

  16                   Maintenance & Improvement                         \$ 47,331,000

  17                   Sanitation Facilities                             114,175,000

  18                   Health Care Facilities Construction               69,947,000

  19a                  Facilities Support (80%)                          57,113,000

  19b                  Environmental Health Support (60%)                33,973,000

  19c                  OEHE Support (20%)                                2,302,000

  20                   Equipment                                         16,294,000

                       M/M and PI Collections (15%)                      84,258,000

                       Quarters                                          5,900,000

                       Total                                             \$431,293,000

                                                                         

                       PARTNERSHIPS, CONSULTATION, CORE FUNCTIONS, AND   
                       ADVOCACY                                          

  13                   Direct Operations                                 \$ 56,607,000

  19a                  Facilities Support (20%)                          14,278,000

  19b                  Environmental Health Support (5%)                 2,831,000

  19c                  OEHE Support (80%)                                9,207,000

                       Total                                             \$82,923,000

  \* The Dental and                                                      
  Public Health                                                          
  Nursing performance                                                    
  measures will be                                                       
  reviewed in a                                                          
  disaggregated way                                                      
  from the Treatment                                                     
  and Prevention                                                         
  categories in an                                                       
  effort to explore a                                                    
  closer                                                                 
  budget/performance                                                     
  linkage for these                                                      
  programs.                                                              
  ----------------------------------------------------------------------------------------

# GOAL-BY-GOAL PERFORMANCE MEASUREMENT

## Treatment and Prevention Categories

### Program Description and Context

Treatment and Prevention indicators are combined in this section.
Virtually all other activities are supportive of prevention and
treatment. These indicators were chosen based on specific selection
criteria that include but are not limited to the following:

-   critical health problems to our population;

-   identified I/T/U priority areas in terms of addressing health
    problems;

-   existence of relatively passive data sources;

-   no rewards exist for under reporting of conditions; and

-   evidenced-based and supportive of recognized standards of care.

For many indicators, a measurable change in the ultimate outcome is not
likely to be seen in the one-year time span of the performance plan.
Indeed, the one-year target indicators may not be related to funding
levels in a simple linear relationship within that one-year period.

The data that support the treatment and prevention indicators comes
primarily from the IHS automated information system (Resource and
Patient Management System) which collects data on the services provided
by IHS and tribal direct and contract program the patient-specific data
are collected through the Patient Care Component (PCC) of the RPMS. For
a discussion of data validation processes relative to this system and
the diabetes audit, see Appendix 1 on page 4-1.

Ultimately, our performance in treatment and prevention activities will
determine our level of success in improving the health of the American
Indian and Alaska Native population. However, the proposed IHS funding
for FY 2004 does not allow for target level increases over FY 2003 for
many of these indicators. Our commitment to continue to meet these
targets, given the population growth of over 1.7% annually and the
rising cost of providing services, is challenging. Moreover, achieving
these goals is not likely to reverse the downward trend in health status
of the American Indian and Alaska Native population outlined in Table 1
on page vii of this document.

For a more detailed discussion of the issues influencing performance
accomplishments see section 1.0 *Plan and Performance Report Overview*.

### Treatment Aggregation

**Hospitals and Clinics** - supports inpatient and ambulatory care and
support services such as nursing, pharmacy, laboratory, nutrition,
medical records, etc (see page IHS-29 in FY 2004 budget document).

**Dental Services** - supports the provision of dental care through
clinic based treatment and prevention services and community oral health
promotion and disease prevention activities including water fluoridation
and dental sealants (see page IHS-37 in FY 2004 budget document).

**Mental Health** - supports community oriented clinical and preventive
mental health and social services programs (see page IHS-41 in FY 2004
budget document).

**Alcohol and Substance Abuse** - supports the efforts of tribes in the
provision of holistic alcoholism and other drug dependency treatment,
rehabilitation, and preventive services for individuals and families
(see page IHS-49 in FY 2004 budget document).

**Urban Indian Health** - supports contracts and grants to 34 urban
health programs funded under Title V of the Indian Health Care
Improvement Act (see page IHS-93 in FY 2004 budget document).

**Indian Health Professions** - supports self-determination and access
to health care through efforts to enable American Indian and Alaska
Native to enter health professions, and effective recruitment of health
staff by providing scholarships, loan repayment, temporary employment,
and health professions recruitment (see page IHS-99 in FY 2004 budget
document).

**Self-Governance** - supports the Office of Tribal Self-Governance and
Self-Governance Planning and Negotiating grants. (see page IHS-113 in FY
2004 budget document).

**Contract Support** - provides administrative costs for tribal managed
programs in addition to what would have been provided under the direct
provision of the program as authorized under Section 106(a) (2) of P.L.
93-638, the Indian Self-Determination Act, as amended (see page IHS-121
in FY 2004 budget document).

### Prevention Aggregation

Public Health Nursing - supports the community-based Public Health
Nursing program that provides treatment, counseling, health education,
and referral activities carried out in such setting as homes, schools,
jails, bars, and community centers in conjunction with a diversity of
other health care providers (see page IHS-75 in FY 2004 budget
document).

Health Education - supports activities directed towards promoting
healthy lifestyles, community capacity building, and the appropriate use
of health services through public health education targeted at school
health, employee health promotion, community health, and patient
education (see page IHS-79 in FY 2004 budget document).

Community Health Representative - supports the tribally administered
program of training American Indian and Alaska Native community members
in basic disease control and prevention. These activities include
serving as outreach workers with the knowledge and cultural sensitivity
to effect change in community acceptance and utilization of health care
resources and use community-based networks to enhance health
promotion/disease prevention (see page IHS-83 in FY 2004 budget
document).

Alaska Immunization Program - supports the Alaska immunizations program
to address hepatitis and haemophilous influenza through collaboration
with the CDC (see page IHS-87 in FY 2004 budget document).

Environmental Health Support - supports the IHS injury prevention
program that coordinates and provides grants for primary preventive
community-based collaborative programs using defined problem
identification and evaluation methods (see page IHF-37 in FY 2004 budget
document).

### Treatment Indicators

[]{#__RefHeading___Toc31535863 .anchor}Table 6: Treatment Indicators
Performance Summary

+--------------------+-------------------+------------------+---------+
| Performance        | FY Targets        | Actual           | Re      |
| Indicator          |                   | Performance      | ference |
+====================+===================+==================+=========+
| Diabetes Group     |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: maintain   | FY 04:           | P: p.   |
| 1:]{.underline}    | database          |                  | 3-11    |
| Track Area         |                   | FY 03:           |         |
| age-specific       | FY 03: maintain   |                  | B: p.   |
| diabetes           | database          | FY 02: available | IHS-29  |
| prevalence rates   |                   | Sept 2003        |         |
| (as a surrogate    | FY 02: maintain   |                  | p.      |
| marker for         | database          | FY 01: database  | IHS-127 |
| diabetes           |                   | maintained       |         |
| incidence) for the | FY 01: maintain   |                  | 3       |
| AI/AN population.  | database          | FY 00: database  |         |
|                    |                   | maintained       |         |
|                    | FY 00: maintain   |                  |         |
|                    | database          | FY 99: baseline  |         |
|                    |                   | established      |         |
|                    | FY 99: establish  |                  |         |
|                    | baseline          |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | Ideal Glycemic    | FY 04:           | P: p.   |
| 2:]{.underline}    | Control           |                  | 3-12    |
| Increase the       |                   | FY 03:           |         |
| proportion of      | FY 04: +2% over   |                  | B: p.   |
| I/T/U clients with | FY 03 level       | FY 02: available | IHS-29  |
| diagnosed diabetes |                   | Sept 2003        |         |
| that have improved | FY 03: maintain   |                  | p\.     |
| their glycemic     | at FY 02 level    | FY 01: 30%       | IHS-127 |
| control.           |                   |                  |         |
|                    | FY 02: improve    | FY 00: 26%       | 3       |
|                    | from FY 01\*      |                  |         |
|                    |                   | FY 99: 24%       | 5       |
|                    | FY 01: improved   |                  |         |
|                    | from FY 00        | FY 98: 22%       | New FY  |
|                    |                   |                  | 2001    |
|                    | FY 00: improved   | FY 97: 25%       | Data    |
|                    | from FY 99        |                  |         |
|                    |                   | FY 99: 35%       |         |
|                    | FY 99: 25%        |                  |         |
|                    |                   | FY 98: 35%       |         |
|                    | **Good Glycemic   |                  |         |
|                    | Control**         | FY 97: 25%       |         |
|                    |                   |                  |         |
|                    | FY 99: 38%        |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | Ideal             | FY 04:           | P: p.   |
| 3:]{.underline}    | Hypertension      |                  | 3-13    |
| Increase the       | Control           | FY 03:           |         |
| proportion of      |                   |                  | B: p.   |
| I/T/U clients with | FY 04: +2% over   | FY 02: available | IHS-29  |
| diagnosed diabetes | FY 03 level       | Sept 2003        |         |
| and hypertension   |                   |                  | p\.     |
| that have achieved | FY 03: maintain   | FY 01: 41%       | IHS-127 |
| diabetic blood     | at FY 02 level    |                  |         |
| pressure control   |                   | FY 00: 35%       | 3       |
| standards.         | FY 02: maintain   |                  |         |
|                    | at FY 01 level\*  | FY 99: 36%       | 5       |
|                    |                   |                  |         |
|                    | FY 01: improve    | FY 98: 38%       | New FY  |
|                    | from FY 00        |                  | 2001    |
|                    |                   | FY 97: 27%       | Data    |
|                    | FY 00: improve    |                  |         |
|                    | from FY 99        |                  |         |
|                    |                   |                  |         |
|                    | FY 99: 41%        |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | LDL Cholesterol   | FY 04:           | P: p.   |
| 4:]{.underline}    |                   |                  | 3-14    |
| Increase the       | FY 04: +2% over   | FY 03:           |         |
| proportion of      | FY 03 level       |                  | B: p.   |
| I/T/U clients with |                   | FY 02: available | IHS-29  |
| diagnosed diabetes | FY 03: maintain   | Sept 2003        |         |
| who have been      | at FY 02 level    |                  | p\.     |
| assessed for       |                   | FY 01: 60%       | IHS-127 |
| dyslipidemia.      | FY 02: improve    |                  |         |
|                    | from FY 01\*      | FY 00: 54%       | 3       |
|                    |                   |                  |         |
|                    | FY 01: improve    | FY 99: 46%       | 5       |
|                    | from FY 00        |                  |         |
|                    |                   | FY 98: 29%       | \*New   |
|                    | FY 00: improve    |                  | FY 2001 |
|                    | from FY 99        | FY 99: 72%       | Data    |
|                    |                   |                  |         |
|                    | FY 99: 32%        | FY 98: 79%       |         |
|                    |                   |                  |         |
|                    | Total Cholesterol | FY 97: 83%       |         |
|                    |                   |                  |         |
|                    | FY 99: 82%        |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: +2% over   | FY 04:           | P: p.   |
| 5:]{.underline}    | FY 03 level       |                  | 3-15    |
| Increase the       |                   | FY 03:           |         |
| proportion of      | FY 03: maintain   |                  | B: p.   |
| I/T/U clients with | at FY 02 level    | FY 02: available | IHS-29  |
| diagnosed diabetes |                   | Sept 2003        |         |
| who have been      | FY 02: improve    |                  | p\.     |
| assessed for       | from FY 01        | FY 01: 54%       | IHS-127 |
| nephropathy.       |                   |                  |         |
|                    | FY 01: improve    | FY 00: 41%       | 3       |
|                    | from FY 00        |                  |         |
|                    |                   | FY 99: 36%       | 5       |
|                    | FY 00: improve    |                  |         |
|                    | from FY 99        | FY 98: 33%       | New FY  |
|                    |                   |                  | 2001    |
|                    | FY 99: 36%        | FY 97: 36%       | Data    |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: +3% over   | FY 04:           | P: p.   |
| 6:]{.underline}    | FY 03 level       |                  | 3-16    |
| Increase the       |                   | FY 03:           |         |
| proportion of      | FY 03: +3% over   |                  | B: p.   |
| I/T/U clients with | FY 02 level\*     | FY 02: available | IHS-29  |
| diagnosed diabetes |                   | Sept 2003        |         |
| who have been      | FY 02: no         |                  | p\.     |
| assessed for       | indicator         |                  | IHS-127 |
| retinopathy.       |                   |                  |         |
|                    |                   |                  | 3       |
|                    |                   |                  |         |
|                    |                   |                  | 5       |
|                    |                   |                  |         |
|                    |                   |                  | \*      |
|                    |                   |                  | in      |
|                    |                   |                  | dicates |
|                    |                   |                  | revised |
|                    |                   |                  | FY 2003 |
|                    |                   |                  | m       |
|                    |                   |                  | easure. |
|                    |                   |                  | See     |
|                    |                   |                  | Summary |
|                    |                   |                  | of      |
|                    |                   |                  | Changes |
|                    |                   |                  | Table   |
|                    |                   |                  | 10 on   |
|                    |                   |                  | page    |
|                    |                   |                  | 5-1.    |
+--------------------+-------------------+------------------+---------+
| Cancer Screening   |                   |                  |         |
| Group              |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | [Pap              | FY 04:           | P: p.   |
| 7:]{.underline}    | Scree             |                  | 3-18    |
| Increase the       | ning]{.underline} | FY 03:           |         |
| proportion of      |                   |                  | B: p.   |
| women who receive  | FY 04: maintain   | FY 02: 43.2%     | IHS-29  |
| Pap screening.     | FY 03 level       | w/in 3 years     |         |
|                    |                   | (+1.3% over FY   | 3       |
|                    | FY 03: maintain   | 2001)            |         |
|                    | FY 02 level       |                  | 5       |
|                    |                   | FY 01: 21% w/in  |         |
|                    | FY 02: +2% over   | 1 year           | New FY  |
|                    | FY 01 level       |                  | 2001    |
|                    |                   | 42% w/in 3 years | Data    |
|                    | FY 01: +3% over   |                  |         |
|                    | FY 00 level       | FY 00: 12% w/in  |         |
|                    |                   | 1 year\          |         |
|                    | FY 00: +3% over   | 18% w/in 3 years |         |
|                    | FY 99 level[\     |                  |         |
|                    | ]{.underline}     | FY 99: baseline  |         |
|                    |                   | not adequate     |         |
|                    | FY 99: no         |                  |         |
|                    | indicator         | FY 99: 8-10 per  |         |
|                    |                   | 100,000 based on |         |
|                    | [Cervical         | 40% of AI/AN     |         |
|                    | Ca                |                  |         |
|                    | ncer]{.underline} |                  |         |
|                    |                   |                  |         |
|                    | FY 99: determine  |                  |         |
|                    | incidence of      |                  |         |
|                    | cervical cancer   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: maintain   | FY 04:           | P: p.   |
| 8:]{.underline}    | FY 03 level       |                  | 3-19    |
| Increase           |                   | FY 03:           |         |
| proportion of the  | FY 03: maintain   |                  | B: p.   |
| AI/AN female       | FY 02 level       | FY 02: 24.7%     | IHS-29  |
| population over 40 |                   | w/in 2 years     |         |
| years of age who   | FY 02: +2% over   | (+3.7% over FY   | 3       |
| receive screening  | FY 01 level       | 2002)            |         |
| mammography.       |                   |                  | 5       |
|                    | FY 01: +2% over   | FY 01: 21% w/in  |         |
|                    | FY 00 level       | 2 years          | New FY  |
|                    |                   |                  | 2001    |
|                    | FY 00: +3% over   | FY 00: 15% w/in  | Data    |
|                    | FY 99 baseline    | 2 years          |         |
|                    |                   |                  |         |
|                    | FY 99: establish  | FY 99: baseline  |         |
|                    | baseline          | not adequate     |         |
+--------------------+-------------------+------------------+---------+
| Well Child Care    |                   |                  |         |
| Indicator          |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: no         | FY 02: 58.4%     | P: p.   |
| 9:]{.underline}    | indicator         | (+2.9% over FY   | 3-21    |
| Increase the       |                   | 2001)            |         |
| proportion of      | FY 03: no         |                  | B: p.   |
| AI/AN children     | indicator\*       | FY 01: 55.5%     | IHS-29  |
| receiving a        |                   |                  |         |
| minimum of four    | FY 02: +1% over   | FY 00: 52.4%     | 3       |
| Well Child Visits  | FY 01             |                  |         |
| by 27 months of    |                   | FY 99: 38.5%     | 5       |
| age and expand     | FY 01: +2% over   | baseline         |         |
| coverage.          | FY 00             |                  | \*      |
|                    |                   |                  | in      |
|                    | FY 00: +3% over   |                  | dicates |
|                    | FY 99             |                  | revised |
|                    |                   |                  | FY 2003 |
|                    | FY 99: establish  |                  | m       |
|                    | baseline          |                  | easure. |
|                    |                   |                  | See     |
|                    |                   |                  | Summary |
|                    |                   |                  | of      |
|                    |                   |                  | Changes |
|                    |                   |                  | Table   |
|                    |                   |                  | 10 on   |
|                    |                   |                  | page    |
|                    |                   |                  | 5-1.    |
+--------------------+-------------------+------------------+---------+
| Alcohol and        |                   |                  |         |
| Substance Abuse    |                   |                  |         |
| Group              |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | [RTC Assessment   | FY 04:           | P: p.   |
| 10]{.underline}:   | Crit              |                  | 3-23    |
| Maintain the rates | eria]{.underline} | FY 03:           |         |
| and intensity of   |                   |                  | B: p.   |
| follow-up for      | FY 04: +2% over   | FY 02: baseline  | IHS-49  |
| adolescents        | FY 03 for 4       | established      |         |
| discharged from    | criterion         |                  | 1       |
| IHS supported      |                   | FY 02: no        |         |
| Regional Treatment | FY 03: +5% over   | indicator        | 3       |
| Centers (RTC) to   | FY 02 for 4       |                  |         |
| assure reduced     | criterion         | FY 01: 60%       | 5       |
| rates of alcohol   |                   |                  |         |
| and drug use.      | FY 02: establish  | FY 00: 48% % -12 |         |
|                    | RTC baseline for  | mos (+17%)       |         |
|                    | 4 criterion       |                  |         |
|                    |                   | FY 99: 40.9%     |         |
|                    | [Follow-up        |                  |         |
|                    | R                 | FY 02: no        |         |
|                    | ates]{.underline} | indicator        |         |
|                    |                   |                  |         |
|                    | FY 04: no         | FY 01: no        |         |
|                    | indicator         | reliable data    |         |
|                    |                   | source           |         |
|                    | FY 03: no         |                  |         |
|                    | indicator         | FY 00: no        |         |
|                    |                   | reliable data    |         |
|                    | FY 02: no         | source           |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 01: FY 00      |                  |         |
|                    | level or higher   |                  |         |
|                    |                   |                  |         |
|                    | FY 00: 45% (+10%  |                  |         |
|                    | over FY 99 for 3  |                  |         |
|                    | follow-ups by 12  |                  |         |
|                    | months post       |                  |         |
|                    | discharge)        |                  |         |
|                    |                   |                  |         |
|                    | FY 99: establish  |                  |         |
|                    | baseline          |                  |         |
|                    |                   |                  |         |
|                    | [Abstin           |                  |         |
|                    | ence]{.underline} |                  |         |
|                    |                   |                  |         |
|                    | FY 04: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 03: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 02: no         |                  |         |
|                    | indictor          |                  |         |
|                    |                   |                  |         |
|                    | FY 01: +5% over   |                  |         |
|                    | FY 00             |                  |         |
|                    |                   |                  |         |
|                    | FY 00: no         |                  |         |
|                    | indicator         |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: Maintain   | FY 04:           | P: p.   |
| 11:]{.underline}   | FY 03 level       |                  | 3-24    |
| Expand the         |                   | FY 03:           |         |
| percentage of      | FY 03: Maintain   |                  | B: p.   |
| I/T/U prenatal     | FY 02 level       | FY 02: 90.5%     | IHS-29  |
| clinics utilizing  |                   | (increase of     |         |
| screening and case | FY 02: + 2% over  | 5.5% over FY 01) | 1       |
| management         | FY 01\            |                  |         |
| protocols for      | \                 | FY 01: 85%       | 3       |
| pregnant substance | FY 01: + 10% over | (decrease of     |         |
| abusing women and  | FY 00             | 2.6%)            | 5       |
| advocate to expand |                   |                  |         |
| usage.             | FY 00: +5% over   | FY 00: 87.6%     |         |
|                    | FY 99             | (+9.2% over FY   |         |
|                    |                   | 99)              |         |
|                    | FY 99: establish  |                  |         |
|                    | baseline          | FY 99: 78.4%     |         |
+--------------------+-------------------+------------------+---------+
| Oral Health Group  |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: 1% over FY | FY 04:           | P: p.   |
| 12]{.underline}:   | 03 for pop.       |                  | 3-26    |
| Increase access to | receiving fluor.  | FY 03:           |         |
| optimally          | water             |                  | B: p.   |
| fluoridated water  |                   | FY 02: +1% for   | IHS-37  |
| for the AI/AN      | FY 03: 1% over FY | pop              |         |
| population.        | 02 for pop.       |                  | 3       |
|                    | receiving fluor.  | FY 01: 28% over  |         |
|                    | water\*           | FY 00 for demo   | \*      |
|                    |                   | Areas            | in      |
|                    | FY 02: 5% over FY |                  | dicates |
|                    | 01 for AI/AN pop. | > Same % FY 00   | revised |
|                    | receiving fluor.  | > for other      | FY 2003 |
|                    | water             | > Areas          | m       |
|                    |                   |                  | easure. |
|                    | FY 01: 10% over   | FY 00: 18        | See     |
|                    | FY 00 for demo    | systems in       | Summary |
|                    | Areas\            | compliance (38%  | of      |
|                    | 5% over FY 00 for | increase)        | Changes |
|                    | other Areas       |                  | Table   |
|                    |                   | FY 99: 13        | 10 on   |
|                    | FY 00: 15% over   | systems in       | page    |
|                    | FY 99 for demo    | compliance for   | 5-2.    |
|                    | Areas             | demo Areas or 2% |         |
|                    |                   |                  |         |
|                    | FY 99: no         |                  |         |
|                    | indicator         |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: 99% of FY  | FY 04:           | P: p.   |
| 13:]{.underline}   | 03 level          |                  | 3-28    |
| Increase annual    |                   | FY 03:           |         |
| access to dental   | FY 03: maintain   |                  | B: p.   |
| services for the   | at FY 02 level    | FY 02: 27.35%    | IHS-37  |
| AI/AN population.  |                   | (+1% over FY 01) |         |
|                    | FY 02: 1% over FY |                  | 3       |
|                    | 01                | FY 01: 26.3%     |         |
|                    |                   |                  | 5       |
|                    | FY 01: 27%        | FY 00: 25.1%     |         |
|                    |                   |                  |         |
|                    | FY 00: 23%        | FY 99: 25.1%     |         |
|                    |                   |                  |         |
|                    | FY 99: 21%        | FY 98: 24.5%     |         |
|                    |                   |                  |         |
|                    |                   | FY 97: 22%       |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: at FY 03   | FY 04:           | P: p.   |
| 14:]{.underline}   | level             |                  | 3-30    |
| Increase the       |                   | FY 03:           |         |
| percentage of      | FY 03: at FY 02   |                  | B: p.   |
| AI/AN children who | level             | FY 02: 227,945   | IHS-37  |
| have received      |                   | (+7.2% over FY   |         |
| protective dental  | FY 02: +2.5% over | 01)              | 3       |
| sealants on        | FY 01 total       |                  |         |
| permanent molar    | sealants placed   | FY 01: 212,617   | 5       |
| teeth.             |                   |                  |         |
|                    | [6-8              | FY 04:           |         |
|                    | yrs]{.underline}  |                  |         |
|                    |                   | FY 03:           |         |
|                    | FY 04: no         |                  |         |
|                    | indicator         | FY 02: no        |         |
|                    |                   | indicator        |         |
|                    | FY 03: no         |                  |         |
|                    | indicator         | FY 01: 45.6%     |         |
|                    |                   | (1.5+ %)         |         |
|                    | FY 02: no         |                  |         |
|                    | indicator         | FY 00: 44.1% (+  |         |
|                    |                   | 4.5%)            |         |
|                    | FY 01: +3% over   |                  |         |
|                    | FY 00             | FY 99: 39.6%^1^  |         |
|                    |                   |                  |         |
|                    | FY 00: +3% over   | FY 91: 40.1%     |         |
|                    | FY 99             | baseline         |         |
|                    |                   |                  |         |
|                    | FY 99: 50% (36.1% | FY 02: no        |         |
|                    | recalculated)     | indicator        |         |
|                    |                   |                  |         |
|                    | [14-15            | FY 01: 51.5%     |         |
|                    | yrs]{.underline}  | (+2.4 %)         |         |
|                    |                   |                  |         |
|                    | FY 04: no         | FY 00: 49.1%     |         |
|                    | indicator         | (-15.9%)         |         |
|                    |                   |                  |         |
|                    | FY 03: no         | FY 99: 65.0%     |         |
|                    | indicator         |                  |         |
|                    |                   | FY 91: 66.5%     |         |
|                    | FY 02: no         | baseline         |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 01: +3% over   |                  |         |
|                    | FY 00             |                  |         |
|                    |                   |                  |         |
|                    | FY 00: +3% over   |                  |         |
|                    | FY 99             |                  |         |
|                    |                   |                  |         |
|                    | FY 99: 58% (59%   |                  |         |
|                    | recalculated)     |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: 1%         | FY 04:           | P: p.   |
| 15:]{.underline}   | increase over FY  |                  | 3-31    |
| Increase the       | 03                | FY 03:           |         |
| proportion of the  |                   |                  | B: p.   |
| AI/AN population   | FY 03: 2%         | FY 02: available | IHS-37  |
| diagnosed with     | increase over FY  | Sept 2003        |         |
| diabetes that      | 02                |                  | 3       |
| obtain access to   |                   | FY 01: available |         |
| dental services    | FY 02: 2%         | March 2003       | 5       |
| annually.          | increase over FY  |                  |         |
|                    | 01                | FY 00: 32%       |         |
|                    |                   |                  |         |
|                    | FY 01: no         | FY 99: 30%       |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 00: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 99: no         |                  |         |
|                    | indicator         |                  |         |
+--------------------+-------------------+------------------+---------+
| Family Abuse,      |                   |                  |         |
| Violence, and      |                   |                  |         |
| Neglect Indicator  |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | [Scree            | FY 04:           | > P: p. |
| 16:]{.underline}   | ning]{.underline} |                  | > 3-32  |
| Increase the % of  |                   | FY 03:           | >       |
| I/T/U medical      | FY 04: 65%        |                  | > B: p. |
| facilities with    |                   | FY 02: no        | >       |
| Urgent Care or     | FY 03: 60%        | indicator        |  IHS-41 |
| Emergency          |                   |                  | >       |
| departments or     | FY 02: no         | FY 04:           | > p\.   |
| services that have | indicator         |                  | >       |
| written policies   |                   | FY 03:           |  IHS-29 |
| and procedures for | FY 01: no         |                  |         |
| routinely          | indicator         | FY 02: 70%       | 1       |
| identifying,       |                   |                  |         |
| treating and/or    | FY 00: no         | FY 01: no        | 3       |
| referring victims  | indicator         | indicator        |         |
| of family          |                   |                  |         |
| violence, abuse or | FY 99: no         | FY 00: 54%       |         |
| neglect (i.e.,     | indicator         | (baseline)       |         |
| child, spouse,     |                   |                  |         |
| elderly) and train | [Staff            | FY 04:           |         |
| staff in their use | Trai              |                  |         |
|                    | ning]{.underline} | FY 03:           |         |
|                    |                   |                  |         |
|                    | FY 04: 65%        | FY 02: 85%       |         |
|                    |                   |                  |         |
|                    | FY 03: 60%        | FY 01: 82%       |         |
|                    |                   |                  |         |
|                    | FY 02: 56%        | FY 00: 72%       |         |
|                    |                   |                  |         |
|                    | FY 01: no         | FY 99: 64%       |         |
|                    | indicator         |                  |         |
|                    |                   | FY 04:           |         |
|                    | FY 00: no         |                  |         |
|                    | indicator         | FY 03:           |         |
|                    |                   |                  |         |
|                    | FY 99: no         | FY 02: no        |         |
|                    | indicator         | indicator        |         |
|                    |                   |                  |         |
|                    | [Policies and     |                  |         |
|                    | Proced            |                  |         |
|                    | ures]{.underline} |                  |         |
|                    |                   |                  |         |
|                    | FY 04: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 03: 85%        |                  |         |
|                    |                   |                  |         |
|                    | FY 02: 82%        |                  |         |
|                    |                   |                  |         |
|                    | FY 01: 80%        |                  |         |
|                    |                   |                  |         |
|                    | FY 00: 70%        |                  |         |
|                    |                   |                  |         |
|                    | FY 99: 60%        |                  |         |
|                    |                   |                  |         |
|                    | [Data             |                  |         |
|                    | Code]{.underline} |                  |         |
|                    |                   |                  |         |
|                    | FY 04: codes      |                  |         |
|                    | implem. in RPMS   |                  |         |
|                    |                   |                  |         |
|                    | FY 03: develop    |                  |         |
|                    | standard data     |                  |         |
|                    | code              |                  |         |
|                    |                   |                  |         |
|                    | FY 02: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 01: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 00: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 99: no         |                  |         |
|                    | indicator         |                  |         |
+--------------------+-------------------+------------------+---------+
|                    |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| Information        |                   |                  |         |
| Technology         |                   |                  |         |
| Development Group  |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: a.         | FY 04:           | > P: p. |
| 17:]{.underline}   | Implement quality |                  | > 3-34  |
| Expand the         | training in all   | FY 03:           | >       |
| automated          | Areas             |                  | > B: p. |
| extraction of GPRA |                   | FY 02: 5 sites   | >       |
| clinical           | > b\. +2 new      | assessed for     |  IHS-63 |
| performance        | > measures to     | performance      |         |
| measures and       | > automated data  | measures         | 3       |
| improve data       | > quality         |                  |         |
| quality.           | > assessment      | FY 01: 5 sites   | 5       |
|                    | > "package"       | for testing 5    |         |
|                    |                   | performance      |        |
|                    | FY 03: a.         | measures         |         |
|                    | complete baseline | established      |         |
|                    | of initial        |                  |         |
|                    | measures          |                  |         |
|                    |                   |                  |         |
|                    | b\. automate new  |                  |         |
|                    | measures          |                  |         |
|                    |                   |                  |         |
|                    | c\. distribute    |                  |         |
|                    | automated mapping |                  |         |
|                    | tools to all      |                  |         |
|                    | I/T/Us            |                  |         |
|                    |                   |                  |         |
|                    | FY 02: assess 5   |                  |         |
|                    | sites for 5       |                  |         |
|                    | performance       |                  |         |
|                    | measures          |                  |         |
|                    |                   |                  |         |
|                    | FY 01: setup 5    |                  |         |
|                    | sites for testing |                  |         |
|                    | 5 performance     |                  |         |
|                    | measures          |                  |         |
|                    |                   |                  |         |
|                    | FY 00: no         |                  |         |
|                    | indicator         |                  |         |
|                    |                   |                  |         |
|                    | FY 99: no         |                  |         |
|                    | indicator         |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | [Expand MH/SS     | FY 04:           | P: p.   |
| 18:]{.underline}   | Use]{.underline}  |                  | 3-36    |
| Expand the number  |                   | FY 03:           |         |
| of I/T/U programs  | FY 04: +5% use    |                  | B: p.   |
| that have          | over FY 03        | FY 02: 5%        | IHS-41  |
| implemented the    |                   | increase         |         |
| use of the Mental  | FY 03: +3% use    |                  | p\.     |
| Health/Social      | over FY 02        | FY 01: +12.1%    | IHS-49  |
| Services (MH/SS)   |                   | increase         |         |
| data reporting     | FY 02: +5% use    |                  | 3       |
| system or submit   | over FY 01        | FY 00: +24.7%    |         |
| minimum data       |                   | increase\*\*     | 5       |
| elements.          | FY 01: +10% use   |                  |         |
|                    | over FY 00        | FY 99: 51%       |        |
|                    |                   | reported         |         |
|                    | FY 00: +10% use   |                  |         |
|                    | over FY 99        | FY 98: 40-45%    |         |
|                    |                   | baseline est.    |         |
|                    | FY 99: 50%        |                  |         |
|                    | reported          | FY 02: no        |         |
|                    |                   | accepted data    |         |
|                    | [Submit Minimum   | set              |         |
|                    | Data              |                  |         |
|                    | Set]{.underline}  |                  |         |
|                    |                   |                  |         |
|                    | FY 04: 55% submit |                  |         |
|                    | minimum data      |                  |         |
|                    |                   |                  |         |
|                    | FY 03: 50% submit |                  |         |
|                    | minimum data      |                  |         |
|                    |                   |                  |         |
|                    | FY 02: no         |                  |         |
|                    | indicator         |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | [I/T/U IT         | FY 04:           | P: p.   |
| 19:]{.underline}   | Enhance           |                  | 3-37    |
| Expand I/T/U       | ment]{.underline} | FY 03:           |         |
| capacity for       |                   |                  | B: p.   |
| mutually           | FY 04: no         | FY 03:           | IHS-63  |
| compatible         | indicator         |                  |         |
| automated          |                   | FY 02: 2 sites   | 3       |
| information system | FY 03: no         | added            |         |
| that captures      | indicator         |                  | 5       |
| health status, and |                   | FY 01: 32% (11   |         |
| patient care data  | [Urban IT         | of 34) of urban  |        |
| for the Indian     | Enhance           |                  |         |
| health system.     | ment]{.underline} | programs         |         |
|                    |                   |                  |         |
|                    | FY 04: no         | FY 00: tested in |         |
|                    | indicator         | several sites    |         |
|                    |                   |                  |         |
|                    | FY 03: +2 sites   | FY 99:           |         |
|                    | over FY 02 level  | accomplished     |         |
|                    |                   | 8/99             |         |
|                    | FY 02: +2 sites   |                  |         |
|                    | over FY 01 level  |                  |         |
|                    |                   |                  |         |
|                    | FY 01:            |                  |         |
|                    | implemented in    |                  |         |
|                    | 30% of urban      |                  |         |
|                    | programs          |                  |         |
|                    |                   |                  |         |
|                    | FY 00: test in at |                  |         |
|                    | least one site    |                  |         |
|                    |                   |                  |         |
|                    | FY 99: develop    |                  |         |
|                    | specs and plan    |                  |         |
+--------------------+-------------------+------------------+---------+
| Quality of Care    |                   |                  |         |
| Group              |                   |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: 100%       | FY 04:           | P: p.   |
| 20:]{.underline}   |                   |                  | 3-38    |
| Maintain 100%      | FY 03: 100%       | FY 03:           |         |
| accreditation of   |                   |                  | B: p.   |
| all IHS hospitals  | FY 02: 100%       | FY 02: 100%      | IHS-29  |
| and outpatient     |                   |                  |         |
| clinics.           | FY 01: 100%       | FY 01: 100%      | p\.     |
|                    |                   |                  | IHF-9   |
|                    | FY 00: 100%       | FY 00: 100%      |         |
|                    |                   |                  | 3       |
|                    | FY 99: 100%       | FY 99: 100%      |         |
|                    |                   |                  | 5       |
|                    |                   | FY 98: 100%      |         |
|                    |                   | (baseline)       |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: a.         | FY 04:           | P: p.   |
| 21:]{.underline}   | Establishing      |                  | 3-38    |
| Implement          | baseline data for | FY 03:           |         |
| medication error   | medication error  |                  | B: p.   |
| reporting system   | reporting for all | FY 02: 3         | IHS-29  |
| to reduce          | IHS Areas         | elements         |         |
| medication error.  |                   | assessed         | 3       |
|                    | > b\. Pilot test  |                  |         |
|                    | > standardized    | FY 01:           | 5       |
|                    | > medication      |                  |         |
|                    | > error reporting |                  |         |
|                    | > system in two   |                  |         |
|                    | > areas           |                  |         |
|                    |                   |                  |         |
|                    | FY 03: Assess     |                  |         |
|                    | baseline and      |                  |         |
|                    | establish pilot   |                  |         |
|                    | sites             |                  |         |
|                    |                   |                  |         |
|                    | FY 02: assess     |                  |         |
|                    | current systems   |                  |         |
|                    | for 3 elements    |                  |         |
|                    |                   |                  |         |
|                    | FY 01: no         |                  |         |
|                    | indicator         |                  |         |
+--------------------+-------------------+------------------+---------+
| [Indicator         | FY 04: improve 3% | FY 04:           | P: p.   |
| 22:]{.underline}   | over FY 03        |                  | 3-39    |
| Improve AI/AN      |                   | FY 03:           |         |
| consumer           | FY 03: establish  |                  | B: p.   |
| satisfaction with  | baseline          | FY 02: OMB       | IHS-29  |
| the acceptability  |                   | clearance        |         |
| and accessibility  | FY 02: secure OMB | secured          | 3       |
| of health care as  | clearance         |                  |         |
| measured by IHS    |                   | FY 01: waiting   | 5       |
| consumer           | FY 01: secure OMB | final OMB        |         |
| satisfaction       | clearance         | approval         |         |
| survey.            |                   |                  |         |
|                    | FY 00: Federal    | FY 00: submitted |         |
|                    | clearance and     | but clearance    |         |
|                    | establish         | not completed    |         |
|                    | baseline          |                  |         |
|                    |                   | FY 99:           |         |
|                    | FY 99: develop    | instrument and   |         |
|                    | instrument and    | protocol         |         |
|                    | protocol          | complete         |         |
+--------------------+-------------------+------------------+---------+
| Total Treatment    | FY 04:            |                  | P: page |
| Funding:           | \$2,964,983,000\* |                  | \# in   |
|                    |                   |                  | p       |
|                    | FY 03:            |                  | erform. |
|                    | \$2,907,957,000   |                  | plan    |
|                    |                   |                  |         |
|                    | FY 02:            |                  | B: page |
|                    | \$2,746,954,000   |                  | \# in   |
|                    |                   |                  | budget  |
|                    | FY 01:            |                  | justif. |
|                    | \$2,117,008,000   |                  |         |
|                    |                   |                  |         |
|                    | FY 00:            |                  |         |
|                    | \$1,931,326,000   |                  |         |
|                    |                   |                  |         |
|                    | FY 99:            |                  |         |
|                    | \$1,811,951,000   |                  |         |
|                    |                   |                  |         |
|                    | FY 98:            |                  |         |
|                    | \$1,711,018,000   |                  |         |
|                    |                   |                  |         |
|                    | \*includes 85% of |                  |         |
|                    | M/M and PI        |                  |         |
|                    | collections and   |                  |         |
|                    | Diabetes          |                  |         |
+--------------------+-------------------+------------------+---------+

#### Diabetes Group:

The following six indicators address the ongoing monitoring and
treatment of diabetes in the American Indian and Alaska Native
population. Diabetes continues to be a growing problem in American
Indian and Alaska Native communities with rates increasing rapidly in
several IHS Areas. The age at diagnosis is occurring at younger ages,
with no signs of decline in any IHS Area. The treatment indicators (2-6)
were selected because of their proven benefits in reducing the morbidity
and mortality associated with diabetes. For FY 2003 and FY 2004, the IHS
has added retinal screening for diabetics at pilot sites supported by
telemedicine technology.

While two-thirds of the *Special Diabetes Program for Indians* (SDPI)
grantees are focusing significant efforts on primary prevention of type
2 diabetes, one third are focusing resources on secondary and tertiary
prevention geared at reducing diabetes complications. The IHS National
Diabetes Program is developing an infrastructure and methodology that
will track both clinical treatment and prevention efforts carried on by
the SDPI grantees. The grantees are focused on clinical care through the
Annual IHS Diabetes Care and Outcomes Audit. We expect performance to
remain unchanged in grant programs focused on primary prevention. This
is because their target audience is those *at risk for diabetes* and not
patients who already have the disease. We also hope to see improvement
in the GPRA indicators at sites that are focused on improving clinical
care.

The IHS Diabetes Program conducts a yearly medical record review (either
electronically or by manual chart audit) of a random sample of over
19,000 medical records in I/T/U facilities in order to assess compliance
with the IHS Standards of Care for Diabetes. This record review uses a
strict protocol to assure statistical integrity and comparability of
both process and outcome measures over time. Each year,
facility-specific values are reported for each indicator, as well as
values for each Area and for IHS-wide. Trends over time for I/T/U
facilities, service units, Areas, and IHS-wide are also constructed for
indicators 2-5.

Performance targets for the FY 2004 indicators 2-5 are set at a 2%
increase over the FY 2003 level in response to the \$50 million increase
in diabetes funding that has been approved by Congress for FY 2004.

[**Indicator 1**:]{.underline} During FY 2004, continue tracking (i.e.,
data collection and analyses) Area age-specific diabetes prevalence
rates to identify trends in the age-specific prevalence of diabetes (as
a surrogate marker for diabetes incidence) for the American Indian and
Alaska Native population.

![](media/image12.wmf){width="6.395833333333333in"
height="4.645833333333333in"}*\*Age-adjusted based on the 2000
U.S.population.*

*Source: FY 01 IHS APC file. Excludes data from 39 service units (7% of
the IHS user population).*

**[Rationale:]{.underline}** This indicator is an essential part of
monitoring the progress of ongoing efforts in the treatment and
prevention of diabetes. Though incidence rates of diabetes (occurrence
of new cases within a certain time period) are very difficult and
expensive to collect, and are only done reliably in large
population-based studies, trends in age specific prevalence rates of
diabetes can provide evidence of an increase or decrease in diabetes.
This increase or decrease for certain age groups may suggest a true
change in incidence. Analysis of these trends will allow the program and
I/T/Us to target prevention efforts to specific age groups and locations
in ongoing and future interventions.

**[Approach:]{.underline}** The IHS Diabetes Program, in conjunction
with the Office of Public Health, is responsible for overall
coordination of efforts to achieve this indicator. Rates are calculated
using the IHS automated record system (PCC/RPMS data), and are reported
by geographic Area, gender, and age groups for adults. Three-year
running rates (i.e., add the most recent year of data and drop the
oldest year of data) will be used in trend analysis. The IHS Diabetes
Program and the IHS Chronic Disease Epidemiology Program assist I/T/U
facilities with their PCC registries and/or other diabetes registries.
They also establish and organize systematic screening and improved data
entry to ascertain better diabetes prevalence.

Emphasis will be placed upon the specific age groups identified for this
measure. Diabetes prevalence information will be collected, transformed
into similar formats, and transferred to the CDC Division of Diabetes
epidemiologist through an interagency agreement between CDC and IHS for
analysis and adjusting. Reports will be created and disseminated to
I/T/Us, other DHHS agencies, universities, and private foundations for
use in identifying prevention strategies and resources.

[**Data Source**:]{.underline} RPMS/PCC reports and Diabetes Registries.
The prevalence rates are prepared for the American Indian and Alaska
Native population by age based on patients diagnosed with and treated
for diabetes and having at least one outpatient visit (active user) for
the year being reported. Data in RPMS represent about 90 percent of all
tribes because there are some compact and contract tribes that do not
report data into RPMS.

**[Program Performance:]{.underline}** **The FY 2002 report will be
available in September 2003.** The FY 2001 performance measure was to
maintain the Area age-specific prevalence rates for diabetes and this
was met. Area age-specific diabetes prevalence rates have been prepared
for the American Indian and Alaska Native population based on patients
diagnosed with and treated for diabetes and having at least one
outpatient visit during FY 2001. The chart above illustrates the
continuing alarming trend of increasing diabetes prevalence in the
American Indian and Alaska Native population.

Indicator 2: During FY 2004, increase the proportion of I/T/U clients
with diagnosed diabetes that have demonstrated improved glycemic control
by 2% over FY 2003.

![](media/image13.wmf){width="2.8805555555555555in"
height="1.8958333333333333in"}[Rationale:]{.underline} This indicator is
directed at reducing diabetic complications. Large clinical studies have
demonstrated that glycemic control significantly reduces the incidence
of complications and costs related to diabetes.

**[Approach:]{.underline}** Glycemic control is measured with a test
called the Hemoglobin A1C (HgbA1c) that measures the average blood sugar
for a 2-3 month period. The IHS Diabetes Care and Outcomes Audit divides
these control levels into "Ideal" (\<7%); "Good" (7.0-7.9%); "Fair"
(8.0-9.5%); "Poor" (9.5-11.9%); and "Very Poor" (\>12%) based on
national diabetes care standards.

The IHS Diabetes Care and Outcomes Audit recently updated its criteria
for glycemic control based on the American Diabetes Association
guidelines. The current guidelines recommend the use of HgbA1c cutoffs
that determine control at the \"Ideal\" level. Improvements in glycemic
control will be reported for each year to provide trend analysis.

**[Data Source:]{.underline}** Diabetes registries, yearly IHS Diabetes
Care and Outcomes Audit. Achievement of this indicator will be
determined by calculating the mean HgbA1c of the entire diabetic
population for a given audit year as well as dividing these data into
the categories of \"ideal\", \"good,\" \"fair,\" \"poor,\" and \"very
poor.\"

Those sites that have chosen to focus on the problem by applying the
best practices associated with glycemic control will be assessed as a
defined group using the *IHS Diabetes Care and Outcomes Audit.* In FY
2004, the mean HgA1c of this group and categories of glycemic control
will be reported as a baseline and compared with the performance of the
I/T/U system as a whole. Then, in subsequent years, the performance of
this group will be followed and compared to the larger group, with
results for both being reported in the GPRA reports. Further analysis of
their specific activities related to glycemic control may provide
guidance and answers to other sites hoping to address this problem in
the future.

**[Program Performance:]{.underline} The FY 2002 will be available in
September 2003.** The FY 2001 Indicator was to increase the proportion
of I/T/U clients with diagnosed diabetes who have improved their
glycemic control over the FY 2000 level. This indicator was met. Our
current rates of measuring HgA1c values far surpass the Healthy People
2010 target. In FY 1998 the proportion of our patients with diagnosed
diabetes who were classified as \"Ideal\" based on their HgA1c result
was 22%. In FY 1999, that proportion increased to 24%. In FY 2000, the
proportion of clients with "ideal" glycemic control increased to 26%,
and in FY 2001 that proportion increased to 30%, a 4% increase over 2000
rates.

![](media/image15.wmf){width="3.671527777777778in"
height="2.421527777777778in"}**[Indicator 3:]{.underline}** During FY
2004, increase the proportion of I/T/U clients with diagnosed diabetes
who have achieved blood pressure control by 2% over the FY 2003 level.

**[Rationale:]{.underline}** This indicator is directed at reducing
complications of diabetes. Large clinical studies have demonstrated that
blood pressure control significantly reduces the incidence of
complications related to diabetes, most notably heart disease, strokes
and kidney disease.

[**Approach**:]{.underline} National standards recommend that the ideal
goal of diabetic blood pressure control should be 130/80 mm Hg. For the
GPRA process, the "controlled" level will be defined as 140/90 mm Hg and
the "ideal" control will be defined as 130/80 mm Hg.

[**Data Source**:]{.underline} Diabetes registries and yearly IHS
Diabetes Care and Outcome Audits. This indicator will be determined by
calculating the proportion of clients with diabetes who have "ideal"
blood pressure control (defined as systolic BP\<130mmHg and diastolic
BP\<80mmHg) and the proportion who fall into the "controlled" category
(defined as systolic BP\<140mmHg and diastolic BP\<90mmHg) in the
current audit year. Improvements in blood pressure control will be
reported by each year to provide trend analysis for both the ideal and
controlled categories. Finally, the current year mean systolic and
diastolic blood pressures of the "ideal" category will be compared to
that of the previous year to determine if improvements were maintained
for this fiscal year.

**[Program Performance:]{.underline}** **The FY 2002 data will be
available in August 2003.** The FY 2001 indicator was to increase the
proportion of I/T/U clients with diagnosed diabetes who have achieved
blood pressure control over the FY 2000 level, and this was met. The IHS
has adopted the "ideal" control standard as our benchmark for trend
analysis. Performance on this indicator was unchanged when comparing FY
1999 with FY 2000. In the "ideal" control category, the rate changed
from 36% in FY 1999 to 35% in FY 2000, which was not a statistically
significant difference.

In FY 2001 we saw an improvement with 41% of clients falling into the
"ideal BP control" category. This improvement occurred in spite of the
fact that we "tightened" our definition of "ideal control" (lowering the
acceptable diastolic BP from 85mm Hg to 80 mm Hg) in response to new
National Guidelines on Blood Pressure Control in people with diabetes.

**[Indicator 4:]{.underline}** During FY 2004, increase the proportion
of I/T/U clients with diagnosed diabetes assessed for dyslipidemia (i.
e., LDL cholesterol) by 2% over the FY 2003 level.

![](media/image16.wmf){width="3.5006944444444446in"
height="2.4159722222222224in"}

**[Rationale:]{.underline}** This indicator is directed at reducing
diabetic complications. Large clinical studies have demonstrated that
lowering of serum cholesterol significantly reduces the cardiovascular
(CVD) morbidity and mortality associated with diabetes.

**[Approach:]{.underline}** The benefits of aggressive interventions to
lower cholesterol levels in diabetics have been well described in the
literature and numerous practice guidelines and standards exist. The
diabetes grant programs choosing to focus on cardiovascular risk
reduction, of which treatment of dyslipidemia is a large part, will be
tracked separately to see if their overall performance is better than
the group as a whole. Trends over time for I/T/U facilities, service
units, Areas and IHS-wide are constructed for selected indicators.

[**Data Source**:]{.underline} Diabetes registries, yearly IHS Diabetes
Care and Outcomes Audit. Achievement of this indicator will be
determined by calculating the proportion of patients with diabetes who
have had an LDL cholesterol performed in the past year. The current
year's data will be compared to that of the previous year to determine
if improvements were maintained for this fiscal year.

**[Program Performance:]{.underline}** **The FY 2002 indicator will be
available in September 2003**. The FY 2001 indicator that was to
increase the proportion of I/T/U clients with diagnosed diabetes
assessed for LDL cholesterol over the FY 2000 level was met. The
proportion of I/T/U clients diagnosed with diabetes assessed for LDL
cholesterol increased from 46% for FY 1999 to 54% for FY 2000 to 60% in
FY 2001. This represents a 14% increase in 2 years. This improvement in
performance is due likely to several factors including: Better awareness
in both providers and patients through the National Cholesterol
Education Program efforts; increased I/T/U provider awareness of the
growing problem of heart disease in American Indian and Alaska Native
through the Diabetes Program (and others) efforts to publicize results
of the Strong Heart Study showing that the rate of heart disease in
American Indian and Alaska Native is increasing while heart disease is
decreasing in the general U.S.population; and better availability of
"statin" drugs in our pharmacies which are highly effective in treating
dyslipidemias.

**[Indicator 5:]{.underline}** During FY 2004, increase the proportion
of I/T/U clients with diagnosed diabetes assessed for nephropathy by 2%
over the FY 2003 level.

![](media/image17.wmf){width="3.6465277777777776in"
height="2.3958333333333335in"}

**[Rationale:]{.underline}** This indicator is directed at reducing
diabetic complications. End stage renal disease (ESRD), or diabetic
kidney disease, is a significant and growing problem in Indian
communities. The assessment of proteinuria not only indicates who is at
risk for ESRD, but is an independent predictor of cardiovascular risk,
which is the number one killer of American Indian and Alaska Native
adults. Sixty-five percent of AI men and 70% of AI women with
cardiovascular disease also have diabetes. Using the Kidney Health
Profile of the diabetes audit and the Staged Diabetes Management
Treatment Guidelines for diabetes clinical management may significantly
improve the approach to kidney health in Indian communities.

**[Approach:]{.underline}** A special sub-report of the IHS Diabetes
Care and Outcomes Audit, called the Kidney Health Profile, generated
annually, assesses screening and treatment for kidney health in a
community. Each year's reported rate will be used to provide trend
analysis.

The benefits of aggressive interventions to lower blood pressure in
diabetics relative to kidney health have been well described in the
literature and numerous practice guidelines and standards exist. The use
of appropriated diabetes funding enhancements will improve the
performance of this indicator with grants /cooperative agreements for
special activities aimed at targeted diabetes-related treatment and
prevention areas. Local efforts to improve these parameters through
lifestyle intervention and appropriate medication use will be encouraged
through orientation, training, and monitoring provided by Area Diabetes
Consultants.

**[Data Source:]{.underline}** Diabetes registries, yearly IHS Diabetes
Care and Outcomes Audit.

Achievement of this indicator will be determined by calculating the
proportion of patients with diabetes and a normal proteinuria screen who
have had a test for microalbuminuria performed in the past year. The
present year's data will be compared to that of the previous year to
determine if the level of assessments were maintained.

**[Program Performance:]{.underline} The FY 2002 data will be available
in September 2003**. The FY 2001 Indicator was to increase the
proportion of I/T/U clients with diagnosed diabetes assessed for
nephropathy over the FY 2000 and was met. Screening for microalbuminuria
to assess early diabetic nephropathy increased from 33% in 1998 to 36%
in 1999 to 41% in 2000. In FY 2001, screening for microalbuminuria
increased to 54%.

***Note:** **the following is a new indicator for both FY 2003 and FY
2004***

**Indicator 6**: During FY 2003, increase the proportion of American
Indian and Alaska Native diabetics who receive an annual diabetic
retinal examination at designated sites by 3% over the FY 2002 rate.

**Indicator 6:** During FY 2004, increase the proportion of American
Indian and Alaska Native diabetics who receive an annual diabetic
retinal examination at designated sites by 3% over the FY 2003 rate.

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
the level of vision loss from diabetic retinopathy in the American
Indian and Alaska Native population. American Indians and Alaska Natives
have the highest prevalence of diabetes in the USA (some groups
exceeding 50% of adults). Diabetic eye disease is the #1 cause of new
blindness in the USA for ages 20 to 74. According to the Early Treatment
of Diabetic Retinopathy Study (ETDRS) timely laser treatment of diabetic
retinopathy dramatically reduces the chances of vision loss due to
diabetes. All races included, it is estimated the benefits of treatment
include a savings of almost \$500,000,000 and almost 100,000 person
years of sight across the USA.

**[Approach:]{.underline}** Early detection and timely treatment is
necessary to minimize or prevent vision loss due to diabetic
retinopathy. This can be accomplished only by appropriate monitoring of
the eye for diabetic retinopathy. Diabetics should have annual dilated
retinal exams according to the American Academy of Ophthalmology, the
American Optometric Association, and the American Diabetes Association.
The Indian Health Service began tracking the rate of annual eye exams
many years ago, documenting the perennial rate of annual diabetic eye
exams/retinal screenings consistently at between and 53-56%. An improved
strategy is needed to manage the rapidly increasing incidence of
diabetes with its debilitating retinal complications. The strategy
currently prescribed in the IHS is as follows:

-   Identify target populations

-   For annual eye evaluations: all patients with diabetes

-   For treatment/intervention: all patients with high risk for
    blindness or eye complications.

-   Evaluate patients

-   Motivate patients to have annual eye exams.

-   Insure access to eye exams

-   Maintain full staffing, space, and equipment to deliver needed eye
    exams.

-   Increase telemedicine retinal imaging and evaluation in primary care
    settings. Retinal cameras operated by technicians will be
    strategically located in non-eye care outpatient settings. Digitized
    retinal photographs will be taken of diabetics and electronically
    sent to professional readers at Phoenix Indian Medical Center.

-   Establish community-based retinal screenings.

-   Optimize the ease of making appointments for eye exams.

This indicator will be implemented in three phases. The first phase will
involve facilities that have telemedicine projects in place designed to
screen diabetics for diabetic retinopathy. Those facilities
participating in phase one are:

  ----------------------------------- -----------------------------------
  FACILITY                            INDICATOR COORDINATOR

  1\) Phoenix Indian Medical Center   Dr. Mark Horton

  2\) Pine Ridge Indian Hospital      Dr. Adrean Vernon

  3\) Tuba City Indian Med. Ctr.      Dr. Mark Carroll

  4\) Fairbanks, AK                   Walter Palkovitch, R.N.

  5\) Sells Indian Hospital           Dr. Steve Goldwasser

  6\) Carl Albert Indian Health Fac.  Dr. John Garber
  ----------------------------------- -----------------------------------

This list may be adjusted prior to implementation date.

**[Data Source]{.underline}:** The calculation of annual dilated retinal
exams on diabetics will be a standardized process utilizing the RPMS
system.

**[Program Performance]{.underline}**: No FY 2001 or FY 2002 indicator
to report.

#### Cancer Screening Group:

These two indicators are directed at increasing the coverage of women
receiving screening for breast and cervical cancer.

**Indicator 7:** During FY 2004, maintain the proportion of eligible
women who have had a Pap screen within the previous three years at the
FY 2003 levels.

![](media/image18.wmf){width="3.6251968503937007in"
height="2.3610236220472443in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
the mortality and morbidity of cervical cancer, which occurs at higher
rates among American Indian and Alaska Native women than in the general
U. S. population. The long-range goal is to reduce both cervical cancer
incidence and death rates to achieve parity with the U.S. all-races rate
by 2010.

[**Approach**:]{.underline} The IHS Office of Public Health is
responsible for overall coordination of efforts to achieve these
indicators.

[**Data Source**:]{.underline} The total number of women age 21 through
64 who have had at least one Papanicolaou screening test performed
(cervical cytology or Pap smear) in the previous three years will be
determined from IHS Laboratory reports and PCC electronic patient
records. The baseline for this measure as reported in FY 2000
performance report is 18%.

**[Program Performance:]{.underline}** **IHS did not meet this indicator
for FY 2002.** The FY 2002 indicator committed to a 2 % increase in the
proportion of women 18 and older that had a Pap screen in the previous
year.

In FY 2001, 42% of women had a Pap test within three years. In FY 2002,
43.2% of women had a Pap smear within the last 3 years. Our screening
rates increased, but not at the anticipated level.

The IHS performance for 2002 was determined from electronic medical
records. During FY 2002, funding remained stable for Pap screening and
cancer prevention in general. IHS did not increase overall expenditures
for women's health, and CDC did not fund any additional Tribal screening
projects. Problems with recruitment and retention of providers continue
to exist.

IHS plans to renew our focus on cancer screening. This will include
providing feedback to providers on their individual and local facility
pap screening rates. In addition, IHS will distribute GPRA clinical
indicator results to providers as well as increase electronic reminders.

Indicator 8: During FY 2004, maintain mammography screening at the FY
2003 rate.

![](media/image19.wmf){width="3.6255905511811024in"
height="2.601574803149606in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
the mortality and morbidity of breast cancer among American Indian and
Alaska Native women. Current recommendations are for screening every one
or two years. We chose the two-year interval as being more
cost-effective.

**[Approach:]{.underline}** Mammography screening is provided to
American Indian and Alaska Native women either directly by IHS
facilities, by mobile mammography units supported by CDC funds, or
through contract health arrangements with private radiology groups. The
IHS Office of Public Health performs the overall coordination of this
effort. Linkages with CDC and State screening programs are critical to
success. CDC has funded the National Indian Women's Health Support
Center to provide technical assistance to Tribal mammography programs.

**[Data Source:]{.underline}** An IHS electronic medical record is the
principal data source. The numerator is the total number of women age 52
through 64 who have had at least one mammogram performed in the previous
two years, as determined from IHS Radiology reports, Contract Health
records, and PCC electronic patient records. We have increased the lower
age limit from 40 to 52, because considerable controversy remains about
the efficacy of mammography for women under 50. We wished to have our
indicator reflect the screening practices of all clinicians. We set an
upper age limit of 64 to have rates that are comparable with CDC
reporting, and because women over 65 are Medicare eligible and therefore
more likely to have mammograms performed by outside facilities that do
not report to IHS.

**[Program Performance:]{.underline}** **IHS met this indicator for FY
2002.** This indicator committed to increasing by 2% the proportion of
American Indian and Alaska Native women who received clinically
indicated screening mammography in the previous 2 years.

The baseline for this measure, from the FY 2000 Performance Report, is
15.3%. In FY 2001, 21% of American Indian and Alaska Native women had a
mammogram during the previous two years. In FY 2002, 24.7% of American
Indian and Alaska Native women had a mammogram during the previous 2
years.

IHS plans to increase mammography rates by providing electronic
reminders as well as feedback to individual providers.

####  Well Child Care Indicator:

**[Indicator 9]{.underline}:** No FY 2003 or FY 2004 Indicator (*see
change table in section 5 for explanation).*

![](media/image20.wmf){width="3.7708333333333335in"
height="2.6305555555555555in"}Indicator 9: During FY 2002, increase by
2% the proportion of American Indian and Alaska Native children served
by IHS receiving a minimum of four well-child visits by 42 months of age
at the FY 2001 level.

**[Rationale:]{.underline}** This indicator is directed at maintaining
child and family health by supporting access to non-urgent care. Well
child visits have been associated with improved post-neonatal mortality
and opportunities to improve family health and safety in the longer
term. Additionally, well child visits are a recognized national standard
of care. The anticipatory educational interventions given to parents
concerning diet and nutrition, injury prevention, and prevention of
family violence have been historically effective. The current minimum
standard for well child visits is six for first-born children and five
after first-born. Accepting four visits as an acceptable minimum is
based on the high percentage of children who receive well child services
in conjunction with urgent care visits and thus are not coded as well
child visits.

**[Approach:]{.underline}** The responsible parties are the local I/T/U
service sites. 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.

**[Data Source:]{.underline}** RPMS/PCC.

**[Program Performance:]{.underline}** **IHS met and exceeded this
indicator for FY 2002.** The FY 2002 performance indicator committed to
increase by 2% the proportion of American Indian and Alaska Native
children served by IHS receiving a minimum of four Well Child Visits by
3 to 3.5 years of age, over the FY 2001 baseline.

In FY 2002, 6,890 children or 58.39% out of 11,800 children received a
minimum of four well-child visits by 3 to 3.5 years of age. This is an
increase of 3.48% over the FY 2001 proportion of 55.5%.

#### Substance Abuse Treatment Group:

These two indicators address substance abuse treatment. The first
targets improved residential treatment of adolescents with
alcohol/substance abuse problems. The second addresses prevention of
fetal alcohol syndrome.

**Indicator 10:** During FY 2004, Youth Regional Treatment Centers
(YRTC) will collectively achieve at least a 5% increase over the FY 2003
level for each of the following criteria:

a\. Percent of youth who successfully completed alcohol/substance abuse
treatment at IHS funded YRTC's.

b\. Percent of youth (who completed treatment) who developed an
aftercare plan with their appropriate aftercare agency.

c\. Percent of youth who have this after care plan communicated to the
responsible follow-up agency with documentation of this communication in
the youth YRTC record.

![](media/image21.wmf){width="3.6458333333333335in"
height="2.3895833333333334in"}d. Percent of YRTC programs that have a
family week opportunity for youth that participate in the YRTCs.

**[Rationale:]{.underline}** This indicator is intended to evaluate
inpatient and community substance abuse resources for youth who have
participated in residential alcohol/substance abuse treatment. Inpatient
and outpatient community resources specific to the youth population are
an essential part of the continuum of behavioral health care services.
Successful completion of residential treatment can help reduce drug and
alcohol use relapse in youths. Family involvement in treatment is
predictive of treatment outcome.

Studies indicate that the longer individuals are engaged in treatment
(including aftercare/ continuing care), the better the prognosis. The
aftercare measure aims to assure the coordination of effective and
efficient delivery of follow-up treatment services at the local level
following RTC release.

**[Approach:]{.underline}** YRTCs are working to increase their
residential treatment completion rates. The YRTCs must ensure that
adequate aftercare treatment plans are developed and communicated to the
appropriate aftercare agency. The establishment of a continuum of
aftercare can help ensure successful long-term treatment outcomes.

**[Data Source:]{.underline}** Data for this indicator are collected
from the YRTCs. The Division of Behavioral Health, Office of Public
Health will be responsible for coordinating data collection from the
Regional Treatment Centers. Headquarters behavioral health staff reviews
the data for completeness.

**[Program Performance:]{.underline}** **The IHS met this indicator.**
The FY 2002 performance measure was to establish baseline YRTC data for
the following measures:

-   Percent of youths who successfully completed alcohol/substance abuse
    treatment at IHS funded YRTCs.

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-   Percent of youth (that completed treatment) who developed an
    aftercare plan with their appropriate aftercare agency.

-   Percent of youth who have this after care plan communicated to the
    responsible follow-up agency; documentation of this communication
    must be in the youth YRTC record.

-   Percent of YRTC programs that have a family week opportunity for
    youth that participate in the YRTCs.

All YRTC's have reported data on these initial baseline measures.
Completion of treatment, established aftercare, and an established
family week are known factors in predicting success. We anticipate that
improvement in this indicator will correlate with improved treatment
outcomes.

Indicator 11: During FY 2004, establish a baseline rate for alcohol use
in women of ![](media/image22.wmf){width="3.7708333333333335in"
height="2.390972222222222in"}childbearing age.

**[Rationale:]{.underline}** The purpose of this indicator is a
reduction in the incidence of Fetal Alcohol Syndrome (FAS). Surveillance
conducted at two IHS Areas indicated FAS rates greatly exceed general
population rates. Thus, the purpose of this indicator is to assure that
providers consistently screen and make appropriate referrals for women
at risk. Indian Health Service has implemented screening and case
management protocols at the majority of our facilities over the last 4
years.

**[Approach:]{.underline}** The Division of Behavioral Health will work
with facilities to educate and increase the rates of screening for
alcohol use in this age cohort. In addition, RPMS Health Summary will be
modified to ensure that there is an automatic health care reminder for
alcohol screening. This reminder will be visible to the end health care
provider at the time of the provider visit.

**[Data Source:]{.underline}** RPMS data extraction

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2002 indicator committed to increasing the proportion of I/T/U
prenatal clinics utilizing a recognized screening and case management
protocol(s) for pregnant substance abusing women by 2% over the FY 2001
level For FY 2001, all 12 Areas reported for an actual rate of 85% (not
94.7% as previously reported). In FY 2002, 209 out of 231 clinics had
implemented such protocols for a rate of 90.5% (an increase of 5.5%).

In FY 2003, IHS has committed to maintaining the current rate. This
indicator will change in FY 2004 as above. This proposed indicator will
evaluate the actual percentage of women of childbearing age screened for
alcohol and substance abuse from our RPMS data system. We anticipate
that identification of these women will result in appropriate referrals
and treatment.

#### Oral Health Group:

Because oral diseases seldom result in death or severe disability, the
importance of treating and preventing can be overshadowed by other
health priorities. However, the oral conditions of American Indian and
Alaska Native participants are far worse than the U.S. general
population. These poor oral conditions profoundly influence their
quality of life, including their ability to attend school, work, sleep,
eat, and socialize.

The 1999/2000 IHS Oral Health Survey of American Indian and Alaska
Native dental patients underscored the significant disparities in oral
health that continue to exist between native and non-native Americans.
Key findings concerning the Native American population examined include:

-   Native American patients experience roughly three times the amount
    of tooth decay and periodontal disease as compared to the general
    U.S. population;

-   Very young Native Americans experience tooth decay at rates
    significantly greater than general U.S. population children;

-   The use of tobacco is strongly associated with both oral cancer and
    periodontal disease. The prevalence of tobacco use starts at about
    13 years of age among Native Americans and steadily increases with
    age; and

-   Most Native American adults and elders have lost teeth because of
    dental disease or oral trauma.

Dental health has been consistently identified as a high priority in
surveys of American Indian and Alaska Native consumers\' health needs.
Furthermore, dental care has been consistently identified in recent
stakeholder developed budget formulation.

Indicator 12: During FY 2004, increase the proportion of American Indian
and Alaska Native population receiving optimally fluoridated water by 1%
over FY 2003 levels for all IHS Areas.

**[Rationale]{.underline}:** Fluoridation is one of the most cost
effective public health measures for reducing the prevalence of dental
decay in all age groups. However, despite the known benefits of
fluoridation, the number of fluoridated water systems in Indian country
has declined by 68% during the 1990's because of more rigorous
monitoring standards developed by the Center for Disease Control. The FY
2004 fluoridation objective is formulated as a 1% increase in the number
of individuals having access to fluoridated water. The tribal utilities
yet to be fluoridated are the relatively small ones. The average number
of individuals served by tribal utilities that remain unfluoridated is
approximately 300. A proposed 1% increase at first glance might appear
quite modest. However, it will take the fluoridation of approximately 50
individual utilities to achieve this goal. This reasonable objective
postulates a smaller increase in fluoridation coverage than previous
objectives for recent years. This is in recognition of a number of
factors:

-   The successes documented at our pilot sites in previous years have
    proven to be less exportable than originally envisioned.

-   Remaining utilities yet to be fluoridated are relatively small.
    Efforts similar to those made in recent years will yield diminishing
    returns in the future, as in general it takes a similar level of
    effort and resources to start up fluoridation at an individual
    utility regardless of size or number of individuals served.

-   Significant positive outcomes from reorganizing and centralizing
    fluoridation coordination are not expected until FY 2005.

-   Relying upon Area Offices to provide fluoridation data has
    introduced variability into our annual assessments. A primary thrust
    of national efforts during both FY 2003 and FY 2004 will be to
    establish a consistent national database with which to monitor
    future efforts toward fluoridation.

**[Approach]{.underline}:** The IHS Dental Program, Office of
Environmental Health and Engineering Branch, and the Centers for Disease
Control and Prevention's Division of Oral Health entered into an
interagency agreement in FY 2000 to support a demonstration fluoridation
project in the Albuquerque and Phoenix Areas.

This indicator expanded to address all IHS Areas in FY 2001, as a result
of earmarked recurring funding of \$500,000 in FY 2001 to support water
fluoridation IHS-wide. Each Area will submit an annual plan of action
and an annual report of activities and outcomes. In FY 2003, as in FY
2002, the indicator addresses increasing the proportion of the American
Indian and Alaska Native population receiving optimally fluoridated
water by 1%. In recognition of the proposed FY 04 dental program budget,
continued opposition to fluoridation, and continued high levels of
vacancies among dental providers, the FY 2004 indicator proposes an
increase of population drinking optimally fluoridated water by 1%. As a
result of the very limited success Area dental programs have had with
respect to fluoridation in recent years, Headquarters Office of
Environmental Health and Engineering and Headquarters Division of Oral
Health are initiating a new effort to promote fluoridation.

**[Date Sources:]{.underline}** (1) Water Fluoridation Reporting System
(WFRS) and database maintained by CDC. The FY 2002 level will provide
the comparison or baseline for assessing the annual gain. (2) Reports
from IHS Area fluoridation coordinators and Area Dental Officers.
Individual Area reports continue to be solicited for two reasons: (1)
WFRS lacks the detail and the personal observations that can be provided
by field personnel; and (2) few tribal utilities have chosen to use
WFRS.

**[Program Performance:]{.underline}** **IHS did not meet this
indicator.** The FY 2002 indicator committed to a 5% increase in the
number of American Indian and Alaska Native people benefiting from
fluoridated drinking water. However, an increase of 1.0% was achieved
and documented. Fifteen small systems previously not optimally
fluoridated became fluoridated in FY 2002, adding 20,580 individuals to
those enjoying the benefits of fluoridated water. Four small systems
failed to provide data verifying monitoring of fluoride concentration
during FY 2002, and were dropped from our roster of fluoridated locales.

Individual reports from IHS Areas other than the two demonstration sites
make it clear that significant progress has been made in most Areas with
respect to water fluoridation, but the final objective of all the
efforts, successful fluoridation, has not yet occurred. As noted above,
the Headquarters Office of Environmental Health and Engineering and
Headquarters Division of Oral Health are initiating a new centralized
effort to promote fluoridation across the IHS.

![](media/image23.wmf){width="3.6251968503937007in"
height="2.438188976377953in"}Indicator 13: During FY 2004, maintain the
proportion of the American Indian and Alaska Native population who
obtain access to dental services at 99% of the FY 2003 level.

**[Rationale:]{.underline}** This indicator is directed at improving the
oral health status of the American Indian and Alaska Native population.
The growing American Indian and Alaska Native population has resulted in
higher demands for dental care; increasing difficulties in recruiting
dentists have compounded this problem. As a result, there has been
almost a 10% reduction in the percent of the American Indian and Alaska
Native population annually receiving dental services in recent years.
The proposed FY 2004 indicator supports the capacity to maintain dental
access at 99% of the FY 2003 level. In order to maintain the proposed
level of access to care in FY 2004, the number of patients actually
served must increase by approximately 4,000 individuals due to
population growth. In essence, proposing a 1% decrease in access to
care, given this population growth, requires an actual increase in the
number of patients to be treated in FY 2004.

**[Approach:]{.underline}** Access to dental services in FY 2004 will be
maintained at 99% of the FY 2003 level through a combination of
strategies that include:

-   Increasing the I/T/U dental workforce.

-   Increasing retention and productivity of dental providers.

-   Updating and simplify the automated dental record keeping system.

-   Expanding essential dental specialty services through contracts with
    the private sector.

-   Targeting specific populations.

The vacancy rate for dental providers, which has fluctuated slightly
between approximately 18% and 22%, is a key determinant in limiting
access to care. However, the current vacancy rate of approximately 20%
has remained relatively stable over the last few years despite increased
emphasis upon recruiting. This suggests that additional efforts toward
retention of dental providers will be necessary to ensure stabilizing
this indicator.

**[Data Source:]{.underline}** IHS Dental Data System component of the
RPMS.

[**Program Performance**:]{.underline} **IHS met this indicator.** The
FY 2002 indicator committed to a 1% increase in the proportion of the
American Indian and Alaska Native population having access to dental
care compared to FY 2001. 27.35% of the user population received dental
care in FY 2002 compared to 26.3% receiving care in FY 2001. The
population growth increases the denominator by approximately 1.8%
annually. This means that the dental program must treat over 7,000
additional patients each year in order to maintain access to care at a
constant proportion.

The FY 2002 indicator committed to an increase of 1% in access to care
over the FY 2001 objective, which in turn postulated a 4% increase over
the FY 2000 performance. Thus, over two years an increase of over 5%,
relative to FY 2000 level of access to care, was achieved.

Indicator 14: During FY 2004, maintain the number of dental sealants
placed per year in American Indian and Alaska Native children at the FY
2003 level.

![](media/image24.wmf){width="3.5208333333333335in"
height="2.3722222222222222in"}

**[Rationale:]{.underline}** Dental sealants, a recognized standard in
preventive dental care, are an effective measure for reducing dental
decay rates in children and can be effectively applied by dental
auxiliaries at relatively low cost. Because surveys of American Indian
and Alaska Native children have consistently identified them as having
significantly higher decay rates than the general U.S. population,
sealants are essential to reduce both the ravages and costs of treating
dental decay.

The intent of this indicator is to reduce dental decay in children by
increasing both the number of children with dental sealants (the
prevalence of sealants in the population) and the number of sealants per
child (the intensity of coverage per individual). This revised indicator
will provide a better overall assessment of the dental prevention
program than an estimate of the prevalence of children with one or more
existing sealants.

**[Approach:]{.underline}** 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). In order to maintain the number of sealants placed on the
posterior teeth of Indian children and adolescents in FY 2004, an
innovative approach will be required. One option involves the use of
contract 4-handed dental sealant teams hired from the private sector.
Dental Community Health Aides may be trained to assist dental hygienists
and dental assistants in placing sealants. Additional portable equipment
to be used in the schools is an efficient way to make use of lack of
clinic space and going to where the children are -- the schools.

**[Data Source:]{.underline}** IHS Dental Data System component of the
RPMS. This revision of data collection is expected to result in
significantly larger data sets and data that are more reliable. In
contrast to the previous measure, these data will provide an estimate of
both prevalence of sealants and intensity of care, by providing an
estimate of the number of sealants placed per patient.

**[Program Performance:]{.underline}** **IHS met this indicator.** In FY
2001, 212,612 sealants were placed in the IHS dental program. In FY
2002, 227,945 sealants were placed in patients of all ages. This
represents an increase of 7.2% over sealants placed in FY 2001.

Indicator 15: During FY 2004, increase the proportion of the American
Indian and Alaska Native population diagnosed with diabetes who obtain
access to dental services by 1% over the FY 2003 level.

![](media/image25.wmf){width="3.66875in" height="2.404861111111111in"}

**[Rationale:]{.underline}** The purpose of this indicator is to improve
both oral health status and diabetic control for American Indian and
Alaska Native diabetics. Restoring access to both primary and secondary
treatment and preventive services for diabetics can lessen periodontal
disease progression and the subsequent effects on diabetes and overall
health. Improving access and thus increasing utilization of dental
services can also result in less costly care, improved health status,
and quality of life.

**[Approach]{.underline}:** Individual I/T/U hospitals and clinics
provide access to care for diabetic patients in a wide variety of ways.
At a minimum, a yearly examination provides an educational opportunity
to enlighten the diabetic patient on their oral health status and proper
home care to reduce periodontal disease and its effect on diabetic
control. Those programs with additional time and resources can provide
anything from extraction of teeth that are severely involved with
periodontal disease to comprehensive periodontal therapy and dentures.
The proposed FY 2004 IHS budget will support the capacity to maintain
access at the FY 2003 level in the face of population growth and rising
costs of treatment.

**[Data Source:]{.underline}** Diabetes registries, yearly *IHS Diabetes
Care and Outcomes Audit*. FY 2003 actual performance level will serve as
baseline and will be available July 2004. Trend data shows that the FY
1999 performance level was 30%, the FY 2000 level was 32%, and the FY
2001 level was 32%.

**[Program Performance:]{.underline}** **The FY 2002 will be available
in September 2003.**

#### Family Violence, Abuse, or Neglect Indicator:

Indicator 16: During FY 2004 the IHS will address domestic violence,
abuse, and neglect by assuring that:

a\. At least 65% of I/T/U medical facilities (providing direct patient
care) will provide training to the direct clinical staff on the
application of domestic violence policies and procedures.

b\. A standard data code set for domestic violence screening is
implemented into the RPMS data system.

![](media/image26.wmf){width="3.0208333333333335in"
height="1.7708333333333333in"}

**[Rationale:]{.underline}** This indicator is designed to help
ascertain, evaluate and reduce the prevalence of family violence, abuse
and neglect in American Indian and Alaska Native communities. Rates of
intimate partner violence are double for American Indian and Alaska
Native people compared to whites, and 1½ times greater than U.S. all
races. (MMWR)

**[Approach:]{.underline}** IHS will develop training materials that are
specific for American Indian and Alaska Native communities. IHS has
entered into a collaborative agreement with the Family Violence
Prevention Fund as well as ACF, DHHS. This agreement will facilitate the
development of our teaching materials as well as the implementation and
evaluation of a multifaceted systems approach to screening at clinical
facilities throughout American Indian and Alaska Native communities.

[**Data Source:**]{.underline} Annual surveys and/or progress reviews by
IHS Area and Headquarters Staff. RPMS data will be used to obtain and
aggregate domestic violence screening rates.

**[Program Performance]{.underline}**: **IHS met this indicator.** The
FY 2002 indicator was to assure that at least 82% of I/T/U medical
facilities who provide direct clinical care have written policies and
procedures for routinely identifying, treating, and/or referring victims
of domestic violence, abuse or neglect as well as child abuse/neglect
and elder abuse/neglect.

In addition, 56% of sites needed to provide staff training to their
direct clinical staff on these policies. The indicator expanded this
year to capture policies and procedures from sites that provided ANY
direct clinical care, not just ER and/or urgent care. This change
resulted in reports from 139 sites, as opposed to 97 in FY 2001. The
aggregate rate for FY 2001 was 82%. The policy and procedure rate for
2002 is 85%, with 139 sites reporting. 70% of sites provided training in
these policies and procedures.

#### Information Technology Development Group:

The following three indicators address the development of improved
automated data capabilities that support clinical care and performance
measurement.

Indicator 17: During FY 2004, implement a national program to improve
the quality, accuracy and timeliness of Resource Patient Management
System (RPMS) Patient Care Component (PCC) clinical data to support the
Agency's GPRA clinical measures by:

a\. Implementing a "regional" RPMS PCC "data quality" assessment
training at each IHS regional office;

b\. Expand the current automated data quality assessment "package" to
include two new additional clinical measures.

**[Rationale:]{.underline}** This indicator is part of an on-going
effort to improve the overall accuracy, completeness and timeliness of
clinical data from the Agency's primary clinical data repository -
Resource Patient Management System (RPMS) Patient Care Component (PCC)
used for GPRA clinical measures. The goal of this indicator is to
improve the overall quality of clinical data including completeness,
timeliness, accuracy and movement of data to the national programs for
future national electronic GPRA reporting.

**[Approach:]{.underline}** The I/T/Us are responsible for managing
local RPMS clinical applications including data quality. A systematic
training approach to provide the necessary tools and skills will be
developed from the national program level and made available at each IHS
regional office to allow local staff to utilize the training. This
approach will facilitate data quality improvements in at least two
ways: 1) all sites will receive consistent training to ensure quality
issues are approached in a systematic way; 2) local staff will be
provided tools and skills necessary to support local on-going data
quality activities.

The agency will also provide an expanded data quality application that
will allow individual sites to assess electronically collected clinical
data received at the national program level with patient "medical
records" maintained at the local health facility.

**[Data Source:]{.underline}** Local programs will export RPMS clinical
data to the national programs.

**[Program Performance:]{.underline}** **IHS met this indicator.** For
FY 2002 this indicator committed to:

-   Complete analysis of pilot study to evaluate the potential of
    electronically extracting data from the RPMS to report on clinical
    performance measures;

-   Begin to collect pilot baseline data for any performance measures
    where electronic data collection was implemented during this FY;

-   Complete and report on the pilot web-based training program; and

-   Complete collaborative development of LOINC mapping tool for IHS's
    clinical information system.

This serves as part of a long-term effort to expand the IHS capacity to
derive GPRA performance data directly from clinical automated
information systems, including the Resource and Patient Management
System (RPMS). This will allow IHS to add new performance measures in
the most cost-effective way and efficient way.

The following details how IHS fully met this indicator:

-   Over the last several years, IHS has been conducting a pilot study
    to evaluate the accuracy of using electronically extracted data from
    the RPMS for various performance measures;

-   Data is being collected at the national level that will allow
    electronic reporting on a number of clinical measures. Changes are
    being made in how data is collected and stored at the national level
    to allow us to begin to perform other measures and derive additional
    information important to managing our programs;

-   Data gathered during FY 2002 from sites for which web-based training
    and reporting has been provided reveal significant data quality
    improvements at participating sites; and

-   Lab tests in the nationally distributed, standard lab test file
    included in the RPMS Laboratory Package have been mapped to
    Laboratory Observation Identifier Nomenclature Codes (LOINC) codes.
    Furthermore, IHS has begun to provide tools and assistance to local
    sites in mapping their own local lab test files to LOINC.

Indicator 18: During FY 2004, improve the Behavioral Health (BH) Data
System by:

a\. Assuring at least 55% of the I/T/U programs will report minimum
agreed-to behavioral health-related data to the national data warehouse.

b\. Increasing the number of I/T/U programs utilizing any behavioral
health data reporting systems by 5% over the FY 2003 rate.

![](media/image28.wmf){width="3.6458333333333335in"
height="2.3958333333333335in"}

**[Rationale:]{.underline}** The purpose of this indicator is to collect
data in order to track and evaluate improvements in the behavioral
health status of American Indian and Alaska Native people. Better BH
data collection and analysis will improve planning, implementation and
evaluation of mental health, alcohol and substance abuse, and social
services efforts across I/T/U programs.

**[Approach:]{.underline}** Improving behavioral health outcomes relies
on two important activities: data collection as close to point of care
as possible, and data reporting in a standardized way that can be
understood across the Indian health system. Standardized data reporting
can be achieved by providing a usable, provider-driven and provider
friendly computerized application to I/T/U sites.

A key activity that began in FY 2002 was the design and implementation
of an integrated Behavioral Health system. The multi-phased Interim
Solution, with a planned deployment during 2002, will help address the
need for incremental improvements in existing RPMS systems, as well as
allow for an integrated suicide data collection system within the RPMS
package.

The IHS Indian Health Performance Evaluation System (IHPES), a
performance measurement system initially designed to satisfy Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) hospital
ORYX standards, has also developed a national Mental Health SAS
database.

**[Data Source:]{.underline}** RPMS, the Mental Health Database, and
appropriate surveys.

[**Program Performance**:]{.underline} **IHS met this indicator.** The
FY 2002 performance measure was to increase the percent of I/T/Us that
have implemented the use of the Mental Health/Social Services (MH/SS)
data reporting system by 5% over the FY 2001 level. In FY 2002, an
additional 23 sites began to collect and share data.

The FY 2002 totals for this indicator were taken directly from the
national data center "actual" data that was exported and received from
all I/T/U programs by the national data center. This comparative data
was based upon data sent to the national database since 1990.

Indicator 19: No FY 2004 indicator

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2002 performance measure was to increase by 5% (+2 sites) the
proportion of Urban Indian health care programs that have implemented
mutually compatible automated information systems that capture health
status and patient care data over the FY 2001 level.

IHS met this indicator with the addition of the IHS Resource and Patient
Management System (RPMS) at two new sites. The new sites are Pierre,
South Dakota and Denver, Colorado.

In addition, the measure was surpassed through a pilot project to
develop an urban Indian health care data mart within the IHS data
warehouse. The UIHP defined program requirements of a diabetes specific
data mart pilot project that would provide a user friendly, web-based
application. The system was designed, developed and hosted by the Indian
Health Performance Evaluation System (IHPES). All defined requirements
of Phase I of the pilot project were met or exceeded and included six
(6) urban programs. Those sites now have access to a web-based reporting
system to assist in monitoring and tracking currently exported PCC data
and they have access to a menu driven "point and click" series of
reports to assist in better managing health services provided for
Diabetes related care.

#### Quality of Care Indicator Group:

The following indicators address the quality of health care provided in
IHS settings from both the perspective of accreditation, medication
errors, and consumer satisfaction.

Indicator 20: During FY 2004, maintain 100% accreditation of all IHS
hospitals and outpatient clinics.

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

**[Approach:]{.underline}** 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 growing clinical quality of care assessments that are required
as well as issues related to health facilities maintenance, improvement,
and renovation that are critical to accreditation. The accrediting body
used for hospitals and some ambulatory health centers is the Joint
Commission on the Accreditation of Health Care Organizations (JCAHO).
However, there was an increase in the ambulatory health centers that
obtained accreditation from the American Association of Ambulatory
Health Centers (AAAHC).

**[Data Source:]{.underline}** IHS compiled a database generated from
accreditation reports submitted by IHS Area Quality Assurance
coordinators.

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2002 committed to maintaining 100% accreditation of all IHS hospitals
and outpatient clinics and was achieved. During FY 2002, fifteen IHS
hospitals were evaluated by JCAHO and all fifteen maintained full
accreditation. In addition, 13 ambulatory health centers participated in
accreditation visits from JCAHO and AAAHC and all were accredited.

Indicator 21: During FY 2004, the IHS will continue the development of a
standardized non-punitive anonymous medication error reporting system
and will develop system improvement recommendations to lower the rate of
medication errors to improve the quality of healthcare by:

a\. Establishing baseline data for medication error reporting for all
IHS Areas using an approved instrument and compare this national data
with other national benchmarks.

b\. Pilot test a standardized anonymous medication error reporting
system in two areas.

**[Rationale:]{.underline}** The intent of this indicator is to improve
patient safety by reducing medication errors. The current system in
place does not require national reporting. Many sites still have
punitive systems in place that discourage reporting of medication
errors. By developing a national anonymous reporting system, IHS will be
able to determine a more accurate medication error rate and identify
frequent problems throughout our health care system.

**[Approach:]{.underline}** The IHS will examine the many different
medication error reporting processes and training used throughout the
I/T/U, as well as other health networks. IHS will work with Areas to
establish baseline data for medication error reporting.

**[Data Source:]{.underline}** In FY 2004, baseline medication error
reporting data will be obtained from sites using in place local systems
including reports to Risk Management Officers and data entered into the
Resource and Patient Management System (RPMS).

**[Program Performance:]{.underline}** **IHS met this indicator.**
Number range CHAPTERThe FY 2002 performance indicator was that the IHS
would assess the current processes in place in I/T/Us that affect
medication error reporting, and:.

> a\. Adopt standardized definitions for medication errors for use in
> I/T/Us.
>
> b\. Determine where facilities are in the process of medication error
> reporting.
>
> c\. Communicate to health care providers and administrators the need
> for a non-punitive medication error reporting system for all medical
> errors, not just medication errors or sentinel events.

All three sections of the target indicator related to Medication Error
Reporting have been met. Standardized Medication Error definitions have
been developed for IHS and are very similar to those from the National
Coordinating Council for Medication Error Reporting and Prevention.
Reporting from IHS and tribal sites revealed that all IHS sites and many
tribal facilities have medication error reporting systems in place. All
sites were reminded of the detrimental effect of punitive medication
error reporting systems and were asked to review their policies to
encourage reporting of medication errors and to view errors as system
problems, not problems with individual providers.

One of the indicators in the FY 2003 Medication Error indicator has
already been started. The pilot test of the Medication Error Reporting
System (MedMarx) has begun in the Phoenix and Albuquerque Areas.

Indicator 22: By the end of FY 2004, improve consumer satisfaction rates
by 2% over the FY 2003 baseline.

**[Rationale:]{.underline}** The intent of this indicator is to improve
consumer satisfaction. Assessing consumer satisfaction is fundamental to
quality management, assuring improved customer satisfaction, and
required for accreditation of hospitals and clinics. Improved consumer
satisfaction is also associated with higher consumer compliance levels
with provider health recommendations, which can result in improved
health outcomes.

**[Approach:]{.underline}** In FY 1999 the IHS developed a comprehensive
culturally sensitive consumer satisfaction survey instrument that was
based on a tested and validated instrument from the private sector. In
FY 2000 the instrument and data collection protocol were to have
completed the Paperwork Reduction Act clearance process and to be used
to identify baseline scores for IHS hospitals and clinics. However, the
submission package was delayed in completion and did not reach OMB until
late FY 2001. Clearance was not anticipated until late FY 2002. Baseline
assessment was moved into FY 2003, with a follow-up survey to determine
improvement scheduled to be completed in FY 2004.

The responsible parties for implementation are the local I/T/U service
sites with assistance from the IHS Area office staff. The local staff
will be part of the local quality assurance program and the aggregate
staff will be part of the IHS epidemiology centers/program.

**[Data Source:]{.underline}** IHS Consumer Satisfaction Survey

[**Program Performance**:]{.underline} **IHS met this indicator.** The
FY 2002 indicator committed to securing OMB clearance on revised
consumer satisfaction instrument. The step to obtain full approval of
the instrument moved forward again after receiving no public comments
from the 30 and 60-day Federal Register Notices publications. It was
reviewed by the Department and forwarded to the OMB for final clearance
in late FY 2001, but clearance was not obtained until FY 2002. Initial
plans for implementing the survey are completed, and we anticipate use
of the survey instrument early FY 2003.

### Prevention Indicators

[]{#__RefHeading___Toc31535873 .anchor}Table 7: Prevention Indicators
Performance Summary

<table style="width:100%;">
<colgroup>
<col style="width: 0%" />
<col style="width: 28%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 29%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 27%" />
<col style="width: 0%" />
<col style="width: 12%" />
</colgroup>
<thead>
<tr class="header">
<th></th>
<th colspan="3">Performance Indicator</th>
<th colspan="3">FY Targets</th>
<th colspan="2"><p>Actual</p>
<p>Performance</p></th>
<th>Reference</th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td></td>
<td colspan="9">Public Health Nursing Indicator</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"><u>Indicator 23:</u> Increase the number of public
health nursing services (primary and secondary treatment and preventive
services) provided to infants and elders.</td>
<td colspan="3"><p><u>Total Visits</u></p>
<p>FY 04: maintain FY 03 level</p>
<p>FY 03: maintain FY 02 level</p>
<p>FY 02: +2% over FY 01</p>
<p>FY 01: +3% over FY 00</p>
<p>FY 00: 7% over 97 or 363,033</p>
<p>FY 99: no indicator</p>
<p><u>Home Visits</u></p>
<p>FY 04: maintain FY 03 level</p>
<p>FY 03: +2% over FY 02</p>
<p>FY 02: +2% over FY 01</p>
<p>FY 01: +3% over FY 00</p>
<p>FY 00: 7% over 97 or 127,846</p>
<p>FY 99: no indicator</p></td>
<td colspan="2"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: 3-03</p>
<p>FY 01: 383,436 (+3.1%)</p>
<p>FY 00: 371,548 (9.5 % over FY97)</p>
<p>FY 99: 336,134</p>
<p>FY 97: 339,283 baseline</p>
<p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: Data pending</p>
<p>FY 01: 153,852 (+20%)</p>
<p>FY 00: 127,873 (7% over 97)</p>
<p>FY 99: 111,836</p>
<p>FY 97: 119,482 baseline</p></td>
<td><p>P: p. 3-46</p>
<p>B: p. IHS-75</p>
<p>1</p>
<p>3</p>
<p>5</p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="9">Immunization Group</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"><u>Indicator 24:</u> Increase the proportion of AI/AN
children who have completed all recommended immunizations by the age
two.</td>
<td colspan="3"><p>FY 04: +2% over FY 03</p>
<p>FY 03: at FY 02 level</p>
<p>FY 02: +1% over FY 01 level</p>
<p>FY 01: +1% over FY 00 level</p>
<p>FY 00: +2% over FY 99 level</p>
<p>FY 99: 91%</p></td>
<td colspan="2"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: 78% (-5%)</p>
<p>FY 01: 83% 12 of 12 Areas (-3%)</p>
<p>FY 00: 86% 12 of 12 Areas (-3%)</p>
<p>FY 99: 89% 12 of 12 Areas</p>
<blockquote>
<p>87% 11 of 12 Areas</p>
</blockquote>
<p>FY 98: 88% (baseline 11 of 12 Areas)</p></td>
<td><p>P: p. 3-47</p>
<p>B: p. IHS-29</p>
<p>p. IHS-75</p>
<p>p. IHS-83</p>
<p>p. IHS-87</p>
<p>1</p>
<p>3</p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"><u>Indicator 25:</u> Increase overall influenza
vaccination levels among diabetics and adults aged 65 years and
older.</td>
<td colspan="3"><p><u>Influenza</u></p>
<p>FY 04: at FY 03 level</p>
<p>FY 03: at FY 02 level</p>
<p>FY 02: +1% over FY 01 level</p>
<p>FY 01: +1% over FY 00 level</p>
<p>FY 00: 65%</p>
<p>FY 99: no indicator</p>
<p><u>Pneumococcal</u></p>
<p>FY 04:</p>
<p>FY 03: no indicator</p>
<p>FY 02: no indicator</p>
<p>FY 01: secure electronic baseline</p>
<p>FY 00: 65%</p>
<p>FY 99: no indicator</p></td>
<td colspan="2"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: 31%</p>
<p>FY 01: 34.8%</p>
<p>FY 00: 30.7%</p>
<p>FY 03:</p>
<p>FY 02: no indicator</p>
<p>FY 01: data not available</p>
<p>FY 00: data source inadequate</p></td>
<td><p>P: p. 3-48</p>
<p>B: p. IHS-29</p>
<p>p. IHS-75</p>
<p>p. IHS-83</p>
<p>1</p>
<p>3</p>
<p>5</p>
<p>New FY 2001 Data</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"><u>Indicator 26:</u> Increase overall Pneumococcal
vaccination levels among AI/AN diabetics and elderly.</td>
<td colspan="3"><p>FY 04: at FY 03 level</p>
<p>FY 03: at FY 02 level*</p>
<p>FY 02: no indicator</p>
<p>FY 01: secure electronic baseline</p>
<p>FY 00: 65%</p>
<p>FY 99: no indicator</p></td>
<td colspan="2"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: 17%</p>
<p>FY 01: 11.2%</p>
<p>FY 00: data source inadequate</p></td>
<td><p>P: p. 3-49</p>
<p>B: p. IHS-29</p>
<p>p. IHS-75</p>
<p>p. IHS-83</p>
<p>1</p>
<p>3</p>
<p>5</p>
<p>New FY 2001 Data</p>
<p>* indicates revised FY 2003 measure. See Summary of Changes Table 10
on page 5-2.</p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="9"><p id="injury-prevention-group" class="heading">Injury
Prevention Group</p></td>
</tr>
<tr class="even">
<td colspan="2"><u>Indicator 27:</u> Expand the number of tribes/tribal
organizations with comprehensive injury prevention programs</td>
<td colspan="3"><p><u>IP Intervention Projects</u></p>
<p>FY 04: maintain at least 36 injury prevention projects.</p>
<p>FY 03: implement at least 36 injury prevention projects.*</p>
<p><u># of Comprehensive IP Progs</u></p>
<p>FY 03: no indicator</p>
<p>FY 02: maintain at least 25 sites*</p>
<p>FY 01: no indicator</p>
<p>FY 00: no indicator</p></td>
<td colspan="3"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 03:</p>
<p>FY 02: 25 sites</p>
<p>FY 01:</p>
<p>FY 00: baseline 25 sites</p></td>
<td colspan="2"><p>P: p. 3-50</p>
<p>B: p. IHF-37</p>
<p>1</p>
<p>3</p>
<p>* indicates revised FY 2003 measure. See Summary of Changes Table 10
on page 5-2.</p></td>
</tr>
<tr class="odd">
<td colspan="2"><u>Indicator 28:</u> Reduce the number of unintentional
injuries for AI/AN people.</td>
<td colspan="3"><p><u>Deaths</u></p>
<p>FY 04: maintain or reduce FY 03</p>
<p>FY 03: maintain or reduce FY 02 rate</p>
<p>FY 02: at FY 01 rate, or less</p>
<p>FY 01: no indicator</p>
<p>FY 00: no indicator</p>
<p>FY 99: 93/100,000 (ICD-9)<br />
95.84/100,000 (ICD-10)</p>
<p><u>Hospitalizations</u></p>
<p>FY 01: 70 per 10,000</p>
<p>FY 00: 71.5 per 10,000</p></td>
<td colspan="3"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: Available December 2005</p>
<p>FY 01: Available December 2004</p>
<p>FY 00: Available December 2003</p>
<p>FY 99: 95.5/100,000</p>
<p>FY 96-98: 94.7/100,000 deaths</p>
<p>FY 94-96: 92.6/100,000 deaths</p>
<p>FY 92-94: 95.0/100,000 deaths</p>
<p>FY 01: data not available</p>
<p>FY 00: data not available</p>
<p>FY 98: 72.5 /10,000 hosp.</p>
<p>FY 96: 74.7/10,000 hosp.</p></td>
<td colspan="2"><p>P: p. 3-50</p>
<p>B: p. IHF-37</p>
<p>1</p>
<p>5</p></td>
</tr>
<tr class="even">
<td colspan="10"><p id="suicide-prevention-indicator"
class="heading">Suicide Prevention Indicator</p></td>
</tr>
<tr class="odd">
<td colspan="2"><u>Indicator 29</u>: Increase percentage of I/T/Us that
have implemented a suicide surveillance system to monitor the incidence
and prevalence rates of suicidal acts (attempts and completions) which
assure those at risk receive services, and that appropriate
population-based prevention interventions are implemented.</td>
<td colspan="3"><p>FY 04: + 3% over FY 03 level</p>
<p>FY 03: + 5% over FY 02 level</p>
<p>FY 02: + 10% over FY 01 level</p>
<p>FY 01: 50% of I/T/Us implem.</p>
<p>FY 00: no indicator</p>
<p>FY 99: no indicator</p></td>
<td colspan="3"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: 22% of I/T/Us implem. (+10% over FY 01)</p>
<p>FY 01: 12% of I/T/Us implem.</p>
<p>FY 00:</p>
<p>FY 99:</p>
<p>FY 98: estimated 25%</p></td>
<td colspan="2"><p>P: p. 3-52</p>
<p>B: p. IHS-41</p>
<p>P. IHS-49</p>
<p>3</p>
<p>5</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="9"><p id="developmental-prevention-and-treatment"
class="heading">Developmental Prevention and Treatment</p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"><u>Indicator 30:</u> Collaborate with NIH and AI/AN
sites in developing and implementing culturally sensitive
community-directed pilot cardiovascular disease prevention
programs.</td>
<td colspan="3"><p>FY 04: Evaluation implemented and 1 site added</p>
<p>FY 03: Evaluation implemented and 1 site added</p>
<p>FY 02: 3 sites implementing interventions</p>
<p>FY 01: 3 sites with intervention plans</p>
<p>FY 00: no indicator</p>
<p>FY 99: no indicator</p></td>
<td colspan="2"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: 3 sites implemented intervention plans</p>
<p>FY 01: 3 sites with intervention plans</p></td>
<td><p>P: p. 3-53</p>
<p>B: p. IHS-79</p>
<p>p. IHS-29</p>
<p>1</p>
<p>3</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><u>Indicator 31</u>: Develop an overall 3 element IHS
obesity prevention and control plan based on findings from emerging
research and recent projects in AI/AN settings.</td>
<td colspan="3"><p>FY 04: continue implementation with Area plans
devel.</p>
<p>FY 03: implement a 3 element obesity prevent./treat. plan</p>
<p>FY 02: develop a 3 element obesity prevent./treat. plan*</p>
<p>FY 01: implement obesity prevention program and monitor pilots and
comparisons sites</p>
<p>FY 00: establish five pilot sites</p>
<p>FY 99: develop approach and baselines</p></td>
<td colspan="3"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: 3 element obesity prevent/ treatment plan developed</p>
<p>FY 01: implementation and monitoring commenced at sites</p>
<p>FY 00: pilot sites established</p>
<p>FY 99: approach and baseline accomplished</p></td>
<td><p>P: p. 3-54</p>
<p>B: p. IHS-29</p>
<p>1</p>
<p>3</p></td>
</tr>
<tr class="odd">
<td colspan="3"><u>Indicator 32:</u> Develop an overall IHS tobacco
control plan based on findings from CDC sponsored AI/AN tobacco control
pilot sites.</td>
<td colspan="3"><p>FY 04: implement control plan</p>
<p>FY 03: develop 5-year tobacco control plan for IHS</p>
<p>FY 02: commence all prescribed control activities in 5 sites</p>
<p>FY 01: establish 5 tobacco control centers</p>
<p>FY 00: establish baseline rates for tobacco usage</p>
<p>FY 99: no indicator</p></td>
<td colspan="3"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: commence all prescribed control activities in 5 sites</p>
<p>FY 01: 7 tobacco control centers established</p>
<p>FY 00: baseline rates established</p></td>
<td><p>P: p. 3-55</p>
<p>B: p. IHS-29</p>
<p>1</p>
<p>3</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="9"><p id="hivaids-group" class="heading">HIV/AIDS
Group</p></td>
</tr>
<tr class="odd">
<td colspan="2"><u>Indicator 33:</u> Maintain ongoing surveillance of
HIV/AIDS and determine the level of completeness of reporting.</td>
<td colspan="3"><p>FY 04: no indicator</p>
<p>FY 03: no indicator*</p>
<p>FY 02: 3 Areas assessed</p>
<p>FY 01: one Area assessed</p>
<p>FY 00: establish baseline rates</p>
<p>FY 99: no indicator</p></td>
<td colspan="3"><p>FY 02: 3 areas assessed</p>
<p>FY 01: Area baseline partially established</p>
<p>FY 00: partially established</p></td>
<td colspan="2"><p>P: p. 3-56</p>
<p>B: p. IHS-29</p>
<p>p. IHS-59</p>
<p>* indicates revised FY 2003 measure. See Summary of Changes Table on
page 5-3</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><u>Indicator 34:</u> Increase the percentage of
high-risk sexually active persons who know their HIV status and have
received risk reduction counseling.</td>
<td colspan="4"><p>FY 04: +10 Sites</p>
<p>FY 03: +5% over FY 02</p>
<p>FY 02: secure baseline in 3 new Areas</p>
<p>FY 01: Establish baseline</p>
<p>FY 00: no indicator</p>
<p>FY 99: no indicator</p></td>
<td colspan="2"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: baseline in 3 areas</p>
<p>FY 01: baseline for limited sites</p>
<p>FY 00: no baseline</p></td>
<td><p>P: p. 3-56</p>
<p>B: p. IHS-29</p>
<p>p. IHS-59</p>
<p>1</p>
<p>3</p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="9"><p id="environmental-surveillance-indicator"
class="heading">Environmental Surveillance Indicator</p></td>
</tr>
<tr class="even">
<td colspan="2">Indicator 35: Implement automated web-based
environmental health surveillance data collection system in tribal
systems.</td>
<td colspan="3"><p>FY 04: +15% over FY 03 level</p>
<p>FY 03: +15% over FY 02 level</p>
<p>FY 02: implement in at least 10 sites</p>
<p>FY 01: 15% of communities assessed</p>
<p>FY 00: develop surveillance protocol and plan</p>
<p>FY 99: no indicator</p></td>
<td colspan="3"><p>FY 04:</p>
<p>FY 03:</p>
<p>FY 02: implemented in 19 more sites</p>
<p>FY 01: automated system distributed to all IHS field sites</p>
<p>FY 00: protocol and plan partially completed</p>
<p>FY 99: no surveillance systems in place</p></td>
<td colspan="2"><p>P: p. 3-57</p>
<p>B: p. IHF-37</p>
<p>3</p>
<p>4</p></td>
</tr>
<tr class="odd">
<td colspan="2">Total Prevention Funding :</td>
<td colspan="3"><p>FY 04: $128,083,000</p>
<p>FY 03: $125,387,000</p>
<p>FY 02: $118,224,000</p>
<p>FY 01: $113,558,000</p>
<p>FY 00: $109,216,000</p>
<p>FY 99: $102,712,000</p>
<p>FY 98: $99,647,000</p></td>
<td colspan="3"></td>
<td colspan="2"><blockquote>
<p>P: page # in perform. plan</p>
<p>B: page # in budget justif.</p>
</blockquote></td>
</tr>
</tbody>
</table>

#### Public Health Nursing Indicator:

> [Indicator 23:]{.underline} During FY 2004, maintain the total number
> of public health nursing services (primary and secondary treatment and
> preventive services) provided to neonates, infants, and elders in all
> settings and the total number of home visits at the FY 2003 workload
> levels.
>
> ![](media/image29.wmf){width="3.0319444444444446in"
> height="2.5208333333333335in"}

**[Rationale:]{.underline}** The purpose of this indicator is to improve
the health status of American Indian and Alaska Native people through
maintaining access to services associated with improved health outcomes.
Many of the successes in Indian health such as a decrease in infant
mortality, high immunization rates, and increased prenatal care are
attributed to the efforts of public health nursing.

The unique quality of Public Health Nursing (PHN) service is that care
can be provided in any setting where the patient is accessible. This is
especially effective for high-risk patients and families (e.g.,
substance abusing prenatal patients, communicable disease cases,
families with dysfunctional life styles, etc.). Therefore, public health
nursing workload, especially community based visits and home visits, is
used as measure of program effectiveness and an overall indicator of
health status of the community.

**[Approach:]{.underline}** The population base for public health
nursing services is the IHS user population residing within the official
boundaries of the Area. However, in some service units, the user
population is greater than the reported census population. In these
cases, the Indian user population is used as an estimate of the service
population to reflect PHN service to both stable communities and
transient populations.

**[Data Sources:]{.underline}** IHS PCC, IHS Program Statistics Team,
and written reports submitted by Tribes using non-RPMS systems.

**[Program Performance:]{.underline} Data will be available April
2003.** The FY 2002 performance indicator committed to increasing the
total number of Public Health Nurse visits to the American Indian and
Alaska Native population by 2% over the 2001 level. The FY 2001, Public
Health Nurse report reflects that 383,436(3.1% increase) total Public
Health Nurse visits were provided and 153,852 (20% increase) were visits
in the home over FY 2000 data.

#### Immunization Group:

The following three indicators support immunization coverage in children
and adults at high risk for preventable diseases and represent perhaps
the most efficacious \"impact\" interventions known to public health.

Indicator 24: During FY 2004:

a\. Increase the rates for all recommended immunizations for American
Indian and Alaska Native children ages 3‑27 months by 2% over the FY
2003 rates;

![](media/image31.wmf){width="3.6458333333333335in"
height="2.4166666666666665in"}

**[Rationale:]{.underline}** Although reports on children 3 - 27 months
are an important indicator for the individual clinic, in order to put
immunization coverage for American Indian and Alaska Native populations
in context, it is important that we be able to compare coverage rates
with State and national immunization coverage rates. The National
Immunization Survey, which is used to estimate immunization coverage for
each state and for the U.S., collects information on children 19 - 35
months. In addition, the Healthy People 2010 is 90% coverage with
routine immunizations for children 19 - 35 months. In order to be able
to compare coverage of American Indian and Alaska Native children to the
rest of the population, and to monitor IHS progress towards the Healthy
People 2010 target, we need to begin collecting data on children 19 - 35
months. For this reason, in FY 2004 we will establish a baseline for
immunization coverage among children 19 -35 months. After 2004, we will
continue to assess our performance using the 19 - 35 month indicator
rather than the 3 - 27 month indicator.

**[Approach:]{.underline}** The purpose of this indicator is increase
age appropriate immunization coverage for American Indian and Alaska
Native children. Immunizations are one of the most cost-effective public
health measures available for improving health outcomes in children and
are a recognized standard of care and a standard of public health. This
will result in decrease of vaccine-preventable diseases including
measles, mumps, rubella, haemophilous influenza b, pneumococcal disease,
polio, diphtheria, pertussis, tetanus, hepatitis A and B, and varicella
as recommended by the USPHS Advisory Committee on Immunization
Practices.

**[Data Source:]{.underline}** Quarterly immunization reports are based
on IHS patient care records and public health nursing records of
children who receive immunizations at an IHS facility. IHS will be
primarily responsible for completing the reports. Comparison data for
the 19 -- 35 month rate are available from the National Immunization
Survey reported by CDC.

**[Program Performance:]{.underline}** **IHS did not meet this
indicator.** The FY 2002 performance indicator was to reduce the
incidence of preventable disease by increasing the proportion of
American Indian and Alaska Native children who have completed all
recommended immunizations for ages 0-27 months (as recommended by
Advisory Committee on Immunization Practices) during FY 2001 by 1% over
the FY 2001 rate. In 2001, 83% of children were fully immunized. In
2002, 78% of children were immunized.

Impediments to achieving this indicator include vaccine shortages,
increasingly complex vaccine schedule, and incomplete tracking of
vaccination delivery due to continuity of care issues. Steps taken to
address these challenges include ongoing work with the CDC, data quality
initiatives, software updates and support, and a pilot immunization data
exchange project with 3 states and the CDC.

**[Indicator 25]{.underline}:** In FY 2004, maintain the FY 2003 rate
for influenza vaccination levels
![](media/image32.wmf){width="3.6255905511811024in"
height="2.3429133858267717in"}among non-institutionalized adults age 55
years and older.

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
morbidity and mortality due to influenza among adults. Improving
immunization coverage rates for influenza among adults will reduce the
incidence of this disease.

[**Approach**:]{.underline} IHS clinics are encouraged to provide
influenza vaccine to adults 55 years of age during clinic visits and
during mass immunization clinics. Educating patients is a part of the
strategy to ensure influenza vaccine is provided. The proposed FY 2004
IHS budget will support the capacity for sites to continue existing
strategies and maintain current immunization coverage levels in the face
of population growth.

**[Data Source:]{.underline}** RPMS data system. Influenza vaccination
rates will be based on having received vaccination within the year.

**[Program Performance:]{.underline}** **IHS did not meet this
indicator.** [Indicator #24b (FY 2002): Influenza]{.underline}

The percent of adults 65 years and older that received influenza vaccine
in FY 2001 was 35%. The FY 2002 goal was 1% higher, or 36%.

In FY 2002, 82,231 American Indian and Alaska Native 65 years and older
were eligible for influenza vaccination. Of those, 25,700 or 31 %
received an influenza vaccination.

Reasons for not meeting this indicator include vaccine shortage,
incomplete data due to the availability of the vaccine outside of the
health care facility, and lack of historical medical information in RPMS
at the national level. IHS is addressing this issue by implementing the
current recommendations for immunization coverage, changing the data
system to ensure that historical data is available, and working with CDC
to ensure equitable distribution of influenza vaccine. In addition,
there will be a continued emphasis on electronic healthcare reminders as
well as individual electronic provider feedback.

Indicator 26: In FY 2004, maintain the FY 2003 rate for pneumococcal
vaccination levels among non-institutionalized adults age 65 years and
older.

![](media/image33.wmf){width="3.8929133858267715in"
height="2.3429133858267717in"}

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
morbidity and mortality due to pneumococcal disease among adults.
Improving immunization coverage rates for pneumococcal disease among
adults will reduce the incidence of these diseases.

**[Approach:]{.underline}** IHS clinics are encouraged to provide
pneumococcal vaccine to adults 65 years of age during clinic visits. The
proposed FY 2004 IHS budget will support the capacity for sites to
continue existing strategies and maintain current immunization coverage
levels in the face of population growth.

**[Data Source:]{.underline}** RPMS data system. Pneumococcal
vaccination rates will be based on clinically appropriate patients
having ever received the pneumococcal vaccine.

**[Program Performance:]{.underline}** **No FY 2002 Indicator**.
However, we developed an approach to obtain the needed data for this
indicator and in FY 2002, 82,231 American Indian and Alaska Native were
eligible for pneumococcal vaccination. Of those, 13,866, or 17% received
a pneumoccocal vaccination. This is a 5% increase over the 12% rate from
2001 we were able to extract. IHS achieved this increase in this
immunization rate by focusing on improving pneumoccocal immunization
rates at the local facilities. IHS will continue to focus on improved
pneumococcal vaccine rates through increasing electronic healthcare
reminders to providers.

#### Injury Prevention Group: {#injury-prevention-group-1}

The following two indicators address the process and outcome of
comprehensive community-based injury prevention efforts across I/T/U
settings.

[Indicator 27]{.underline}: During FY 2004, implement at least 36
community-based, proven injury prevention intervention projects across
I/T/U settings.

**[Rationale:]{.underline}** The purpose of this indicator is to reduce
injury rates in the American Indian and Alaska Native communities
through the implementation of proven injury intervention strategies
across I/T/U settings. This indicator builds on the work conducted by
the IHS Injury Prevention Program and documents initiatives and
strategies initiated through the Injury Prevention Program 5-year Plan.

Proven injury prevention interventions are projects that address a
specific identified injury problem; employ a multiple-strategy approach;
are based on a proven effective, evaluated injury prevention strategy;
or are epidemiologically identified from local data and designed on a
proven prevention approach. Examples of projects include Sleep Safe
Project sites, national IHS Part II Injury Infrastructure Grants, and
Injury Prevention Specialist Fellowship.

**[Approach:]{.underline}** Since the mid-1980\'s IHS has developed the
capacity of IHS staff and tribes to epidemiologically assess the injury
hazards and risk factors in communities and develop intervention
strategies. Injury intervention projects are underway through I/T/U
settings to reduce the burden of injury experienced. This measure will
report on the community specific initiatives underway throughout IHS.
The goal of 36 projects is established on a base level of three projects
per Area.

**[Data Sources:]{.underline}** Data to report on this indicator will be
compiled and reported by Area Injury Prevention Specialists.

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2002 indicator committed to maintaining the number of tribes/tribal
organizations that meet the criteria standards of IHS comprehensive
injury prevention programs from the baseline of 25 tribes in FY 2000.

The intent of the indicator was to continue developing the tribal injury
prevention infrastructure through the maintenance of a national
cooperative agreement program. The success of the programs described
through this indicator will be used to influence the creation of
additional tribal programs with funding and technical assistance. This
indicator was maintained by funding in FY 2002 budgets. This indicator
was changed for FY 2003.

Indicator 28: During FY 2004, assure that the unintentional
injury-related mortality rate for American Indian and Alaska Native
people is no higher than the FY 2003 level.

**[Rationale:]{.underline}** Injuries are a leading cause of
hospitalization for American Indian and Alaska Native people. Annually,
forty six percent (46%) of the Years of Potential Life Lost (YPLL) for
American Indian and Alaska Native people are the result of injuries.
Furthermore, injuries are the number one cause of mortality for American
Indian and Alaska Native people for ages 1-44 years and third for
overall death rates. The IHS spends more than \$150,000,000 annually for
the treatment of non-fatal injuries. The single largest expenditure of
contract medical care funds is for the treatment of injuries. The
systematic implementation of prevention strategies through partnerships
with tribes and outside agencies has demonstrated significant
improvements in injury rates across American Indian and Alaska Native.

**[Approach:]{.underline}** The IHS has assigned an Injury Prevention
Program Manager, in the Office of Public Health, at Headquarters who
coordinates activities and resources with specially trained Injury
Prevention Specialists at the Area, District, Service Unit and tribal
levels. IHS maintains a broad base Injury Prevention program that
includes a \$1.475 million Infrastructure Grant Program, an
internationally recognized training program, community-based
epidemiologic assessment, and partnerships with other agencies to fund
and implement proven intervention projects in communities.

**[Data Source:]{.underline}** In its original form in the FY 1999
performance plan, this indicator targeted injury mortality as the
performance measure. The time lag of 2-3 years in the release of
official injury mortality data from the National Center for Health
Statistics (NCHS) prompted IHS to change to unintentional injury-related
hospitalization rates as a more effective measure for the rate of
unintentional injuries as this measure is available much sooner.
However, efforts to apply this approach in FY 2000 and FY 2001 revealed
that the hospitalization data do not accurately reflect the number of
unintentional injury cases that are hospitalized in IHS or tribal
hospitals. Coding omissions have resulted in injury codes frequently not
being noted. For FY 2002, the IHS will again depend on adjusted death
rates generated from the official injury mortality data from the NCHS.

**[Program Performance:]{.underline} No data is currently available to
report on this indicator. IHS expects that we will be able to report on
this indicator by 2005.**

The FY 1999 indicator committed to reduce deaths by unintentional
injuries for American Indian and Alaska Native people to no more than 93
per 100,000 people. The Healthy People 2010 target is 17.5
deaths/100,000 population. Our preliminary GPRA Performance Report for
1999 stated that this indicator was not met, because data for American
Indian and Alaska Native\'s revealed a mortality rate of 95.5 /100,000
while the target was 93/100,000. However, IHS has determined that the
indicator was met for 1999. The 1999 unintentional injury rate of
93/100,000 indicator was established using the International
Classification of Disease, 9^th^ edition (ICD-9). The IHS reported rate
of 95.5/100,000 used the newer ICD-10 classification system.

The two versions of the classification system are not directly
comparable. In the September 21, 2001 edition of \"National Vital
Statistic\" (Deaths: Final Data for 1999), the National Center for
Health Statistics published comparability ratios to adjust and compare
ICD-9 and ICD-10 data.

When the performance target of 93/100,000 is adjusted for ICD-10, using
the adjustment ration of 1.0305 for unintentional injuries, the rate is
95.84/100,000. The rate IHS reported was 95.5/100,000, based on ICD-10.

#### Suicide Prevention Indicator: {#suicide-prevention-indicator-1}

Indicator 29: During FY 2004, increase by 3% over the FY 2002 level, the
proportion of I/T/Us that have implemented systematic suicide evaluation
and referral systems that include:

a\. Monitoring the incidence and prevalence rates of suicidal acts
(attempts and completions);

b\. assuring appropriate population-based prevention and interventions
are available and services are made accessible to individuals identified
at risk;

c\. establishing baseline rates for adolescent suicide (12-19 year
olds).

**[Rationale:]{.underline}** This indicator is part of an expanding
systematic effort at reducing the prevalence of suicide in the American
Indian and Alaska Native population. The suicide death rate for the
American Indian and Alaska Native population has actually increased in
the 1990s and is currently 72% greater than the national average. This
problem has been particularly devastating for a number of American
Indian and Alaska Native communities that have experienced dramatic
increases in adolescent suicides in recent years and represents one of
the greatest tragedies that the IHS must address.

**[Approach:]{.underline}** The I/T/Us will be responsible for reporting
the implementation of suicide evaluation and referral forms to the
national data center. A suicide surveillance and prevention system is
being encouraged for use in I/T/Us to assure that routine suicide
screenings and case management are nationally consistent, but also
tailored to the needs and resources of each site. This suicide
surveillance instrument will be integrated into the interim behavioral
health software application (scheduled to be deployed in FY 2003).

**[Data Source:]{.underline}** Local programs will send reports to the
national ITSC with identified data sources linked with RPMS as
appropriate. Refinement of data source activity will remain with the
seven IHS Areas that are currently reporting data to the ITSC.

**[Program Performance:]{.underline}** **IHS met this indicator.** The
2002 indicator committed to reducing suicide rates by assuring that by
the end of FY 2002, there would be at least a 10% increase in the number
of I/T/U programs that have implemented a suicide surveillance system to
monitor the incidence and prevalence rates of suicidal acts (attempts,
and completions). This surveillance system is coupled with assuring that
those at risk receive appropriate services, and that appropriate
population-based prevention interventions are implemented. The FY 2001
indicator was not met with only 28 I/T/U sites out of 227 (12%) that
reported suicide data monitoring rates of attempts and completions in FY
2001. In FY 2002, 5 IHS Areas used a suicide data collection form
(Aberdeen, Albuquerque, Alaska, Billings, Phoenix and Tucson), enabling
IHS to meet this indicator.

The IHS, at a national level, is currently unable to track whether
appropriate population based prevention and interventions are
implemented and that those identified at risk receive services at a
local level. However, JCAHO requires appropriate mental health patient
screening and referral. 100% of our facilities are JCAHO certified. IHS
believes that this accreditation indicates compliance with part b of
this indicator.

#### Developmental Prevention and Treatment Group:

The following three indicators represent efforts to identify and
disseminate the finding and learning from research and demonstration
projects addressing significant chronic diseases afflicting American
Indian and Alaska Native people. These measures target the development
and implementation of effective prevention and treatment programs to
address cardiovascular disease, diabetes and tobacco use.

Indicator 30: During FY 2004, the IHS will continue collaboration with
NIH to assist three American Indian and Alaska Native communities to
implement culturally sensitive community-directed pilot cardiovascular
disease prevention programs and initiate expansion into one new American
Indian and Alaska Native site.

**[Rationale:]{.underline}** Cardiovascular disease represents the
single largest cause of death for American Indian and Alaska Native
people above the age of 45. This indicator demonstrates the support of
IHS leadership to establish collaborative partnerships with other
governmental agencies. The scope of this project requires a working
relationship with NIH; the Laguna Pueblo of New Mexico; the Ponca Tribe
of Oklahoma; and Bristol Bay, Alaska. Additionally, a working
relationship with other governmental agencies such as the Centers for
Disease Control, Head Start, and BIA is needed**.**

**[Approach:]{.underline}** This indicator is focused on collaborating
to enhance long-term community commitment and capability in developing
approaches to the prevention of cardiovascular disease at three American
Indian and Alaska Native sites. Community intervention activities vary
from organization-based fitness and diet control programs (worksites,
churches), school-based fitness and diet control programs, education
programs for Head Start and high schools, social marketing of healthy
practices through available media sources (Tribal radio, TV, Tribal
newspapers), and social events such as Feasts and powwows, to the use of
field public health staff to reach families in homes or other sites
(e.g., public health nurses, health aides, health educators, dieticians
and nutritionists, CHRs).

**[Data Source:]{.underline}** Selected and developed by each local
site, consistent with interventions, to be tracked through RPMS. While
being designated primarily as a community-directed cardiovascular
prevention program (versus a "medical model" program), GPRA+ clinical
data sources will be used to track cardiovascular disease. Tribes will
also have the benefit of community assessment upon which to build
community-directed programs.

**[Program Performance:]{.underline}** **IHS met this indicator.** The
major achievement during FY 2001 was the development of a Community
Action Plan for each of the three Tribes. During FY 2002, Tribes
began 1) implementing their Plan, and, 2) selected clinical indicators
with which to track the success of the community interventions and
activities. During FY 2003, the three Tribal programs will:

-   Continue to implement their Community Action Plan;

-   begin the actual tracking of the Cardiovascular Disease Clinical
    Indicators selected by the three Tribes (lipids, cholesterol, body
    mass index, tobacco cessation rates, and exercise education) through
    GPRA+ software designed especially to track CVD; and

-   assessment of their communities through mechanisms developed by the
    communities to assess community knowledge, behaviors, and risks of
    CVD.

Phase III Projected activities for FY 2004 includes the assessment and
evaluation of the 3 original pilot sites to determine if the original
project is successful. If the project is successful and adequate funding
is available, the project will be replicated in one new American Indian
and Alaska Native site**.**

Indicator 31: During FY 2004 continue the incremental implementation of
all components of the Indian Health Service Obesity Prevention and
Control Plan that was developed in FY 2001. This includes IHS Area or
regional planning meetings; staff development and IT development to
monitor American Indian and Alaska Native BMI (height weight data); an
infrastructure to collect, interpret, and diffuse the approaches from
obesity related demonstration projects and studies to IHS Areas and
I/T/Us.

a\. Each IHS Area is responsible for implementation for an Area wide,
long range, comprehensive Obesity Prevention and Control Plan

b\. Each Area will decrease height and weight measurement omission rates
and will report BMIs on children and adults.

c\. Area Offices to host National and Area training(s) among I/T/U
stakeholders that emphasize Area wide Obesity Prevention and Control
Plan.

**[Rationale:]{.underline}** This indicator is part of a comprehensive
long-term effort to identify effective interventions to prevent and
reduce obesity in American Indian and Alaska Native people. IHS must
blaze a new trail into unknown territory in order to address the
escalating obesity and diabetes rates. Previous versions of this
indicator have focused on pilot demonstrations in partnership with Head
Start and Indian sites in the NIH, National Heart Lung and Blood
Pathways obesity prevention study of elementary school children. The
redirection of this indicator for FY 2003 and FY 2004 is based on new
research findings and the growing realization that obesity reduction and
prevention represents a challenge for virtually all Indian communities
in all age groups and thus warrants a more global system-wide focus to
address.

**[Approach:]{.underline}** The approach to this revised indicator for
FY 200~~4~~ includes an area-planning meeting including stakeholders,
obesity experts, and key partners. Activities to complete this process
for each element include:

-   Formation of the Obesity Prevention and Treatment Planning Group

-   Developing Data Collection Capacity

-   Developing the Infrastructure for Collection and Diffusing
    Information

**[Data Source:]{.underline}** CDC Pediatric Nutrition Surveillance
System (PDNSS), IHS RPMS system, IHS/ITCA national pediatric height
weight survey, consumer surveys, focus groups, observational surveys,
and rates of participation.

**[Program Performance:]{.underline}** **IHS met this indicator.** This
FY 2002 indicator committed to developing a 3-element obesity prevention
and treatment plan. IHS developed this three-element plan in conjunction
with tribes and local facilities.

Indicator 32: By the end of 2004, the IHS and its stakeholders will have
implemented the identified activities as specified by the five-year plan
for tobacco control in American Indian and Alaska Native communities.

**[Rationale:]{.underline}** The use of tobacco represents the second
largest cause of preventable deaths for American Indian and Alaska
Native people. Smoking rates in many American Indian and Alaska Native
communities are almost twice the national average. The Indian Health
Service has not yet addressed the tobacco problem with a specific action
plan or budget request. Because tobacco has a unique status among many
American Indian and Alaska Native tribes as a sacred plant, any plan for
control activities must have significant input from American Indian and
Alaska Native community leaders.

**[Approach:]{.underline}** The 2004 indicator calls for the IHS and its
stakeholders (I/T/U and outside of the Indian health system) to
implement key elements of the Five Year Plan. In FY 2003, IHS will
develop additional appropriate roles and actions that should take in
support of a comprehensive plan for tobacco use and reduction in the
American Indian and Alaska Native population. Before the end of FY 2003,
recommendations made by the workgroup will be presented to IHS senior
leadership and to the National Indian leadership organizations for
further refinement and anticipated implementation in FY 2004.

**[Data Source:]{.underline}** IHS Program records.

[**Program Performance**:]{.underline} **IHS met this indicator.** The
FY 2002 committed to commencing all prescribed control activities in 5
sites. These organizations are currently in their second year of a
five-year funding project from the Office on Smoking and Health, Centers
for Disease Control. Their purpose is to build capacity and
infrastructure at the tribal level for tobacco control and prevention.
Thus far, the assistance provided to tribes includes: training and
technical assistance, partnership building, education/awareness, and
policy development.

#### HIV/AIDS Indicator:

The following indicator addresses implementation of risk reduction
counseling for high-risk sexually active individuals with the long-term
goal of reducing the spread of HIV infection in the American Indian and
Alaska Native population.

Indicator 33: No FY 2003 or FY 2004 indicator

Program Performance: IHS met this indicator. During FY 2002, IHS
maintained ongoing surveillance of HIV/AIDS and determine the level of
completeness of reporting in three areas. Data extraction from RPMS was
done in 3 Areas of Indian Health Service. This data extraction showed
varied levels of completeness of surveillance data for American Indian
and Alaska Native people.

Indicator 34: During FY 2004, determine the percentage of high-risk
sexually active persons who have been tested for HIV at an additional 10
sites.

**[Rationale]{.underline}:** The purpose of this indicator is to reduce
the spread of HIV infection in American Indian and Alaska Native
communities. The Indian Health Service is working to increase
availability and access to voluntary and confidential HIV diagnostic
testing by constituents who do not know their HIV status, link them to
care and prevention services, and assist them in adhering to treatment
regimens and in sustaining risk reduction behavior. The FY 2002
indicator was designed to obtain baseline measures in at least 3 areas.
The FY 2004 indicator is designed to measure the expansion of obtaining
HIV testing data in high-risk sexually active patients in additional
sites throughout IHS.

**[Approach:]{.underline}** A baseline was established in FY 2002. In FY
2004, RPMS will once again be queried for documentation of completed HIV
testing for this defined high-risk population.

**[Data Source:]{.underline}** RPMS database and chart reviews

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2002 performance indicator was committed to obtaining the baseline
measure of the percentage of high-risk sexually active persons (defined
as people who have a positive test for gonorrhea, Chlamydia and/or
syphilis) who know their HIV status in at least 3 areas.

In 2002, 3 areas reported baseline data on testing for HIV in high-risk
populations. Testing for HIV in these 3 areas ranged from 8% through
66%; risk reduction counseling ranged from 10% through 22%. These data
should be interpreted with caution, because the low percentages may
reflect data quality or capture issues, rather than actual program
performance.

Forty-seven percent of the budget for development of the web-based
system supporting this measure was IHS funding, obtained through a
one-time award from the Secretary's Emergency Fund. The remainder of the
funding was contributed by the National Center for HIV, STD, and TB
Prevention, Centers for Disease Control and Prevention. To continue this
project into the next fiscal year, other sources of funding will be
needed to replace the amount awarded from the Secretary's Emergency
Fund.

#### Environmental Surveillance Indicator: {#environmental-surveillance-indicator-1}

Indicator 35: During FY 2004, the IHS will increase the number of active
tribal user accounts for the automated Web-based environmental health
surveillance system by 15% over the FY 2003 level for American Indian
and Alaska Native tribes not currently receiving direct environmental
health services.

**[Rationale:]{.underline}** This indicator is directed at reducing
environmental threats to health by collecting community information for
decision-making. Community environmental health status has traditionally
been determined by completing environmental health surveys of individual
facilities listed on the Facility Data System (FDS) inventory. Current
changes in data collection methodology and technological advances will
support more consistent assessment of community environmental health
services by building a more comprehensive dataset for planning and
evaluation. Ultimately, this change will support setting specific
targets for reducing environmental threats across I/T/U settings. In
order to collect a more complete set of data it is necessary to have the
participation of American Indian and Alaska Native tribes to add to the
data and to verify the accuracy of FDS elements that are not part of the
Indian Health Service.

**[Approach:]{.underline}** The Environmental Health Services program
will utilize the Web-based Environmental Health Reporting System
(WebEHRS) in conjunction with Tribal partners to collect community and
facility information to be used for ongoing surveillance. At the
regional level, this project will be coordinated with the IHS Area
Environmental Health Officers in partnership with the tribes and local
IHS Environmental Health Services programs.

**[Data Source:]{.underline}** Data will be gathered using the current
Web-based Environmental Health Reporting System (WebEHRS) developed in
FY 2000 and implemented in IHS in FY 2001.

**[Program Performance:]{.underline}** **IHS met and surpassed this
indicator.** The FY 2002 indicator committed to add 10 active tribal
user accounts not currently receiving direct environmental health
services to the WebEHRS. Approximately 70 tribal environmental health
programs were eligible to begin using the reporting system. Of those 70
tribal environmental health programs, 19 began using WebEHRS by the end
of FY 2002.

The Division of Environmental Health developed and implemented WebEHRS,
[webehrs.hqe.ihs.gov](http://www.webehrs.hqe.ihs.gov/), a web-based
bottom up driven environmental health data and field support system. The
data fields consist of environmental health related facilities and
services found in American Indian and Alaskan Native communities. The
WebEHRS database is maintained on an IHS HQ-based server. The data and
associated files are aggregated and available for analysis and reporting
by users on successively higher levels.

## Capital Programming/Infrastructure Category 

### Program Description and Context

Capital Programming/Infrastructure indicators represent the physical
infrastructure that contributes to a healthy environment by assuring
safe water and sewage facilities, medical facilities where health
services can be adequately provided, and the ability to maintain the
medical facilities that are critical to our mission.

**Sanitation Facilities Construction** -- supports the construction of
water, sewage, and solid waste systems (see page IHF-13 in FY 2004
budget document).

**Health Care Facilities Construction** -- supports the construction of
new or replacement health care facilities (see page IHF-19 in FY 2004
budget document).

**Maintenance and Improvement** -- supports ongoing health care facility
maintenance, alteration, and repair (see page IHF-9 in FY 2004 budget
document).

### Capital Programming /Infrastructure: Performance Indicators

These indicators were selected and based on the following criteria:

-   Supports components of the Indian Health Facilities Appropriation
    and funding priorities of I/T/Us identified in the budget
    formulation process;

-   are supported by existing data systems that record the need for
    physical infrastructure or improvements to the existing
    infrastructure;

-   follows the formula-based prioritization of each project\'s relative
    need; and

-   has demonstrable link to improved access to health services or
    healthier living environments.

Data is recorded at the local level where projects are conceptualized
based on strict protocols and formulas. These data are compiled at the
Area and Headquarters level and reviewed for accuracy and then compared
against similar projects. The validation and verification of this
information is essential to the facilities programs since it is used to
distribute resources as well as measure performance. The link between
funding levels and our ability to accomplish these indicators is
relatively direct and supported by well-quantified and validated
planning formulas.

These indicators support many of the Departmental and IHS areas of focus
by providing a foundation where health services can be effectively
delivered and objectives reached. Without a healthy living environment,
access to safe medical facilities, and proper maintenance most of the
objectives could not be met.

### Capital Programming/Infrastructure Indicators

[]{#__RefHeading___Toc31535885 .anchor}Table 8: Capital
Programming/Infrastructure Performance Summary

+---------------------+-------------------+------------------+--------+
| Performance         | FY Targets        | Actual\          | Ref    |
| Indicator           |                   | Performance      | erence |
+=====================+===================+==================+========+
| Capital             |                   |                  |        |
| Program             |                   |                  |        |
| ming/Infrastructure |                   |                  |        |
| Group               |                   |                  |        |
+---------------------+-------------------+------------------+--------+
| [Indicator          | FY 04: indicator  | FY 03:           | P: p.  |
| 36:]{.underline}    | discontinued      |                  | 3-60   |
| Address the net     |                   | FY 02: indicator |        |
| backlog of          | FY 03: indicator  | discontinued     | B: p.  |
| essential           | discontinued      |                  | IHF-9  |
| maintenance,        |                   | FY 01: addressed |        |
| improvement, and    | FY 02: indicator  | \$12 million of  |        |
| renovation (BEMAR)  | discontinued      | FY 2000 BEMAR    |        |
| needs for health    |                   |                  |        |
| care facilities.    | FY 01: address    | FY 00: \$12      |        |
|                     | \$12 million of   | million          |        |
|                     | FY 2000 BEMAR     | addressed        |        |
|                     |                   |                  |        |
|                     | FY 00: address    | FY 99: backlog   |        |
|                     | \$12 million of   | maintained at\   |        |
|                     | FY 1999 BEMAR     | \$243 based on   |        |
|                     |                   | FY 1997 formula  |        |
|                     | FY 99: maintain   |                  |        |
|                     | backlog at \$243  | FY 98: \$243     |        |
|                     | million           | million baseline |        |
+---------------------+-------------------+------------------+--------+
| [Indicator          | **FY 04:** 18,150 | FY 04:           | P: p.  |
| 37:]{.underline}    | homes             |                  | 3-61   |
| Provide sanitation  |                   | FY 03:           |        |
| facilities to new   | FY 03: 3,800      |                  | B: p.  |
| or like-new homes   | New/L. New        | FY 02: 3,342     | IHF-13 |
| and existing Indian |                   | New/L.           |        |
| homes.              | [11               |                  | 3      |
|                     | ,455]{.underline} | [17,             |        |
|                     | Existing          | 883]{.underline} |        |
|                     |                   | Existing         |        |
|                     | Total 15,255      |                  |        |
|                     |                   | Total: 21,225    |        |
|                     | FY 02: 2,528      |                  |        |
|                     | New/L. New        | FY 01: 3,551     |        |
|                     |                   | New/L. New       |        |
|                     | [12               |                  |        |
|                     | ,727]{.underline} | [14,             |        |
|                     | Existing          | 451]{.underline} |        |
|                     |                   | Existing         |        |
|                     | Total 15,255      |                  |        |
|                     |                   | Total 18,002     |        |
|                     | FY 01: 3,800      |                  |        |
|                     | New/L. New        | FY 00: 3,886     |        |
|                     |                   | New/L. New       |        |
|                     | [10               |                  |        |
|                     | ,930]{.underline} | [14,             |        |
|                     | Existing          | 490]{.underline} |        |
|                     |                   | Existing         |        |
|                     | Total 14,730      |                  |        |
|                     |                   | Total 18,376     |        |
|                     | FY 00: 3,740      |                  |        |
|                     | New/L. New        | FY 99: 3,557     |        |
|                     |                   | New/L. New       |        |
|                     | [11               |                  |        |
|                     | ,035]{.underline} | [13,             |        |
|                     | Existing          | 014]{.underline} |        |
|                     |                   | Existing         |        |
|                     | Total 14,775      |                  |        |
|                     |                   | Total 16,571     |        |
|                     | FY 99: 5,900      |                  |        |
|                     | New/L. New        |                  |        |
|                     |                   |                  |        |
|                     | [9                |                  |        |
|                     | ,330]{.underline} |                  |        |
|                     | Existing          |                  |        |
|                     |                   |                  |        |
|                     | Total 15,230      |                  |        |
+---------------------+-------------------+------------------+--------+
| [Indicator          | FY 04: complete   | FY 04:           | P: p.  |
| 38:]{.underline}    | scheduled phase   |                  | 3-62   |
| Improve access to   | of construction   | FY 03:           |        |
| health care by      | of appropriated   |                  | B: p.  |
| construction of the | facilities        | FY 02: 10 of 10  | IHF-19 |
| approved new health |                   | projects         |        |
| care facilities.    | FY 03: complete   | completed on     | 3      |
|                     | scheduled phase   | scheduled        |        |
|                     | of construction   |                  |        |
|                     | of appropriated   | FY 01: 5 of 7    |        |
|                     | facilities        | projects         |        |
|                     |                   | completed on     |        |
|                     | FY 02: complete   | schedule         |        |
|                     | scheduled phase   |                  |        |
|                     | of construction   | FY 00: 5 of 6    |        |
|                     | of appropriated   | projects         |        |
|                     | facilities        | completed on     |        |
|                     |                   | schedule         |        |
|                     | FY 01: complete   |                  |        |
|                     | scheduled phase   | FY 99: all       |        |
|                     | of construction   | projects         |        |
|                     | of appropriated   | completed on     |        |
|                     | facilities        | schedule         |        |
|                     |                   |                  |        |
|                     | FY 00: complete   |                  |        |
|                     | scheduled phase   |                  |        |
|                     | of construction   |                  |        |
|                     | of appropriated   |                  |        |
|                     | facilities        |                  |        |
|                     |                   |                  |        |
|                     | FY 99: complete   |                  |        |
|                     | scheduled phase   |                  |        |
|                     | of construction   |                  |        |
|                     | of appropriated   |                  |        |
|                     | facilities        |                  |        |
+---------------------+-------------------+------------------+--------+
| Total Capital       | FY 04:            |                  | P:     |
| Programming/        | \$431,293,000\*\* |                  | page   |
| Infrastructure      |                   |                  | \# in  |
| Funding:            | FY 03:            |                  | pe     |
|                     | \$411,630,000     |                  | rform. |
|                     |                   |                  | plan   |
|                     | FY 02:            |                  |        |
|                     | \$357,034,000     |                  | B:     |
|                     |                   |                  | page   |
|                     | FY 01:            |                  | \# in  |
|                     | \$322,377,000     |                  | budget |
|                     |                   |                  | j      |
|                     | FY 00:            |                  | ustif. |
|                     | \$277,303,000     |                  |        |
|                     |                   |                  |        |
|                     | FY 99:            |                  |        |
|                     | \$255,953,000     |                  |        |
|                     |                   |                  |        |
|                     | FY 98:            |                  |        |
|                     | \$221,009,000     |                  |        |
|                     |                   |                  |        |
|                     | \*\* includes 15% |                  |        |
|                     | of M/M and PI     |                  |        |
|                     | Collections and   |                  |        |
|                     | Quarters          |                  |        |
|                     | Collections       |                  |        |
+---------------------+-------------------+------------------+--------+

#### Capital Programming /Infrastructure Group:

Indicator 36: This indicator was discontinued beginning in FY 2002.

Indicator 37: During FY 2004, provide sanitation facilities projects to
18,150 Indian homes with water, sewage disposal, and/or solid waste
facilities.

![](media/image34.wmf){width="3.671527777777778in"
height="2.421527777777778in"}

**[Rationale:]{.underline}** This indicator directly supports improved
environmental health for American Indian and Alaska Native people. 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 and contributed funds from Tribes and other Federal
agencies (for the past five years contributions have ranged from \$30 to
45 million) to provide potable water and waste disposal facilities for
American Indian and Alaska Native (American Indian and Alaska Native)
people. This work has been recognized as a significant factor
contributing to a reduction in the rates for infant mortality,
gastroenteritis morbidity, and other environmentally related diseases by
as much as 80 percent since 1973. However, American Indian and Alaska
Native homes are still seven times more likely to be without clean water
than homes in the broader U.S. with most of these homes located in
geographically isolated areas, particularly Alaska and the Navajo
Reservation.

**[Approach:]{.underline}** This program regularly updates the needs for
sanitation facilities based on the Indian Health Care Improvement
Amendments (Title II, Section 302(g) 1 and 2 of P.L. 100-713). From this
process, a backlog of needed sanitation facilities to serve existing
homes is identified and updated annually. Based on the end-of-year FY
2002 estimates, the cost of technically and economically feasible
projects to correct these needs for existing homes was \$900 million out
of a total need of \$1.578 billion. It is considered feasible to provide
sanitation facilities for between 95 and 98 percent of all existing
Indian homes.

**[Data Source:]{.underline}** The SFC Sanitation Deficiency System
(SDS), and Project Data System (PDS).

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2002 performance measure to provide sanitation facilities to 2,528
new or like-new homes and 12,727 existing Indian homes by the end of FY
2002 was met and was exceeded significantly. This measure indicates the
number of homes served with water, sewer and solid waste facilities,
which has been shown to be directly related to an improvement of public
health. In FY 2002, the IHS provided sanitation facilities to 3,342 new
and like-new homes and 17,883 existing homes for a total of 21,225
homes. This exceeded the total goal of providing sanitation facilities
for 15,255 homes.

The significant increase in existing homes was the result of funding
more projects to upgrade existing community sanitation facilities
infrastructure. In addition to the \$94 million appropriated for this
program, IHS has received between \$30 million to \$44 million annually
from outside contributors since FY 1996. IHS will continue to work
cooperatively with tribes to attract funds from outside IHS to construct
needed sanitation facilities.

The reported data is based on Project Data System (PDS) information that
is updated twice per year by all 12 IHS Area Offices, for projects
funded in FY 2002. These data include projects funded for construction
under the P.L. 86-121 Sanitation Facilities Construction program that
were managed directly by IHS and through tribal contracts and compacts.
The data also includes projects that were funded partially or wholly by
entities other than IHS.

Indicator 38: During FY 2004, increase the modern health care delivery
system to improve access and efficiency of health care by assuring the
timely phasing of construction of the following outpatient health care
facilities:

a\. Pinon, AZ -- continue construction of a new health center, including
supporting staff quarters.

b\. Red Mesa, AZ -- continue construction of a new health center,
including supporting staff quarters.

c\. Metlakatla, AK -- continue construction of replacement tribal health
center, including supporting staff quarters.

d\. Sisseton, SD -- complete design of a replacement health center,
including supporting staff quarters.

**[Rationale]{.underline}:** This indicator supports the replacement of
health care facilities to increase access to medical services supported
by the IHS. These medical services can be compared to medical services
available to the general population (appointments to see primary care
physicians, nurses, dentists, etc.). Efficient space for health care
delivery allows for more appointments, and for patients to see more
health care providers in one trip. People are reluctant to use old
run-down facilities, but are more likely to seek needed health care when
provided in modern facilities. Although accessible is synonymous in this
usage with obtainable health care services, the IHS can demonstrate that
workloads have increased or more comprehensive services are provided in
new facilities.

The Northern Navajo Medical Center (inpatient facility) in Shiprock, New
Mexico, is an example. The planned workload in 1995 for this facility
was 101,572; in 1999 the workload was 117,764. Another example is Wagner
Health Center (outpatient facility) in South Dakota, where the planned
workload in 1991 for this facility was 16,656 and in 1999 the workload
was 19,551. In the examples given, the measure of access is overall
workload while the types of health services that are offered may be as
important as the overall availability of health services, depending on
the circumstances. These issues are addressed individually in the
Program Justification Documents (PJDs) for each planned facility.

Likewise, modern facilities help recruit and retain health care
providers, which, in turn, can result in improved access and continuity
of health care. Once a replacement facility has been completed and fully
staffed, the IHS has experienced an average increase in patient visits
of approximately 60% over the old facility. The planning and designing
of additional facilities is the first step in improving access for
identified locations.

Where private sector housing is not available for the increased staffing
levels, additional staff quarters are needed for non-local staff in
support of the identified IHS health care facilities.

**[Approach]{.underline}:** 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 facility
construction from the IHS Area Offices and ranks them according to their
relative need for construction.

Factors used to determine relative need are workload, existing facility
age, isolation (availability of alternatives sources of care), and
existing space data. The highest-ranking proposals are added to the
Priority Lists. The IHS uses the HFCPS methodology to review these
proposals and to determine which will be considered during the more
intensive Phase II review. The IHS examines these Phase II proposals in
detail and applies the methodology to determine the proposals that will
be considered during Phase III. During Phase III, applicable IHS Area
Offices prepare a Project Justification Document (PJD) for review by IHS
Headquarters. If the PJD justifies construction, it is approved and the
project is placed on the appropriate priority list below those already
on the list.

The IHS has developed the Quarters Construction Priority System (QCPS)
to identify staff quarters projects to support existing health care
facilities. (Note, staff quarters associated with replacement health
care facilities are part of those projects and are not processed under
the QCPS.) Like the HFCPS, quarters projects are processed through three
phases and new staff quarters projects are added to the Quarters
Priority List as Program Justification Documents for Staff Quarters
(PJDQ) are approved.

Proposed projects that have been approved and placed on the respective
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 five-year planned
construction budget. That budget is updated yearly and is used as the
basis for funding requests.

**[Data Source]{.underline}:** The HFCPS and QCPS generate projects that
are reflected in a five-year funding plan in the Health Care Facilities
Planned Construction Budget. The IHS Inpatient, Outpatient and Quarters
Priority Lists are used to show the needed construction priorities.

**[Program Performance:]{.underline}** **IHS met this indicator.** The
FY 2002 indicator was accomplished with the timely phased construction
of the following health care facilities as outlined below and will lead
to enhance access to care for the American Indian and Alaska Native
population.

[Ft. Defiance, AZ]{.underline}: Construction was completed for the
replacement inpatient health care facility, which was opened for service
on August 1, 2002. The design-build contract for the staff quarters
portion of the project was awarded on June 12, 2002.

[Winnebago, NE]{.underline}: Construction continued for the replacement
hospital, which was 50% complete at the end of FY 2002.

[Pinon, AZ]{.underline}: The design for the health center, which had
been on hold since it was completed in 1999 pending the receipt of
construction funding, was updated. Construction of the health center
portion of the project was started with the award of the first phase of
a construction management contract on August 19, 2002.

[Red Mesa, AZ]{.underline}: Under a construction management contract
awarded August 16, 2001, construction will commence in the third quarter
of FY 2003 for the new health center.

[Pawnee, OK]{.underline}: Construction for the health center commenced
on May 13, 2002, which was 28% complete at the end of FY 2002.

[St. Paul, AK]{.underline}: Funds for the health center design were
provided through HRSA to the Alaska State Denali Commission for their
design of the health center portion of the project. The design is
underway and the IHS is in position to proceed with construction.

[Metlakatla, AK]{.underline}: The construction contract for the health
center site work was awarded on August 20, 2002.

[Sisseton, SD]{.underline}: The design contract for the health center
was awarded on September 9, 2002.

[Bethel, AK]{.underline}: Funds for the construction of the staff
quarters were transferred to the Tribe under the P.L. 93-638, Subpart J,
contract, for the tribe's continuation of the project. As of the end of
FY 2002, the Tribe has completed 50% of the housing units for which
funding has been provided to date.

[Zuni, NM]{.underline}: The Tribe was awarded a P.L. 93-638, Subpart J,
contract on May 1, 2002, who has a design contract ready for award.

[Joint Venture Construction Program]{.underline}: For the FY 2001
Program, on August 21, 2002, a program agreement was executed with the
Jicarilla Apache Nation. Negotiations are in process for the second
program agreement, and are expected to be completed during the second
quarter of FY 2003. On August 20, 2002, proposals were requested from
tribes for competitive selection of eligible health center projects in
FY 2003 for the FY 2002 program.

[Small Ambulatory Program]{.underline}: Awards have been made for all 17
projects selected through a competitive process for the funds
appropriated in FY 2001 and FY 2002.

[Dental Units]{.underline}: An additional three projects received
funding under this program.

## Partnerships, Consultation, Core Functions, and Advocacy Category

### Program Description and Context

The Partnerships, Consultation, Core Functions, and Advocacy aggregation
encompasses the IHS administrative and management functions,
relationships with stakeholders and consumers, and strategies for
collaboration in pursuit of the IHS mission. Data for these indicators
come from recognized sources including budget reports and audits, a HHS
survey, and a survey of the universe of stakeholders using recognized
social survey methods. The two components of this aggregation are:

-   **Direct Operations** - supports management and administrative
    functions for Area and Headquarters staff including policy
    development, budget formulation, health program support, and
    accountability requirements (see page IHS-107 in FY 2004 budget
    document).

-   **Facilities and Environmental Health Support** - provides
    administrative and management support for the construction,
    maintenance, and operation of health care facilities, staff housing,
    and sanitation facilities (see page IHF-29 in FY 2004 budget
    document).

### Performance Indicators

The choice of indicators for this aggregation category are based on the
following criteria:

-   Supports and encourages tribal sovereignty, the government to
    government relationship between tribes and the Federal government,
    and tribal self-determination;

-   supports and encourages collaboration with stakeholders, agencies,
    and organizations directed toward improving the health of American
    Indian and Alaska Native people; and

-   supports and encourages sound management practices.

Achieving these performance indicators, as well as the overall
coordination of the GPRA and other Federal accountability requirements,
represent a significant challenge for the IHS and its reduced management
and public health infrastructure. The reorganization of Headquarters and
many Area offices has resulted in flatter organizational structures,
less specialization in function, and greater use of self-directed teams
in order to increase efficiency. However, it has become increasingly
clear that, coupled with improved data management capacity, there are
two functions that must be supported to assure overall program success
and these are:

-   Assuring that continued and expanded opportunities for tribal
    consultation and participation in IHS endeavors is supported;

-   assuring effective recruitment of needed health disciplines is
    achieved and that orientation, training, and support are available
    to enhance the retention these staff.

### Partnerships, Consultation, Core Functions, and Advocacy Indicators

[]{#__RefHeading___Toc31535891 .anchor}Table 9: Consultation,
Partnerships, Core Functions, and Advocacy Indicators Performance
Summary

+---------------------+-------------------+-----------------+---------+
| Performance         | FY Targets        | Actual          | > Re    |
| Indicator           |                   |                 | ference |
|                     |                   | Performance     |         |
+=====================+===================+=================+=========+
| Consultation        |                   |                 |         |
| Improvement         |                   |                 |         |
| Indicator           |                   |                 |         |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | FY 04: 3%         | FY 04:          | P: p.   |
| 39:]{.underline}    | increase over FY  |                 | 3-69    |
| Improve the level   | 03                | FY 03:          |         |
| of I/T/U            |                   |                 | B: p.   |
| satisfaction with   | FY 03: 5%         | FY 02:secured   | IHS-107 |
| the processes for   | increase over     | clearance; no   |         |
| consultation and    | baseline          | baseline        | 3       |
| participation       |                   |                 |         |
| provided by the     | FY 02: secure OMB | FY 01: policy   |         |
| IHS, as measured by | clearance for     | implemented and |         |
| a survey of I/T/Us. | instrument and    | instrument      |         |
|                     | baseline          | submitted       |         |
|                     |                   |                 |         |
|                     | FY 01: implement  | FY 00: revised  |         |
|                     | policy and submit | policy proposed |         |
|                     | instrument        | and instrument  |         |
|                     |                   | developed       |         |
|                     | FY 00: revise     |                 |         |
|                     | policy and        | FY 99: policy   |         |
|                     | instrument        | established but |         |
|                     |                   | baseline        |         |
|                     | FY 99: establish  | delayed         |         |
|                     | policy and        |                 |         |
|                     | collect baseline  |                 |         |
+---------------------+-------------------+-----------------+---------+
| Administrative      |                   |                 |         |
| Efficiency,         |                   |                 |         |
| Effectiveness, and  |                   |                 |         |
| Accountability      |                   |                 |         |
| Group               |                   |                 |         |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | FY 04: +1% over   | FY 04:          | P: p.   |
| 40:]{.underline}    | FY 03             |                 | 3-70    |
| Improve the level   |                   | FY 03:          |         |
| of Contract Health  | FY 03: +1% over   |                 | B: p.   |
| Service (CHS)       | FY 02             | FY 02:          | IHS-55  |
| procurement of      |                   | Available in    |         |
| inpatient and       | FY 02: 88%        | Sept 2004       | 3       |
| outpatient hospital |                   |                 |         |
| services for        | FY 01: 79%        | FY 01:          | 8       |
| routinely used      |                   | Available in    |         |
| providers under     | FY 00: no         | Sept 2003       |        |
| contracts or rate   | indicator         |                 |         |
| quote agreements at |                   | FY 00:          |         |
| the IHS-wide        | FY 99: no         |                 |         |
| reporting level.    | indicator         | FY 99: 86%      |         |
|                     |                   |                 |         |
|                     |                   | FY 97: 74%      |         |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | FY 04: assess     | FY 04:          | P: p.   |
| 41:]{.underline}    | pub. health       |                 | 3-71    |
| Assure appropriate  | infrastructure 3  | FY 03:          |         |
| administrative and  | Area Offices      |                 | B: p.   |
| public health       |                   | FY 02: no       | IHS-107 |
| infrastructure is   | FY 03: assess     | indicator       |         |
| in place in         | pub. health       |                 | 2       |
| response to agency  | infrastructure    | FY 01: no       |         |
| reorganization and  | for HQ and 6      | indicator       | 3       |
| accountability      | Areas             |                 |         |
| requirements.       |                   | FY 00: 1,569    |        |
|                     | FY 02: no         | FTE             |         |
|                     | indicator         |                 |         |
|                     |                   | FY 99: -22%     |         |
|                     | FY 01: no         | (1,619 FTE)     |         |
|                     | indicator         |                 |         |
|                     |                   | FY 97: 2085 FTE |         |
|                     | FY 00: 1876 FTE   | baseline        |         |
|                     | or less           |                 |         |
|                     |                   |                 |         |
|                     | FY 99: at least   |                 |         |
|                     | 10% under FY 97   |                 |         |
|                     | level or 1876 FTE |                 |         |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | FY 04: no         | FY 02: IT       | P: p.   |
| 42:]{.underline}    | indicator         | capacity        | 3-72    |
| Continue            |                   | expanded        |         |
| implementation of   | FY 03: no         |                 | B: p.   |
| Managerial Cost     | indicator\*       | FY 01: IT       | IHS-107 |
| Accounting systems  |                   | capacity        |         |
| across IHS          | FY 02: expand IT  | expanded        | \*in    |
| settings.           | capability        |                 | dicates |
|                     |                   | FY 00:          | revised |
|                     | FY 01: expand IT  | implementation  | FY 2003 |
|                     | capability        | continued but   | m       |
|                     |                   | pilots sites    | easure. |
|                     | FY 00: continue   | not developed   | See     |
|                     | implementation &  |                 | Summary |
|                     | develop pilot     | FY 99: \"cost   | of      |
|                     | sites             | centers\"       | Changes |
|                     |                   | implemented in  | Table   |
|                     | FY 99: begin      | FY 1999         | on page |
|                     | implementation    |                 | 5-3.    |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | FY 04: improve    | FY 04:          | P: p.   |
| 43:]{.underline}    | 10% over\         |                 | 3-72    |
| **Increase the      | FY 03             | FY 03:          |         |
| proportion of       |                   |                 | B: p.   |
| I/T/Us who have     | FY 03: improve    | FY 02: no       | IHS-107 |
| implemented         | 10% over FY 02    | indicator       |         |
| Hospital and Clinic | baseline          |                 | 3       |
| Compliance Plans to |                   | FY 01: no       |         |
| assure that         | FY 02: no         | indicator       |        |
| claims** meet the   | indicator         |                 |         |
| rules, regulations, |                   |                 |         |
| and medical         | FY 01: no         |                 |         |
| necessity guidance  | indicator         |                 |         |
| for Medicare and    |                   |                 |         |
| Medicaid payment.   |                   |                 |         |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | Technical         | FY 04:          | P: p.   |
| 44:]{.underline}    | Assistance        |                 | 3-73    |
| Support the Tribal  |                   | FY 03:          |         |
| Self-Determination  | FY 04: 100% of    |                 | B: p.   |
| through technical   | new tribes        | FY 02: tribal   | IHS-121 |
| assistance and      |                   | approval        |         |
| application of the  | FY 03: 100% of    |                 | > 3     |
| IHS Contract        | new tribes        | FY 01: protocol | >       |
| Support Cost        |                   | developed       | >      |
| Policy.             | FY 02: tribal     |                 |         |
|                     | approval of       | FY 04:          |         |
|                     | protocol          |                 |         |
|                     |                   | FY 03:          |         |
|                     | FY 01: develop    |                 |         |
|                     | protocol          | FY 02: tribal   |         |
|                     |                   | acceptance      |         |
|                     | Contract Support  |                 |         |
|                     | Cost Review       | FY 01: protocol |         |
|                     |                   | developed       |         |
|                     | FY 04: 100% use   |                 |         |
|                     | of protocol for   |                 |         |
|                     | new tribes        |                 |         |
|                     |                   |                 |         |
|                     | FY 03: 100% use   |                 |         |
|                     | of protocol for   |                 |         |
|                     | new tribes        |                 |         |
|                     |                   |                 |         |
|                     | FY 02: secure     |                 |         |
|                     | tribal acceptance |                 |         |
|                     |                   |                 |         |
|                     | FY 01: develop    |                 |         |
|                     | protocol          |                 |         |
|                     |                   |                 |         |
|                     | FY 00: no         |                 |         |
|                     | indicator         |                 |         |
|                     |                   |                 |         |
|                     | FY 99: no         |                 |         |
|                     | indicator         |                 |         |
+---------------------+-------------------+-----------------+---------+
| Quality of Work     |                   |                 |         |
| Life and Staff      |                   |                 |         |
| Retention Group     |                   |                 |         |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | FY 04: indicator  | FY 02: 96       | P: p.   |
| 45:]{.underline}    | discontinued      | points          | 3-75    |
| The IHS will        |                   |                 |         |
| improve its overall | FY 03: indicator  | FY 01: 96       | B: p.   |
| Human Resource      | discontinued\*    | points          | IHS-107 |
| Management (HRM)    |                   |                 |         |
| Index score as      | FY 02: +one point | FY 00: 96       | p\.     |
| measured by the     | over FY 01        | points          | IHF-195 |
| DHHS annual HRM     |                   |                 |         |
| survey.             | FY 01: at least   | FY 99: 93       | \*in    |
|                     | 97 points         | points          | dicates |
|                     |                   |                 | revised |
|                     | FY 00: at least   | FY 98: 93       | FY 2003 |
|                     | 94 points         | points baseline | m       |
|                     |                   |                 | easure. |
|                     | FY 99: no         | FY 97: 92       | See     |
|                     | indicator         | points          | Summary |
|                     |                   |                 | of      |
|                     |                   |                 | Changes |
|                     |                   |                 | Table   |
|                     |                   |                 | on page |
|                     |                   |                 | 5-4     |
+---------------------+-------------------+-----------------+---------+
| [Indicator          | FY 04: Implement  | FY 04:          | P: p.   |
| 46:]{.underline}    | plan in all IHS   |                 | 3-75    |
| Improve retention   | Areas and         | FY 03:          |         |
| of I/T/U health     | Headquarters.     |                 | B: p.   |
| care providers.     |                   | FY 02 :no       | IHS-29  |
|                     | FY 03: identify   | indicator       |         |
|                     | nurse retention   |                 | 3       |
|                     | problems and      | FY 01: no       |         |
|                     | develop plan      | indicator       | 8       |
|                     |                   |                 |         |
|                     | FY 02: no         |                 |        |
|                     | indicator         |                 |         |
|                     |                   |                 |         |
|                     | FY 01: no         |                 |         |
|                     | indicator         |                 |         |
+---------------------+-------------------+-----------------+---------+
| Total Consultation, | FY 04:            |                 | > P:    |
| Partnerships, Core  | \$82,923,000      |                 | > page  |
| Functions, and      |                   |                 | > \# in |
| Advocacy Funding:   | FY 03:            |                 | > p     |
|                     | \$89,907,000      |                 | erform. |
|                     |                   |                 | > plan  |
|                     | FY 02:            |                 | >       |
|                     | \$89,282,000      |                 | > B:    |
|                     |                   |                 | > page  |
|                     | FY 01:            |                 | > \# in |
|                     | \$75,823,000      |                 | >       |
|                     |                   |                 |  budget |
|                     | FY 00:            |                 | >       |
|                     | \$72,884,000      |                 | justif. |
|                     |                   |                 |         |
|                     | FY 99:            |                 |         |
|                     | \$69,729,000      |                 |         |
|                     |                   |                 |         |
|                     | FY 98:            |                 |         |
|                     | \$67,038,000      |                 |         |
+---------------------+-------------------+-----------------+---------+

####  Consultation Improvement Indicator:

Indicator 39: During FY 2004, the IHS will improve the stakeholder
satisfaction with the agency\'s consultation process by 3% over the FY
2003 level.

**[Rationale:]{.underline}** The purpose of this indicator is to survey
Tribes/Tribal Organizations (T/TO), and Urban programs (stakeholders) to
determine their level of satisfaction with the headquarters and area
offices implementation of the tribal consultation policy. To achieve
this indicator, the IHS is committed to conducting an annual survey of
elected tribal leaders of federally recognized tribes and board
chairpersons or executive directors authorized to represent a national
tribal organization or urban Indian health program.

**[Approach:]{.underline}** This activity began with development of a
survey instrument designed to measure the level of satisfaction with
consultation by stakeholders and also meet the approval requirements for
survey by the Office of Management and Budget (OMB). OMB approved the
survey in FY 2002. The FY 2002 survey data then established a baseline
the Agency would use to determine stakeholders level of satisfaction
with the agency's consultation process in subsequent years. The survey
data collected is evaluated to identify how well the processes are
perceived by the stakeholders as working, to generate improvements in
the process that are practical and feasible, and to provide a written
report for the Agency that is shared with the stakeholders.

**[Data Source:]{.underline}** The FY 04 responses will be tallied and
compared to the FY 03 responses to assess if the agency achieved a 3%
improvement in implementation of the tribal consultation policy. The
agency will accomplish, at a minimum, an 80% rate for the number of
completed questionnaires that are returned.

**[Program Performance:]{.underline}** **IHS partially met this
indicator.** The FY 2002 indicator was to improve the level of I/T/U
satisfaction with the process of consultation and participation provided
by the IHS, by obtaining OMB clearance for a survey instrument and
establishing a baseline measure. Clearance from OMB was obtained late in
the fiscal year. Due to this, baseline measures were not obtained.
However, the agency will conduct a survey in accordance with the Office
of Management and Budget approval, OMB \# 0917-0027, granted on August
5, 2002. The agency will negotiate a contract with an Indefinite
Delivery Indefinite Quantity vendor. Program Support Services will
solicit a vendor to conduct the annual survey, tabulate the results,
write and distribute a final report to the stakeholders. This will
ensure that this indicator will be met in future years.

#### Administrative Efficiency, Effectiveness, and Accountability Group:

This group of indicators addresses the improvement of administrative
functions that support the improvement of health care efficiency and
effectiveness, as well as improved agency accountability.

Indicator 40: During the FY 2004 reporting period, the IHS will have
improved the level of Contract Health Services (CHS) procurement of
inpatient and outpatient hospital services for routinely used providers
to at least 1% over the FY 2003 level of the total dollars paid to
contract providers or rate quote agreements at the IHS-wide reporting
level.

**[Rationale:]{.underline}** The CHS regulations require the use of
medical priorities to assure that persons with the most urgent need
receive services and that alternate resources pay prior to IHS expending
funds. We are seeking to ensure that contracts or rate quote agreements
are in place that provide reduced rates to IHS and its patients with
routinely used hospitals. It should be noted that IHS might never be
able to reach 100 percent because the majority of our facilities are in
rural settings. Many times there is only one hospital in the vicinity
and they are unwilling to offer discounted rates to the IHS. The 90%
level of procuring inpatient and outpatient facility services to
routinely used providers of the total dollars paid to contract providers
will be maintained in future years.

**[Approach:]{.underline}** IHS is primarily interested in obtaining
contracts or rate quote agreements with frequently used providers. As
providers determine that agreements are feasible with the IHS, the
percentage of facilities on contract should increase.

 Frequently used hospitals are defined as those facilities to which IHS
paid more than \$50,000 for inpatient services per year and/or more than
\$10,000 in outpatient services per year. Not all hospitals meet both
criteria, and inpatient and outpatient service contracts and rate quotes
will be tracked separately.

**[Data Source:]{.underline}** The IHS contracts with Blue Cross and
Blue Shield of New Mexico for Fiscal Intermediary (FI) services. The FI
collects the claims data and maintains the IHS/CHS database. The IHS
will use FY 1999 claims paid data as the baseline because data for this
year are 99 percent complete. The IHS is the payor of last resort, which
means any alternate resource available to the patient must be billed
first. It typically takes 2 years for claims data to become complete for
a fiscal year. As the FY data becomes complete, the percent of providers
under contract within the thresholds stated above will be updated in the
GPRA Performance Report annually. Listed below are some of the
assumptions made in analyzing the data:

1.  All inpatient and outpatient claims for hospital services, processed
    by the FI for the reporting year, defined as the Purchase Order
    Fiscal Year (POFY), are eligible.

2.  Providers are considered under contract if there is a number in the
    contract field and an effective date for appropriate reporting year.
    This includes regular contracts and Rate Quotes.

3.  Payments were defined as contract or open market at a claim level.
    If any charge on a claim was paid at a contract rate, the claim is
    considered a contract payment. If all charges on a claim were paid
    at open market (i.e., paid at billed charges), the claim is
    considered open market.

4.  The provider number used to determine the total paid for the POFY is
    defined as the provider's base EIN. This is a 9-digit provider
    EIN/TIN, and includes all suffixes assigned to that EIN.

5.  Under IHS regulations, certain catastrophic cases are eligible for
    Catastrophic Health Emergency Fund (CHEF). These cases often involve
    emergencies or the need for specialized providers, which may be out
    of the area. The area may have little control over which providers
    these patients see. The CHEF threshold is \$21,700 for an episode of
    care for FY 2002. To target inpatient claims that could be CHEF
    eligible, data was run excluding any inpatient claim where IHS paid
    \$21,700 or more.

6.  Outpatient providers were included if they were paid \$10,000 or
    more under contract and/or open market. Inpatient providers were
    included if they were paid \$50,000 or more under contract and/or
    open market.

The percent of dollars paid under contract is calculated as follows:

$$\frac{\text{IHS payments  to contract providers}}{\text{Total  IHS paid dollars to providers meeting thresholds}}$$

**[Program Performance:]{.underline}** **This data will be available in
September 2003.** Purchase Order Fiscal Year 2002 claims data is used in
the calculation and is only 89% complete as of December 2002. Typically
it takes 2 years for claims data to complete processing through the
Fiscal Intermediary (FI). The CHS indicator for FY 2002 had an 88%
target for contracts in place for frequently used providers.

Indicator 41: By the end of FY 2004, the IHS will have completed a
systematic assessment of the public health infrastructure for
Headquarters in three additional Area Offices.

**[Rationale:]{.underline}** The purpose of this indicator is to assure
a systematic and rational process is utilized to assess public health
performance to support plans for further reorganization of the IHS. This
indicator serves to address the directive given by OMB for the FY 2003
Performance Plan. This includes a performance measure as a baseline for
reducing management layers and organizational streamlining. This new
indicator commits IHS to evaluate our current delivery of essential
public health and related administrative services to American Indian and
Alaska Native populations.

The reorganization plan implemented in FY 1996 has resulted in
Headquarters reducing from ten major offices to three and from 111
functional components to 38. This reorganization also resulted in a
Headquarters FTE reduction from the high of 937 FTEs in 1993 to 379 in
FY 2000, or a 60 percent reduction. Similarly, IHS Area Offices have
reduced from 2,705 FTEs in FY 1993 to 1,190 in FY 2000 for a 56 percent
reduction. Given the magnitude of these organizational changes, the IHS
believes that it is prudent to assess systematically the delivery of
public health services to its client population using established
assessment tools. This approach can provide a rational basis for public
health planning, including workforce and organizational changes in the
IHS.

**[Approach]{.underline}**: IHS will use instruments developed by CDC\'s
National Public Health Performance Standards Program (NPHPSP), based
on the nationally recognized "Ten Essential Services of Public Health"
The NPHPSP has tested and validated the assessment process with state
and local public health programs over the past two years with very
positive ratings of the value of the process to public health programs
and is now considered by many to be the best available approach to
benchmarking public health programs.

**[Data Source:]{.underline}** The data for determining this indicator
will be derived from the adapted survey instruments that assess public
health and administrative infrastructure at IHS Headquarters and Area
Offices (including Tribal Epidemiology Centers). The indicator will be
considered accomplished if IHS Headquarters and six of 12 Area Offices
are formally assessed, using the adapted protocol and instruments, by
the end of FY 2003.

[**Program Performance**:]{.underline} No FY 2002 indicator

Indicator 42: No FY 2003 or 2004 indicator

Indicator 42: During FY 2002, the IHS will continue to expand Managerial
Cost Accounting (MCA) capacity through an incremental investment in
necessary information technology in accord with DHHS and OMB guidance.

**[Program Performance:]{.underline}** **IHS met this indicator.**
During FY 2002, the IHS continued to expand Managerial Cost Accounting
(MCA) capacity through an incremental investment in necessary
information technology in accord with DHHS and OMB guidance.

During FY 2002, the Indian Health Service continued testing of Health
Data Manager, an integrated clinical and financial data package. The
system was tested and implemented to incorporate inpatient as well as
outpatient data. In addition, the Health Data Manager was implemented at
one additional site in FY 2002.

Work was completed on a customized clinical encounter form that includes
an electronic medical record and electronic claims submission, pharmacy
point of sale, electronic funds transfer lock-box for payments and
automated posting of remittance advices.

Indicator 43: By the end of FY 2004, the IHS will increase by 10% over
the FY 2003 level the proportion of IHS facilities that have implemented
Hospital and Clinic Compliance Plans to assure that claims meet the
rules, regulations, and medical necessity guidance for Medicare and
Medicaid payment.

**[Rationale:]{.underline}** By law IHS has been given the authority to
bill and collect reimbursement from the Medicare and Medicaid (M&M)
programs, per Title XXVIII and XIX of the Social Security Act. These
dollars are used to maintain compliance with the Joint Commission on
Accreditation of Healthcare Organizations in order to maintain
accreditation, and to maintain current level of services. In order to
receive payments for services rendered, bills must be submitted to M&M
fiscal intermediaries. All bills must be supported by medical record for
provider documentation, medical necessity and coded accurately for
billing in order to comply with the rules and regulations of the M&M
programs. Hospital and Clinic Compliance Plans set up policy and
procedures that help insure that claims that are generated by our
facilities meet the rules and regulations and medical necessity for
payment purposes. These policies and procedures work to prevent fraud,
waste and abuse so prevalent in the health care industry.

**[Approach]{.underline}**: A survey will be provided to Areas asking
how many of their facilities have compliance plans adopted by their
respective Governing Boards and which facilities have draft plans. In
addition, Areas and Service Unit hospital and clinics will be required
to submit copies of audits and corrective actions plans for further HQs
analysis. Key criteria include status of plan development and
implementation and analysis of any external third party audits on
compliance with the rules and regulations of Medicare and Medicaid for
reimbursement.

**[Data Source:]{.underline}** The data source will be a survey provided
by HQs to the SUs through the Area Office. This information will be
tabulated by HQs and shared with Areas/SUs through its management
control tracking system.

**[Program Performance:]{.underline}** No FY 2002 indicator

Indicator 44: During FY 2004, the IHS will support the efficient,
effective and equitable transfer of management of health programs to
tribes who submit proposals or letters of intent to contract or compact
IHS programs under the Indian Self-Determination Act. IHS will do this
by:

a\. Providing technical assistance to each tribe submitting proposals or
letters of intent based on identified areas of need and with specific
technical assistance in the area of calculating contract support costs.

b\. Reviewing each initial contract support cost request submitted using
IHS Contract Support Cost Policy Review Protocol. This is to insure the
application of consistent standards so requests are equitable and
approvable.

**[Rationale:]{.underline}** Funding appropriated for contract support
costs has grown to approximately \$270 million over the last five years.
The Congress and the Office of Management and Budget have requested that
the Indian Health Service continue to review the soundness of its
allocation policies concerning contract support costs and to take steps
to assure that contract support costs provided to tribes are reasonable
and do not duplicate other funding provided to tribes by the IHS under
self-determination agreements. Technical assistance provided to tribes,
and the review of Contract Support Cost requests that are consistent
with the IHS contract Support Cost Policy and the Indian
Self-Determination Act, will address the concerns of the Congress and
the OMB.

**[Approach:]{.underline}** During the last quarter of FY 2002 and the
first quarter of FY 2003, the IHS met with tribal representatives to
discuss and complete the development of review standards and obtain
acceptance by the Director, IHS. The IHS will continue to meet with
tribal representatives to refine the standards as necessary. These
standards will be utilized in the review of contract support cost
requests from contracting and compacting tribes. Verification that
protocols are being used will be documented in the Annual Funding
Agreements that are approved and signed by tribes and the IHS. In FY
2003 the IHS will complete implementation of the annual IHS Contract
Support Cost Policy Review Protocol, in which each ISD approved request
is reviewed to ensure adherence to the standards, identify areas where
the standards may require additional clarification, and confirm
technical accuracy and consistency with the Indian Self-Determination
Act and the IHS Contract Support Cost Policy.

The ISD Peer Review Process will provide a quality assurance check and
will foster consistency in the application of IHS CSC Policy. The
overall goal of this review is to insure that no less that 95% of the
ISD requests reviewed are accurate and that there is no duplication of
CSC funding.

**[Data Source:]{.underline}** CSC Requests and Signed Annual Funding
Agreements.

**[Program Performance:]{.underline} IHS met this indicator.** The FY
2002 performance indicator committed to support the efficient, effective
and equitable transfer of management of health programs to tribes
submitting proposals or letters of intent to contract or compact IHS
programs under the Indian Self-Determination Act by:

-   Developing a technical assistance "needs assessment" protocol for
    systematically identifying the technical assistance needs of new
    compacting and contracting Tribes;

-   securing tribal acceptance of a Contract Support Cost Review
    Protocol for systematically applying the IHS Contract Support Cost
    Policy to all initial contract support cost requests.

Part (a) was accomplished. During FY 2002, the IHS Headquarters and Area
staff along with tribal stakeholders were able to determine and
negotiate a Tribe's CSC requirement based on the description of those
activities associated with the determination of initial CSC (ISD)
requirements as stated in IHS CSC Circular No. 2001-05, the Agency's
Contract Support Cost policy.

For part (b), all the necessary components to develop *Interim Standards
for the Review and Approval of Contract Support Costs in the Indian
Health Service* have been completed. These standards are currently in
the Agency's clearance process awaiting approval by the Director, IHS.

#### Quality of Work Life and Staff Retention Group:

These two indicators address improving the quality of work life for all
disciplines across IHS settings and improving the retention of nurses at
local I/T/Us.

Indicator 45: No FY 2003 or FY 2004 Indicators

**[Program Performance:]{.underline} IHS did not meet this indicator.**
For FY 2002 performance goal was to improve the IHS HRM Index score to
at least 97. The FY 2002 score remained at 96 as it was in FY 2000. This
lack of progress is attributed to continued high vacancy rates for
health care providers in many clinical settings putting considerable
strain on current IHS staff. Indicator 46 that follows is representative
of current activities direct at addressing the retention of a diversity
of health care providers.

Indicator 46: During FY 2004, the IHS will systematically work to
improve nurse attrition rates by:

a\. Implementing the National Council of Nurses Recruitment and
Retention Plan in all IHS Areas and Headquarters.

b\. Assessing Area vacancy and attrition rates, on-line exit interviews,
and job satisfaction surveys to include salary and benefits analysis to
identify those locations where nursing vacancy and attrition rates are
most problematic.

[**Rationale**:]{.underline} The purpose of this indicator is to reduce
nursing vacancy and attrition rates at the local I/T/U clinical setting
and ultimately improve the quality of care. The current number of nurse
positions in I/T/U programs is approximately 4000. The vacancy rate for
nurses during FY 2002 was between 11% and 15%. This equates to more than
300 vacant positions at any given time. The average I/T/U attrition rate
for registered nurses during FY 2002 was 2.8% to 20%. It is anticipated
that the attrition rates will improve by 2% to 5% with the
implementation of Title 38 pay authority and by utilizing recruitment,
retention and relocation bonuses to address specific pay inequities
associated with labor market demands. Retention of well-oriented,
skilled nursing staff can decrease the cost of hiring and orienting new
staff. It is estimated that the educational and training cost of hiring
a new nurse costs \$7,500 to \$10,000 per nurse. A nation-wide nursing
shortage exists at the current time. This will affect the ability of
I/T/Us to recruit nurses. The current nursing shortage makes it even
more imperative that we retain the nurses we currently employ, providing
a potential for significant cost savings and improved quality of nursing
and overall health care.

**[Approach]{.underline}:** The IHS will utilize vacancy, turnover, and
attrition rates, exit interviews and job satisfaction surveys to
establish a baseline retention rate for FY 2005. During FY 2004, on-line
exit interviews and job satisfaction surveys will be utilized and
identified for analysis of the data collected, collaboratively with the
Office of Management Services, Division of Human Resources and
implemented at the local service unit level by the Personnel Officers.
Once analyzed, a plan of action will be developed to address the results
of the data collection.

**[Data Source:]{.underline}** Internal nurse vacancy reports; HR
attrition, Exit Interviews; and Staff Satisfaction Surveys.

**[Program Performance:]{.underline}** No FY 2002 indicator.

# APPENDIX 1: Linkage to HHS and Agency Strategic PlanS

The IHS FY 2004 GPRA Performance Plan was developed to be a supportive
and interdependent extension of the HHS Strategic Plan and the new IHS
Strategic Plan. In Table 3 on page 2-1 of this plan, we have shown the
relationship between the four broad Strategic Goals of the IHS Strategic
Plan and the FY 2004 performance indicators. Every indicator selected
for our performance plan directly or indirectly supports Objective 3.6
*Increase access to health services for American Indians and Alaska
Natives* and Objective 3.4 *Eliminate racial and ethnic health
disparities.* In addition, many IHS indicators address other components
of the HHS plan and include:

> 1\. Cardiovascular Disease Prevention Indicator 30 and Obesity
> Prevention Indicator 31 directly support HHS Objective 1.1 *Reduce
> behavioral and other factors that contribute to the development of
> chronic diseases.*
>
> 2\. HIV Indicator 34 directly supports HHS Objective 1.2 *Reduce the
> incidence of sexually transmitted diseases and unintended
> pregnancies.*
>
> 3\. Immunization Indicators 23 and 24 directly support HHS Objective
> 1.3 *Increase immunization rates among adults and children*.
>
> 4\. Substance Abuse Indicators 10 and 11 directly support HHS
> Objective 1.4 *Reduce substance abuse.*
>
> 5\. Tobacco Indicator 32 directly supports HHS Objective 1.5 *Reduce
> tobacco use, especially among youth.*
>
> 6\. Injury Prevention Indicators 27 and 28 and Domestic Violence
> Indicator 16 directly support HHS Objective 1.6 *Reduce the incidence
> and consequences of injuries and violence.*
>
> 7\. Public Health Infrastructure Indicator 41directly supports HHS
> Objective 2.1 *Build the capacity of the health care system to respond
> to public health threats in a more timely and effective manner,
> especially bioterrorism threats*
>
> 8\. Medication Error Indicator 21 directly supports HHS Objective 5.1
> *Reduce medication errors.*
>
> 9\. Accreditation Indicator 20 directly supports HHS Objective 5.4
> *Improve consumer and patient protections.*
>
> 10\. IT Development Indicators 17 and 18 directly support HHS
> Objective 5.5 *Accelerate the development and use of an electronic
> health information infrastructure.*
>
> 11\. Staff Retention Indicator 46 directly supports HHS Objective 8.2
> *Improve the strategic management of human capital.*
>
> 12\. Contract Health Care Indicator 40 directly supports HHS Objective
> 8.3 *Enhance the efficiency and effectiveness of competitive sourcing*
>
> 13*.* IT Development Indicators 17 and 18 directly support HHS
> Objective 8.6 *Enhance the use of electronic commerce in service
> delivery and record keeping.*

In a similar vein, there is considerable consistency of focus between
the new IHS Strategic Plan and the current version of the HHS Strategic
Plan. While this is not surprising relative to health care specific
areas that could fill pages, we would offer the following associations
between objectives from **HHS Goal 8 *Achieving Excellence in Management
Practices*** and selected Action Performance Goals from the IHS
Strategic Plan:

**HHS Objective 8.2 Improve the Management of Human Capital**

-   Increase the percentage of IHS Area and Headquarters staff meeting
    recommended training and experience standards for their respective
    positions.

-   Increase the number of people completing Executive Leadership
    Development Program training annually.

-   Increase the relative annual amount of training provided to I/T/U
    staff by non-IHS resources.

-   Increase the number of I/T/U staff funded through IHS completing
    long-term training annually.

-   Increase the number of partnerships with universities or other
    organizations to help train Indian people.

HHS Objective 8.3 Enhance the Efficiency and Effectiveness of
Competitive Sourcing

-   Increase the number and scope of negotiated contracts with health
    care providers.

**HHS Objective 8.4 Improve Financial Management**

-   Increase the percentage of I/T/U sites with a comprehensive IT
    system that allows for aggregation and export (sharing) of clinical,
    financial and administrative data.

-   Increase the percentage of I/T/U sites developing managerial cost
    accounting capacity.

-   Increase the percentage of I/T/U sites developing business plans
    with identified service/product lines.

**HHS Objective 8.5 Enhance the use of Electronic Commerce in Service
Delivery and Record Keeping**

-   Increase the percentage of I/T/U sites with a comprehensive IT
    system that allows for aggregation and export (sharing) of clinical,
    financial and administrative data.

-   Increase the percentage of I/T/U site able to extract clinical data
    on lifestyle components (tobacco use, alcohol us, seat belts use,
    etc).

**HHS Objective 8.6 Achieve Integration of Budget and Financial
Performance Information**

-   Increase the percentage of I/T/U sites with a comprehensive IT
    system that allows for aggregation and export (sharing) of clinical,
    financial and administrative data.

# Appendix 2: Changes and Improvements

## FY 2004 Performance Plan

The FY 2004 Performance Plan represents our first effort to link annual
performance indicators to the long-term health outcome goals from the
recently revised IHS Strategic Plan. This plan and it performance
targets are based on updates in baseline data and other data related
issues, the ability to address key external factors influencing success,
the level of attainment of related FY 2002 performance indicators, and
the most current proposed funding level.

The IHS has discontinued four performance indicators for FY 2003 and FY
2004 that address well child visits, HIV/AIDS, quality of work-life, and
cost accounting. A table summarizing all FY 2003 changes that follows
outlines the rationale for these deletions.

Two performance indicators have been added for both FY 2003 and FY 2004.
Indicator 19 has been expanded from the original focus on developing
urban program compatible patient care IT capacity to developing this
capacity across I/T/Us. However, based on the proposed IHS FY 2004
budget, this indicator has currently been placed on hold. In addition,
an adult pneumococcal vaccination indicator has been added.

## Revisions to FY 2003 Performance Plan

The iterative process of developing the FY 1999-FY 2003 performance
plans and drafting the FY 2001 performance report has been a significant
learning process for the IHS. It has required the auditing of many
different data sets to assess current access to health services and
baseline rates of various conditions. This iterative process continues
to point to needed changes in the performance evaluation process. The
table that follows summarizes the significant changes in content or
magnitude to FY 2003 indicators originally submitted with the FY 2003
budget.

[]{#__RefHeading___Toc31535899 .anchor}Table 10: Summary of Changes to
the FY 2003 IHS Performance Indicators

+----------------------+----------------------+------------------------+
| Original FY 2003     | Revised FY 2003      | Rationale for Change   |
| Indicator            | Indicator            |                        |
+======================+======================+========================+
| [Indicator not       | [Indicator           | This indicator has     |
| Originally           | 6:]{.underline}      | been added to address  |
| P                    | During FY 2003,      | vision loss from       |
| roposed]{.underline} | increase the         | diabetic retinopathy   |
|                      | proportion of        | in the AI/AN           |
|                      | American             | population.            |
|                      | Indian/Alaska Native |                        |
|                      | diabetics who        |                        |
|                      | receive an annual    |                        |
|                      | diabetic retinal     |                        |
|                      | examination at       |                        |
|                      | designated sites by  |                        |
|                      | 3% over the FY 2002  |                        |
|                      | rate.                |                        |
+----------------------+----------------------+------------------------+
| [Indicator           | [Indicator           | This process indicator |
| 9:]{.underline}      | Disco                | has been discontinued  |
| During FY 2003,      | ntinued]{.underline} | due to a lack of       |
| maintain the         |                      | consensus on what      |
| proportion of AI/AN  |                      | services should be     |
| children served by   |                      | counted. This will     |
| IHS receiving a      |                      | allow IHS to focus on  |
| minimum of four      |                      | outcome related        |
| well-child visits by |                      | performance measures.  |
| 27 months of age at  |                      |                        |
| the FY 2002 level.   |                      |                        |
+----------------------+----------------------+------------------------+
| [Indicator           | [Indicator           | Proposed funding       |
| 12:]{.underline}     | 12:]{.underline}     | levels and the need to |
| During FY 2003,      | During FY 2003,      | reorganize and         |
| increase the         | increase the         | centralize             |
| proportion of AI/AN  | proportion of AI/AN  | fluoridation           |
| population receiving | population receiving | coordination between   |
| optimally            | optimally            | the IHS Dental Program |
| fluoridated water by | fluoridated water by | and the Office of      |
| 5% over the FY 2002  | 1% over the FY 2002  | Environmental Health   |
| levels for all IHS   | levels for all IHS   | have necessitated      |
| areas.               | areas.               | reducing the           |
|                      |                      | performance target for |
|                      |                      | FY 2003.               |
+----------------------+----------------------+------------------------+
| [Indicator           | [Indicator           | The PHN data reporting |
| 23:]{.underline}     | 23:]{.underline}     | system is not yet      |
| During FY 2003,      | During FY 2003,      | adequate to            |
| maintain the total   | maintain the total   | consistently capture   |
| number of public     | number of public     | services by specific   |
| health nursing       | health nursing       | age groups so the      |
| services (primary    | services (primary    | target will remain     |
| and secondary        | and secondary        | more generic for PHN   |
| treatment and        | treatment and        | services until the     |
| preventive services) | preventive services) | refined data capacity  |
| provided to          | provided to          | is available.          |
| neonates, infants,   | individuals in all   |                        |
| and elders in all    | settings and the     |                        |
| settings and the     | total number of home |                        |
| total number of home | visits at the FY     |                        |
| visits at the FY     | 2002 workload        |                        |
| 2002 workload        | levels.              |                        |
| levels.              |                      |                        |
+----------------------+----------------------+------------------------+
| [Indicator not       | [Indicator           | Despite limitations in |
| Originally           | 26:]{.underline} In  | extraction of          |
| P                    | FY 2003, maintain    | historical data from   |
| roposed]{.underline} | the FY 2002 rate for | the IHS data system,   |
|                      | pneumococcal         | this indicator has     |
|                      | vaccination levels   | been reinstated for FY |
|                      | among                | 2003. Recommendations  |
|                      | n                    | for pneumococcal       |
|                      | on-institutionalized | vaccine are for most   |
|                      | adults age 65 years  | recipients to be given |
|                      | and older.           | the vaccination only   |
|                      |                      | once after age 65.     |
|                      |                      | While recent changes   |
|                      |                      | to the IHS data system |
|                      |                      | preclude reviewing     |
|                      |                      | medical records older  |
|                      |                      | than five years, we    |
|                      |                      | will begin monitoring  |
|                      |                      | this important health  |
|                      |                      | outcome measure to     |
|                      |                      | assess trends and      |
|                      |                      | assure targets are     |
|                      |                      | achieved from FY 2003  |
|                      |                      | forward.               |
+----------------------+----------------------+------------------------+
| [Indicator           | [Indicator           | This indicator has     |
| 27:]{.underline}     | 27]{.underline}:     | been revised to        |
| During FY 2003,      | During FY 2003,      | reflect a broader      |
| maintain the number  | implement at least   | focus of injury        |
| of tribes/tribal     | 36 community-based,  | intervention           |
| organizations that   | proven injury        | strategies across      |
| meet the criteria    | prevention           | I/T/U settings.        |
| standards of IHS     | intervention         |                        |
| comprehensive injury | projects across      |                        |
| prevention programs  | I/T/U settings.      |                        |
| at the FY 2002       |                      |                        |
| level.               |                      |                        |
+----------------------+----------------------+------------------------+
| [Indicator           | [Indicator           | IHS has elected to     |
| 33:]{.underline}     | Disco                | discontinue this       |
| During FY 2003,      | ntinued]{.underline} | indicator for 2003. In |
| maintain ongoing     |                      | 2001, IHS evaluated    |
| surveillance of      |                      | HIV/AIDS data that was |
| HIV/AIDS and         |                      | available from the     |
| establish baselines  |                      | RPMS data system in    |
| for completeness of  |                      | pilot communities.     |
| reporting in at      |                      | These results,         |
| least 2 additional   |                      | reported in the 2001   |
| Areas.               |                      | GPRA report, indicated |
|                      |                      | 98% completeness in    |
|                      |                      | the RPMS data system.  |
|                      |                      | This initial           |
|                      |                      | evaluation was         |
|                      |                      | financed through a     |
|                      |                      | nonrenewable award     |
|                      |                      | from the Secretary\'s  |
|                      |                      | Emergency Fund. Our    |
|                      |                      | goal was to replicate  |
|                      |                      | this evaluation in an  |
|                      |                      | additional 2           |
|                      |                      | communities in 2002.   |
|                      |                      | However, support for   |
|                      |                      | this evaluation        |
|                      |                      | requires ongoing       |
|                      |                      | funding, which is not  |
|                      |                      | currently available.   |
|                      |                      | Establishment of an    |
|                      |                      | independent HIV/AIDS   |
|                      |                      | surveillance system    |
|                      |                      | currently is not       |
|                      |                      | feasible due to these  |
|                      |                      | fiscal constraints.    |
|                      |                      |                        |
|                      |                      | Traditionally,         |
|                      |                      | surveillance of AIDS   |
|                      |                      | is overseen by the     |
|                      |                      | State public health    |
|                      |                      | departments. Ideally,  |
|                      |                      | IHS would like to work |
|                      |                      | with the States and    |
|                      |                      | the national CDC       |
|                      |                      | program to establish a |
|                      |                      | coordinated            |
|                      |                      | surveillance system    |
|                      |                      | that interfaces with   |
|                      |                      | both state and         |
|                      |                      | national reporting     |
|                      |                      | databases.             |
+----------------------+----------------------+------------------------+
| [Indicator           | [Indicator           | HHS is investing in a  |
| 42:]{.underline}     | Disco                | new unified accounting |
| During FY 2003, the  | ntinued]{.underline} | system and has asked   |
| IHS will continue to |                      | agencies to not        |
| expand Managerial    |                      | proceed in this        |
| Cost Accounting      |                      | direction until the IT |
| (MCA) capacity       |                      | architecture for the   |
| through an           |                      | new system is          |
| incremental          |                      | developed and          |
| investment in        |                      | specification are      |
| necessary            |                      | available.             |
| information          |                      |                        |
| technology in accord |                      |                        |
| with DHHS and OMB    |                      |                        |
| guidance.            |                      |                        |
+----------------------+----------------------+------------------------+
| [Indicator           | [Indicator           | This indicator has     |
| 45:]{.underline} For | Disco                | been eliminated to     |
| FY 2003, the IHS     | ntinued]{.underline} | focus on more          |
| will improve its     |                      | "outcome" related      |
| overall Human        |                      | activities and because |
| Resource Management  |                      | proposed IHS funding   |
| (HRM) Index score to |                      | for FY 2003 and FY     |
| at one point above   |                      | 2004 may require cuts  |
| the FY 2002 level as |                      | in long and short term |
| measured by the DHHS |                      | training, lapsing      |
| annual HRM survey.   |                      | position, and other    |
|                      |                      | adjustments that       |
|                      |                      | affect quality of work |
|                      |                      | life and make          |
|                      |                      | improvements unlikely. |
+----------------------+----------------------+------------------------+

# APPENDIX 3: PARTNERSHIPS AND COORDINATION

The magnitude of American Indian and Alaska Native health disparities
and the resource demands require the IHS to identify and collaborate
with secondary available outside organizations that have the capacity,
capability, and interest to assist in addressing these diverse health
problems. Our resolve to develop this crosscutting network is evident by
the number and diversity of collaborative activities that are currently
in place and described in this section.

The IHS has continued to develop and expand its crosscutting
collaborations and partnership with other agencies and organizations to
achieve common goals and objectives addressing health disparities of
American Indians and Alaska Natives. These partnership and
collaborations include building capacity across institutions, enhancing
program outreach through shared resources, opening dialogue with new
partners, developing or disseminating new health care and/or
surveillance technologies, securing a variety of training and technical
assistance support for I/T/U providers, networking to maximize knowledge
and resources, disseminating information through activities of mutual
concern, and developing tribally specific community-based, community
driven research.

## Program Coordination By Partners Within DHHS

**[Administration for Children and Families/Head Start
Bureau]{.underline}**

-   training and technical assistance to 177 Head Start grantees,
    including a full-time health and safety specialist position and a
    computerized data system for the IHS Head Start program.

-   monitor and develop programs to address the 0-5 age group of
    American Indian and Alaska Native in prevention. This is an
    intervention program to address rising trends in obesity in this age
    group.

-   co-sponsor pilot projects to improve the health care response to
    domestic violence. (Indicator 16)

**[Agency for Healthcare Research and Quality]{.underline}**

-   supporting work to strengthen health services research; increasing
    opportunities for the Native American population into research;
    development of an Indian Primary Care Based Research Network;
    involvement of American Indian and Alaska Native in the Medical
    Expenditures Planning Survey; incorporation of IHS data into the
    Healthcare Utilization Project and strengthening the research
    infrastructure of American Indian and Alaska Native organizations.

-   support evaluation of medication errors in the Indian health system
    (Indicator 21)

**[Centers for Disease Control and Prevention Umbrella
Agreement]{.underline}**

Annually develop a collaborative umbrella work plan that includes
specific agreements with the following CDC entities:

-   [CDC/Agency for Toxic Substances and Disease Registry Tribal
    Liaison]{.underline}: strengthen inter-government response to tribal
    public health needs

-   [Epidemiology/Preventive Medicine Training:]{.underline} hosts CDC
    Epidemic Intelligence Service (EIS) Officers for their two-year
    field epidemiology training experience, and Preventive Medicine
    Residents (PMRs) for a one-year field training.

-   [CDC/National Center for Chronic Disease Prevention and Health
    Promotion-Chronic Disease Annual Workplan:]{.underline} intra-agency
    agreement/workplan was developed in 1990:

    -   Division of Cancer Prevention and Control (DCPC):

        -   provide technical assistance/guidance for capacity building
            with state health departments, IHS tribes and tribal
            organizations.

        -   provides funds for colposcopy training and other IHS cancer
            control activities.

        -   direct technical assistance and consultation to tribes and
            tribal organizations through the National Breast and
            Cervical Cancer Early Detection Program (Indicator 7-8)

    -   Health Promotion Activities for Older Adults: technical
        assistance in the design, implementation and analysis of surveys
        for health promotion activities for older adults.

    -   Behavioral Surveillance Branch (BSB): uses the CDC Behavioral
        Risk Factor Surveillance Survey (BRFSS).

    -   Cardiovascular Health: technical assistance in the design,
        implementation, and evaluation of cardiovascular risk factor
        prevention and intervention programs. (Indicator 30)

    -   Division of Oral Health: develop, implement and promote water
        fluoridation in American Indian and Alaska Native communities
        for dental disease prevention. (Indicator 12)

    -   Division of Diabetes Translation (DDT): providing technical
        consultation and assistance on public health surveillance of
        diabetes to define the burden of diabetes and diabetes-related
        complications among the Native population. (Indicators 1-6)

    -   Gallup National Diabetes Prevention Center: provide national
        leadership to plan, develop, implement and evaluate the National
        Diabetes Prevention Center. (Indicators 1-6).

> o Office on Smoking and Health (OSH): develop, establish, and maintain
> a community-based program for the prevention and control of tobacco
> use, and related health problems among American Indian and Alaska
> Native populations. (Indicator 32)

-   Division of Reproductive Health (DRH): address reproductive-related
    health problems in American Indian and Alaska Native, including
    Sudden Infant Death Syndrome, and to assist tribes in community
    health surveys.

```{=html}
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-   [National Center for HIV, STD and TB Prevention
    (NCHSTP)]{.underline}

> o Division of Sexually Transmitted Disease Prevention: planning,
> development and implementation of sexually transmitted disease control
> programs among American Indian and Alaska Native.
>
> o Division of HIV/AIDS Prevention:

-   assist in the coordination of national surveillance, prevention, and
    control activities for HIV/AIDS and related opportunistic
    infections, STDs, and hepatitis B and C among American Indian and
    Alaska Native people. (Indicator 33)

-   provide HIV prevention program activities for the implementation and
    evaluation of HIV prevention education for American Indian and
    Alaska Native children and youth in schools on reservations, rural
    areas, and urban metropolitan areas. (Indicator 33)

```{=html}
<!-- -->
```
-   [National Center for Infectious Diseases (NCID)]{.underline}

    -   Division of Viral and Rickettsial Diseases, Hepatitis Branch:
        epidemiologist to assist in the planning development, and
        implementation of hepatitis prevention and control programs
        among American Indian and Alaska Natives.

    -   Special Pathogens Branch: assist in the planning, development
        and implementation of Hantavirus prevention and control programs
        among American Indian and Alaska Natives.

-   [National Center for Injury Prevention and Control
    (NCIPC):]{.underline} reduce unintentional and intentional injuries
    among American Indian and Alaska Natives. The CDC has assisted IHS
    with pilot injury surveillance projects (Indicators 27-28 )

-   [National Immunization Program (NIP)]{.underline}:
    Vaccine-Preventable Disease Control - assist in the planning,
    development and implementation of vaccine-preventable disease
    control programs among American Indian and Alaska Natives.
    (Indicators 24-26)

### [Food and Drug Administration]{.underline} {#food-and-drug-administration .unnumbered}

-   reduce patient and occupational exposures; to promote principles of
    radiation protection, and to allow the FDA to monitor radiation
    protection for conformance with existing agency and Federal
    policies.

-   support in the evaluation and use of medical radiologic equipment.

### [Centers for Medicare and Medicaid Services]{.underline}  {#centers-for-medicare-and-medicaid-services .unnumbered}

The collaboration with the Centers for Medicare and Medicaid Services
(CMS) covers an array of issues that critically impact operational
issues related to the Indian health care system and the provision of
services by the IHS to its stakeholders.

-   The IHS and CMS Joint Indian Health Steering Committee includes:

    -   Legislation Subcommittee: work on legislative issues, e.g.,
        reauthorization of the Indian Health Care Improvement Act, using
        Medicare rates for CHS payments

    -   Operations Subcommittee: work on program policy and operation
        issues such as reimbursement policies, outreach and education,
        and data sharing and other policy guidance.

    -   Cost Reports Subcommittee: addresses short and long-range plans
        for development of hospital cost reports.

    -   the National Medical Education program (NMEP) Task Force, which
        ensures that beneficiaries receive accurate, reliable
        information about their benefits, rights and health plan
        options; have the ability to access information needed to make
        informed choices.

-   Home Health Care workgroup to develop draft regulations to implement
    the Prospective Payment System.

-   HHS Value-Based Purchasing Work Group that is part of the Quality
    Interagency Coordination Council. They have pursued the national
    goal to reduce the number of medical errors in health care
    environments and to build a safer health system nationally.

-   Input into the Prospective Payment System Minimum Data Sets that
    include current cost reports.

-   New Medicare and Medicaid reimbursement rates for the IHS and
    IHS-funded tribal facilities.

-   guidance and proposed regulations exempting American Indian and
    Alaska Native from any cost sharing provisions under CHIP for
    eligible children.

-   Medicare enrollment data to provide more accurate information for
    assessing outreach to Medicare beneficiaries that are American
    Indian and Alaska Native to establish an accurate database for IHS.

### [Health Resources and Services Administration]{.underline} {#health-resources-and-services-administration .unnumbered}

-   support for the PHS Primary Care Policy Fellowship program

-   provide HIV/AIDS education and training to health care providers
    that provide health care services to American Indian and Alaska
    Native people (Indicator 33)

-   share software enabling IHS to receive occupational health,
    environmental assessment and health information management support
    services

### [National Institutes of Health]{.underline} {#national-institutes-of-health .unnumbered}

-   collaborating academic research institutions, Indian tribes or
    Indian community based organizations.

-   development of treatment regimens for individuals with diabetes who
    also suffer from periodontal disease. (Indicator 15)

-   conduct clinical research studies primarily in the areas of diabetes
    and digestive diseases

### [HHS Office of Women\'s Health]{.underline} {#hhs-office-of-womens-health .unnumbered}

-   conducting 11 surveys through Indian country to identify women\'s
    health issues

### [Substance Abuse and Mental Health Services Administration]{.underline} {#substance-abuse-and-mental-health-services-administration .unnumbered}

-   support several Native American collaborations addressing mental
    health and the \"Indian Self Determination: Summit on Tribal
    Strategies to Reduce Alcohol, Substance Abuse and Violence.\"

## Collaboration With Other Federal Agencies

### [Department of Interior/Bureau of Indian Affairs]{.underline}  {#department-of-interiorbureau-of-indian-affairs .unnumbered}

-   support several Native American collaborations addressing mental
    health, domestic violence abuse and neglect (Indicator 16)

-   provide technical assistance and training for background checks of
    employees of tribal health programs.

-   support of the IHS/BIA Annual Youth Conference reaching junior high
    and high school and college teens

### [Department of Justice]{.underline} {#department-of-justice .unnumbered}

-   support coordinated activities in mental health and community safety
    for American Indian and Alaska Native children, youth, and families.

-   co-sponsor the \"Indian Self Determination: Summit on Tribal
    Strategies to Reduce alcohol, Substance Abuse and Violence.\"

### [Department of Veterans Affairs]{.underline} {#department-of-veterans-affairs .unnumbered}

-   collaborating with the VA on targeted data systems and credentialing

-   develop an agreement targeting education and outreach of veteran
    beneficiaries who are underutilizing their benefits and services.

-   develop care agreements and pharmaceutical supply agreements

-   participates in the VA Pharmaceutical Prime Vendor Program

## Injury Prevention

[National Center for Injury Prevention and Control of the
CDC]{.underline}. Present briefing on injury issues to staff from the
Senate Select Subcommittee on Indian Affairs.

# Appendix 4: Data Verification and Validation 

Data validation and verification are defined as:

> [Validation]{.underline} is the process for ensuring that data
> collected matches the intended area of performance.
>
> [Verification]{.underline} is the assessment of data completeness,
> accuracy, consistency and timeliness and related quality control
> practices.

The verification of many of the clinically based performance indicators
is supported by the IHS automated data system, and/or the [IHS Diabetes
Care and Outcomes Audit.]{.underline}

For the Capital Programming/Infrastructure Indicators 34-36, the data
are recorded at the local level where projects are conceptualized based
on strict protocols and formulas. These data are compiled at the Area
and Headquarters level and reviewed for accuracy and then compared
against similar projects.

For indicators that survey our consumers (indicators 21 and 37), the
required Paperwork Reduction Act clearance process effectively addresses
both validation and verification process as required in submitting the
instrument and collection protocol. Surveys of our facilities about the
adoption of policies and procedures for screening and referral for
victims of family violence, abuse, or neglect, and staff training that
support these policies are done on an annual basis. Similarly, Indicator
43, which addresses the quality of work life, is collected by HHS staff
through recognized survey procedures.

The remaining indicators in this plan are process measures for which
verification is less formalized. They are based on the integrity of IHS
reporting structures.

## Data Sources to Describe the American Indian and Alaska Native Population

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, once every 10 years. The IHS prepares American Indian and Alaska
Native population estimates for years between the Censuses.

The NCHS provides IHS with natality and mortality files that contain all
births and deaths for USA 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. 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
have been thoroughly verified, and the results are continuously
monitored. The IHS utilizes factors based on a National Death Index
study to adjust Indian mortality rates for race miscoding. Because of
significant time lags in obtaining mortality and natality data, 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.

## IHS Automated Data Systems

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). It is estimated that the
national RPMS data set accounts for approximately 90 percent of the IHS
user-population and clinical visits.

The local RPMS system supports a robust clinical and administrative data
set. The PCC component (patient care component) of RPMS facilitates the
collection, aggregation, display, and utilization of patient specific
information. The PCC component includes many different software
applications that are pertinent to the electronic retrieval of GPRA
data, including lab, patient education, purpose of visit, and referral
information.

IHS applies a series of edits at the facility and central database
levels to detect and correct invalid data. Some examples include the
following:

-   when ICD-9 and CPT-4 data is input into RPMS, edit checks are
    conducted for sex, age, and diagnosis to prevent data from being
    processed that could not be true;

-   the Medical Record supervisors have access to the medical records
    reports which provide the capability to check the data entered for
    completeness (e.g., does each visit have a provider, date of
    service, etc.) and flags the entries that should be edited; and

-   when records are flagged for export, the PCC Export routine has edit
    checks to prevent transmission of records with incomplete data
    elements.

At the central database level when data is processed, additional edit
checks are applied to ensure that the validity of data sorts. Reports
are also assessed for linearity (is the data consistent month to month)
and completeness (how it compares to last year) prior to sending data
for review and approval. Other data quality issues that cannot be
detected by computer are identified through the monitoring for
reasonableness that is performed in the field, and by Area and
Headquarters health program staff.

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; these measures reflect
prevention activities and morbidity and do not have the time lags
described previously for mortality data. .

The IHS has developed a new clinical software application, GPRA+. This
software is designed to monitor the IHS GPRA clinical indicators at a
local level, and to ensure standard data queries (through specified data
logic and data fields) at individual sites. This software facilitates
ongoing local feedback on GPRA indicators based upon site-specified
times, locations, and providers. This application enables sites to track
performance in a timelier manner, and implement appropriate responses to
their results.

Defining current user population is also critical to our data systems.
New user population data reflects a process of eliminating duplicate
patients. The current Master Person Index project is designed to ensure
the identification and use of unique person indicators. This will allow
for the generation of ongoing accurate user population data, as well as
improved GPRA indicator data quality.

IHS is also implementing a data quality integration project. This will
ensure that national clinical indicators, regardless of etiology, will
be developed in a similar manner, rely on specific data sets, and have
well-defined data extract routines. The development of these processes
will help improve data quality and reproducibility.

Our information technology path is designed to increase quality data, as
well as improve health care outcomes. Ensuring quality data for GPRA and
performance indicators remains a major focus of our information
technology development path.

## IHS Diabetes Care and Outcomes Audit 

A final important data set that underpins the diabetes treatment
indicators 2-5 is the [IHS Diabetes Care and Outcomes
Audit]{.underline}. Since 1986 a yearly medical record review to assess
diabetes care has been conducted in more than 75% of the IHS and tribal
facilities, representing care to nearly 70,000 American Indian and
Alaska Native people with diabetes. The medical staff at participating
facilities are encouraged to maintain active diabetes registries using
uniform definitions. Each registry is maintained in the IHS medical
record system and includes information about individuals with diagnosed
diabetes who have been seen at least once in the past three years. Each
year a systematic random sample is drawn from each facility\'s registry,
using a sample size sufficient to provide estimates of
[+]{.underline}10% of the true rates of adherence for that facility with
a confidence of \>90%.

The medical record review measures selected clinical interventions,
performance measures, and intermediate outcomes using the uniform set of
definitions. The Area diabetes consultants conduct chart reviews and
other professional staff trained by them in accordance with written
instructions and definitions provided by the IHS Diabetes Program. The
abstracted data are entered into a microcomputer-based epidemiologic
software program. Summary reports are printed for immediate use by
facility staff in their quality improvement and program planning
activities. Regional and national rates are constructed for each item of
the medical record review after data are aggregated from all
participating sites.

During the period 1995-1999, approximately 150 sites submitted data to
be compiled for the IHS total. Indian health facilities and tribally
contracted facilities that do not provide direct patient services did
not participate in the audit. Participation from each of the 12 IHS
administrative regions varied by year and by federal or tribal
management. All regions were represented in each year and approximately
2/3 of all the facilities contributed data in a given year. Tests of
trend over the 3- year period were performed by the Mantel-Hanzel test
except as noted in the text.

# Appendix 5: Performance Measurement Linkages 

## Performance Measurement Linkages with Budget

Responding to the requirements of demonstrating an outcome focus on one
hand and better linkages to funding (and hence, costs) on the other
remains challenging. The IHS has integrated the use of process, impact
and outcome indicators into our GPRA plan.

Enhancing short-term detailed cost accounting as well as discipline
specific outcome assessment capability would require the reprogramming
of a significant proportion of resources away from patient care into
administrative infrastructure. Given this current reality, our plan
meets the requirements and intent of the GPRA. We are able to show how
our health care funding is annually prioritized to the problems of
greatest concern of our consumers. Health outcomes (i.e., mortality and
morbidity) are well articulated annually in our publication *Trends in
Indian Health* with 2-3 year old data.

The IHS has elected to keep general reference to funding levels in the
plan and build estimated accomplishments around the request funding
level. We can identify which requested funding enhancements are
generally linked to supporting specific indicators in some cases.
However, applying a linear single path manufacturing accounting model to
many health problems and management issues in a comprehensive public
health program such as the IHS is not feasible.

Similarly, while performance targets for indicators addressing
facilities construction are linked to funding levels in a linear way,
this is often not the case for indicators addressing health care
services when viewed through a one-year timeframe. In some cases,
investments in the supportive infrastructure are the highest priority
for long-term effectiveness but will do nothing in the short-run to
increase access to services.

In addition, the American Indian and Alaska Native population increases
over 1.7 percent annually. Thus, service capacity must be increased over
two percent just to remain at the same level of coverage each year for
the indicators that set a target for the percent of the population
covered. Many health care related indicators have minimal target level
increases or commit to the same level as FY 2002 due to this. Achieving
these levels of care, however, are unlikely to reverse the downward
trend in health status of the American Indian and Alaska Native
population.

## Cost Accounting

In 1999, the current 95 cost center specifications were reviewed for
content and current applications by a cost accounting workgroup. The
workgroup recommended that some of the current cost centers be deleted
in future years. Several new cost centers were recommended for
development. During FY 2000 activities included the implementation of 15
new "cost centers" to improve capturing cost by functions, and sponsored
1 of 2 national training on cost principles for staff at service units,
areas and headquarters.

The effort, in FY 2001, also included completing "cost reports" at 22
IHS facilities, 5 tribal facilities, 10 Area Offices and Headquarters to
be used for Medicare/Medicaid rate negotiation. While cost reports
represent only an incremental step toward full cost accounting, they
have required that the IHS:

-   Improve accounting for capital costs for facilities and equipment;
    and

-   Improve accounting for inpatient versus outpatient costs for
    physician, physician extender and nursing

## Human Resources

The IHS is committed to human resource development (HRD) and worklife
improvements as an essential component of performance planning and
performance management. Historically, we have invested in long- and
short-term training for all staff to assure capable public health
leaders, healthcare providers and administrative support. In recent
years, we have reduced HRD investments in order to support other
priorities. However, the new IHS Strategic Plan includes Objective 2.3
*Expand and Maintain Organizational Capacity and Experti*se that is
support by a series of strategies and the following Action Performance
Goals:

> 1\. Increase the percentage of IHS Area and Headquarters staff meeting
> recommended training and experience standards for their respective
> positions.
>
> 2\. Increase the number of people completing Executive Leadership
> Development Program training annually.
>
> 3\. Increase the relative annual amount of training provided to I/T/U
> staff by non-IHS resources.
>
> 4\. Increase the number of I/T/U staff funded through IHS completing
> long-term training annually.
>
> 5\. Increase the number of partnerships with universities or other
> organizations to help train Indian people.

The requested FY 2004 IHS budget includes a renewed commitment to find
cost-effective approaches to better meet HRD\--including clinical,
public health, management, information technology, and general
organizational effectiveness training\-- and worklife needs. Through our
human capital projects we are addressing succession planning; competency
and development needs of direct health-care providers; developmental
needs of managers, supervisors and leaders; state-of-the-art workplace
practices such as flexible working hours and workplace; and
communication of organizational and professional information to support
performance. In addition, Departmental guidelines. The IHS\' approach to
CCA implementation will follow the example of the Department in
delegating responsibility and authority to the Area Directors for Area
IT capital planning and investment control. Project updates and status
on any ITSC sponsored IT project are now available on the IHS WEB site,
with weekly updates on certain defined projects.

Also during FY 2001, the Secretary has determined that HHS information
technology will be managed on an enterprise basis with a common
infrastructure, rather than by many separate agencies. One of the
efforts underway is a unified financial management system. Specifically,
HHS will have one financial management system for the Centers for
Medicare and Medicaid Systems and the Medicare contractors called
HIGLAS, and another management system for the rest of the department.
The purpose of this endeavor is to achieve greater economies of scale,
eliminate duplication, and provide better service delivery. The unified
financial management system will reduce costs, mitigate security risks
and provide timely and accurate information for management purposes.
With the unified system, IHS and the rest of the department will have
uniform business rules, data standards and accounting policies and
procedures and a more efficient implementation as administrative support
functions are incorporated.

The adoption and integration of the CMM Model (Carnegie Mellon Model) of
software development is an essential part of improved IT management.
This model has been extended to the organizational structure, as well as
the software development process. This alignment of structure with
process will facilitate our goal of reaching CMM Level 2 during FY 2003.

## Capital Planning

The maintenance deficiencies for health care facilities are captured and
presented to Congress in the Backlog of Essential Maintenance,
Alteration, and Repair for IHS and participating tribal facilities.
Sanitation Facilities Construction needs are identified and reported to
Congress through the Sanitation Deficiency System. Capital asset
planning for health care facilities construction is done in accordance
with the IHS Health Care Facilities Priority System Methodology and
submitted to OMB through Circular A-11, Preparation of Budget Estimates,
Section III for reporting capital assets. These activities are
represented in this performance plan by the three Capital
Programming/Infrastructure Indicators in section 3.2.3.

## Program Evaluation

In recognition of the growing importance of evaluation in supporting the
IHS Mission, Goal and GPRA performance planning, the IHS has elected to
add this section addressing program evaluation. The IHS evaluation
process seeks to include American Indians and Alaska Natives as primary
stakeholders in defining the purpose, design, and execution of
evaluations. The IHS has worked with it stakeholders in identifying and
implementing principles of responsive evaluation practice and setting
evaluation priorities.

The purposes of IHS evaluation efforts are:

-   to advise the Director of the IHS on policy formulation; to conduct
    and manage program planning, operations research, program
    evaluation, health services researches, legislative affairs, and
    program statistics;

-   to develop the long-range program and financial plan for the IHS in
    collaboration with appropriate agency staff;

-   to coordinate with HHS, Indian Tribes, and organizations on matters
    that involve planning, evaluation, research and legislation; and

-   to develop and implement long-range goals, objectives, and
    priorities for all activities related to resource planning and
    allocation methodologies and models.

The Office of Public Health (OPH) serves as the principal advisory
office to the IHS on issues of national health policy and coordinates
these four evaluation functions:

-   *Health Program Evaluations*\--Collect and analyze information
    useful for assisting IHS officials in determining the need for
    improving existing programs or creating new programs to address
    health needs;

-   *Policy Analysis*\--Conduct analyses when a change in the IHS health
    service delivery system must be considered, when issues emerge in an
    area where no policy currently exists, or when current policies are
    perceived as inappropriate or ineffective;

-   *Health Services Research*\--Undertake analyses of the organization,
    financing, administration, effects, and other aspects of the IHS;
    and

-   *Special Studies and Activities*\--Conduct studies and prepare
    special reports required by Congress in response to pending
    legislation or policies, often using a roundtable whenever an issue
    or a health problem requires immediate action and it is unclear what
    type of action should be taken.

The OPH meets part of the IHS evaluation needs with two major types of
short-term studies: policy or program assessments and evaluation study.
The policy study contributes to IHS decision-making about budget,
legislation, and program modifications and includes background
information to support IHS projects. Evaluation studies are carried out
at the program level, or area offices, and focus on specific program
goals.

## Summary of Select Evaluations Activities

Several recent evaluation projects have significant direct and/or
indirect implications for IHS performance planning and are thus
summarized below:

***Evaluation of the Behavioral Risk Factor Surveillance System\'s
Results and Their Applicability to the Native Population of
Anchorage:***

This study will determine the relative accuracy, validity and
reliability of the Behavioral Risk Factor Surveillance System (BRFSS)
risk estimates of the Anchorage Native population, compared with data
collected using other techniques that include: (1) door-to-door
household surveys, (2) key informant surveys, and (3) intercept data
collection from Natives seeking primary care services in Anchorage from
the Alaska Native Medical Center and the Primary Care Center.

***Evaluating the Impact of Medical Nutrition Therapy on Patient
Outcomes Among Native Americans Newly Diagnosed with Type II Diabetes***

The intent of this study is to (1) Assess the extent to which RDs at IHS
and tribal health care facilities are able to provide the level of care
recommended by the American Dietetic Association Nutrition Practice
Guidelines for Type 2 Diabetes. (2) Evaluate the impact of MNT provided
for patients newly diagnosed with Type 2 diabetes on the following
clinical outcomes: glycemic control (i.e., fasting blood glucose, random
blood glucose, hemoglobin A1c), total cholesterol, weight; and
behavioral outcomes (e.g., achievement of established eating and
exercise goals). (3) Analyze differences in the level of
comprehensiveness of MNT provided compared with patient outcomes. (4)
Identify potential barriers that might hinder the extent that practice
guidelines care can be delivered by dietitians at IHS and tribal health
care facilities.

***Continuation and Completion of a Study to Analyze Quality Assurance
and HP/DP Monitoring, and Analyze Methods Using the Patient Care
Component (PCC)***

This study will analyze quality assurance (QA) and health promotion and
disease prevention (HP/DP) monitoring and analysis methods using the
Patient Care Component (PCC) and Resource and Patient Management Systems
(RPMS). These systems are currently in use at the Indian Health Service
(IHS) facilities in the Billings area. The project\'s goal is to improve
the health status of Indians living in the Billings area by using the
PCC database to monitor quality assurance activities and HP/DP
objectives, while improving the database\'s accuracy and completeness.

***Effectiveness of Evaluation of Systematic Implementation of Clinical
Prevention Protocols for Chronic Disease Risk Reduction***

This project addresses health prevention and the reduction of chronic
disease complications through development of a tracking system for use
by the physicians and patients. This tracking system serves as a model
for tribes with health contracts.

***Study of the Impact of a Full-Time Community Health Nurse on the
Health of Native American (Sioux) Patients with Hypertension &
Prevention***

This project will study the impact of a full-time community health nurse
on the detection and follow-up of hypertension within a specific Native
American tribe, the Sioux. The impact of having a full-time community
health nurse on the prevention of and education about cerebrovascular,
cardiovascular and renal disease within this population will also be
examined.

## New Directions for Evaluation

The IHS is responding to dramatic changes taking place inside and
outside the Government including greater involvement of tribal
governments in the Indian health care system, technological innovations,
the changing patterns of disease to more chronic conditions, and the
transfer of many Federal programs and resources to individual States.
IHS remains committed to comprehensively community-based, preventive,
and culturally sensitive projects that empower tribes and communities to
overcome health issues.