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**12-Area**

**Indian Health Service**

**Government Performance Results Act Report**

**2004**

### February 25, 2005 

### **Table of Contents**

Explanation of Report 1

Proportion of User Population Represented by Area 2

Twelve-Area Comparative Charts

Documented HbA1c 3

Poor Glycemic Control with Diabetic Patients 4

Good Glycemic Control with Diabetic Patients 5

Blood Pressure Control with Diabetic Patients 6

Dyslipidemia (Cholesterol) Screening with Diabetic Patients 7

Kidney Disease Screening with Diabetic Patients 8

Retinal Examinations with Diabetic Patients 9

Annual Dental visit for Diabetic Patients 10

Influenza Vaccine 11

Pneumococcal Vaccine 12

Cervical Cancer Screening 13

Breast Cancer Screening 14

Access to Dental Care 15

Fetal Alcohol Syndrome Prevention 16

Domestic Violence/Intimate Partner Violence Screening 17

Body Mass Index Measured 18

Tobacco Assessment 19

Area Success Story Summaries and Contact Information 20

**Indian Health Service 12-Area Summary Report**

This report is a companion document to the 2004 GPRA Executive Summary
and is designed to provide Indian Health Service executives and staff
with comparative information about Area level performance. It contains
data about selected clinical indicators that was collected at the
individual health facility level, using GPRA+ software. Information
about the population that the data represents, a brief summary of Area
best practices to improve GPRA participation, improving GPRA data
quality, and performance on specific indicators are also included.

The graphs for the clinical indicators display results by Area for GPRA
Baseline Year (GY) 2000, GY2003, and GY 2004. (The GPRA year begins July
1 and ends June 30.) Each graph also shows the IHS average for GY 2004
and either the Healthy People 2010 or IHS 2010 goal for the indicator.
Areas can use the graphs to review the change in their performance from
GY 2003 to GY 2004, to compare their performance to that of other Areas
or to the national average, and to assess their progress towards
achieving long-term goals.

The information for all three years was extracted from the RPMS
databases of sites participating in the GPRA review in the summer of
2004. For that reason, the 2003 results in this document may differ from
the 2003 data that was reported in the 12-Area Summary Report last year.
Any differences may be attributed to one or more of the following
reasons:

1.  The Area had different facilities reporting in 2003 and 2004.

2.  The 2004 data collection picked up 2003 information that got entered
    after the deadline for the 2003 GPRA review.

3.  The performance measures for some indicators were adjusted.

The map that appears on the following page displays the approximate
percent of the active population that the collected data for each
indicator represents. The 2004 percent was calculated by dividing the
total GPRA user population represented in the 2004 GPRA review (the
denominator for the Access to Dental Care indicator) by the total 2003
Area active user population (from the IHS Official Active User by Area
2003 Report). In addition, population numbers for four Urban clinics
that use RPMS-provided data for the 2004 GPRA review are included in the
GPRA user population for the Areas where they are located. Since the IHS
Official Active Indian User count does not include Urban users, the
percent of participating population may be somewhat higher than if this
population were not included; an asterisk identifies those Areas. The
total percentage of population represented in the 2004 GPRA review is
86%, which is significantly higher than the percentage from last year.

The long-term objective of this report is to provide Areas with
comparable and consistent performance data that can be used to identify
opportunities for improvement. Each Area has the capability to develop a
similar report for each clinical site within their Area. The ability to
access performance data at the local level will allow the Areas to
identify those programs that are performing at a high level as well as
those that need to improve. These distinctions will be more important as
IHS moves toward performance-based budgeting at all levels.

**National Average of Sites Reporting: 86%**

**1,168,311 Patients**

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-   The numerator is the GPRA population. The Denominator is the Active
    Indian Registrants from NPRS 2003 data.

-   **\***Areas including RPMS Urban programs in their denominator
    counts.

-   \^Data error in 2003. Pascua-Yaqui Tribe not reported (\<98%)

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**Area GPRA Success Stories**

At the National GPRA Coordinators October 2004 conference, GPRA
coordinators shared information about 2004 activities aimed at improving
GPRA participation, data quality, and performance on specific
indicators. The following paragraphs are brief summaries of information
that coordinators shared and provide a sample of these activities;
hopefully, these will provide ideas for other Areas and sites.

[Increasing Participation]{.underline}

In the Portland Area continual emphasis on GPRA, as well as efforts to
recognize GPRA performance with awards, improved GPRA participation
dramatically in 2004. The Area added GPRA as a topic of discussion in
orientations, at health board meetings and clinical directors' meetings,
and scheduled GPRA Area trainings throughout the year. In addition, the
Northwest Portland Indian Health Board began a recognition program for
GPRA achievements, awarding certificates to programs that improved
performance or achieved the highest scores on particular indicators.
These actions have generated Tribal program interest and have resulted
in the additional 12 Tribal programs providing GPRA data in 2004; these
twelve as well as additional Tribal programs have also agreed to
participate in 2005. For more information, contact
[Cheryl.Bittle@ihs.gov]{.underline}.

[Improving Data quality]{.underline}

Many of the success stories reported at the conference centered on ways
to improve data quality and collection. Strategies included training,
data assessment, conferences, committees, and working groups.

In Alaska, two new tribes joined in the Alaska GPRA Pilot Project,
bringing the participation rate to 96%. The Alaska GPRA Pilot Project
has undertaken several data quality initiatives. It sponsored "train the
trainer" workshops on data quality, where attendees learned to compare
data from patient charts to the corresponding RPMS and NPIRS records. It
also created a data quality 'swat' team to visit remote sites and assess
data.

One Alaska tribe performed a data quality assessment for the pneumovax
indicator. The assessment reviewed the records of 543 elders.. Among the
findings: 180 of the elders were deceased, had moved, or didn't receive
primary care; 58 immunizations were documented in the chart but not
recorded in RPMS; 95% of the missing documentation occurred prior to a
change to point-of-service RPMS data entry. The assessment concluded
that the GPRA+ data is reliable and that point-of-service RPMS data
entry is an effective method of assuring electronic patient records are
updated. For more information, contact
[BBoedeke@akanmc.alaska.ihs.gov]{.underline}.

The Nimkee Memorial Wellness Center is the pilot site for implementation
of GPRA in the Bemidji Area. In 2004 this tribal program provided GPRA
training and mentoring to five other tribal sites as well as one urban
program that is preparing to implement RPMS. Training includes:
discussing indicators, data entry, and documentation; analyzing the
reports to identify areas for improvement; and providing hands-on
training on different RPMS functions. Beyond these basics, the training
covers ways to improve documentation (requesting records from outside
providers) and ways to increase patient cooperation through traditional
methods (sending letters and making follow-up telephone calls) as well
as some innovative approaches (one tribe entered men returning their
occult stool cards into a drawing for a canoe; women coming in for
annual gynecological exams were entered into a drawing for a spa
package). The Tribes also learn how the benefits of GPRA extend to other
areas, and are using the data for grant writing, budget justification,
and requests for staff increases. For more information, contact
[Mary.Fairbanks@ihs.gov]{.underline}.

During FY 2004 the Nashville Area, in collaboration with the United
South & Eastern Tribal Organization (USET), implemented an Area Data
Quality Committee which focuses on data collection and data integrity.
The Nashville Area also has planned a Medical Providers Best Practice
conference to educate providers about clinical best practices and data
and quality improvement. This Continuing Medical Education (CME)
conference will focus on improving patient care through GPRA/CRS
tracking and implementing best practices. The conference will feature
presenters (including senior clinicians and academics) on every category
of GPRA indicators. To insure good attendance, the Area has made the
training mandatory for clinic directors and has funded each tribal site
to send providers, including Contract Health Service (CHS) only
programs, which can invite their CHS providers. After the conference,
the Area plans to continue provider documentation training and best
practices tracking, using senior clinicians, with the USET Epi-Center to
provide updates on disease in the AI/AN community. For more information,
contact [Byron.Jasper@ihs.gov]{.underline}.

The Albuquerque Area established a Documentation Improvement Committee
that brings together representatives of each facility. Its goal is to
help improve the documentation process in order to improve patient care,
data, GPRA results, and all other workload outputs. The committee, which
includes providers and staff from the medical records, billing, and
coding functions, meets once each month. If the primary member is not
able to attend, an alternate must be designated to attend in person or
via conference call. At meetings, members share best practices,
standards, policies, and procedures. As a group, they have been able to
identify problems, such as a lack of GPRA training for providers, and
develop responses to these issues on the spot. For more information,
contact [Regina.Robertson@ihs.gov]{.underline}.

In the Navajo Area, where 100% of sites reported GPRA data, every
service unit has a GPRA coordinator, and there are individual GPRA
indicator leads to increase the understanding of the facility's RPMS
data process and the need for improvement at the facility level. There
is also a "Strategic Planning for Data Quality Group," consisting of a
mix of physicians, nurses, business office staff, and data entry
personnel that report to the Area's Service Unit Management Council. The
group's one-day meetings focus on workflow monitoring, data flow, and
integrated GPRA problem solving by sharing success stories. The group
identified and is addressing a need to improve provider documentation
and awareness of performance measures. In 2005, their focus will be
improving documentation of domestic violence screening and diabetic
indicators. For more information, contact
[Genevieve.Notah@ihs.gov]{.underline}.

The Oklahoma Area created I/T/U Work Groups to focus on improving GPRA
data quality, in terms of collection, data entry, extraction, and
analysis of results. One project undertaken was a "Who uses What" survey
to identify which RPMS packages each employee was using. The Area used
the information to plan training. In addition, the Area designated a
super user for each package in use. The super-users will be a resource
for all other users who may have data entry questions or difficulty
using a package. More standardized data entry is one outcome the Area
expects to result from these actions. For more information, contact
<Marjorie.Rogers@ihs.gov>.

[Improving Results on Targeted Indicators]{.underline}

*Diabetic Retinal Screening Indicator*

Seven Tribal clinics in California have been able to obtain retinal
cameras for tele-opthalmology, using a California Endowment grant
obtained by the California Rural Indian Health Board. The clinics have
implemented this tele-ophthalmology initiative using a community-based
model. Lay technicians have been trained to operate the cameras, conduct
non-dilated exams and transmit the retinal photos electronically to an
ophthalmologist for examination. If the findings are positive, the
patient is referred for laser treatment.

The clinics use various methods to maximize screening rates. At one
site, the tele-ophthalmology coordinator takes pictures once monthly or
every other month, after a community health representative has contacted
eligible patients and arranged to transport them to the clinic; at this
site the screening rate went to 70%. At another site, two lay people
were trained to do eye exams, and the exams are done whenever anyone
needing one walked through the door. The clinic staff pages overhead
that retinal pictures are needed and the patient is assessed at that
same visit. For more information, contact
[Dawn.Phillips@ihs.gov]{.underline}.

*Influenza Immunization Indicator*

In the Billings Area, at the Blackfeet Service Unit, a "Beat the Bug"
campaign increased influenza immunization rates. Special "love bug"
letters, sent to high risk patients, provided patient education and
instructions for obtaining an immunization. In addition, the facility
established standing orders to allow vaccination without a provider
examination, created laminated cards with immunization eligibility
requirements for the nursing staff, and prepared customized Patient Care
Component (PCC) forms with pre-printed codes to properly document
administration of the vaccine. The laminated cards and customized PCC
forms allowed for standardization of documentation, so that data entry
staffs were able to quickly find accurately coded immunization
information. For more information, contact
[Diane.Jeanotte@ihs.gov]{.underline}.

*Diabetic Indicators*

The Phoenix Area has established a quality council to provide guidance
to facilities in the Area and share information, including success
stories. Working with the Council, the Colorado River Service Unit
established a diabetes process team to design a comprehensive diabetes
team to improve care. The team developed and implemented weekly diabetic
clinics with laboratory tests, dental and optometry screenings, medical
assessment, and patient & family education. The team also participated
in numerous community prevention activities. GPRA 2004 results for
Parker Indian Health Center show the positive impact of these efforts
with increases in good glycemic control, nephropathy, and diabetic
dental access between 2003 and 2004. For more information, contact
[Steven.Tetrev@ihs.gov]{.underline}.

*BMI Indicator*

At the Saginaw tribe's Nimkee Memorial Wellness Center in the Bemidji
Area, the diabetes coordinator has been focusing on the BMI indicator
for a childhood obesity initiative. Staff collected data on tribal
elementary and middle school students and worked with the schools'
administration. They presented the data to the tribal council, and the
council was convinced to approve and hire a school fitness director. For
more information, contact [Mary.Fairbanks@ihs.gov]{.underline}.

*Mammogram Indicator*

The Tucson Area Sells Service Unit is using a mobile van to provide
mammogram screening at its Sells, Santa Rosa, and San Xavier sites, and
this program is improving mammogram rates. When the contract for this
program began in September 2002, the mammogram rate for that year at
those sites was 42% as measured by GPRA+. In 2003 the rate rose to 47%,
and in 2004 the rate was 48%. For additional information, contact
[Karen.Higgins@ihs.gov]{.underline}.