**FTS HQE ADMINISTRATION & MGMT (US)**

**Moderator: Bruce Finke**

**October 25, 2007**

**11:00 am CT**

Coordinator: All sites please stand by as today\'s conference call is
about to begin. Hello and welcome to today\'s Open Door Forum on the
Indian Health Services Three Health Initiatives. This is the fifth Open
Door Forum and will focus on the Chronic Care Initiative.

At this time all participants are in a listen-only mode. After the
presentation we will have a question and answer session. At that time to
ask a question please press star 1. You will be prompted to record your
first and last name for the Q&A portion. At the request of the Indian
Health Service this call is being recorded.

And now I will turn the meeting over to Dr. Bruce Finke, moderator for
the session. Dr. Finke you may begin.

Bruce Finke: Thank you. Good morning and good afternoon. This is Doctor
Bruce Finke and I have the honor of welcoming you to the Fifth
Director\'s Initiative Open Door Forum.

This is one of a series of teleconferences that are designed to open up
communication and offer opportunities for sharing and for learning about
work being done in the Director\'s Health Initiatives and health
promotion and disease prevention, in behavioral health, and in the
prevention and management of chronic conditions.

Today\'s open door forum will focus on work being done in the
Director\'s Chronic Care Initiative, work that is aimed at improving the
health status of American Indian and Alaska Native patients, their
families and communities affected by chronic conditions and working to
reducing the prevalence and the impact of those conditions.

So today we\'ll hear about the Chronic Care Initiative and we\'ll learn
from 3 of the 14 IHS, Urban and Tribal programs that are working in the
innovation community to help us identify and sequence strategies that
work to improve care across conditions.

On this call also we\'ll have the participation of experts from IHI, the
Institute for Healthcare Improvement, our partner in the Chronic Care
Initiative. Finally we\'ll have a bulletin from the Phoenix Indian
Medical Center about Indian Health hospital\'s participating in IHI\'s
national campaign to reduce medical harm to hospitalized patients.

On today\'s call we\'re testing out some new features. These are
features that were requested by participants in previous Open Door Forum
calls. First of all participants now have two options for viewing the
slides used for the presentations today.

You can download the slides as usual from the Director\'s Three
Initiatives website and that website can be found at - in the Nationwide
Programs and Initiatives section of [www.ihs.gov](http://www.ihs.gov/).

You can also view the slides as they are being presented in real-time on
a Web-Ex platform. Connection information was sent out in earlier
announcements for that Web-Ex.

This session we\'re also offering CMEs and CEUs for the first time. At
this time credits are limited to medical and nursing professionals but
if this works we\'ll be expanding to offer educational credits for other
professionals.

I\'ll take a minute now to ask Gary Quinn from the Division of
Behavioral Health to tell us how to obtain credit for today\'s call.
Gary?

Gary Quinn: Thank you Dr. Finke. Yes we are working on a few bugs. And
one of them is we don\'t have e-mail access to everyone that checked
into the call. That is if you were to call from one site with three of
your colleagues we would only have just one source of contact.

So what we\'re going to do for this time only is if you want CEUs or
CMUs please send your e-mail address to me. That\'s gary.quinn@ihs.gov.
And that way I\'ll ensure that you get a copy of the SurveyMonkey and
therein you\'ll get the CEU or CMU link.

So to just repeat that e-mail address if that is what you want from this
event send an e-mail message to me. And that\'s gary.quinn@ihs.gov.
Thanks.

Bruce Finke: Thank you Gary. And now let\'s get going. I have the
privilege now of introducing Dr. Rick Olson, the Acting Director of the
Office of Clinical and Preventive Services for the Indian Health
Service. Dr. Olson is going to formally open this session on behalf of
Mr. Robert McSwain, Acting Director of the IHS. Dr. Olson?

Rick Olson: Good morning. Thank you very much. Mr. McSwain is not able
to be with us today, but he asked that I say a few words for him to
begin this Open Door Forum.

If we go to the second slide, as all of us who work in the Indian Health
System are aware, the incidents of chronic diseases has been increasing
markedly over the last several decades. In the second slide we can see
the prevalence of diagnosed diabetes among children and young adults
since the 1990s.

In the next slide similarly we can see a rapid increase in one
location - of coronary artery disease occurring since the late 1980s.
And then the next slide shows the trend in end stage renal disease by
race and ethnicity for the nation. You can see the American
Indian/Alaska Native line is in yellow here. The one thing that I would
like to point out though is the last two dots which are 1999 and the
year 2000.

It looked at that time that perhaps the increasing incidents of end
stage renal disease was finally turning the corner. And last spring CDC
published in its MMWR the statistics through 2004 showing a definite
downward trend in end stage renal disease in American Indians and Alaska
Natives whereas for whites and blacks and Hispanics, it has continued to
rise. The article discussed that good management of diabetes and
hypertension in American Indian and Alaska Native populations is most
likely the reason for this encouraging statistic. So things are changing
and hopefully will continue to change in the right direction.

On the next slide Dr. Finke already mentioned the Director\'s three
health initiatives in health promotion/disease prevention, chronic care,
and behavioral health. Dr. Grim launched these over the past several
years. I would like to point out that these three initiatives are linked
and have the potential to deliver profound improvements in the health
and wellness of Indian people if they are integrated. Mr. McSwain the
new acting IHS Director has stated that he\'s strongly committed to
continuing the efforts in all three of these health initiatives.

On the next slide something that I think we all know but just to
reiterate that change does not necessarily mean improvement. We\'ve all
seen changes that are either neutral or maybe negative.

> The interesting thing about Chronic Care Initiative is that it is
> particularly focused on evaluating changes and then implementing and
> spreading those changes that do result in improvements in health care
> processes and in the health of American Indian and Alaska Native
> people. We need to make sure that others in the Indian Health Care
> System can use these changes that do lead to improvement.

On the next slide, I\'d like to just define a couple of terms that you
may or may not be aware of. The first has to do with the Chronic Care
Initiative as opposed to chronic care collaborative.

The chronic care initiative of course is the overall national program
that\'s looking at chronic conditions and striving to improve the health
and wellness of American Indian and Alaska Native people with these
chronic conditions, whereas the collaborative is a process that will
introduce the IHS to an organized system of improvement and facilitate
the work of the initiative.

There are 14 sites that are participating in this collaborative which is
named the Innovations in Plan Care in the Indian Health system. In that
group of 14 sites there are 8 Federal sites, 5 Tribal sites, and 1 Urban
site. These are the development team for the effort to improve care
across conditions, across the entire system but in an accelerated
fashion.

The initiative will also be identifying successful improvement work
outside of the collaborative to highlight successes and potentially help
with the spread of lessons learned. One example is what we\'re going to
hear from Dr. Wilson from the Phoenix Indian Medical Center on the
participation of IHS and Tribal hospitals in the Institute for Health
Care Improvement's Five Million Lives campaign.

In the next slide it talks a little bit about the Chronic Care
Initiative. Improving care of all conditions is a huge challenge. The
Care Model provides that framework. If we are to succeed, it will be
through embracing the chronic care initiative and the other two of the
director\'s health care initiatives.

And next slide - the IHS is committed to see that the Chronic Care
Initiative succeeds. We\'ve partnered with the Institute for Health Care
Improvement this past year. One of the things that we\'re doing in
December is sending approximately 250 individuals mainly in leadership
positions from the Indian Health System to the IHI\'s forum in Orlando
\-- area directors, area chief medical officers, area diabetes
coordinators, area behavioral task force members, participants from the
14 collaborative pilot sites, and many others will be attending this
meeting. At the meeting we\'ll join with over 5,000 other health care
professionals from around the world to learn about improvement
methodologies and to learn from other systems of care that have embraced
improvement in their health care systems.

On the next slide is the headline from one and one half weeks ago in the
New York Times that talked about the report from the CDC on the falling
death rates from cancer in the United States, which is obviously
extremely encouraging. But on the last slide, part of that article
states that these statistics don\'t look as good for American Indians
and Alaska Natives. These are the types of headlines that make the news;
but we don\'t tend to hear about all the good things that are going on
throughout the Indian Health Care System to make profound improvements
in care such as the chronic care initiative.

So I\'m looking forward to hearing from the other speakers about what\'s
happening in the chronic care initiative where good things are
happening. Thank you.

Bruce Finke: Thank you Dr. Olson. Our next speak is Dr. Ty Reidhead who
is the Chief Clinical Consultant in Internal Medicine. He\'s a
practicing internist at WhiteRiver Service Unit in Arizona and he\'s one
of the co-chairs of the Chronic Care Initiative.

Dr. Reidhead is going to talk to us about where we are and where we\'re
going in terms of the Chronic Care Initiative. Ty?

Ty Reidhead: Okay. Thank you Bruce. You can hear me okay?

Bruce Finke: You sound great.

Ty Reidhead: Okay. Never know if I\'m on mute or not. So thank you for
the introduction. So you gave me the ball. I am going to mention that I
moved to another slide so those of you that aren\'t on WebEx will be
able to follow along.

So I\'m going to start out with this quote from Dr. Berwick who\'s the
Institute for Health Care Improvement President and CEO. Institute for
Health Care Improvement is a strategic partner of ours in this
initiative. And you\'ll be hearing from a couple of those
representatives or members of IHI on this call today.

And Dr. Berwick - his quote is that every system is perfectly designed
to get the results it gets. If we believe Dr. Berwick then the results
that we see on our current health system with the increasing incidents
of conditions that diabetes and cardiovascular disease and end stage
renal disease that Dr. Olson mentioned is because basically the system
is designed to get those results.

Now obviously that\'s not necessarily the case. But other things such as
wait times and decreased access to primary care all of those issues is
because we - you might say even designed the system to do that.

But the reason that that is true is because we\'ve had a focus on acute
care and that\'s been out of necessity and it\'s been responsive to
acute needs of the population because it really has to. Patients have
acute issues that have to be dealt with and so we respond.

And that\'s what the next slide basically just lists the bullet that
we\'ve grown into the current health system because of the need and the
in the face needs of acute curable conditions that might present to the
emergency department as an example.

The next slide \-- which is the fourth slide \-- is a picture of how I
believe that our current system is now. And I mentioned this in the past
because this picture will become a picture of the past.

It depicts the fact that currently we\'re reliant on a system which as
the health care provider - whether it be physician, nurse practitioner,
physician assistant \-- at the center of the care and the patient is
really on the periphery. And that provider patient interaction occurs
and then most of the referrals are because the provider asks for those
referrals to occur.

Now there\'s some things that happen outside. And we\'re fortunate in
the Indian Health System - you can see the green circles - the CHR
patient has a community health representative and the patient hopefully
have some interaction and hopefully a relationship as well as a public
health nursing.

But we\'re fortunate to have diabetes educators and pharmacies that the
patient obviously doesn\'t have to go through the provider. But some of
that interaction is definitely facilitated by that.

I\'m going to go to the next slide. I wanted to make sure that I pointed
out how the finances have - I think the finances have also responded to
facilitate this acute care management.

And the next slide is a slide that I\'m putting up and mostly - it\'s
sort of a theory of mine or something that I\'ve just started to think
about is that - and I would be curious to see if people will also agree.

I\'m still learning about some of the difficulties that the Indian
Health System facilities are facing. But it seems to me that it depicts
a cycle that we face. It doesn\'t matter where a system enters this
cycle.

You notice that the money sign is really red because we do function
under funded system so some of this cycle is driven because of that. And
it doesn\'t matter where you enter the cycle if it\'s decreased primary
care or whether its need for increased staff and ED and urgent care.

I think we tend to move in the circle and it\'s driven by decreased
funding. If you have decreased primary care access you end up with
people seeking urgent care in emergency room setting because you can\'t
focus on primary care.

Well then if you have more people in urgent care or ER setting you have
increased wait time then you have to respond to this increased wait time
and tend to add more staff to emergency department urgent care.

And then of course we have primary care clinic provider nursing staff
shortage. At least that\'s what I\'ve seen in a few of the facilities
that I\'ve visited. And we\'ve got to figure out a way I think to get
out of that cycle.

The next slide is a picture of a patient of mine who was looking for me
in the hallway because she couldn\'t get help with her medication. And
she basically had to wait until I ran by and was able to corner me and
we were able to go to her room and I was able to help her with the
medication.

Now that\'s not - the reason she had to find me in the hallway because
the system wasn\'t built to have her be able to locate me or gain access
through pharmacy or talk to the pharmacist. It just didn\'t work very
well. So we\'ve got to figure out a way to make that system work better.

This next picture - the next slide is the model for improvement. And any
time that we identify something that we need to improve something as in
our system - our system of local care we want to do it intentionally.

And if we want to do it intentionally then we really need to ask
ourselves three questions. Number one, what are we trying to accomplish.
Number two, how will we know that a change is an improvement. And then
number three what change can we make that will result in an improvement.

And I\'m going to start - I\'m going to go through this - we\'re going
to go through this within this presentation as well as the next one. And
the first is what are we trying to accomplish.

This slide again just I think it\'s important to reiterate. We all know
it. We all know that change is not necessarily an improvement. But it\'s
something we need to keep thinking about as we make improvements in our
facilities.

The next slide is the Chronic Care Initiative aim and this is really
focused to try to answer the question of what we\'re trying to
accomplish. Number one we want to increase the health status of patients
in populations affected by chronic conditions and improve the care of
patients with those conditions as well as prevalence of those.

We\'re going to do that through the use of the Care Model and I\'ll
introduce that in a minute. The system that we\'re using to test some of
these changes and use the Care Model is the innovations and plan care
for the Indian Health System collaborative.

Now I just want to iterate this is not an experiment. I say test but
it\'s not really test in the sense of an experiment. It is local
facility quality care improvement efforts that we try to learn from and
we\'ll hopefully spread those improvements.

Improvement across multiple chronic conditions instead of disease
focused improvement is a real focus both for the initiative and the
collaborative. Hopefully we are looking for improvements that not only
affect one condition but can be applied to all conditions.

Next is we want to seek tribal and community involvement in changes and
support of course all the other innovative efforts that are occurring
throughout the Indian Health System that may not be a part of the
collaborative.

The next slide is I\'m going to jump basically to the third question.
What change can we make that will result in an improvement. And then the
next slide is the Care Model. This Care Model was originally developed -
it was called the Chronic Care Model and it\'s developed by Dr. (Robert
Wagner) with the Institute for Chronic Conditions - improvement of
chronic conditions.

And the general idea of this is if people are familiar with the Chronic
Care Model there are some changes to that that we\'ve adapted for our
use in the Indian Health System.

And the first is improve the - if we want accomplish improved
achievement of patient, family and community goal and care of chronic
conditions then we really have to build a relationship with a patient
and family and a proactive prepared practice team.

It\'s no longer just the physician. We really need to try to move to
working together as a team so that we can build this relationship
between the patient and the team.

Now I do want to mention that there are some additional changes that
were made in this model based on some of the stuff that we\'ve learned
from South Central Foundation in Alaska.

And this is one of them - the productive interaction through effective
asset based partnering over time is some of the wording that they use.
And it really hits home on some of the changes that we want to bring as
part of the Chronic Care Initiative.

The components up on top are really the change ideas that you can bring
into the system to facilitate this interaction between the team and the
patient and family. And these are self management support, delivery
system design, decision support, and clinical information system.

Recognizing the fact that we can\'t forget about the community because
really the patient only spends maybe 1% of their time - their living
time in the health system and most of their time is spent in the
community.

It\'s easy to say but how do we get there. The next slide is one of the
things we have to do is we have to start to optimally use our assets
that we have. We have to start - we have to improve our communication
with tribal diabetes program, behavioral health programs, business
office.

They feel sometimes like they\'re out in the periphery - traditional
healers but we really have to figure out how to bring them in to be a
member of the care team and so that we can help with interactions and
really bring a team interaction with the patient.

The next slide which is I believe is Slide 15 is just focusing on the
fact - we tend - when we look at the Care Model we tend to focus on the
big green bold circle up on top. But really the key piece of it is this
interaction between the proactive practice team and the patient and
family.

Just another re-emphasis on the next slide of what the care team is. The
care team is a small interdependent people who work together regularly
to provide care for specific groups of patients. It\'s just important
that we start to think outside of the provider patient interaction.

And the next slide is the last slide which is 17 \-- I believe it\'s
Slide 17 \-- is establish priorities that we are recognizing as part of
the collaborative that we hope to spread as we move forward after the
collaborative and as part of the collaborative.

The first one - the biggest one is improve continuity. We\'ve got to
figure out to improve continuity. And you can read through these either
now or later but the other one is you really have to have leadership
support for improvement especially at the local facility and area
national leadership. And I think we have that. But the local leadership
really has to get involved with improvements and changes if we want to
succeed.

And I think that that\'s the end of my part. I\'ll give the ball back to
you Bruce.

Bruce Finke: Okay. Thank you Ty. You set the stage and I think the next
speaker will address that question - you answered two of the questions.
What change are we hoping to create and the third question about the
ideas that create the change. The middle question about how will we know
change is an improvement I think is the topic of the next section.

Our speaker, Lisa Dolan Branton, is a nurse who has been working with
the Office of Information Technology \-- OIT \-- at IHS and also with
the chronic care team and Mr. Jerry Langley who is with Institute for
Healthcare Improvement. And they\'re going to give us an overview and
address that question how will we know that a change is an improvement.

I\'ll leave it to you.

(Lisa Dolan Branton): Thank you Dr. Finke. This is Lisa Dolan Branton
and Dr. Reidhead as well for the great foundation on the improvement
model. Let\'s talk a little bit more about that powerful quality
improvement model that our innovation in planned care collaborative is
working in depth with.

And I just want to warn everybody that these slides are just a slight
adaptation of what was posted on the web page. So you\'ll see on the
second slide that small picture of the model for improvement.

And it has really two parts. The first is composed of the three
fundamental questions that Dr. Reidhead just spoke a little bit about.
This is the fundamental questions for improvement that are intended to
guide the improvement process to keep the focus on the aims of the
improvement project and get maximum results.

The bottom part which I think many folks are familiar with \-- that PDSA
circle there \-- is a plan to study a cycle where most of the learning
occurs. So let\'s go back up and focus on the second question on how
will we know that a change is an improvement.

And this question really guides the feedback or the measurement of the
improvement work in order to drive the health care system improvement
forward at a rapid pace we must have a balanced and comprehensive
measurement plan to tell us if the changes being tested are resulting in
the improvement being sought.

Next slide which is another graphic of ramping up (unintelligible)
cycles. So this slide shows the process of how the improvement team like
the pilot sites that we have in our innovations and planned care
collaborate run small scale tests on big system changes - some of the
ideas that Dr. Reidhead showed in his last slide.

So here\'s another example. For instance in our robust change package
some of which you saw on that last slide of Dr. Reidhead\'s presentation
includes the use of information systems to proactively plan visits for
patients.

And I\'ll give you a concrete example the care team that I had the
pleasure of working with at (unintelligible) Health Center in Wyoming
was testing the use of iCare and EHR reminders.

So they started out with three patients in a clinic on a Wednesday and
checked who was due for which preventive service or lab by their care
team nurse. And this was ahead of the visit by printing out the due
list.

And then she completed each reminder that was due. So for instance a
patient that came up on the list being due for a mammogram she would
either get - out the order in the EHR, make the appointment for the
patient, and then follow up later to be sure that the patient that they
had the - that they got the test results back and that it got entered
appropriately into the information system.

Another example would be doing the intake screenings that all patients
are due for and then being sure that each one is documented in the right
place so that information system is really aligned with the measures
that they\'re tracking.

So the teams run sequential tests like these in order to learn how to do
it better each time until they have as you can see from the ramping of
the PDSAs they have a high degree of expertise and confidence that doing
this process for all patients will accomplish their aim.

Next slide. So here is a map. We talked - Dr. Olson talked about the
pilot sites and I just wanted to show you a quick picture of where they
all are around the country spread across each area. And that was done by
design to be sure that as we spread the work of the pilot that we have a
reach into each area to help the rest of the system pick up all this
work.

So just to jump to the next slide and give you some more detail about
measurement set - the draft measurement set for the pilot at this point
the faculty with the broad scope that we\'re covering in mind had a few
criteria that we used in order to choose which measures to use.

And the first one being that they were evidence based, that they were
able to drive multi-disciplinary care, that they focused on the broad
range of chronic condition and prevention that the scope of this
collaborative focuses on. That it optimally meet patient needs, puts the
patients at the center of the care.

And that they are able to be (unintelligible) relatively easy so it
doesn\'t, you know, create a huge measurement burden for all the
improvement teams. So many of the clinical ones that you see are
actually already part of measurement for Indian Health Service that are
clinical GPRA measures.

So here\'s just a quick snapshot on one page of the domains of
measurement that we\'re focusing on. And so these are system changes
within the clinical focuses of clinical (unintelligible) and the
management and prevent of chronic conditions, system changes around cost
effective primary medical homes, and focused on creating a system and is
centered around the patient.

Next slide. And then we have two slides of the more detail of the
measurement sets that the ITC is focusing on. And again you\'ll see that
in the core measures column that many of these are GPRA measures.

The other important point to note is that we\'re able to do some
innovative things with measures because of the new tool that the Office
of Information Technology and IHS released in May called iCare which is
our population management GUI. And it allows folks to look at a broad
range of measures in a very user friendly format.

So I just wanted to give you an example so you have a picture of the
nursing practice that did the screening for the patients. And these
measures are designed to have the patient\'s perspective at the center.

So the intake screening bundle is the whole set of screenings that a
patient would receive based on their age and gender as they walked into
the facility. And we want to make sure that that is fully reliable. All
those things that the patient needs when they walk in the door are able
to be taken care of.

And that intake screen bundle is designed to capture all of those so
that improvement teams are not only able to look into each measure on
depression, tobacco screening, domestic violence screening, alcohol
screening, and whether their BMI and blood pressure were assessed. But
they\'re also able to look across all of those to see that they reliably
met all of the needs of the patient.

Another one I just wanted to point out on the slide is the nutrition
education and exercise education for at risk populations which is not a
GPRA measure and it can be reached through the clinical reporting system
of RPMS but it is a really core non-provider focused measure that
patients are needing our services for. So both tracking whether they
received the medical nutrition therapy as well as exercise education.

Next slide. And the last set of measures you can see focuses on
decreasing costs outside of primary care and a whole set of measures
around driving patient centered care around activation, satisfaction and
really building that continuity of care with the patients with their
primary care team as Dr. Reidhead spoke about.

Here we\'re just going to focus on one specific measure of colorectal
cancer screening because of time. But this is a run chart of the
colorectal cancer screening measure. And this is aggregate quality
improvement results from the 14 pilot sites from the start of the pilot
collaborative in March through September of \'07.

And you\'ll note that almost all of the sites are showing improvement
\-- I\'m going to show a little bit more on the next slide on that. And
a wide range of results between the sites you can see clumping at around
70% again between 30% and 40% and then just below 20%.

Next slide. Sorry. My slide forwarding function isn\'t being very
cooperative here. So there\'s the last slide. And this is the same graph
showing the results of the colorectal cancer screening from March
through September with three of the site lines deleted.

And I just want to point out that all the remaining sites show some
increase in screening rates. And these - they have many stories to tell
about how they\'re accomplishing this and other improvements which
we\'ll hear about in a moment.

And also note that the three sites that were removed have their own
story. One has made some changes that they think will show results in
the next month or so and one already has top results.

So really exciting improvements. We are going to - that\'s the end of my
slides. So I\'m going to out up the next person\'s Power Point. Dr.
Finke?

Bruce Finke: Great. Thanks Lisa. So we\'ll move quickly along now.
We\'re running a little bit behind our agenda. But we have plenty of
time for what are really the core presentations - the core discussion
today which is, you know, where the rubber hits the road, where the
patients get care.

And we\'re really delighted and honored to have folks from the Cherokee
Nation, from Rapid City Service Unit and from Indian Health Council
present. I\'ll tell you straight off we may actually not have folks from
the Indian Health Council.

As many of you know the fires in the San Diego area have been
extraordinarily disruptive and difficult. The Tribal site that Indian
Health Council serves - the nine Tribes have been evacuated and the
clinic has been closed. The staff from Indian Health Council is hoping
to join us. We\'ll see if they\'re with us.

In the meantime we\'ll go ahead and introduce the Cherokee Nation Dr.
Brett Gray and Heather Zimmerman from Cherokee Nation will be telling us
about their program and their progress and what they\'ve learned and
what we can learn from them.

Brett Gray: Thanks Bruce. This is Dr. Brett Gray. Thanks for the
introduction and we\'ve enjoyed the previous speakers and we\'ll begin
our slide presentation. Can you hear us okay?

Bruce Finke: You sound great.

Brett Gray: Okay. Thank you. This is simply a slide of our clinic in
Salina, Oklahoma - in Northeast Oklahoma. The Cherokee Nation Health
System, as the slide denotes, has 8 outpatient clinics, 54,000 active
patients (active patients defined as patients with a visit in the last
year), and 376,000 visits in the past year. This is the Cherokee
Nation\'s jurisdictional boundary, a 14 county area in Northeast
Oklahoma. And Salina is located within this, in Mayes County.

The pilot site is the Salina Clinic which is where Heather and I work.
You can see the statistics there with the number of visits and primary
care providers. Next slide.

Our Aim statement that we developed back in March when we began the
Chronic Care Initiative has been reworked a couple of times. And I
won\'t belabor everyone listening to me read it. But you\'re free to
read it. We\'ll leave it up there a couple of seconds.

And we\'ve gone back and revisited it and it\'s really helped guide us
in the direction that we think is going to help improve chronic care in
our clinic and in Cherokee Nation.

The pilot project micro system is listed there. I don\'t see Teresa
Chaudoin on there. Well anyway this is our care team at the clinic. It
consists of me, I\'m a family practitioner, an RN and an LPN.

Heather Zimmerman has done the bulk of the work as far as reporting,
documentation, computer work etcetera and she\'s a nurse practitioner
who specializes in diabetes care and Kim Bobb is her medical assistant.
And through our impanelment process, which I'll discuss more later, my
panel currently consists of approximately 750 patients.

Other members of our team that have been vital are listed there -- Dr.
Gloria Grim (who is Charles Grim\'s wife). She is the Medical Director
for Cherokee Nation. Chuck Smith is the administrator for our clinic.
Rhonda Stanley is our QI guru and Teresa Chaudoin is our diabetes
program director but she is taking a vital role in this chronic care
initiative as well.

And with those listed up there I\'d like to kind of revisit something
that Ty mentioned earlier about having the leadership involved and that
things like this can\'t work without leadership. Everything gets
stymied, but when the leadership is on board it makes a big difference.

One thing that we\'ve worked on is impaneling patients so that they do
have a designated provider or primary care provider and obviously this
should help improve continuity of care which should improve overall
outcomes.

So this is a process that we\'ve been going through to get patients
impaneled properly with their appropriate primary care provider. This
slide outlines what we\'ve done and what we are continuing to do. I
think we have about 25,000 charts at our clinic.

And it\'s been quite an ordeal as we\'ve had a provider or two leave and
brought a couple of new providers on. But it\'s going to be worth it in
the end as we get everyone appropriately impaneled.

This notes a couple of other things as we moved along. One thing that we
did that I think is going to be helpful is we identified all of the
active patients \-- which we determined to be a patient with a visit in
the past 12 months \-- who did not have a designated provider.

We mailed letters to each of those patients asking them to choose a
primary care provider or designated provider at Salina. And we provided
them with a self-addressed stamped envelope and we also gave them an
option to decline if they were receiving services elsewhere. And those
responses are coming in and we\'re impaneling as they come in.

The next slide which is a copy of the letter - we tried to stress the
importance of continuity, listed all of our providers, and gave them an
option to choose or note if they no longer receive care here.

We had several areas that we focused on for improvement. One of the
things that we felt deficient in was cycle times and intake screenings
and cancer screenings so we\'ve worked on these things. And the next
slides will kind of delineate what we\'ve done for these.

The cycle time - I think we have a later slide that shows the
improvement. It was about two hours I believe when we first measured it
for the toes in to toes out.

And what we did was, we developed a template for patients to pick up at
registration, carry it to each of their stops, logging the times and
then drop it off as they were leaving the clinic and then we tabulated
those and figured out where bottlenecks were, did process mapping and
came up with ways to improve cycle times.

This slide kind of reiterates that. Also the last bullet there, I think
Lisa was the one who mentioned about iCare reminders, and our care team
has begun utilizing this and doing the intake screenings.

And as Ty mentioned earlier about the provider centric model, we\'re
trying to get away from that model by allowing more of the care team to
do things that they\'re capable of doing and practicing at the top of
their licensure.

So a lot of the things that need to be done can be done by nurse
assistants, MAs, NAs, LPNs, or RNs. And that\'s what we\'re trying to
accomplish in getting them to do all of the pre-visit planning, the
screening, etcetera.

This is a graph that shows our cycle time. I guess it\'s actually worse
than I remembered. Toes in to toes out was 2-1/2 hours in March. And as
we have done cycle times with patients almost on a weekly basis and have
reviewed those, identified bottlenecks, made changes, performed PDSAs. I
think the graph clearly shows that we\'ve improved that dramatically. So
we\'re pleased with that.

When we described to the patients what we were doing and they\'re
carrying their little lists around they\'re very protective and do a
good job of keeping those completed. They understand the problem of
having a 2-1/2 hour visit versus a 1 hour visit. And also they\'re glad
to contribute to our improvement.

The intake screenings - as we measure our numbers those are improving
also. And these that are listed here by each bullet basically are done
by the MA, NA, LPN, or RN who rooms the patient. And these are all
prepared and complete when I go in to see the patient.

So by taking things out of the provider\'s hands - or not necessarily
out of the provider\'s hands but away from their responsibility, the
numbers are improving, and in turn this helps our care team numbers
improve.

And it doesn\'t take a lot of effort on my part other than if they
forget and I have to go out and get on them a little bit! And I\'m just
teasing about that because our care team really does a good job.

Let\'s see, one thing that I would note on the second bullet that took a
little bit of convincing and a little bit of getting used to for some
people were the screenings that were only \"necessary\" once a year.

We found that if we made it a practice to do each and every one of those
screenings at each and every visit then our chances of missing those
went way down.

So we are generally trying to do each of the intake screenings at each
and every visit and that way we know that they\'re not getting missed,
as long as the patient presents to the clinic.

We have a preprinted PCC that has all the screenings available and we
actually have on our bullet that we\'re using that. And as of now we
haven\'t received those. But we\'re looking forward to those and think
that our numbers will improve even further when we have that.

So our tobacco screening has been routine. Our referral for tobacco
cessation hasn\'t been optimal but now that we have more classes and we
have access to some more options we think that will improve also.

There\'s a slide that lists the bundled measure for intake screening
outcomes and the IPC goal is noted at 70%. Our current percentage is
77.5%. We continue to feel that we can improve and will continue
basically to hit each of those measures every time patients come in.

That is our graph noting our assessment of tobacco use and exposure. And
it has improved steadily throughout the use of these intake measures.

The cancer screening bundle - the things that are being measured and are
noted there \-- breast cancer, cervical cancer, and colorectal cancer in
the appropriate ages.

Some things that we are utilizing to improve are noted there. The fecal
occult blood test cards - they can be handed out automatically by the
nurse if indicated. They don\'t have to wait for a provider order.

One thing that has helped our cancer screening numbers a little bit is
focusing on documentation and appropriate data entry. We are still
working on this and still finding some colorectal screenings that are
not getting entered appropriately etcetera.

And for anyone who is going to work on this measure I would say that
proper documentation and data entry cannot be stressed enough to allow
you to get credit for what you\'re doing. So that\'s one thing that you
probably will have to do some manual audits to see if everything is
getting entered appropriately.

Another thing is that some of our patients have insurance or have access
to attend a different clinic or different IHS facility or private
provider for their PAP screens, breast exams and mammograms. And
obviously that does not get entered in RPMS.

So we are questioning patients whether or not they\'re up to date. If
they say they are, we get a release and send for the records and try and
get those all back into our case manager or our CDC case manager. And
between the two of them they are getting the outside information entered
into RPMS and allowing us to get "credit" for it.

So I think that documentation and data entry once again can\'t be
stressed enough to allow you to get credit for what\'s being done.

Bruce Finke: Dr. Gray this is Bruce. I\'m just going to let you know
we\'re running short of time in terms of questions. I just wanted to cue
you in.

Brett Gray: All right. Well we\'ll move along. Cancer screening
outcome - there\'s some numbers you can look at. Next slide. Colorectal
cancer screening with our improved documentation has made an improvement
as noted on the graph.

This is the last slide - the things that we have planned are to improve
access by utilizing the third next available appointment plan. We\'re
going to conduct some focus groups to see what\'s needed or necessary.

We have spread teams that are developing and beginning the first part of
November we\'re going to involve all providers and a representative from
each department in the clinic to begin spreading these steps throughout
the clinic, and further empanelment as noted there.

Cherokee Nation has a new clinic that\'s opening in the next couple of
months and they plan to implement a lot of the Chronic Care Initiative
things that have been worked out here at the time of opening there.

And that rounds out our presentation.

Bruce Finke: That was great. Thank you. And we do have time for a couple
of questions, but first, I\'m just going to comment on some things that
I\'ve heard. First of all these are really remarkable improvements that
you\'re demonstrating.

And I think we have heard the theme from others that leadership is the
key and that you really have strong leadership - committed leadership at
Cherokee Nation Health Program.

I heard you say that you\'re doing these tests - you\'re testing these
improvements in a micro system - in a small subset of your clinic and
that you\'ll then spread once you\'ve shown that they work to the rest
of the system.

I\'ve heard you say that some of what\'s driving this is very frequent
measurement - weekly I think I heard you say to help you guide the
improvement. And that you\'re really maximizing the care team.

And really the change in cycle time is quite remarkable. And I\'m just
guessing from my own experience that your patients - your community
really appreciates the tremendous work you\'ve put into that and the
results you\'ve shown.

So operator if it\'s okay I\'d like to open this up for a couple of
questions if anyone has questions for Dr. Gray or for Heather Zimmerman.

There\'s always a little bit of a pause while we wait to see if anyone
comes on board. Operator do we have questions?

Coordinator: I\'m showing none at this time. But as a reminder if you do
have a question please press star 1 on your touch tone phone. Again to
ask a question please press star 1.

Bruce Finke: That\'s great. What we\'ll do then is move onto the next
presenter and just know that if you have a question for that team from
Cherokee - for Dr. Brett Gray or Heather Zimmerman go ahead and let the
operator know and we\'ll get that in. Our next presenters are (Jennifer
Heil) and (Lorraine) from the Rapid City Service Unit. And I\'ll turn
the phone line over to you.

(Lorraine): Very good. Thanks so much for the introduction and I just
want to echo every time I get the updates from the other teams in the
collaborative you just have this sense of wow especially when you look
at the time that this collaborative has actually been in effect.

So one of the things that we want to concentrate on in the presentation
\-- and we can go to the next slide \-- is describing just a little bit
about where we are. We are in Rapid City, South Dakota. We\'re in the
middle of the Black Hills. We\'re in the middle of Rapid City which is
our second largest city in the state. We\'ll let you read those - next
slide please.

Our micro systems - we actually have one team. We\'re a smaller
organization than Cherokee Nation. We\'re one hospital in that. And our
clinical director Dr. (Clark) is actually the head of our micro system
team and his membership is on there. Next slide.

We also are in the process of impanelment and have been for about a year
and a half. We actually started this a little bit before the
collaborate. And we\'re moving ahead. As of yesterday Dr. (Clark) has
811 patients impaneled to his panel. Next slide please.

Where we want to spend some time is on the use of PDSA cycle. It\'s
something that we\'ve seen lots of improvement with in a very short
period of time.

Part of the issue that we faced with some of our staff is this may work
in other places but can it work in IHS. We\'ve already heard from Dr.
Reidhead about some of the financial issues that we have in areas where
money isn\'t plentiful and I thinks most health care organizations share
that challenge.

Improvement is possible. And so we\'ve put a process in place. And we do
believe in the model. We think it has a lot of effect on improvement.
You\'ve heard from two speakers not all change equals improvement. What
we\'ve seen though is that all improvement requires change. The system
can\'t stay static and recognize improvement.

The other message that we\'re going to try to highlight is that change
can happen rapidly. It doesn\'t have to be a six month plan phase before
you execute your first change out of fear of failure with that.

What we\'ve learned is that there isn\'t any failure, just lots of
learning. Some things will work and get the results they want and some
things won\'t and those are the best pieces.

So we chose to concentrate some of our efforts on our colorectal cancer
screening project. We\'re trying to appeal to the fact that if we do
colorectal cancer screening really well we\'re not just improving
numbers, we\'re saving lives. These are people who may be around in a
few years who might not have otherwise if we hadn\'t caught it.

So (Jennifer) is our expert on our rapid cycle change. She\'s engaged in
a number of those and teaching people how to do this. I\'d like to turn
this over to her and she\'s going to do the rest of it.

(Jennifer Heil): All right. Thank you. And we can go to the next slide.
Our performance that we found through our GPRA reports was that we
weren\'t meeting goals for our service unit and for the micro system.

So the first thing that the team did was set an aim that all patients in
the micro system would receive a screening and then looked at how we
could measure that.

And it\'s really important to give the team the measurements daily if
possibly, weekly so they can see the impact of what they\'re doing. We
developed an action plan and then within that action plan we started
really doing quick cycle changes, reviewing the CHS data to collect
historical information. That was the first thing that we did do.

We did an RN initiated screening with visit planning. The second - or
the third thing was the RN group visits. And we learned a lot there of
what the RN could do if the access isn\'t there for those patients we
still could move forward.

We did some telephone education using iCare. And we updated - at the
time we couldn\'t put historical data right into our electronic health
record so we did make sure that those PCCs got routed right to a data
entry person who was geared at our tested change.

Then we did mail outs for the patients which we put identification
information on the cards and we saw results from that. Next slide
please. Within our micro system with things that I just described we did
go up - or we did increase to 11.3% - by 11.3% excuse me and the overall
by 6.8%.

We have increased our skills. Our RN staffs are now growing more
comfortable with their expanded responsibilities. We have added group
visits and visit planning to our tool kit and the iCare is extremely
important in that. Everybody is more comfortable using measures and
assessing their data with the CRS and the iCare.

And is this is some of the - one of the slides that we\'ve shown the
staff and the care team to help them kind of visualize where we\'re at.
Part of the important points for us is we\'ve annotated this. So as we
made each improvement we try to put that on the slide so people can see
what impact that particular change did or didn\'t have.

So again was all change improvement. In this particular one kind of but
that\'s not usually the case. And it also gives the staff a chance to
see like when we initiated our RN group visits they get to see that all
performance after that was much better than it was before.

And you\'ll notice along the x axis that\'s the frequency with which we
were pulling the data out and reporting it to the team. So once again
they had to learn how to interpret data and use data but the results
really do speak for themselves. So are our efforts mattering? Yes they
do. You can go to the next slide.

This is just a different view of actually our whole service unit and the
patients that we serve. Okay you can go to the next slide. Our next
steps that we want to look at are celebrating the successes for the
staff.

And looking at spread - using the team members to help spread what works
with the other teams and identify next improvement challenges which will
include glycemic control and screening bundles and with additional teams
that we\'re going to set up.

Do you have any questions for us?

Bruce Finke: Operator are there any questions now?

Coordinator: I\'m showing no questions.

Bruce Finke: All right. Let us know if there. I\'m noticing - what I\'m
struck with again is a really impressive level of commitment and of the
work involved. You make it sound easy and I know it isn\'t.

And I\'m struck with the fact that we\'re used to looking at measures
like the colorectal cancer screening measure in terms of GPRA - in terms
of measurement which is really for accountability. These are measures
which we check infrequently, quarterly, every six months, or every year,
which we check and we report out.

But because we check infrequently, it isn\'t really available to use on
a regular basis to help guide improvement. And here you\'re using that
same measure, but you're checking it frequently, using it to help test
whether or not some of these changes you\'re doing are in fact
improvement.

So you\'re taking those numbers -- numbers we\'re used to looking at and
watching our heart sink and you\'re acting on them and making our heart
fly as the numbers get better.

Charlton Wilson: Bruce this is Charlton. Do you hear me?

Bruce Finke: I do.

Charlton Wilson: Can I ask a question?

Bruce Finke: Yes.

Charlton Wilson: From both of the groups I saw run charts which I\'m a
big fan of. And I think both of them sort of basically showed annotative
run charts which I\'m really a big fan of.

That\'s been one of the difficult things though to get people in my
health system sort of used to and also the technical aspects of
translating our usual performance measures which are translatable into
run charts but sort of the skill and the experience that people have in
putting things in run charts.

Has that required some additional training or do you guys just - some
people just have a knack for it? That\'s my question?

Woman: Rapid City could respond to that. One of the things that I\'ve
found Excel spreadsheets are pretty self-explanatory to most staff.
We\'ve gotten very familiar with the commands and the things you do in
Word and they translate really well to Excel.

But we have especially early on identified a couple of higher level data
people - our hospital accreditation specialist and one of our clinic
coordinator staff who had more skills in those areas.

But we\'ve also found that meeting trainings for staff, helping them put
the data together helps a lot. So some training but not as much we
would\'ve expected. But we have identified organization experts as well.

Woman: And we\'re also trying to demystify the numbers. That they are
really numbers but you can look at them and your actions can determine
what\'s going to happen.

So I think that\'s the biggest thing. At point of care we want the RNs
and the LPNs be able to pull their own numbers. And that\'s our ultimate
goal is looking at point of care within the teams to actually be able to
run their own numbers and not rely on other staff to do it.

So that\'s our ultimate goal.

(Lisa Dolan Branton): And Charlton also to add \-- this is (Lisa Dolan
Branton) \-- we do provide that TA to the teams that need it as well -
how to annotate run charts, how to use run charts in the system that
they\'re working with. Not only Excel but we have a reporting system
that people report on monthly. So there is that support for those that
have the internal expertise.

Man: We have another question Dr. Finke.

Bruce Finke: Yes go ahead.

(Jim Schaeffer): Hi. Excuse me. This is (Jim Schaeffer) from
headquarters. And this is relatively new information for me so I wanted
to ask for clarification on what does CRS stand for and what exactly is
iCare?

(Lisa Dolan Branton): I can...

Bruce Finke: Lisa that would be great.

(Lisa Dolan Branton): They\'re both applications within RPMS. And the
clinical reporting system is basically our quality measures, query
engines that are all preprogrammed. So most folks know it across the
country as our GPRA system.

So it has predefined logic into CRS that pulls from all the fields that
people enter their clinical documentation into to produce the results
for these quality measures.

iCare takes the logic and displays it in a much more user friendly
format than CRS. It takes the same logic though - and I can show or
share with anybody the very long logic document of all the measures that
are contained within CRS.

And it shows it in a much more user friendly easy to manipulate so that
you can figure out, you know, where you need to work with patients on
proactive plan care.

Bruce Finke: Okay. Thank you (Lisa). At this point we\'ll have to hold
on further questions. We will have some time for more questions at the
end and we may even have time after the next presentation.

Our next presentation was scheduled to be the team from Indian Health
Council. Are you there? Okay. We thought not. As I said earlier their
clinic is North of San Diego in the mountains.

Their tribes have been suffering through the fires so the clinic has
been closed. Certainly our thoughts are with them and all the folks
displaced by the fires in Southern California.

Cindy Hupke one the directors from IHI who has been working very closely
with us on the Chronic Care Initiative is going to pinch hit for us and
do her best at walking through some of the Indian Health Council slides.

And Cindy we won\'t hit you too hard if you don\'t know all the answers
to all the questions.

Cindy Hupke: Fantastic. Can you hear me?

Bruce Finke: Loud and clear.

Cindy Hupke: Okay. When I first got on they put me in listen-only mode.
So I was panicking trying to figure out how to get on the call to be
able to speak as well.

Bruce Finke: We\'ve been trying to figure how to put you on listen-only
mode but...

Cindy Hupke: Yeah yeah. But you know that that\'s not possible. I feel
very privileged to be given the honor actually to speak on behalf of
Indian Health Council. It\'s a fantastic organization and has done
amazing work as all of ours have. But let me try to do their work some
justice as I walk through the slides.

The second slide gives background information on this particular center.
They\'re located as Bruce said in North San Diego County right in the
middle of the fires right now and did have to evacuate.

The population served is Native Americans and their family members. And
they have 5,000 active clinical users with a user population of 18,000
and 9 North San Diego County tribes. They have two sites as you can see
there. That (unintelligible) is actually I believe the name of one of
the fires so you know that they\'re right in the gist of it.

The next slide \-- I\'m not on WebEx Bruce and so hopefully one of you
is changing the slides for me \-- but it talks about IHC\'s micro
system. I don\'t know if anyone else prior to this was able to talk at
all about micro systems. Bruce?

Woman: Yes they were.

Bruce Finke: We mentioned micro system but go ahead and review it real
briefly and we are following along. And I\'ll let you know Cindy if we
get out of sync with your slides.

Cindy Hupke: Okay. And also if there\'s any questions or chat that comes
up because I can\'t be on the WebEx. What I see first - was trying to
identify which system they were going to be working with I think perhaps
people have alluded to in maybe their previous discussions because you
had two amazing organizations before this as well. They start working
with a smaller defined group of patients and a care team and a
provider - they all work together. And they are associated with one
another.

At IHC when we made our initial site visit there they were struggling
with how they were going to identify this micro system because they
didn\'t have any shall we say impaneling or regularity with any one
provider.

There was a very loose sense of who somebody\'s panel was. And so to be
able to do that they felt was going to be very difficult. They did end
up selecting one provider. It was a family nurse practitioner.

The core team consists of that FMP and RN and two medical assistants
with a lot f support from leadership and the CMO. The pharmacist sits
within this micro system. Community health is very active within this
organization and behavioral health.

Now the way they identified the patients that were associated with that
team or with that care team initially they took a look at active
clinical users of their clinic with at least three visits in the last
year to the provider who was recognized as the first one they were going
to test some of their changes on.

And this particular provider has a population that crosses across all
ages and conditions and is comprised - was comprised initially of 772
patients. But that\'s a moving target. This is a relatively new provider
and as new patients come on they will distribute them to different
panels.

What IHC has found which they didn\'t predict initially - this initial
test with paneling - impaneling for them I think their prediction was
that they weren\'t quite sure that this was going to work for them.

But the test really proved to be very successful for them from the
perspective of the staff - the provider themselves understanding who
their patient was and what their needs were, realizing that continuity
with them brought value not only to the provider but brought it to the
patient and their family as well because they really understood their
needs and their history. They didn\'t have to repeat things over and
over again.

What IHC has subsequently done is they have spread impanelment
throughout their entire organization. And they did it fairly rapidly.
They did it - I believe it was by July 1 this year where they impaneled
all of their patients to specific providers trying to bring more equity
to the panel sizes and also making sure that the patients were satisfied
with that break down as well.

So that was a huge change within the organization that has proven to be
very successful for everyone all the way around. I don\'t know what
slide you\'re on Bruce - impanelment population?

Bruce Finke: Empanel population and just to let you know Cindy, we\'ve
got about ten minutes.

Cindy Hupke: We\'ve done about ten did you say?

Bruce Finke: We\'ve got about ten minutes left in the presentation time.

Cindy Hupke: Thank you. So I think we actually covered the empanel
patient population, what they did, the client base that they saw most
frequently etcetera. So we can go on to the team huddle.

Another significant change for a lot of our organizations but certainly
for IHC they have found it very important is the team huddle. They
huddle as a care team first thing in the morning.

And they try to make sure that they\'re using each member of their care
team to the highest level of their ability and/or their licensure. We
call it optimizing the care team, making sure that everyone can do to
the highest of their ability.

Now this says a lot of things. It moves work away from the provider so
that perhaps they can have more productivity. There are certain things
that the provider perhaps doesn\'t need or want to do necessarily.

And maybe the next step of licensure would be pleased as punch to be
able to expand their workload to be able to do that. And it just makes
people more happy with their work. They find more joy in their work.
They find it more rewarding.

They use this huddle to also anticipate what their clients\' needs are
that they know are coming in for that day. They feel that it moves the
teams together and allows for continuous communication among members is
another improvement that they\'ve moved. So they\'ve moved those teams
together so that they can communicate directly with one another.

And they also \-- the next slide Bruce \-- as well as reviewing clients
for the day doing a chart review they\'re also having these huddles
throughout the day for add-ons and walk-ins.

Now when they review the clients for the day they initially used the
GPRA health (unintelligible). But now they\'ve started using iCare as of
June 2007. And iCare provides those review reminders and also gives them
prompts and reminders about national measures that are met or not met so
that they can be proactive in addressing this patient\'s needs.

Medication records and refills needs are addressed at the time of that
huddle also when they review the clients for the day. The iCare
reminders is the next slide group. And Ty is on the phone is he not?

Man: Yes Ty are...

Ty Reidhead: Can you hear me?

Cindy Hupke: And Ty I\'m not as aware of the use of the iCare reminders
as obviously you are. But this is I believe just a slide being able to
demonstrate how clear it is to be able to see when something is due so
that they can use this at the time of their huddle.

Ty Reidhead: That\'s right. And it is a replication of the reminders
that are available in CHR as well as RPMS.

Cindy Hupke: Okay. The next slide is the iCare national measures. And Ty
maybe you can comment to how this might be used as well.

Bruce Finke: You\'re muted Ty.

Ty Reidhead: Sorry, now can you hear me?

Bruce Finke: We\'ve got you now.

Ty Reidhead: It\'s GPRA measures for a patient panel. So you can create
a panel in iCare and then look at each of the GPRA measures with this
slide to see how this panel is doing. So you can look at it by provider
or however you might define that panel.

Cindy Hupke: And one thing that I know IC has found remarkable with this
is once they went to impaneling their patients they were able to take
responsibility then for that panel of patients and then use this data
just as on this screen right here to drive improvement on a regular
basis.

And I know that there are some other sites that have been talking about
putting these up on the walls so that people have really easy access to
them, making sure the data is right in front of their face at all time
so that they understand where they need to improve and how they can
improve.

Their next step \-- which is the next slide I think \-- is using that
data to drive the actual visit rather than take a look at it
retrospectively let\'s have that data right in front of us at the time
of the visit.

They have made changes to the PCC form to capture screening data points.
And as far as spread goes they\'ve added iCare to workstations
throughout the medical department and the community health department.

So they\'ve spread it outside their one site. And additional teams that
have been set up have been training on huddles, have been trained on the
use of iCare, have already been impaneled.

And so this is an example of another organization - you\'ve heard from
two prior to this but another organization that\'s not waiting until the
end of this pilot work or this initiative to start spreading great
ideas.

They\'ve identified that there are certain things that certainly works
for them quite well and they want to make sure that they get that
initiated tested, and that implemented within the rest of their
organization.

The next slide shows some examples of some of the progress that IC has
made. If you take a look at their alcohol screening you can see that
they\'ve made some major improvements in this particular area - down
around 32% up to preferably 51% or 52% with the alcohol misuse
screening.

The next one shows improvement in colorectal screening. And this one
shows remarkable progress. It\'s not just in the changes in the process
itself but it\'s also in its interaction and communication with outside
resources that that they have to refer the patient to.

And if they\'re not getting that kind of information back obviously
their idea as far as patient wellness and health is impacted. They
can\'t really see the real picture if they\'re not getting the
information back. So this is outreach to make sure that that information
got back to them and then got entered into the charts as well.

The next one is on continuity of care and as you can see here they\'ve
made a remarkable difference by impaneling their patients. And they hope
to continue to improve this. They know that it\'s an iterative process
and it\'s constantly changing and improving.

And I think another one - the next one is a really good demonstration of
the no show rate, patient satisfaction, they\'re communicating with
their patients much better than they were in the past. And the no show
rates have dropped to 13%. Obviously access has improved as a result of
that as well.

The next slide Bruce is on the delivery system. They as well as many of
the other teams are using process mapping to identify inefficiencies, to
identify areas for improvement.

Their pharmacy refill process was one that they focused on initially.
They had complaints about the length of time to refill meds. It was a
patient satisfaction issue.

They mapped out the process and showed that the initial map had 49 steps
to it and their goal was to eliminate 50% of those steps in that
pharmacy refill process.

They looked at the process from start to finish \-- this is the next
slide Bruce \-- identified multiple areas of duplication and waste and
it affected staff across many departments. They tested and made changes
to the delivery system and they continue to refine that process.

You can see the graph on the next slide where it shows results. And it
was difficult for me at first to determine what the graph was showing me
but these are the days that it took to fill - for their pharmacy refills
and what percent of those refills took that amount of time.

And as you can the 5 or more has decreased from June to July from 37% to
27% and the 4 days has increased. And as you can see even the 2 days I
think has probably increased the most - maybe even 1 day.

So they\'re starting to refill their meds more quickly. And as a result
I haven\'t seen the patient satisfaction results but I\'m assuming that
that has improved as well.

Okay I don\'t know if I made it Bruce but I\'m to the questions slide
and I can try to answer any questions as best I can.

Bruce Finke: You did great actually. So why don\'t we see if there are
any questions. Operator do we have any questions on the line?

Coordinator: I\'m showing no questions at this time.

Bruce Finke: Are there any questions from anyone in any of the rooms or
on the phone otherwise?

Man: Dr. Finke we have a question here.

Bruce Finke: Yes.

(Nancy Bill): This is Nancy Bil, Injury Prevention from headquarters. I
have a question about iCare - a general question. If you can add - I
didn\'t see it on there but can (unintelligible) be added to that or is
it already added and is it a question that physicians ask the patient?

Bruce Finke: Lisa can you take the iCare question?

(Lisa Dolan Branton): Yeah it is not in there currently because it\'s
not one of the critical GPRA measures. And it can be suggested to the
iCare development team in IT to add that.

(Nancy Bell): Thank you.

Bruce Finke: Thanks (Nancy) and thanks (Lisa). So why don\'t - if there
aren\'t further questions waiting on line we\'re going to go ahead and
segue to Cindy\'s presentation - the one that she expected to present.

And she\'s going to share with us kind of an outside inside view of this
whole process from the perspective of IHI - the Institute for Health
Care Improvements.

Cindy Hupke: Thanks Bruce. If you want to just jump to the second slide
that\'s fine. I don\'t know how many of you are aware of IHI but we\'ve
focused on building will and capacity for change in the health care
industry since it was founded in 1991.

And as all of us on the call probably are aware it\'s an industry
that\'s sorely in need of innovation and redesign. Each year it seems
that we need more innovation and redesign.

The current care initiatives as it evolved certainly is a great example
of the promotion and support of health care innovation and ultimately
speaks I think total system redesign.

So you can see then why this relationship between IHI and IHS is really
truly a fusion of will and energy together. On top of that from the IHI
perspective we are blessed to be able to working with 14 unique clinical
settings around the country that are just incredibly hard workers that
are willing to go beyond what seems feasible each and every day.

And their work does not go unnoticed. I\'m sure sometimes they\'re
thinking oh my gosh how can they ask us to do one more thing. But each
day then they do it.

They\'re an amazing source of energy. They\'ve generated a phenomenal
amount of great ideas. They\'re building capacity within each of their
organizations to contin8ue with this work and expand their improvement
efforts.

And they\'re building a strong base on which others will be able to
stand and flourish in the future in relation to chronic care illness,
prevention, access, patient centeredness. They\'re also building on the
previous successes within IHS.

So it\'s always tough to go first and these 14 teams are going first. I
think to quote and I always laugh at this one change is good, you go
first. And these 14 have stepped up to the plate and are willing to be
that first.

This initiative is unique in that there is no other system of care
around the world that has really taken on and has been successful at
this level of ambition. So there is much to take pride in for these
organizations as well as for the entire IHS system of care. I just
wanted to tout their successes.

Now the next slide group talks about synergy between IHI and IHS and
it\'s because of the synergy of these strategies and the goals of the
two organizations that there\'s this opportunity I think for real
innovation.

This means that these organizations are building new approaches for
care. They sometimes are tearing apart their current delivery system and
rebuilding an entirely new one. It\'s kind of like they\'re not adding
on a screened porch onto their house. They are bulldozing it and
building a whole new structure.

These new approaches are definitely upon previous improvements and
strong ideas. Many of them have already been built within the IHS \--
healthy heart, tobacco cessation, certainly your diabetes program. It\'s
a stellar one. And a lot of the work that has been done in that is being
expanded then to be incorporate with other conditions.

We are expecting these teams and ourselves to have significant learning.
And we also anticipate dramatic improvement in all of them. We\'re all
working though towards that common goal down at the bottom and that\'s
to support the community and individual wellness and strength in these
communities.

The next one Bruce is three factors contributing to breakthrough
improvement. And I know the teams are used to hearing it over and over
again from me. But the will is vital. Status quo can\'t be good enough
in order for this to be a successful initiative.

And what we see from the IHS leadership is nothing close to being
satisfied with the status quo. They are so supportive and so incredibly
engaged in this work that I can\'t even speak to how impressed I am.

They recognize that there\'s an opportunity for improvement. They were
good before. They want to move to great. And they are in the process of
doing that.

Organization wide we look at these 14 organizations. They voluntarily
signed up for this initiative knowing that I was going to be difficult.
But they recognized the need for their own communities to expand into
greater wellness and patient centeredness. And system wide many of these
organizations already have spread plans in development and have already
started it.

Others not currently involved in the initiative - those of you who are
not on the call who are not from these sites certainly will build will
from having heard about it, seeing the results, understanding that it
only theory but seeing that it\'s actually been successful in multiple
settings and organizations and those are your peers.

Ideas - Ty\'s slides at the beginning, organizational examples that
you\'ve heard from, the use of the Care Model, all of those bring us
ideas and these are thoughtful and energized organizations that are
participating and they generate many other great ideas. They share them
senselessly with one another and they definitely steal them shamelessly
from one another.

The execution piece (Lisa) was talking about earlier and the model fro
improvement - the measurement piece. And these organizations are working
at an accelerated pace.

And it\'s not something where they sit back and wait until one month to
see how things have worked. They\'re looking at the data on a day to day
basis many times and deciding on what changes they need to make.

Bruce - and tell me how we are on time.

Bruce Finke: You\'re doing fine.

Cindy Hupke: Okay. The challenges that were recognized within all the
participating organizations that we saw first hand on our site visits
and these sites seem to be incredibly willing to take on these
challenges.

The first one was access issues resulting in the overuse perhaps of
urgent care in ED in many of the sites and resulting subsequently in
patient and staff dissatisfaction. This is an issue that could be
associated with safety issues, quality proactive care being diminished.

The greater efficiencies and lean - eliminating redundancies and extra
steps and identifying waste through process mapping are some of the
changes that the teams are looking at to try to improve their access.

Delays and waits - we saw in some of the sites patients waiting for
hours for a scheduled appointment. Walk-ins waiting maybe up to six
hours maybe sometimes longer in some circumstances. We think about this.

Within IHI from our perspective care should be patient centered. It
should be focused on the patient. Is having them wait that long patient
centered? Absolutely not.

So are they getting the care that they want and need when they want and
need it. In some cases not. And it\'s frustrating for the patients but
it\'s also frustrating for the staff who work on that type of stress and
tension.

So staff retention we know is a huge issue in many organizations across
the country. And we\'ve heard from our participating organizations that
it is within IHS as well. And we have to pay attention to that valuable
resource.

Starting appointments on time are some things that people are taking a
look at for changes, creating efficiencies in the process, pushing that
work away from the provider, developing alternative type visits. Up at
South Central Foundation they\'ve done a great job at that. Telephone
visits, group visits, those types of things and matching the access to
the demand.

Bruce Finke: Cindy I\'m sorry. You asked me how you were doing on time.
And I gave you an unhelpful answer. Let me give you a better answer
which is about two minutes.

Cindy Hupke: Okay. I will finish in that time then.

Bruce Finke: Thanks.

Cindy Hupke: Continuity with the provider - this is one thing that we
didn\'t see much of when we first started out with this initiative with
these teams. From an IHI perspective we feel that it is one of the high
leverage changes that needs to occur in organizations around the world.

Increased continuity with providers has been demonstrated to be able to
reduce hospitalization by up to 28%. When we think of a system of care
like IHS think of the amount of money that that could save but also the
improvement in one\'s life from a patient perspective. Nobody likes to
be hospitalized if they don\'t have to be.

Care tends to be safer with fewer errors when they have continuity with
their care team and their provider. Patients tend to be more satisfied.
They\'ve actually demonstrated that less meds are ordered because they
know the patient better. It\'s definitely patient centric rather than
provider centric.

I can tell you that impanelment is not easy. These teams can tell you
that. But each of our teams is working on it and many of them are
reaping the successes associated with it. So it\'s something that is an
early change that the teams have identified.

The lack of a care team is a problem - was a problem in some of the
organizations. I would say that every single one has worked together to
optimize that team, develop the team, and work together and have them
working at their highest level. And we talked about that probably enough
but that\'s a change concept that again around the world is key.

We saw issues obviously challenges within IHS with systems and
transportation at some of the sites. Patients come in when they can get
transportation and often can\'t make it back in. So they\'re willing to
wait.

That doesn\'t mean they\'re happy with the wait. But they\'re willing to
wait because that\'s the only way they can get in. And so that issue
obviously has to be worked on separate probably from this.

And then traditional and I hate to (unintelligible) because that\'s not
what it means. Our teams are working on integrating the medical culture
into the community culture rather than doing the opposite.

How can we integrate the community into our care? No. It\'s how can we
make sure that we\'re engaged in the community. We\'re guests in our
patients\' lives. And they\'re aware - the teams are aware of the rich
cultural histories and practices that play such a large role.

We have one of our team members \-- Dr. (Lastern) who said we\'d like to
see a system where traditional and Western practices work alongside one
another. And that\'s what we\'re working towards and it\'s a great
vision.

So the last slide I have is I never lost a game. I just ran out of time
on a few occasions. That was Vince Lombardi. And given today\'s
challenges the results of running out of time is far more significant in
health care than it is in a ball game.

The quality of life for future generations depends on what we accomplish
today within health care. So how do we explain to our grandchildren that
we meant well but we just ran out of time before we could establish
priorities to be able to manage their health.

IHS has proactively decided to address these issues before it\'s too
late. The 14 sites represent a slice of the system. They\'re not waiting
until they run out of time. They\'re developing priorities to address
the prevention and management of chronic disease. They\'re building
behavioral health and prevention into the initiative.

And it\'s quite an honor from all of us at IHI to be able to work at
their side and to help create that change package that builds on many of
the other successful initiatives and programs that IHS already has in
place.

So that\'s from our perspective at IHI and we are pleased as punch to be
here.

Bruce Finke: Thank you Cindy. We\'ll go on to our next and our last
presentation from Dr. Charlton Wilson who is the Chief Operating Officer
at Phoenix Indian Medical Center.

Most folks know him as leading the Center of Excellence at PIMC in the
past. And Dr. Wilson is going to talk about the Indian Health System
involvement in the Five Million Lives campaign.

I\'ll turn it over to you Charlton.

Charlton Wilson: Thanks Bruce. Well today what I\'m going to do is
actually - or what I\'d like to is actually sort of briefly share with
the group my story about my awareness of and interest in and
participating in the Five Million Lives campaign - a campaign that seeks
to reduce medical harm. If you go the next slide.

I think we\'d better start with actually some common vocabulary. And to
use that I\'m going to use - and sort of spend a little bit of time with
this definition of medical harm.

In this medical harm is defined as nay unintended physical injury
resulting from or contributed to by medical care including the absence
of it that requires additional monitoring, treatment, hospitalization or
that results in death.

And this is I think a really important second part. And such injury is
considered harm whether or not it is considered preventable, whether or
not it results from a medical error, and whether or not it occurred in a
hospital.

With such a broad definition of medical harm and some time to think
about it it really began me thinking that in fact this issue of medical
harm does affect me as a professional. And it even made me think it
really affects me as a person as my own family receives care and I
receive care in whatever healthcare system I may be in. You can go to
the next slide.

The next question that sort of came to me was well who are these people
in the campaign and what are their values. And as they talk about what
they\'re doing why should I listen to them.

Well I found out as shown here that they were people who like me
actually had come to recognize that there is a lot of medical harm out
there. And I sort of knew that again both from my professional and my
personal life.

I knew - I found that they were people who had like us and me and people
I worked with tried to do a lot of things in here and actually found
some sense of pride in what we were doing.

They were people who wanted a better health care system like me. And
there are people who said, you know what, we really can do it and we can
do it at the front line. So let\'s go to the next slide.

So I said okay well I understand their values. What about this campaign
and what is a campaign? And a campaign is pretty simple in that it is an
organized movement of people around a specific purpose.

And the purpose of this campaign is to organize people from hospitals
and communities and facilities and health stations around the common
purpose of reducing medical harm. Next slide.

The objectives of the campaign are pretty straightforward. And I won\'t
go through - and you can get this information from other places but the
idea that by applying proven intervention there are at least 5 million
lives that we can - or 5 million incidents of harm that we can avoid. We
would do this by enrolling at least 4,000 hospitals and communities and
clinics in applying those proven interventions.

The other objective of the campaign and it\'s been mentioned in some of
the other talks as well is to actually through this relationship build a
sustainable infrastructure for change.

And finally and is always important part we know in any campaign is the
awareness - or raising the awareness of the problem and so that we can
mobilize those resources - public, private and into improving the
outcomes. Next slide.

I won\'t read each of the interventions that form the platform of these
proven interventions or the platform that result in the reduction of
medical harm. But I will show these first six you may recognize from a
previous similar campaign called the One Hundred Thousand Lives
Campaign.

The next slide when you take a look at it is some of the interventions -
proven interventions that the Five Million Lives Campaign chooses to
support. As you look all of these interventions on these last two slides
you\'ll see that because of the scope of both the definition of medical
harm and the scope of the types of interventions that are known to
reduce medical harm there\'s probably a way of applying at least one of
these if not more to any site or location or community that we may
practice in. Next slide.

Well as I sort of got my own awareness raised it also made me think a
little bit more as a leader in the Indian Health Service and in my
organization. Well yeah but why should we specifically participate in
the campaign?

And I sort of frame it actually within these three models of questions
that sort of form the model of improvement. And I said well what is this
campaign trying to achieve? Reduction in medical harm which I\'ve talked
about. And the good thing is those were some of my same goals. Those
were some of the things that we as an organization had already committed
to doing.

How would we know if we achieved it? Is this just a verbal campaign?
Well no actually this is a very defined campaign that looks at measures
and indicators. And those are things that me and my organization - and
our organization at Indian Health Service are very committed to.

And finally I said well what changes might we make that would result in
improvement? Well and here again it was clear that by \-- these were
proven interventions \-- that by applying them or learning how to apply
them better by working with others or gathering or taking information
that I previously hadn\'t had I\'d actually be able to make the change
and achieve a reduction in medical harm. So let\'s go to the next slide.

Can - my next question then and it might be a question that you might
have is can my facility participate? And the simple answer is yes. And
you can begin where you are. You don\'t have to have already completed
or ever achieved perfection in any measures. You start where you\'re at
and improve from there.

And how to do it turns out to be very simple. You just go to the IHI
website which I\'ve listed there. You sign on through the web page. And
I would like you to when you get to that section identify your
affiliation as the Indian Health Service. And I\'ll tell you why in just
a minute.

If you go to the next slide by signing on you actually now become able
to gain access to a number of different information, white pages, best
practices, educational events, phone calls, and the opportunity to join
up with other people from like facilities or like systems and learn from
people that you may feel have something to share or that you may have
something to share with them. And that\'s where this concept of node
comes in.

If you go to the next slide along with the \-- and I\'m a little bit
repetitive here in that along with the web page and the phone calls and
the materials \-- one of the resources that comes by joining the
campaign is that you get in affinity groups or affiliations with other
like providers.

And there are some very interesting ones out there - small rural
hospitals, large hospitals, Western hospitals, Eastern hospitals. And
you may find some common organizations and affiliation groups that
you\'d like to join.

We are just starting the process of starting the Indian Health Service
affiliation and using my organization as a contact point to help
organize an affiliation group around the unique aspects of providing
health care and reducing medical harm in the Indian Health Service and
in our communities.

And I do want to say that there\'s been a lot of support from
headquarters including Dr. Finke and Sheila Warren, from Wanda Subsinksi
and with the Chronic Care Initiative. And I appreciate all of their help
in helping me to begin this process and begin an affiliation group. You
can go to the last slide.

Well I hope that my story of awareness and what I\'ve learned about the
Five Million Lives Campaign may have interested you in looking further
and reading about it and considering even joining the campaign.

And when you do I hope that we will be able to join together at some
point in an affiliation group for the Indian Health Service. And I hope
to see you on this campaign sometime in the future.

And with that I\'m happy to answer any questions.

Bruce Finke: Thank you Charlton. Operator let\'s open - let us know if
there are any questions now.

Coordinator: Thank you. I show no questions at this time. But again as a
reminder please press star 1 on your touchtone phone to ask a question.

Bruce Finke: Well all of the presenters are available for questions if
any of any listeners have questions. In the meantime and while we wait
I\'m going to ask Gary Quinn to get on again \-- if you\'re still there
Gary \-- and let the folks know both how they can get CME credit for
this session.

And also if you would let us know about the SurveyMonkey and how they
can give us feedback on how we can do this Open Door Forum better and
what topics they\'d like to hear in the Open Door Forum.

Gary Quinn: Very good. Thank you Bruce. As Bruce said in order to get
CME or CEU credit if you could send me your e-mail address and you can
send that to gary.quinn@ihs.gov. And the reason is that we haven\'t
fully worked out all the bugs but we are working to improve in how to do
this more efficiently.

At this time we do offer CEU, CMU credit for physicians, nurses, dental
professionals and physician assistants. We\'re going to expand beyond
this for upcoming Open Door Forums if the need is there.

And Bruce referred to the SurveyMonkey and that is the method that we
use to evaluate what we\'re doing in Open Door Forums and we seek to
improve. And there\'s always a question that asks you as a participant
how we can improve the next Open Door Forum.

And interestingly enough there were many requests for CEU and CMU credit
in previously Open Door Forums and therefore that\'s why we\'re offering
them this time.

So an example of how we do work to improve but we do want to address
other ways that we can improve this process. And we do that via the
SurveyMonkey.

So how this works is if you send your e-mail address then what I can do
is send you a link to the SurveyMonkey survey. There\'s ten questions -
real short questions for you to complete.

At the bottom of this SurveyMonkey there will be an additional link
where once you finish the survey you click on this link and it will take
you to where you can print out your own CEU CMU certificate.

And so that in a nutshell is the process to ensure that you get the
e-mail link to the SurveyMonkey to tell us how we can improve. And also
if you\'re looking for the credit how you can do that as well too.

Thank you Bruce.

Coordinator: I do have a couple of audio questions.

Bruce Finke: Okay. We have about five minutes. So let\'s take those
questions.

Coordinator: Thank you. (Phyllis Spears) your line is open.

(Phyllis Spears): I just wanted to know what is an RN group visit? I
think it was Rapid City talking about that.

Bruce Finke: Great. (Lorraine) or (Jennifer) are you still on? Can you
respond to that?

Woman: The RN visit is basically having the RN do anything that she can
up to her license potential. And that\'s looking at health maintenance,
preventive care, and patient education.

Woman: There is a manual called Group Visit (unintelligible) that if
anybody is interested we have a link - I think it\'s on our web page.
But we can also send it out.

Bruce Finke: I think it\'s fair to say that group visits are really hot
topic among programs looking at program innovation and delivering better
care. And that might be a topic for a future Open Door Forum. So let us
know if that is of interest to you all.

Woman: We know that they\'re not billable. But that\'s not our concern
right now. We\'re looking at getting the patient the access they need
and then breaking it down to (unintelligible) the clinical part of it,
the doctor and then billing for that.

Bruce Finke: Thank you. (Phyllis) does that answer the question for you?

Woman: I\'m sorry. She is out of the queue at this time.

Bruce Finke: That\'s fine. Next question?

Coordinator: (Linda Westover) your line is open.

(Linda Westover): Okay. Thank you. These were all excellent
presentations this morning. I really, really enjoyed them. One of the
things that I just wanted to bring up and it\'s probably not possible
but I always need to advocate for elders. And one of our really, really
weak areas is in screening for falls.

I\'m just wondering - I know that there\'s so many screenings that need
to be done but it\'s just so easy to ask. And I\'m sure that there\'s
elders in this micro system population that\'s being selected.

So I just wanted to maybe bring that up. Thank you.

Bruce Finke: And I\'ll ask \-- at the risk of conflict of interest I
won\'t answer that question \-- I\'ll ask Ty to answer that question.
Thank you (Linda) for that excellent question.

Ty Reidhead: You\'re asking me?

Bruce Finke: Yes.

Ty Reidhead: As most of you know Bruce is our national lead for the
elder care initiative. So please go ahead.

Bruce Finke: Okay. I\'ll just say that in fact (Linda) that I agree with
you completely and so does the rest of the team. And fall screening is
actually in the scope of work for collaborative. And we are phasing in
work for the collaborative.

We tried as hard as we could to just swamp them. They\'ve been
resistant - they don\'t swamp easily. But we\'re not dumping everything
on them all at once. They\'re sort of phasing in topics for improvement.
And so they will be addressing and integrating fall risk screening in
the future into the whole bundle of screening.

And again the concept here is we\'re encouraging and working with them
to figure out how to use these change concepts to create improvement
across conditions.

But fall risk screening will very much be part of that package. So thank
you.

(Linda Westover): Thank you.

(Jennifer Heil): This is Jennifer from Rapid City. I just wanted to add
to that that we\'re also looking at through these group visits, RN group
visits, empowering the nurses to grab that assessment and do something
with it.

So even though yes there is a cookie cutter method to our bundling
we\'re not looking at just the bundle. So if we do see patients that
come in that have red flag situations those are the patients we need to
create individual care plans for and get them the services that they
need.

Bruce Finke: Great. Thank you. Operator, are there other questions?

(Nancy Bill): This is Nancy Bill from headquarters. I have a question.

Bruce Finke: Yes, Nancy.

(Nancy Bill): Yes I just want to say that all the presenters had great
information. I appreciate all the information. I\'m coming from a
community perspective and I want to know if IHI will also embrace
community programs such as injury prevention.

You know, prevention of injuries is one of the serious issues in Indian
Health Service as we, you know - a person mentioned earlier - falls that
in some of the hospitals that\'s the second leading cause of
hospitalization. Also motor vehicle crashes and disability. Those issues
in health care.

But as far as community prevention how do you see us fitting in?

Bruce Finke: And Ty actually I think this one might be - we only have
about a minute left. Are you comfortable taking this one or would you
rather have Cindy take this one?

(Jerry Langley): This is (Jerry). I\'m going to pretend to be Cindy.

Bruce Finke: You be Cindy (Jerry).

(Jerry Langley): I am Cindy. I\'m going to speak with a high - no anyway
Cindy just had to get off. She just IM\'d me. She\'s catching a plane in
Philadelphia. My comments are a little bit off the wall on this because
I have a great interest in what you\'re talking about - what the
question was.

And IHI had an traditional focus on hospital and inpatient work not 100%
but 70% or 80% of their work has been on that for many years. And it\'s
only in the last two years maybe - it started maybe three years ago that
they\'ve really at the board level changed their thinking that they need
to embrace all of health care but also in the last year they\'ve been
talking about all of health which expands to the community level to
think about things.

So this is something they\'re very interested in learning about. So
it\'s actually one of the reasons they look at IHS as a strategic
partner is to learn about community related health issues. And what can
be done there that can have the biggest impact to improve health for the
community.

Bruce Finke: Thank you (Jerry). Ty did you have other comments? Okay.
And I think (Jerry)\'s comments point out that we\'re in this journey
together. And we\'re all learning. And I think that\'s what the session
today has been about for me.

We\'re a little over time so we\'re going to have to close out on any
further questions and invite you though to e-mail. And if you e-mail
them to Gary Quinn \-- and he gave his address earlier
gary.quinn@ihs.gov \-- he will make sure that those go to the
appropriate person.

I want to thank all the presenters for being with us and all of the
participants who were on the call as well. I want to remind you that the
next Open Door Forum call is scheduled for January 24, 2008. And the
topic for that call will be around the Behavioral Health Initiative.

Thanks to everyone and have a good afternoon.

Man: Thank you Bruce. Great call.

END