# Presentation: 137401

## GPRA

- Stanley P. Griffith, MD
- Division of Information Resources
- Indian Health Service
- Albuquerque, NM

## GPRA

- What is GPRA?
- What is its significance for you?
- How have GPRA measures been selected?
- What is the status of the FY99 GPRA report?
- What is likely for the future?

## What Is GPRA?

- G overnment
- P erformance
- 	and
- Results
- Act

## Acronym “Soup”of Performance Measurement Systems

- HEDIS

- ORYX

- GPRA

- DQIP

- HP 2010

- HP 2000

- SES

## The Details...

- IHS must provide a performance plan as part of its budget submission.
- The major elements of this plan are the performance indicators.
- These measures are health systems measures - they deal with both clinical and management issues.
- They are intended to link appropriated dollars to customer benefits and outcomes.

## The Political Realities of GPRA

- It is both a political fad, and a law that will not easily go away
- It is likely to be a two-edged sword
- It appears to have served us well thus far

## The IHS Approach to GPRA

- Area GPRA /Budget Formulation Teams formed  and sessions held with stakeholders (Feb & Mar 97, 98,& 99)
- GPRA data meetings (June 98 & 99)
- Ongoing presentations at IHS, Urban and Tribal meeting since 1996

## GPRA

- What is GPRA?
- What is its significance for you?
- How have GPRA measures been selected?
- What is the status of the FY99 GPRA report?
- What is likely for the future?

## What Is Driving GPRA?

- “Follow the money...”
- 		(Watergate’s “Deep Throat”)

## Is It Important to All of Us?

- GPRA is critical to our budget.
- Whether or not we all choose to participate, GPRA affects all of us:  The I’s, the T’s, and the U’s.
- It will inevitably be a major determinant of the “size of the pie” for all of us.

## Is GPRA a QI or Advocacy Tool?

- There are more effective tools for our QI and many of our advocacy needs.

## GPRA Is Not an EffectiveQI Tool

- All QI is local.  (Tip O’Neill).
- GPRA must not be allowed to interfere with or supplant your already effective (we hope...) local initiatives.
- GPRA should reflect our many effective QI initiatives, not drive the QI process.

## GPRA Will Not Meet Many Advocacy Needs

- Many advocacy needs are very targeted.
- GPRA measures are finalized years before they are calculated.
- Once finalized GPRA measures have little flexibility.
- GPRA measures are designed “by committee.”

## GPRA should...

- Not be used as an excuse to micro-manage regional or local programs.
- Reflect, in broad brushstrokes, our highest priority issues.
- Demonstrate the effectiveness of our local and Area QI initiatives.

## GPRA

- What is GPRA?
- What is its significance for you?
- How have GPRA measures been selected?
- What is the status of the FY99 GPRA report?
- What is likely for the future?

## How Were GPRA MeasuresSelected?

- We have to be able to calculate the indicators from already available data.  We cannot afford to impose _*additional*_ data collection burdens on Areas or local facilities.

## Initial Screening Criteria

- Can this measure be calculated from already existing data?
- Vital Statistics
- U.S. Census
- Cancer registries
- Diabetes audits
- NPIRS (IHS National Data Center)
- Local information system repositories

## How Were GPRA MeasuresSelected?

- GPRA should not be used as a “club” to improve data collection, even with the best of intentions.

## A More Recent Criteria

- How well do they match up with other important federal initiatives?
- Healthy People 2010
- President’s Initiative to Eliminate Health Disparities in Health Status Among Americans
- Recent Secretarial initiatives
- DHHS Strategic Plan

## Subject Areas forFY 99 Clinical GPRA Measures

- Diabetes
- Substance Abuse/ Alcoholism
- Injuries
- Cancer
- Dental
- Renal Disease

- Mental Health
- Heart Disease
- Infant/Child Care
- Women’s Health
- Elder Care
- Domestic Violence
- Sanitation

## Objective #1

*By the end of FY 1999, identify **Area age-specific diabetes prevalence rates** (as a surrogate marker for diabetes incidence) for the AI/AN population.*
- _Data Source_:**  ***NPIRS, Census data*

## Objective #3

*By the end of FY 1999,  increase the proportion of I/T/U clients with diagnosed diabetes and hypertension that have achieved **diabetic blood pressure control** standards by 3% over the FY 1998 level.*
- _Data Source_:  *Diabetes audit*

## Objective #7

*By the end of FY 1999, determine the proportion of the AI/AN female population 50-69 years of age who have had **annual screening mammography**.*
- _Data Source_:* CDC Breast & Cervical Cancer Screening Program data,  RPMS Radiology Package,  FI, BRFSS surveys.*

## Objective #13

*By the end of FY 1999, assure that 50% of I/T/U medical facilities with Urgent Care or Emergency departments or services will have **written policies** and procedures for routinely identifying, treating and/or referring **victims of family violence, abuse or neglect**. *
- _Data Source_:  *Survey of local I/T/U facilities.*

## Objective #18

*During FY 1999, increase by 3% the proportion of AI/AN children who have **completed all recommended immunizations by age two** over the FY 1998 rate.*
- _Data Source_:  *State immunization programs, PHS nursing records, RPMS Immunization package, NPIRS.*

## Objective #20

*By the end of FY 1999, identify the Area-specific **prevalence of obesity** in AI/AN both in a Head Start  population **(3-5 year olds)** and in third grade children **(8-10 year olds)**, and develop a multidisciplinary and multidimensional intervention plan for one or both age groups to address this problem.*
- _Data Source_:  *CDC Pediatric Nutrition Surveillance System and NPIRS.*

- GPRA measures need to cover each of these areas, they do not have to be the one “perfect” measure for each.

## Other Selection Criteria

- Universally accepted?
- Evidence-based?
- Important issue for AI/ANs?
- Feasible intervention?
- Measurable improvements?
- General population data available?
- Reward poor recording?

## Remaining Challenges

- Have we set the bar too high or two low?
- What will be the best data sources for a given measure?
- How accurate will our measures be?
- Have we covered all the key budget areas?
- How can we assure adequate information infrastructure to collect, compile, analyze, and report these data?
- How can we maintain participation across the I/T/U spectrum?

## GPRA

- What is GPRA?
- What is its significance for you?
- How have GPRA measures been selected?
- What is the status of the FY99 GPRA report?
- What is likely for the future?

## Status of Performance Plans

_*FY 1999*_
- Data for 18-20 of 27 indicators expected for performance report due February 2000.
_*FY 2000 *_
- Currently revising the submitted draft list of 34 indicators.
- List must be finalized for submission in February 2000 with FY 2001 budget request.
_*FY 2001*_
- Initial draft list of 37 indicators must be submitted in February 2000 with FY 2001 budget request.
_*FY 2002*_
- Planning will soon begin.  Data meeting anticipated this spring.

## GPRA

- What is GPRA?
- What is its significance for you?
- How have GPRA measures been selected?
- What is the status of the FY99 GPRA report?
- What is likely for the future?

## Future Trends

- Requirements for GPRA measures will likely increase, not decrease.
- Therefore we must develop an improved ability to passively measure a wider and more complete array of outcomes.

## Future Trends (cont.)

- Although we want it to remain passive, we want data useful at the regional and local levels, as well.
- Therefore, increasingly we will need to derive these measures directly and automatically from our clinical information systems.

## In Summary

- GPRA is critically important to all of us – the I’s the T’s and the U’s of our system.
- GPRA should reflect, in broad brushstrokes, our highest priority issues.
- Increasingly we will need to derive these measures directly and automatically from our clinical information systems.

## Questions and Suggestions

- <date/time>

- Elizabeth Fowler, agency lead for GPRA
- Voice: (301)443-3024
- E-mail: _[elizabeth.fowler@mail.ihs.gov](mailto:elizabeth.fowler@mail.ihs.gov)_
- Ric Bothwell, GPRA consultant
- Voice: (301)443-1106
- E-mail:  _ebothwel@hqe.ihs.gov_