2019-03486. Indian Health Service Strategic Plan Fiscal Year 2019-2023

AGENCY:

Indian Health Service, IHS.

ACTION:

Notice.

SUMMARY:

In follow-up to the Indian Health Service (IHS) request for comments on the Draft IHS Strategic Plan Fiscal Year (FY) 2018-2022 issued in the Federal Register (FR) on July 24, 2018, (see 83 FR 35012; July 24, 2018; hereafter “July 2018 FR document”), the IHS is announcing the final plan entitled: IHS Strategic Plan FY 2019-2023. The IHS is also making available on the IHS Strategic Plan website, a response to comments document that addresses comments received on the Draft IHS Strategic Plan from the July 2018 FR document.

FOR FURTHER INFORMATION CONTACT:

RADM Francis Frazier, Director, Office of Public Health Support, IHS, 5600 Fishers Lane, Mail Stop: 09E10D, Rockville, Maryland 20857. Telephone number: 301-443-0222 (This is not a toll-free number), email address: [e-mail]. In addition, progress on the IHS Strategic Plan will be periodically updated on the IHS website at: https://www.ihs.gov/​strategicplan/​.

SUPPLEMENTARY INFORMATION:

General Information

The IHS, an agency within the U.S. Department of Health and Human Services (HHS), is responsible for providing federal health services to American Indians and Alaska Natives. The provision of health services to members of federally-recognized Tribes grew out of the special government-to-government relationship between the federal government and Indian Tribes. Established in 1787, this relationship is based on Article I, Section 8 of the U.S. Constitution and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. The IHS is the principal federal health care provider and health care advocate for Indian people. The IHS provides a comprehensive health service delivery system for American Indians and Alaska Natives.

The IHS Strategic Plan, covering FY 2019-2023, includes a mission statement, a vision statement, and details on how the IHS will achieve its mission through three strategic goals: (1) To ensure that comprehensive, culturally appropriate personal and public health services are available and accessible to American Indian and Alaska Native people; (2) To promote excellence and quality through innovation of the Indian health system into an optimally performing organization; and (3) To strengthen IHS program management and operations. These strategic goals are supported by objectives that reflect the outcomes the IHS is working to achieve and strategies describe how the IHS plans to make progress toward the objectives.

Background

The IHS Strategic Plan reflects the feedback received from Tribes, Tribal organizations, urban Indian organizations, staff, and other stakeholders. The IHS used a process similar to the HHS Strategic Plan FY 2018-2022 and gathered feedback from key partners including staff, Tribes, and urban Indian organizations. Informed by a variety of source documents, the IHS first developed a draft initial framework and initiated Tribal consultation and urban Indian confer on the draft initial framework from September 15, 2017, through October 31, 2017. During the initial framework comment period, the IHS held listening sessions, presented at Tribal meetings, and held conference calls with Tribal and urban Indian organization leaders. Comments were also accepted after October 31, 2017, on an ongoing basis.

An IHS Federal-Tribal Strategic Planning Workgroup (workgroup) reviewed the draft initial framework comments received from 150 Tribes, Tribal organizations, urban Indian organizations, and IHS staff. The workgroup suggested strategies during six meetings from November 2017 through February 2018 and made recommendations for the Draft IHS Strategic Plan FY 2018-2022, published in the FR on July 24, 2018. Workgroup membership included Tribal leaders or their designees, a representative from the IHS Office of Urban Indian Health Programs, and IHS staff from areas, service unit, and headquarters.

On July 24, 2018, the Draft IHS Strategic Plan was published in the FR for a 30-day public review and comment period. The IHS provided formal letters regarding the Draft IHS Strategic Plan release to Tribal and urban Indian organization leaders and notification of two virtual town hall sessions, one for urban confer and one for Tribal consultation on August 3 and August 6, 2018, respectively. The IHS received 123 comments, including questions, comments, and recommendations on the specific elements of the plan and other comments related to the terminology used in the IHS Strategic Plan, implementation of strategies, measures, and the IHS strategic planning process. The IHS reviewed all comments and carefully considered changes before publishing the IHS Strategic Plan FY 2019-2023.

The IHS Strategic Plan FY 2019-2023 includes minor language updates to the Vision, Goal 1, Objectives 2.2 and 3.1, and several strategies to clarify intent and adds urban Indian organizations, where appropriate. The IHS Strategic Plan timeframe is updated from FY 2018-2022 to FY 2019-2023 since the plan is being released during FY 2019. Significant changes to the IHS Strategic Plan include the following additional sections: an introduction, strategic plan development, performance, and appendices. These additional sections are in response to the comments received. Several commenters recommended addressing the unique government-to-government relationship with Tribal governments and the provision of health services based on this relationship, clarification about non-IHS participation in the development of the IHS Strategic Plan, recommendations to include measures and track progress, and to include more information about the alignment with the HHS Strategic Plan FY 2018-2022.

The text of the final IHS Strategic Plan FY 2019-2023 is available below and on the IHS Strategic Plan website at: https://www.ihs.gov/​strategicplan/​.

Indian Health Service (IHS)

IHS Strategic Plan Fiscal Year (FY) 2019-2023

INTRODUCTION

Overview

The Indian Health Service (IHS), an agency within the United States (U.S.) Department of Health and Human Services (HHS) is responsible for providing federal health services to American Indian and Alaska Native (AI/AN) people. The IHS is the principal federal health care provider and health advocate for Indian people.

Organizational Structure

The IHS organizational structure includes the Rockville, Maryland headquarters office and 12 administrative area offices located throughout the United States. The 12 IHS areas encompass a network of hospitals, clinics, and health stations.

Serving approximately 2.3 million American Indians and Alaska Natives from 573 federally recognized Tribes in 37 states, the IHS provides a wide range of clinical and public health services, along with community and facilities infrastructure services. Comprehensive primary health care and disease prevention services are provided through a network of hospitals, clinics, and health stations on or near Indian reservations. These facilities, which are managed by the IHS, Tribes, and Tribal organizations, are predominately located in rural and primary care settings. In addition, the IHS contracts with urban Indian organizations (UIOs) for health care services provided in some urban centers. The Indian health care system strives to provide comprehensive care through a network of IHS, Tribal, and urban health facilities and by purchasing health care services from non-IHS providers through the Purchased/Referred Care (PRC) program.

In 2017, the Indian health care system had more than 39,367 hospital admissions and almost 13.8 million outpatient medical care visits. The Indian health care system also provides dental services, nutrition services, pharmacy services, community health, sanitation facilities (water supply and waste disposal), injury prevention, and institutional environmental services.

A unique government-to-government relationship exists between Indian Tribes and the U.S. Government. Consistent with the government-to-government relationship and its statutory authorities, the IHS is committed to ensuring that comprehensive, culturally appropriate personal and public health services are available and accessible to AI/AN people. Over 60 percent of the IHS appropriation is administered by Tribes,^[1] primarily through Self-Determination contracts or Self-Governance compacts. The IHS retains the remaining funds and delivers health services directly to the Tribes that choose to have IHS administer the programs. The IHS works closely with Tribal governments as they assume a greater role in improving health care in their own communities.

Tribal Consultation and Urban Indian Confer

IHS implements Tribal consultation ^[2] and urban Indian confer ^[3] policies to facilitate the involvement of Tribes and UIOs.

The IHS Tribal consultation policy states that consultation occurs to the extent practicable and permitted by law before any action is taken that will significantly affect Indian Tribes. The IHS is committed to regular and meaningful consultation and collaboration with Tribes. It is IHS policy to confer with UIOs, to the maximum extent practicable, whenever a critical event or issue arises, as defined in the policy, in implementing or carrying out the Indian Health Care Improvement Act (IHCIA). This policy is used to ensure that the health needs of the urban Indian population are considered at the local, area, and national levels when implementing and carrying out the IHCIA.

IHS Partnerships

The IHS has established partnerships to address AI/AN issues and strengthen services. Partnerships include local communities, not-for-profit organizations, universities and schools, foundations, businesses, and federal agencies such as the Department of the Interior (including the Bureau of Indian Affairs and the Bureau of Indian Education), Department of Justice, Department of Housing and Urban Development, and the Department of Veterans Affairs. These IHS partnerships impact AI/AN communities in critical areas, such as housing, education, public safety, and health care for Veterans. It is essential to continue to build upon these partnerships.

Strategic Plan Development

To develop the IHS Strategic Plan FY 2019-2023, the IHS used a process similar to the HHS Strategic Plan FY 2018-2022,^[4] including the use of goals, objectives and strategies, environmental scans, Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis, and workgroup participation.

An IHS-initiated environmental scan reviewed strategic plans of several IHS area and headquarters offices, and other available documents. The SWOT exercise was conducted with IHS executive staff. Informed by these documents and analysis, the IHS developed an initial framework for review and comment of the Strategic Plan by Tribes, Tribal organizations, UIOs, and IHS staff. The IHS first initiated Tribal consultation and urban Indian confer on the IHS Strategic Plan initial framework on September 15, 2017, and formed an IHS Federal-Tribal Strategic Planning Workgroup (workgroup) to review all comments and recommend a list of final goals and objectives for IHS leadership review and approval.

During the initial framework comment period (September 15, 2017-October 31, 2017), the IHS held listening sessions, presented at Tribal meetings, and held conference calls with Tribal and UIO leaders. Workgroup membership included Tribal leaders or their designees, a representative from the IHS Office of Urban Indian Health Programs, and IHS staff from areas, service units, and headquarters. The workgroup reviewed comments on the initial framework received from 150 Tribes, Tribal organizations, UIOs, and IHS staff. Subsequently, the workgroup met six times over a four-month period to develop their final recommendations on the IHS mission, vision, goals, objectives, and strategies.

The workgroup prioritized strategies by importance, and not all strategies were recommended. Quality as a Business Strategy (QBS) ^[5] was used as a model for developing the IHS Strategic Plan. Strategies were developed in alignment with defined goals and objectives to continue current operations or improve the Indian health care system. In doing so, the IHS Strategic Plan addresses quality throughout all aspects of its clinical, operational, and administrative operations and creates a plan for improvement across all three areas.

Feedback received from all stakeholders formed the basis of the Draft IHS Strategic Plan 2018-2022 sent out for public comment on July 24, 2018. During the 30-day comment period, which ended on August 23, 2018, the IHS received comments from 30 entities, including Tribes, Tribal organizations, UIOs, IHS staff, and national organizations. The final IHS Strategic Plan FY 2019-2023 reflects changes made to the initial framework based on consideration of all comments received. The IHS Strategic Plan FY 2019-2023 may be accessed through the IHS website at https://www.ihs.gov/​strategicplan/​.

The IHS intends to identify appropriate performance measures and outcomes to achieve the mission and goals. The IHS is working to develop an implementation process that will include measures to address the strategies and objectives in the IHS Strategic Plan. The IHS will review periodically the agency's progress in implementation of the IHS Strategic Plan and will provide updates to IHS staff and to Tribal and UIO leaders.

Priorities and Challenges

The IHS has historically established four priorities to guide operations. The IHS Strategic Plan FY 2019-2023 incorporates these priorities and builds on the important work being done throughout the system.

The IHS four priorities are interrelated with the strategic goals of the IHS Strategic Plan FY 2019-2023:

• People—Recruit, develop, and retain a dedicated, competent, caring workforce collaborating to achieve the IHS mission.
• Partnerships—Build, strengthen, and sustain collaborative relationships that advance the IHS mission.
• Quality—Excellence in everything we do to assure a high-performing Indian health system.
• Resources—Secure and effectively manage the assets needed to promote the IHS mission.

The AI/AN population continues to face health disparities in comparison to the national population. Over the past two decades, there have been some important health improvements, such as reduced mortality rates from tuberculosis and heart disease, among others. However, the infant mortality rate for AI/ANs is 26 percent higher than the national rate,^[6] and AI/ANs are three times as likely as the overall population to have diabetes.^[7] American Indian and Alaska Native populations also have disproportionately high rates of suicide, unintentional injuries, and drug overdose deaths. The IHS Strategic Plan aims to strengthen the overall health status of the AI/AN population.

In recent years, the agency has faced challenges related to access to care, quality of care, and program management and operations. The IHS Strategic Plan includes three strategic goals focused on access, quality, and management and operations.

Access: Many facilities operated by the IHS and Tribes are located in rural or remote settings and may be unable to provide comprehensive health care services and/or acute and specialty care services. To help meet the health care needs, the PRC program purchases services from private health care providers for eligible patients. Although PRC funding may meet the full patient need in some IHS areas, funding may not be sufficient to meet the need in others. Some facilities also face longstanding challenges in recruiting and retaining essential staff, ensuring access to needed care and training resources, and maintaining clinical proficiency of professional staff. Recruitment and retention challenges are attributable to a variety of factors that include, but are not limited to, the remoteness of some IHS facilities, rural reservation communities, aging IHS facilities and medical equipment, housing shortages, limited access to schools and basic amenities, limited spousal employment opportunities, and competition with higher paying public and private health care systems. The IHS Strategic Plan Goal 1 aims to address some of these challenges.

Quality: Assuring that IHS hospitals and clinics are accredited is a high priority for IHS. Meeting Medicare standards also allows IHS facilities to be reimbursed for all eligible Medicare and Medicaid services. The IHS monitors federal hospitals through area offices, which have access to information about the quality of care and oversight through a governing body process. Staffing and funding shortages at area offices also have an impact on the clinical support and guidance provided to service units. The IHS is working to strengthen organizational capacity to improve our ability to meet and maintain accreditation of IHS direct service facilities, align service delivery processes to improve the patient experience, ensure patient safety, establish agency-wide patient wait time standards, and improve processes and strengthen communication for early identification of risks.

Within the Indian health care system, quality is also impacted by rising costs from medical inflation, population growth, increased rates of chronic diseases, and aging facilities and equipment. These challenges may be heightened at facilities located in rural, remote locations. The Indian health care system is also challenged with balancing the needs of patients served in IHS, Tribal, and UIO health programs. Goal 2 aims to address these challenges.

Management and Operations: The Indian health care system continues to face management and operational challenges in the years ahead. Communication and collaboration across the system requires improvement and managers need tools and resources to make data-driven decisions. Additionally, while some AI/AN communities have modern IHS hospitals and ambulatory facilities, the average age of IHS facilities is 36 years. Many IHS and Tribal health care facilities and UIOs are operating at or beyond capacity, and their designs may not be efficient in the context of modern health care delivery. Information Technology also continues to be a major concern with rising costs and increased security threats. Goal 3 aims to address these challenges.

Performance

The IHS currently reports agency-wide performance measures. Existing performance measures may be used to monitor progress on goals and objectives included in the IHS Strategic Plan FY 2019-2023. Additional measures for specific objectives or strategies may be developed as the agency moves forward with implementation of the IHS Strategic Plan.

The IHS is working to develop an implementation process based on the feedback received during the open comment period and based on action recommendations received during the 2018 National Combined Councils Annual Meeting.^[8] Updates on the agency's progress in implementation of the IHS Strategic Plan will be made available at the IHS Strategic Plan website.

Government Performance and Results Act (GPRA) and GPRA Modernization Act (GPRAMA): For IHS, performance improvement is a concerted effort by all members of the Indian health care system working together to improve a comprehensive set of existing GPRA and GPRAMA performance measures. Although not required by law, some tribally managed health programs voluntarily submit performance data for participation in GPRA/GPRAMA performance reporting. All UIOs report on all GPRA/GPRAMA measures. The IHS performance measures are focused on monitoring population health and assessing program trends and management. The measures support the IHS's strategic goals and improvement of AI/AN health outcomes. See Appendix B: GPRA/GPRAMA Measures and IHS Strategic Plan Crosswalk. Progress on performance measures is tracked annually and reported in the IHS Congressional Justification and on the IHS Quality website. GPRAMA measures are also reported in the HHS Annual Performance Plan and Report. The GPRA and other National Reporting website includes additional information about the GPRA and other clinical care performance measures.

National Accountability Dashboard for Quality (NAD-Q): The IHS gathers and reports data on key quality measures to ensure compliance with IHS policy requirements, accreditation standards, and/or federal regulations at IHS hospitals and ambulatory health centers. Reports are generated on a quarterly basis and available at the IHS Quality website. The NAD-Q supports the agency's strategic goals and improvement of AI/AN health outcomes. See Appendix C: National Accountability Dashboard for Quality and IHS Strategic Plan Crosswalk.

Other: The IHS cascades performance goals and objectives and performance-related metrics agency-wide. Agency leadership periodically reviews progress in meeting these agency performance objectives, holding regular discussions with senior executives to identify challenges to success and determine feasible solutions. The connection between performance objectives, performance measures, and employee accountability enables agency leadership to direct the efforts of the workforce more accurately, and to make more informed and effective decisions. The impact is greater success in meeting the full array of mission requirements.

IHS Strategic Plan FY 2019-2023

The IHS Strategic Plan FY 2019-2023 details how the IHS will achieve its mission through three strategic goals. Each goal is supported by objectives and strategies. The strategies are activities to make progress on the stated objectives. The goals and objectives are inter-related and success in one area may overlap and influence successes in other areas. Multiple sectors across the Indian health care system may contribute to the successful achievement of a goal or objective.

Mission

To raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

Vision

Healthy communities and quality health care systems through strong partnerships and culturally responsive practices.

Goal 1: To ensure that comprehensive, culturally appropriate personal and public health services are available and accessible to American Indian and Alaska Native people.

Goal Explanation: The IHS provides comprehensive primary health care and public health services, which are critical to improving the health of AI/AN people. The Indian health care system delivers care through health care services provided in IHS, Tribal, and Urban (I/T/U) health facilities (e.g., hospitals and clinics) and by supporting the purchase of essential health care services not available in IHS and Tribal health care facilities, known as the Purchased/Referred Care (PRC) program. Additional services include environmental health improvements, as well as traditional healing practices and services to complement the medical, dental, pharmacy, laboratory, behavioral health, and other primary care medical programs. Expanding access to these services in AI/AN communities is essential to improving the health status of the AI/AN population. This goal includes securing the needed workforce, strengthening collaboration with a range of public and private organizations, as well as Tribal, and urban Indian providers, and expanding access to quality health care services to promote the health needs of AI/AN communities.

Objective 1.1: Recruit, develop, and retain a dedicated, competent, and caring workforce.

Objective Explanation: Consistent, skilled, and well-trained leadership is essential to recruiting and retaining well-qualified health care professionals and administrative professionals. Attracting, developing, and retaining needed staff will require streamlining hiring practices and other resources that optimize health care outcomes. Within the Indian health care system, staff development through orientation, job experience, mentoring, and short- and long-term training and education opportunities are essential for maintaining and expanding quality services and maintaining accreditation of facilities. Also, continuing education and training opportunities are necessary to increase the skill sets and knowledge of employees, which enables them to keep pace in rapidly evolving areas of medical science, prevention science, improvement science, and information technology, as well as to increase opportunities for employee career advancement and/or to maintain necessary professional credentialing and accreditation.

Strategies—The following strategies support this objective:

Health Care Recruitment and Retention:

1. Improve and innovate a process that increases recruitment and retention of talented, motivated, culturally knowledgeable, and competent workers, including through partnerships with AI/AN communities and others.

2. Continue and expand the utilization of the IHS and Health Resources and Services Administration's National Health Service Corps scholarship and loan repayment programs, as authorized by law, to increase health care providers at I/T/U facilities.

3. Support IHS sponsorship of fellowship slots in certain specialized leadership programs for recruitment of future clinical and administrative leaders.

4. Evaluate new organizational structure options and reporting relationships to improve oversight of the Indian Health Professions program.

5. Expand the use of paraprofessionals, Advanced Practice Nurses, and Physician Assistants to increase the workforce and provide needed services.

6. Develop training programs in partnership with health professional schools and training hospitals and expand opportunities to educate and mentor AI/AN youth interested in obtaining health science degrees.

7. Enhance and streamline IHS human resources infrastructure to hire well-qualified personnel.

Staff Capacity Building:

8. Strengthen the workforce to improve access to, and quality of, services.

9. Improve leadership skills, adopt a consistent leadership model, and develop mentoring programs.

10. Improve continuity processes and knowledge sharing of critical employee, administrative, and operational functions through written communications and documentation within the IHS.

11. Improve workplace organizational climate with staff development addressing teamwork, communication, and equity.

12. Strengthen employee performance and responsiveness to IHS, Tribes, urban Indian organizations (UIOs), and patients by improving employee orientation and opportunities for training, Graduate Medical Education programs, and other educational offerings, including customer service skills and cultural competency.

Objective 1.2: Build, strengthen, and sustain collaborative relationships.

Objective Explanation: Collaboration fostered through an environment that values partnership is vital to expanding the types of services to improve population health outcomes that can be achieved within the Indian health care system. These relationships include those between Tribes, UIOs, states, communities, federal agencies, not-for-profit organizations, universities/schools, foundations, private industry, as well as internal cooperation within the agency and collaborative project management.

Strategies—The following strategies support this objective:

Enhancing Collaboration:

1. Collaborate with Tribes and UIOs in the development of community-based health programs, including health promotion and disease prevention programs and interventions that will increase access to quality health programs.

2. Develop a community feedback system/program where community members can provide suggestions regarding services required and received.

3. Support cross-collaboration and partnerships among I/T/U stakeholders.

Service Expansion:

4. Promote collaborations among the IHS, federal agencies, Tribes, Tribal organizations, UIOs, and states to expand services, streamline functions and funding, and advance health care goals and initiatives.

5. Work with community partners to develop new programs responsive to local needs.

Objective 1.3: Increase access to quality health care services.

Objective Explanation: Expanded access to health care services, including individual and community health services, requires using many approaches. Greater access is critical to improving the health of AI/AN people and reducing risk factors contributing to the leading causes of death. Among the needs identified are increased prevention, specialty care, innovative use of health care providers, traditional medicine, long-term and aftercare services (which may require advancing holistic and culturally centered population health models), and expanded facilities and locations. To assess the success of these efforts, measures are needed to evaluate provider productivity, patient satisfaction, and align improvements in support operations (e.g., human resources, contracting, technology) to optimize access to quality health care services.

Strategies—The following strategies support this objective:

Health Care Service Access Expansion:

1. Develop and support a system to increase access to preventive care services and quality health care in Indian Country.

2. Develop and expand programs in locations where AI/AN people have no access to quality health care services.

3. Overcome or mitigate challenges and enhance partnerships across programs and agencies by identifying, prioritizing, and reducing access limitations to health care for local AI/AN stakeholders.

4. Increase access to quality community, direct, specialty, long-term care and support services, and referred health care services and identify barriers to care for AI/AN communities.

5. Leverage technologies such as telemedicine and asynchronous electronic consultation systems to include a more diverse array of specialties and to expand, standardize, and increase access to health care through telemedicine.

6. Improve team effectiveness in the care setting to optimize patient flow and efficiency of care delivery.

7. Reduce health disparities in the AI/AN population.

8. Provide evidence-based specialty and preventive care that reduces the incidence of the leading causes of death for the AI/AN population.

9. Incorporate traditional cultural practices in existing health and wellness programs.

10. Improve the ability to account for complexity of care for each patient to gauge provider productivity more accurately.

11. Hold staff and management accountable to outcomes and customer service through satisfaction surveys.

12. In consultation with Tribes, modernize health care facilities and staff quarters to expand access to quality health care services.

13. In consultation with Tribes, review and incorporate a resource allocation structure to ensure equity among Tribes.

14. Develop and coordinate environmental engineering, environmental health, and health facilities engineering services to provide effective and efficient public health services and enable response, recovery, and mitigation to disasters and public health emergencies.

Goal 2: To promote excellence and quality through innovation of the Indian health system into an optimally performing organization.

Goal Explanation: In pursuit of high reliability health care services ^[9] and care that is free from harm, the IHS has implemented several innovations in health care delivery to advance the population health needs of AI/AN communities. In many cases, innovations are developed to meet health care needs at the local level and subsequently adopted across the Indian health system, as appropriate. The IHS will continue to promote excellence and quality through innovation by building upon existing quality initiatives and integrating appropriate clinical and public health best practices. Recent IHS efforts have been aimed at strengthening the underlying quality foundation of federally operated facilities, standardizing processes, and sharing health care best practices with federal, state, Tribal, and urban Indian programs.

Objective 2.1: Create quality improvement capability at all levels of the organization.

Objective Explanation: Ensure that quality improvement is operational in all direct care, public health, administrative, and management services throughout the system. Quality improvement will be achieved at all levels of the organization, including headquarters, area offices, and service units. Quality improvement methods will be made available to Tribes, Tribal organizations, and UIOs, as requested. Creating quality improvement capability at all levels will require training, resources, commitment, and consistency to assure that every employee shares a role in quality improvement in all IHS operations and services. This objective will build upon efforts of the 2016-2017 IHS Quality Framework ^[10] to strengthen quality improvement related to data, training, and standards of care.

Strategies—The following strategies support this objective:

Quality Data:

1. Improve the transparency and the quality of data collected regarding health care services and program outcomes.

2. Develop and integrate quality standards and metrics into governance, management, and operations.

3. Standardize quality metrics across the IHS and use results to identify emerging needs, share information on best practices and performance trends.

Quality Improvement:

4. Provide training, coaching, and mentoring to ensure quality improvement and accountability of staff at all levels of the organization.

5. Evaluate training efforts and staff implementation of improvements, as appropriate.

Standards of Care:

6. Develop and provide standards of care to improve quality and efficiency of health services across the IHS.

7. Adopt the Model for Improvement in all clinical, public health, and administrative activities across the IHS.

8. Adopt patient-centered models of care, including patient-centered medical home recognition and care integration.

Objective 2.2: Provide care to better meet the health care needs of American Indian and Alaska Native communities.

Objective Explanation: Key to improving health outcomes and sustaining population health is culturally responsive health care that is patient-centered and community supported. The IHS will implement culturally appropriate and effective clinical and public health tools to improve the health care needs of AI/AN communities. This objective reinforces current efforts addressing culturally appropriate care and supports dissemination of best practices.

Strategies—The following strategies support this objective:

Culturally Appropriate Care:

1. Strengthen culturally competent organizational efforts and reinforce implementation of culturally appropriate and effective care models and programs.

2. Promote and evaluate excellence and quality of care through innovative, culturally appropriate programs.

3. Promote total health integration within a continuum of care that integrates acute, primary, behavioral, and preventive health care.

4. Explore environmental and social determinants of health and trauma-informed care in health care delivery.

5. Continue to develop and implement trauma-informed care models and programs.

Sharing Best Practices:

6. Work collaboratively within the IHS, and among federal, state, Tribal, and urban Indian programs to improve health care by sharing best practices.

Goal 3: To strengthen IHS program management and operations.

Goal Explanation: This goal addresses issues of management, accountability, communication, and modernized information systems. The IHS is committed to the principles of improved internal and external communication, and sound management. Assuring the availability and ongoing development of a comprehensive information technology (IT) system is essential to improving access to integrated clinical, administrative, and financial data to support individual patient care, and decision-making.

Objective 3.1: Improve communication within the organization with Tribes, Urban Indian Organizations, and other stakeholders, and with the general public.

Objective Explanation: This objective addresses the critical need to improve communication throughout the IHS, with employees and patients, with Tribes, UIOs, with the many organizations working with the IHS and with the general public. Most important is to assist Tribes, UIOs, and the IHS in better understanding Tribal and urban Indian needs and IHS program needs, to encourage full participation in information exchange, and to engage Tribes and urban Indian programs in partnerships and building coalitions. This includes defining and characterizing community and health-specific program needs, modifying programs as needed, and monitoring the effectiveness of programs and program modifications.

Strategies—The following strategies support this objective:

Communication Improvements:

1. Improve communication and transparency among all employees, managers, and senior leadership.

2. Develop and define proactive communication plans for internal and external stakeholders.

3. Enhance health-related outreach and education activities to patients and families.

4. Design social media platforms that will ensure wide dissemination of information to interested and affected individuals and organizations.

Strengthen Partnerships:

5. Assure quality reporting relationships between service units, area offices, and headquarters are clearly defined and implemented.

6. Effectively collaborate with other IHS offices (e.g., the IHS Loan Repayment Program) and HHS staff and operating divisions where missions, goals, and authorities overlap.

Objective 3.2: Secure and effectively manage the assets and resources.

Objective Explanation: This objective supports the delivery of health care through improved management of all types of assets and non-workforce resources. To elevate the health status of the AI/AN population and increase access to medical care, the IHS must continue to help ensure patients understand their health care options and improve health care system business processes and efficiencies. The IHS will also increase the effectiveness of operations and reporting, while providing more assistance and infrastructure support to IHS areas and facilities.

Strategies—The following strategies support this objective:

Infrastructure, Capacity, and Sustainability:

1. Enhance transparency of IHS management and accountability infrastructure to properly manage and secure assets.

2. Promote collaboration among federal, state, Tribes, and local health programs to develop the necessary health care and public health infrastructure to effectively provide essential public health services.

3. Provide technical assistance to strengthen the capacity of service units and area offices to enhance effective management and oversight.

4. Apply economic principles and methods to assure ongoing security and sustainability of federal, Tribal and urban Indian facilities.

Improved Business Process:

5. Routinely review management operations to effectively improve key business management practices.

6. Optimize business functions to ensure that the IHS is engaged in discussions on value-based purchasing.

7. Develop policies, use tools, and apply models that ensure efficient use of assets and resources.

8. Strengthen management and operations through effective oversight.

9. Develop standardized management strategies for grants, contracts, and other funding opportunities to promote innovation and excellence in operations and outcomes.

Patient Education and Resources:

10. Strengthen patient awareness of their health care options, including Medicaid and Medicare enrollment, which may increase access to health care and optimize third-party reimbursements.

Objective 3.3: Modernize information technology and information systems to support data driven decisions.

Objective Explanation: This objective is to assure the availability and ongoing improvement of a comprehensive IT system that meets the needs of providers, patients, and I/T/Us by using technology to provide improved, timely access to care and to reduce the need for transit. This objective recognizes that qualified and capable IT staff and leadership are fundamental to achieving the strategies listed below and further reinforce the workforce objectives outlined elsewhere in the IHS Strategic Plan.

An improved Indian health IT network fosters transparency, integration, and access to the clinical, administrative, and financial data necessary to support patient care, decision-making, and advocacy. This will require the development of a system integrated with Tribal and urban Indian programs that will address the current and projected clinical, administrative, and fiscal data needs. Timely fiscal data dissemination to all federal partners when developing budgets is necessary to accurately address health care needs of AI/AN communities. Data quality (i.e., accuracy, reliability, and validity) and quality patient care will continue to play a highly visible role both within and outside the IHS. Data quality is only partially dependent upon technology. Improved data quality also reflects other sustained initiatives, such as data entry accuracy, legibility of handwriting, appropriate and timely data exports, and coding accuracy.

Strategies—The following strategies support this objective:

Health Information Technology (HIT):

1. Evaluate electronic health record needs of the IHS and the ability for the health information systems to meet those needs, create seamless data linkages, and meet data access needs for I/T/U health information systems.

2. Develop a consistent, robust, stable, secure, state-of-the-art HIT system to support clinician workflow, improve data collection, increase transparency, and provide regular and ongoing data analysis.

3. Modernize the HIT system for IHS Resource and Patient Management System or commercial off-the-shelf packages.

4. Align with universal patient record systems to link off-reservation care systems that serve American Indians and Alaska Natives.

5. Enhance and expand technology such as the IHS telecommunications to provide access for consultative care, stabilization of care, decreased transportation, and timeliness of care at any IHS-funded health program.

Data Process:

6. Provide available data to inform I/T/U decision-making.

7. Act upon performance data and standardize data and reporting requirements.

8. Assure system of data sharing to solidify partnerships with Tribal and urban Epidemiology Centers and other Tribal programs and UIOs.

9. Establish capability for data federation ^[11] so that data analytics/business intelligence may be applied to disparate data stored in a single, general-purpose database that can hold many types of data and distribute that data to users anywhere on the network.

Note

: The intent of the IHS Strategic Plan is to improve the health of American Indians and Alaska Natives through better management and administration of the IHS. It is not intended to replace or create any right, benefit, or legal responsibility, substantive or procedural, enforceable by law by a party against the U.S., its agencies, or any person.

Michael D. Weahkee,

RADM, Assistant Surgeon General, U.S. Public Health Service, Principal Deputy Director, Indian Health Service.

Footnotes

1.  IHS Profile: https://www.ihs.gov/​newsroom/​factsheets/​ihsprofile/​.

2.  25 U.S.C § 1602 (5); 25 U.S.C 5301; 25 U.S.C § 5381.

3.  25 U.S.C § 1660d(b); 25 U.S.C § 1602 (5); 25 U.S.C § 1631 (f); 25 U.S.C § 1665k(a)(2)(A)(vii).

4.  A crosswalk of the HHS Strategic Plan FY 2018-2022 and IHS Strategic Plan FY 2019-2023 goals and objectives is available in Appendix A.

5.  QBS is a leadership framework and set of activities to help organizations prepare to participate in system transformation and continuous quality improvement. QBS guides strategic planning through a vision of the system that operates in its present condition (maintaining operations that achieve goals and objectives) and improves to meet new needs through redesign of existing conditions or design of new processes, products, or services. QBS helps leaders plan to operate the system and plan to improve the system.

6.  U.S. Department of Health and Human Services, IHS. (2014). Trends in Indian Health: 2014 Edition. Retrieved from: https://www.ihs.gov/​dps/​publications/​trends2014/​.

7.  Data comparing the AI/AN population to the U.S. general population are documented and updated annually by the IHS. As of April 2018, the most current IHS mortality data available is from 2009-2011. AI/AN mortality data accounts for misclassification of AI/ANs on death certificates and there is a time lag in producing IHS mortality data.

8.  The 2018 National Combined Councils Annual Meeting was held in Portland, Oregon, on August 14-17, 2018. During the meeting, breakout sessions were held by the IHS to develop action plans for implementation of the objectives in the Draft IHS Strategic Plan. For more information about the meeting, please visit: https://www.ihs.gov/​forproviders/​ncc/​2018meeting/​. The action plans presented during the meeting are subject to the review and recommendations of IHS senior leadership.

9.  High reliability health care means consistent excellence in quality and safety for every patient, every time. High reliability in health care improves: Organizational effectiveness, efficiency, culture, customer satisfaction, compliance, and documentation. Additional information about High Reliability Organizations is available online at https://psnet.ahrq.gov/​primers/​primer/​31/​high-reliability.

10.  The IHS Quality Framework 2016-2017 is available online at https://www.ihs.gov/​newsroom/​includes/​themes/​newihstheme/​display_​objects/​documents/​IHS_​2016-2017_​QualityFramework.PDF. The IHS Strategic Plan 2019-2023 is a longer-range plan and replaces the short-term IHS Quality Framework.

11.  Data federation provides an organization with the ability to aggregate data from disparate sources in a virtual database so it can be used for business intelligence or other analysis.