[Federal Register Volume 84, Number 40 (Thursday, February 28, 2019)]
[Notices]
[Pages 6796-6807]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-03486]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Indian Health Service


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: [email protected]. 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

[[Page 6797]]

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.
---------------------------------------------------------------------------

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

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.
---------------------------------------------------------------------------

    \2\ 25 U.S.C Sec.  1602 (5); 25 U.S.C 5301; 25 U.S.C Sec.  5381.
    \3\ 25 U.S.C Sec.  1660d(b); 25 U.S.C Sec.  1602 (5); 25 U.S.C 
Sec.  1631 (f); 25 U.S.C Sec.  1665k(a)(2)(A)(vii).
---------------------------------------------------------------------------

    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

[[Page 6798]]

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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

    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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

    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.
BILLING CODE 4160-16-P

[[Page 6799]]

[GRAPHIC] [TIFF OMITTED] TN28FE19.001

BILLING CODE 4160-16-C
    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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

    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,

[[Page 6800]]

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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

    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

[[Page 6801]]

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

[[Page 6802]]

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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

    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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------

    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

[[Page 6803]]

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.
---------------------------------------------------------------------------

    \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.
---------------------------------------------------------------------------



    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.

BILLING CODE 4610-16-P

[[Page 6804]]

[GRAPHIC] [TIFF OMITTED] TN28FE19.002


[[Page 6805]]


[GRAPHIC] [TIFF OMITTED] TN28FE19.003


[[Page 6806]]


[GRAPHIC] [TIFF OMITTED] TN28FE19.004


[[Page 6807]]


[GRAPHIC] [TIFF OMITTED] TN28FE19.005


Michael D. Weahkee,
RADM, Assistant Surgeon General, U.S. Public Health Service, Principal 
Deputy Director, Indian Health Service.
[FR Doc. 2019-03486 Filed 2-27-19; 8:45 am]
 BILLING CODE 4160-16-C