Once the facility is built and in operation (i.e., within one year), it undergoes review for accreditation by the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) or other national accreditation bodies such as the Accreditation Association for Ambulatory Health Care (AAAHC).  This comprehensive review assesses services, departmental organization, safety, staffing, and quality of care. Currently, all IHS facilities maintain national accreditation.

An additional evaluation of individual projects is the Post Occupancy Evaluation (POE) [3].  This evaluation by a multi-disciplinary team of independent planners, engineers, and architects who did not perform the original planning identifies areas for improvement in the process and planning tools.

Adding to the evaluation process is the growing importance of evaluative measures such as the Program Assessment Rating Tool (PART) and the Government Performance and Results Act (GPRA), measures initiated by the Office of Management and Budget.  The OMB reviews link clinical measures to service delivery with a focus on the ultimate outcome of improved health indicators such as increased years of productive life.  These measures are based on the construction of logic models that link inputs to outputs and outcomes. They play an increasing role in defining the success of service delivery in the area and in budget allocations for the whole IHS.  The coordination of these measures is often co-located within Planning and Statistics at the area and headquarters levels.

Each area was also called on by the IHS director to develop, by July 2004, a Area Health Service Delivery Plan that includes existing health services, the primary service area delivery plan with maps of native communities and other population clusters, a visiting professional summary plan, an IHS area referral delivery plan, and contract health summary.  In addition, the Area Health Service Delivery Plans are to include a facilities master plan with IHS supportable space, size, and condition for each health care facility, travel time, and distance from each service area to nearest clinics, and innovative health care initiatives.  These plans, approved by the area directors, will assist areas in conducting needs assessments for planning for services and facilities, and will also document the total unmet need for health care services and facilities among American Indians/Alaska Natives.

Overall, the IHS continues to operate with very limited resources relative to much unmet need.  Even with projects comprehensively planned and thoroughly reviewed, waits for funding are so long that by the time the facilities are actually built, the local circumstances and needs may change.  Likewise, technological advances in health care provision and equipment, such as the use of digital radiology, may change the needs for staff and space.

Coordination remains an important issue.  There are many players in the planning process with different perspectives, expertise and focus, such as engineers, clinicians and planners.  Staffing within the service includes three sets of employment regulations: the Commissioned Corps service, the federal civil service and tribally funded staff.  Even coordination of the staff at headquarters is difficult with so many offices and individuals involved in the planning process.  Currently, three different offices at headquarters work with area planners for the approval of services, staff and space.  Coordination with these three offices may create misunderstanding, delays and duplication of effort.

The American Indian/Alaska Native population is quite diverse, requiring negotiations with 550-plus sovereign nations for 78 self-governance compacts and 293 self-determination contracts.   These negotiations are extremely important to providing health care that is responsive to tribal needs.  However, doing so requires time, resources and cultural sensitivity.

The real need is for additional resources.  IHS is one of the few places where population and needs-based planning still operate in the public sector.  While IHS planning is needs based, the actual provision of care does not begin to meet the identified needs.  Many disparities in health care measures remain, with American Indians lagging behind most population groups.[6]  Even though the system is comprehensive at no direct cost to the patients, budget constraints limit the availability of services.  The average amount spent in 2002 for IHS care was approximately half that spent on U.S. per capita users: $2,533 ($1,914 appropriations plus $619 collections) versus $5,065 as shown in the following figure.

Furthermore, funding for new staff must be coupled with new space, creating an incentive for new, larger facilities.  While many facilities have adopted business-oriented practices to expand services and staff through collections of third-party reimbursement, these efforts have not begun to address the gap in a significant way.  Future planning must identify effective strategies for augmenting Congressional funding with tribal resources and private sector funds.