Introduction
July 2005 marked the fiftieth anniversary of the Indian Health Service, a unique public health care system of almost 600 facilities employing over 16,000 health care workers providing service to 1.6 million American Indians and Alaska Natives. This comprehensive health system evolved from nineteenth century treaty contracts between the United States government and tribes, becoming part of the Public Health Service in the then Department of Health, Education and Welfare on July 1, 1955. This two-part paper will briefly describe the history of planning for services, facilities and staffing in the Indian Health Service during its 50 year history, examine the current planning process, and discuss important new policy issues in planning for future needs.
History and Description
The IHS is one of the oldest health care systems in the United States to include programs of preventive, curative, rehabilitative, and environmental health services. The statutory basis for the government to provide health care to American Indians began with assignment to the War Department in 1803. The Bureau of Indian Affairs (BIA) began to build hospitals and facilities with limited funding following the Snyder Act that authorized funds for federal health programs for all recognized tribes in 1921. In 1926 Commissioned Corpsmen of U.S. Public Health Service were assigned to augment staffing. The Indian Reorganization Act of 1934 provided funding to construct many additional hospitals such as Albuquerque, New Mexico (1934), Fort Defiance, Arizona (1938), Browning, Montana (1937), Cherokee, North Carolina (1936), and Crown Point, New Mexico (1939).
On July 1, 1955, the Indian Health Service became part of the Department of Health, Education and Welfare and inherited from BIA a patchwork system of 61 facilities, serving 500,000 American Indians and Alaska Natives. [i]
From the beginning, the Mission of the IHS was to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level. Following the transfer, the Indian Health Service initiated a program of accelerated building and staffing new and replacement facilities to meet changing health care needs. With the first appropriation in 1956, the focus of the initial building program of the reorganized Indian Health Service was to update the hospitals inherited from the BIA that were inadequate to meet the needs for infectious diseases, dental problems and nutritional deficiencies. Additional hospitals were needed to address the leading illnesses of the era that included dysentery, diarrhea, tuberculosis, pneumonia, and communicable childhood diseases such as measles and mumps, and to serve areas that previously had no facilities.
Table 1:Number of facilities constructed between 1955 and 2005.
|
Decade |
Hospital |
Health Center |
Health Station |
|
1950s |
|
3 |
11 |
|
1960s |
12 |
17 |
36 |
|
1970s |
9 |
18 |
|
|
1980s |
11 |
8 |
|
|
1990s |
5 |
15 |
|
|
2000s |
2 |
5 |
|
Hospitals are inpatient facilities with less than 30,000 inpatient days and limited specialty care. Health Centers are ambulatory care facilities operating a minimum of 40 hours a week staffed with a basic health team providing services for acute and chronic ambulatory problems. Health Stations are ambulatory care facilities, fixed or mobile, geographically separate from an inpatient or health center facility and operating with less than a basic health center staff or less than 40 hours a week. The system also includes several large referral centers with specialty care and inpatient days greater than 30,000 in Gallup, N.M.; Phoenix and Anchorage, Alaska.
The Indian Health Care Improvement Act of 1976 began a shift from treating communicable diseases to prevention and the incorporation of traditional healing practices. The 1990s brought new funding authorities such as Joint Ventures with tribes, Small Ambulatory Grants Renovation and Construction Program, and the contracting and compacting of facilities construction and management out of IHS to tribal ownership and control.
Throughout this period all facilities were constructed to provide care in a primary care focused system staffed mostly with primary care providers. The goal today is to assure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people. The result is a system that operates 594 facilities through direct service, tribal ownership and management or the Urban Health program.
 |
|
Figure 1: Administrative structure encompasses 12 regions |
Each area office has a director and a core of administrative, engineering and planning staff ranging from 17 to 50. Areas designate administrative service units to plan and manage inpatient and ambulatory programs that may include one or more facilities serving the population within an established standard of accessibility. Each service unit has a manager as do the facilities within the service unit. Many of the service unit designations reflect historical service patterns and usually encompass a single reservation or tribe.
 |
|
Reporting structure |
Service is provided in these facilities by IHS personnel if the facility is owned and managed by the IHS; otherwise tribes own and manage facilities through self determination contracts and self governance compacts.
The earliest planning model incorporated an existing operational health system in an iterative process of planning, implementing, monitoring and evaluation.
 |
|
Iterative planning model |
It used demand forecasting – measuring the size of the service population in each area and determining their requirements for health care. Demand was expressed in “inpatient days” and “outpatient visits.” It called for maximum involvement of Indian tribes in defining their health needs, setting health priorities and managing the delivery system.
To aid in the planning process and provide consistency in service, the IHS developed several planning guidelines. The first of these was the Resource Allocation Criteria (RAC) developed by a multi-disciplinary team of IHS staff between 1972 and 1977 to “provide IHS with a comprehensive, systematic and consistent process for determining resource requirements”.[ii] The committee used historical data from IHS facilities to develop standards for staffing and workloads for the following inpatient departments: laboratory, X-ray, medical records, physical therapy, occupational therapy, surgery, pharmacy, housekeeping, laundry, nursing, medicine, dietary, maintenance, surgery and anesthesiology. In addition, the RAC provided criteria for demand forecasting, ambulatory care services, community health services, special programs, administration, and contract services.
The RAC also established the following accessibility guidelines:
15 minutes for emergency care.
30 minutes for ambulatory care.
90 minutes for inpatient care.
240 minutes for inpatient specialty care.
Once the criteria for staffing and workloads were developed they were benchmarked with national planning guidelines.
The RAC was converted to a spreadsheet format in the 1980s, updated and renamed the Resource Requirements Methodology (RRM). In its current Excel format, RRM2005 continues to use formulas that calculate staffing needs based on factors such as primary care provider visits and average daily patient load.[iii]
The Health Facilities Planning Manual was published in 1980 for use by Headquarters, area planning officers, service unit planners, regional offices of facilities engineering and construction and tribal health planners.[iv] It used workload and staffing as criteria for the allocation of space. It also outlined many of the spatial concepts and terminology still in use.
The current planning process builds on this early model, adding these automated tools to project population, workloads, and space requirements. Planning for a new or replacement facility, the area planner develops two written planning documents, the Project Justification Document that outlines the need for the facility, its size and staffing and the Program of Requirements that provides information for architects and engineers.
The planning steps in developing the Project Justification Document (PJD) and Program of Requirements (POR) are: (1)estimate population; (2) plan services; (3) project staff; and (4) plan space.
It begins with the establishment of the Project Leadership Team with area IHS and Tribal members. This work team reviews the planning assumptions and area master plan, identifying communities needing additional service and determining the type and location of the proposed facility. To validate the need for a facility the team works with the statistical officer to develop accurate population estimates and projections.
The next step is to plan the services that the facility will provide. For this step the project leadership team consults with clinical and professional staff at the service unit, area and headquarters level. Once services are approved, the area planner can use special IHS planning software tools to project workloads to plan staff and space.
The Health Systems Planning Process that replaced the Health Facilities Planning Manual in 1999 is a FOXPRO program that uses inputs of communities for health facilities to project population and produce workload statistics, space projections, equipment lists and room templates[v]. It interacts with the earlier developed RRM to project staffing needs based on primary care visits and workload.
Inputs for the software included key drivers and standards developed by workgroups of disciplines (specific medical specialties), collection and analysis of data from twenty service units with recently completed facilities such as inpatient beds days by specialty, births, etc, ancillary workloads and questionnaires on operations practices and problems, analysis of projected workloads and defining characteristics from Project Justification Documents and Program of Requirements from 27 planned facilities, documentation and approval of space programming and design notes, and development and approval of architecture and medical equipment, furniture and design criteria. The resulting software also meets guidelines from the American Institute of Architects and Society of Construction Engineers, and other professional organizations.
The current HSP2007 provides for a standard set of services based on population, remoteness of area, and availability of alternative services nearby. The area may propose additional services by providing justification to the Headquarters Division of Clinical and Preventive Services. It also attempts to combine the RRM staffing into a single system with the population, workload and space projections.
Both the Resource Requirement Methodology and the Health Systems Planning Process provide very general guidelines. The approval process is iterative with special area needs and circumstances incorporated into the Project Justification Documents by adjusting the projections of the Health Systems Planning Process and Resource Requirement Methodology. An example of an adjustment is increasing the projected visits because of higher than average health needs within an area. With the approval of the staffing and space projected by the Resource Requirement Methodology and Health Systems Planning Process, adjusted for local needs, the Project Justification Documents is approved and the Program of Requirements developed.
With the approval of the Project Justification Documents and the Program of Requirements, the project is then added to the IHS Priority List, a list of facilities that are then proposed for funding. With the budget proposal, additional adjustments can be made to allow for changes in population and staffing needs. Once funding is received, contractors perform the architectural planning and construction.
[i] F. Mullan, Plagues and Politics (New York: Basic Books, Inc., 1989).
[ii] Resource Allocation Criteria for Indian Health Services (Rockville, MD: USDHEW, 1978) iii.
[iii] http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/pe-facilities-planning.asp#rrm.
[iv] Health Facility Planning Manual (Rockville, MD: U.S. Department of Health and Human Services, January 1981).
[v] http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/pe-facilities-planning.asp#hsp.
by Lucy Vogel,MS, MBA
Planning Evaluation and Research
Indian Health Service, Department of Health and Human Services
lvogel@hqe.ihs.gov