TRIBAL PERSPECTIVES ON QUALITY IMPROVEMENT AND ACCREDITATIONAleena M. Hernandez, MPH, Red Star InnovationsRachel Ford, MPH, NW Portland Area Indian Health BoardNancy Young, Institute for Wisconsin’s Health, Inc.

National Network Of Public Health Institutes – Open Forum

June 19, 2012

TRIBAL PERSPECTIVES ON QUALITY IMPROVEMENT AND

ACCREDITATION

Aleena M. Hernandez, MPH, Red Star InnovationsRachel Ford, MPH, NW Portland Area Indian Health Board

Nancy Young, Institute for Wisconsin’s Health, Inc.

Welcome and Introductions

Objectives• Provide an overview of the historical basis of

Indian health and Tribal health departments• Share work that has been done nationally to

inform accreditation and prepare tribes• Share regional approaches to build capacity

and prepare Tribes for accreditation• Discuss opportunities, challenges and future

directions

Tribal Sovereignty• Tribes are inherently sovereign• Government-to-Government relationship

established through: – Treaties – U.S. Constitution– Federal legislation– Court decisions

TRIBES• 566 Federally-recognized Tribes in 35 States• Sovereign; individually governed• Distinct culture, language and traditions• Landbase and non-landbase; checkerboard• Tribal membership• Economic diversity• Unique history

American Indians and Alaska Natives

2010 Census• AI/AN alone 2.5 million (1%)

• AI/AN in combination with 2.5 million one or more other races

• Total AI/AN 5 million (1.6%)

• IHS User Population (registered) 2.5 million• IHS User Population (active) 1.5 million

States with Largest AI/AN Populations

Total Number of AI/AN•California•Oklahoma•Arizona•Texas•New Mexico

Percent Population•Alaska•Oklahoma•New Mexico & South Dakota•Montana

Historical Basis for Indian Health

Significant Policy/Legislation Affecting Indian Health

• 1800’s – Responsibility of the War Department• Indian Removal– Indian Removal Act of 1830– 1836 – Medical services for land cessions

• 1849 - BIA/Department of Interior• Dawes Act – General Allotment Act 1887– Reservation land divided into allotments– Ban on traditional practices– Introduction of boarding schools

Significant Policy/Legislation Affecting Indian Health

• Indian Reorganization Act 1934

• Termination Program of the 1950’s

• The Transfer Act of 1954 – Transferred health services from the BIA to PHS

• 1955 - Indian Health Service established

Federal Trust Responsibility• Established by treaties/court

decisions/legislation• Land and resources were ceded to the U.S

government by treaty, forced removal or other means

• Provided, in exchange, with health, education, social services, housing and other services

Indian Health Service

• Under the US Department of Health and Human Services

• Comprehensive, primary health care system and some public health services• Only federal agency to provide direct medical

care

• 12 Service Areas

Per Capita Health Expenditures• Indian Health Service (2005) $2,130

• Bureau of Prisons (2005 estimate)$3,986• In California and New Mexico over $4000

• Veterans Administration (2002) $4,653

• US General Population (2003) $5,670

Department of Health and Human Services, www.dhhs.gov, Source published January 2006

Tribal Public Health Systems

Assuring the conditions for community (population) health

Tribal Public Health Systems

Key Stakeholders

Tribal Management of Health Programs

The Indian Self-Determination and Educational Assistance Act 1975 P.L. 93-638

• Tribes can manage their health programs- Title I: CONTRACT part or all of the services- Title V: COMPACT entire health programs

• Tribes supplement contract services with other public health services

Indian Health Boards/Inter Tribal Councils

• 1970’s Tribes began to form organizations to advocate on behalf of their collective interests

• Governed by the highest elected official of member tribes

• National, IHS Service Area, State, Region, other commonalities

• Tribal Epidemiology Centers funded by CDC and IHS

Unique Context for Tribal Accreditation

• Tribal sovereignty; government-to-government relationships

• Land base and non-landbase; checkerboard• Tribal Program Management or Direct IHS service • Multi-jurisdictional relations with local and state

health departments to address health needs • Wide variation in public health activities, structures,

partnerships

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Preparation for Tribal Accreditation

• Accreditation Readiness Workshops– Accreditation 101 – process and benefits– Self-Assessment using WIQI/IWHI Tool– 3 Prerequisites

• Quality Improvement Trainings• Role of public health law and tribal health code

development• Accreditation Roundtables• Facilitation and technical assistance with

prerequisites

Common Challenges• Defining the “Tribal Health Department”– Tribal clinics and public health services– 638 Programs and the role of IHS– Health and Human Services

• Defining public health• Infrastructure and resources to prepare for

accreditation• Tribal law and policy; enforcement• Data collection, management; surveillance

Common Opportunities• Strengthen self-determination• It’s about the health of our communities• Improve health services and public health

performance• Improve communication and coordination• Standards and measures provide guidance• Establish Tribe as a “public health authority”

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