Fiscal Year-2021 Quarter 4

The national percentage of ambulatory facilities that have an active Quality Improvement Program (QIP) documented in a policy that includes the collection, aggregation, analysis, and reporting of quality improvement data.

Why is this important?

Active quality improvement programs lead to better and safer care while also a requirement for CMS certification and accreditation.

IHS NATIONAL TARGET 100%

The national percentage of IHS hospitals and ambulatory facilities that have earned and maintained accreditation by a National Healthcare Accreditation Organization.

Why is this important?

Accreditation indicates the quality and safety of care services at healthcare facilities.

IHS NATIONAL TARGET 100% 100% of IHS hospitals are CMS certified. The 3 hospitals that have CMS certification without accreditation are not counted as accredited.

The national percentage of IHS healthcare facilities that access, review, and address patient safety event reports to prevent future similar safety incidents/adverse events.

Why is this important?

Safety reporting leads to prevention of recurring safety risks.

IHS NATIONAL TARGET 100%

The national percentage of facilities that have an Emergency Preparedness and Response Plan documented in policy and exercised in accordance with policy.

Why is this important?

An Emergency Preparedness Response Plan ensures readiness for continued service should a major event occur (for example, Severe Winter Storm).

IHS NATIONAL TARGET 100%

The national percentage of IHS Hospitals and Ambulatory Health Centers that have achieved Patient-Centered Medical Home (PCMH) certification to promote high quality patient care, enhance the patient experience, support population health and improve the work environment within the IHS system.

Why is this important?

The Patient Centered Medical Home certification indicates care services designed around patients to improve patient outcomes.

IHS NATIONAL TARGET 100% BY DECEMBER 2021

The national percentage of IHS Hospitals and Ambulatory Health Centers with current local policies aligned with current policies established within the Indian Health Manual (IHM) on Chronic Non-Cancer Pain Management and Prescription Drug Monitoring Programs (PDMPs).

Why is this important?

Local opiate policies aligned with Indian Health Manual requirements will improve the appropriateness of opiate prescribing.

IHS NATIONAL TARGET 100%

The national percentage of health care facilities with an ED reporting rates for Median Time from ED Arrival to ED Departure for Discharged ED Patients and Left Without Being Seen to ensure the delivery of adequate and timely access to care in emergency departments.

Why is this important?

Reporting of Emergency Department quality measures lead to reduced waiting times and earlier patient assessments for emergent conditions.

IHS NATIONAL TARGET 100%

The national percentage of Healthcare Personnel (HCP) who have received the influenza vaccination to protect patient safety and reduce transmission of influenza in healthcare settings. The report reflects data from the 2020-2021 influenza season.

Why is this important?

Health care professionals who receive the influenza vaccination help to reduce the transmission of influenza.

IHS NATIONAL TARGET 90%

The national percentage of IHS federal employees completing the annual Federal Employee Viewpoint Survey during the active survey period. This includes an assessment of employee job satisfaction across all federal categories and professions. The report reflects data from the 2020 survey results.

Why is this important?

Assessment of employee job satisfaction assists in the recruitment and retention of high quality staff.

IHS NATIONAL TARGET 75%