Tribal Self-Governance Health Care and Social Services Delivery Effectiveness Evaluation Feasibility Study: First Technical Work Group Meeting Background Materials. List of Potential Evaluation Issues/Questions

02/05/2003

SUGGESTED EVALUATION ISSUES, QUESTIONS, DATA REQUIREMENTS

For Discussion with the Technical Working Group

 

Overview

An evaluation of Tribal Self-Governance could include a wide range of issues and questions, requiring use of existing data, primary data collection, and qualitative data collection.  In this handout, we offer a comprehensive set of potential areas that could be examined in an evaluation of health related services.  (A separate, similar, analysis will be needed for each non-IHS social services and other that would be included in any evaluation.  Topics and data requirements for such an evaluation effort will be discussed by the Working Group during its review of the activities that will take place during site visits to Tribes which manage one or more non-IHS services.)

 

Qualitative Issues:  Management Structures and Processes

This set of evaluation issues focuses on the role and structure of management of Tribal health systems and on internal management processes and systems.  Data required to address these issues would be collected through site visits, key informant telephone interviews, and review of internal documents (e.g. policies and procedures).  Types of questions that would be addressed include:

  • Management Structure and Stability

n      What are the management structure, departments, and reporting relationships within the health system?

n      How long has each manager served in their current position?

n      Has there been significant turnover in management positions since you took over responsibility for management of the health program?  If so, what are the reasons?

  • Providers and staff

n      How many physicians and other provider staff are currently employed or providing health services?

n      Are there vacant positions?  If so, how many and for what time period?

n      What are the challenges for recruiting and retaining physicians and other provider staff?

n      Have you developed and implemented any special programs to recruit staff and/or to retain staff?

  • Programs and Benefits

n      Have you added any new programs since Tribal management of the health system began?  Which programs?  How did you decide that there was a need for those new programs?

n      Have you eliminated any programs?  Which programs?  What were the reasons that you decided to eliminate those programs?

  • Quality and User Satisfaction

n      What types of quality of care review and assessment do you have in place?

n      Who is responsible for determining the specific areas and baseline measures that are used for quality of care review and assessment? 

n      What are the most important issues for quality of care and performance measures in your health system?  Why are these identified as of greatest importance?

n      Do you occasionally or routinely collect information from users on their experiences with providers, staff, health services provided?  How do you use the information collected?

n      How do you believe quality of care has improved under Tribal management of the health system?

n      Do you think that health system users are more satisfied since Tribal management was implemented?

  • Management Challenges

n      What are the management issues that are most difficult to address for Tribal management of health?

n      What changes would be beneficial and result in improved services to Tribal members?

 

Quantitative Issues:  Impacts and Outcomes

AVAILABILITY OF SERVICES/ACCESS TO CARE

Key Questions

Data Requirements

   

What services are available ‘in house’?

Have the quantity and type of ‘in-house’ services increased/decreased over the past three years?

What is the ratio of primary care physician-to patient users?  Dentist-to-patient users?

At the Service Unit level, most recent year and previous two years:

  • number of FTE physicians, by primary care and type of specialty
  • number of FTE primary care dentists and specialist dentists
  • number of FTE NP, RN, and PA staff
  • number of FTE dental hygienists
  • number other FTE clinical staff, by type
  • availability of full pharmacy services
  • number of patients provided services in SU, by age and gender

What services are referred out to Contract Health Services?

Have the quantity and type of Contact Health Services used changed over the past three years?

What criteria are used to determine whether a patient is referred for Contract Health Services paid by the Service Unit?

Is there ‘rationing’ of Contract Health Services?  All year?  At some point in the fiscal year?

  • number and type of Contract Health Services provided and paid, by quarter of the fiscal year
  • number and type of Contract Health Services denied for payment, by patient insurance coverage and by quarter of the fiscal year
  • Contract Health Services policies and procedures

What is the waiting time for a routine appointment? With a Service Unit primary care physician? With a Service Unit Dentist?

  • Percent of patients who are ‘walk in’
  • Days between making and having appointment with PCP
  • Days between making and having appointment with dentist

QUALITY OF CARE: PROCESS

Key Questions

Data Requirements

   

What proportion of Service Units are JCAHO-accredited or have other accreditation?

What proportion of physicians are board-eligible or board-certified?

What proportion of nursing and ancillary personnel  are licensed and meet federal/state continuing education requirements?

All Service Units, separately by direct service, contracted, compacted:

  • Percent JCAHO-accredited or other accreditation (specified)
  • Percent primary care physicians board-eligible/certified
  • Percent specialist physicians board-eligible/certified
  • Percent specialist physicians board-eligible/certified
  • Percent nursing personnel licensed and meeting CE requirements
  • Percent ancillary personnel licensed/certified
  • Community health reps

What is the annual ‘turnover rate’ for physicians, dentists, nurses, and ancillary personnel?

  • Percent of physicians, dentists, nurses, and ancillary personnel leaving employment at the SU each year

Does the Service Unit have a Quality Assurance/Review Committee? What are its functions/ How often does it meet?

For each Service unit:           

  • QA/QR Committee policies and procedures
  • QA/QR Committee Meeting Minutes

What proportion of patients receive routine preventive services? Has the proportion increased/decreased over the past 3 years?

For each Service Unit, past year and preceding 2 years

  • Percent children under age 5 immunized
  • percent aged 50+ receiving influenza immunizations
  • Percent of women over 18 with annual Pap smears
  • Percent pregnant women obtaining prenatal care in first trimester
  • Percent of adults screened for diabetes

What proportion of people with diabetes receive screening for diabetic complications? Has the proportion increased/decreased over three years?

For each Service Unit, for all patients with diabetes, three years:

  • Percent seeing physician at least once in 3 months
  • Percent receiving HbA1c testing once in 3 months
  • Percent receiving dilated eye exam annually
  • Percent receiving annual dental examinations

 

QUALITY OF CARE: HEALTH OUTCOMES

Key Questions

Data Requirements

   

What is the breast cancer 5-year survival rate?

What is the cervical cancer 5-year survival rate?

What percent of births are low-weight or premature?

What percent of births are high-weight?

For each Service Unit:

  • Percent diagnosed with breast cancer surviving 5 years
  • Percent diagnosed with cervical cancer surviving 5 years
  • Percent of births that are low-weight or premature
  • Percent of births that are high-weight

What is the proportion of deaths attributable to diabetes

What proportion of people with diabetes are diagnosed with diabetic retinopathy?

What is the proportion of people with diabetes who have extremities amputated?

  • Percent of deaths attributable to diabetes
  • Percent of people with diabetes who have diabetic retinopathy
  • Percent of people with diabetes who have had amputation

 

QUALITY OF CARE: PATIENT SATISFACTION

Key Questions

Data Requirements

   

What proportion of the population eligible for services uses the SU annually?

  • Number of eligible people within each SU market area
  • Number of eligible people with at least two visits to a PCP

Does the Service Unit or Tribal Health Department conduct periodic surveys of patients’ experiences and satisfaction?

  • ‘Yes’ or ‘No’ by individual SU

How do SU users rate access to care, their providers, Contract Health Services, and other dimensions of care?

What proportion of the eligible population goes outside for services?

What are the reasons for using non-IHS or non-Tribal health providers?

How do patients who obtain care outside rate their care?

Remaining questions would require a survey of users/non-users

 

FINANCIAL PERFORMANCE

Key Questions

Data Requirements

   

What proportion of users has public or private insurance?

At the Service Unit level, last year and two preceding years:

  • Percent with Medicare
  • Percent with Medicaid
  • Percent with SCHIP
  • Percent with Private Health Insurance

How many total units of service are provided, by type of service?

  • Number of hospital admissions
  • Number of hospital days
  • Number of primary care visits
  • Number of specialist physician visits
  • Number of dental visits
  • Number of prescriptions filled
  • Number of Contract Health services, by type of service

What proportion of potential third-party revenues is billed and collected?

  • Number of patients with third-party insurance, by type
  • Total billing, by type of insurance
  • Total receipts, by type of insurance

Is the Service Unit operating at ‘break even’ or with a ‘surplus’

  • Total revenues from IHS, by category (services, facilities, diabetes, administrative, other (?))
  • Total third-party revenues, separately for Medicare, Medicaid, SCHIP/Private insurance
  • Total revenues from other sources (e.g. grants)

What is average cost per unit of service? Average cost percapita?

  • Total expenses (labor, rent, operating expenses, supplies, depreciation, etc), by department (outpatient, inpatient, dental, nutrition, etc.)
  • Total Contract Health expenses, by provider type
  •  

What is the current financial condition of the service unit’s balance sheet?

  • Balance Sheet/Statement of Financial Position (assets, by category; liabilities, by category)
  •  

Have the prices of services changed?

  • Fee schedule/charges, by type of services

What are average out-of-pocket costs for patients?

  • Total charges to patients for in-house services
  • Total patient liability of Contract Health Services not paid by health facility

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