Driving Success: Best Practices for GPRA Compliance and Performance

GPRA/GPRAMA OVERVIEW:

The Government Performance and Results Act (GPRA) of 1993 is a federal law that mandates agencies to demonstrate effective and efficient use of congressional funds.¹ The Indian Health Service (IHS) has been reporting GPRA data for over a decade.¹ This data helps the IHS to evaluate its progress towards achieving its goals and objectives, which ultimately benefits the health of Native Americans.

To ensure that federal agencies make informed decisions, the Government Performance and Results Modernization Act (GPRAMA) was introduced in 2010 as an update to GPRA. This act requires federal agencies to leverage performance data in their decision-making processes. The GPRA and its modernization counterpart, the GPRAMA, play crucial roles in shaping how federal agencies are held accountable for their performance and results. For instance, in the context of healthcare services, GPRAMA shows Congress how well the IHS is providing care to American Indians and Alaska Natives who use IHS federal, tribal, and urban Indian health facilities.²

The IHS started reporting under GPRAMA in FY 2013, which involves a smaller set of measures compared to GPRA. ¹ The 26 clinical GPRA/GPRAMA measures are collected throughout the GPRA year (October 1 to September 30) using the Integrated Data Collection System (IDCS) and exported to the National Data Warehouse (NDW).¹ This data is cumulative and aggregates results from all reporting clinics, including federal, tribal, and urban Indian health programs, into national outcomes.¹

Regardless of the electronic health record (EHR) system they use, urban Indian health programs can report GPRA data.¹ This makes it easier for them to contribute to a comprehensive national database and ensures that the IHS has access to the information it needs to make informed decisions. By leveraging this data, the IHS can continue to provide effective and efficient healthcare services to Native Americans across the country.

COMPARATIVE UIO PERFORMANCE OF GPRA/GPRAMA MEASURES:^3-5

GPRA/GPRAMA measures are indicators of how well the agency has provided clinical care to its patients. Overall, they measure how well the IHS has done in the prevention and treatment of certain diseases, and the improvement of overall health. The table below outlines the measures of performance of Urban Indian Organizations (UIOs) over three years (2018, 2019, 2020), comparing actual results against set goals. The measures are categorized into the “Top 3” and “Bottom 3” based on performance. In the “Top 3” category, Statin Therapy consistently exceeded its goals, demonstrating a significant improvement. Nephropathy and CVD Statin Therapy measures also performed well, with Nephropathy showing yearly increases in actual achievements. However, the “Bottom 3” measures faced challenges, with Exclusive/Mostly Breastfeeding meeting its goal in 2019, while IPV/DV Screening and Adult Immunizations fell short of their goals every year reviewed.  In 2020, two new measures, Topical Fluoride and Retinopathy Exam, were introduced as part of the GPRA tracking. However, in their first year, they did not meet their targets. This data underscores the substantial progress in some areas and the need for enhanced focus and improvement in others, particularly in preventative screenings and healthcare interventions.

TOP ACHIEVERS AND AREAS OF IMPROVEMENT (2018-2020) ^3-5

	Top 3		Actual	Goal	Bottom 3	Actual	Goal
2 0 1 8	1	Statin Therapy	61.6%	37.5%	Exclusive/Mostly Breastfeeding (Age of 2 Mos)	25.0%	39.0%
	2	Nephropathy	50.2%	34.0%	IPV/DV Screening	30.1%	41.6%
	3	CVD Statin Therapy	41.9%	26.6%	Mammography Screening	33.6%	42.0%
2 0 1 9	1	Statin Therapy	61.4%	37.5%	Adult Immunizations	33.5%	54.9%
	2	Nephropathy	51.6%	34.0%	Exclusive/Mostly Breastfeeding (Age of 2 Mos)	28.6%	28.6%
	3	CVD Statin Therapy	40.3%	26.6%	IPV/DV Screening	32.6%	41.6%
2 0 2 0	1	Statin Therapy	62.6%	51.6%	Adult Immunizations	25.9%	59.7%
	2	CVD Statin Therapy	42.8%	35.7%	Topical Fluoride	14.1%	34.5%
	3	HIV Screening Ever	31.5%	28.4%	Retinopathy Exam	36.0%	53.5%

Definitions of Performance Metrics See Appendix*

BEST PRACTICES TO ADDRESS PROBLEMS AND CHALLENGES IN GPRA DATA:⁷

UIOs face several challenges in their efforts to collect data and achieve GPRA metrics. These challenges include the need to troubleshoot issues, secure healthcare center buy-in, provide adequate training, lack of employee capacity, and implement technology updates and requirements.

To begin to address these challenges, it is essential to prioritize Electronic Medical Record (EMR) reminders or alerts for clinicians, and updated medical coding, taxonomies, and ICD-10 codes. These updates will allow for more efficient and streamlined healthcare services and reporting.

Another critical challenge is the lack of healthcare center buy-in. The prioritization of GPRA within Urban Indian Organizations is an essential aspect of enhancing the quality of care. By visualizing benchmarks as indicators of care quality, as opposed to solely numerical targets, UIOs can integrate these standards into their daily operations. It is recommended that sites hold themselves accountable for adhering to these standards for both internal assessment and external reporting purposes. In instances where metrics are not met, it is advisable that they are considered as opportunities for Quality Assurance Projects.

Establishing a dedicated GPRA team comprising of both medical and non-medical staff can ensure that responsibilities are clearly defined, thereby making the targets more attainable and allowing providers to focus more on patient interactions.⁷ Effective coordination and communication are crucial to overcoming these challenges. Therefore, establishing a GPRA Coordination Committee and holding regular structured interactions, such as morning huddles or weekly medical meetings, provide ample opportunities to discuss GPRA metrics. These interactions facilitate the sharing of insights and strategizing on how best to further improve metrics, fostering a collaborative environment for continuous improvement. Furthermore, ensuring the availability, improvement, and sharing of GPRA data is fundamental. Data should be readily accessible, regularly updated, and shared with all stakeholders, including medical and quality improvement staff, to allow for early identification of issues and collaborative problem-solving.⁷

Encouraging internal development and the use of technology can further enhance the effectiveness of GPRA measures.⁷ UIOs should foster local solutions and employ information technology to track care delays and community health statuses. Innovations such as electronic clinical reminders and specialized clinics that provide comprehensive care and use incentives can significantly improve patient outcomes.  Additionally, learning from peers or other UIOs by visiting sites that exhibit best practices can provide invaluable insights into effective strategies and areas requiring improvement. This peer learning helps in directly understanding what works and what doesn’t from those who have experienced it first-hand.

It is important to focus on the actual health outcomes achieved through the implementation of GPRA measures, rather than merely the activities performed. Adhering to an outcomes-focused approach ensures that the efforts are not solely geared towards meeting metrics but genuinely improving patient health, which is the ultimate goal of these measures. In conclusion, addressing the challenges faced by Urban Indian Organizations is essential to improving healthcare services for communities. By prioritizing the necessary updates and providing adequate training, we can ensure that healthcare centers are fully invested in delivering high-quality care to all patients, and by promoting effective communication, we can continuously improve our services.

For more information on best practices visit: https://www.ihs.gov/crs/toolbox/.

For more information on GPRA Performance Measures visit: https://ihs.gov/sites/crs/themes/responsive2017/display_objects/documents/crsv24/GPRA-FY-2022-2023-2024.pdf

APPENDIX

References:

1. Claymore, V., & Boney, M. (2024, March). UIO GPRA/GPRAMA UPDATES. Indian Health Services. Online; Online.
2. Indian Health Services. (n.d.). Understanding the Government Performance and Results Act (GPRA)/ GPRA Modernization Act (GPRAMA). https://www.ihs.gov/crs/includes/themes/responsive2017/display_objects/documents/toolbox/GPRAHandoutforPatients.pdf
3. Weahkee, R., & Mueller, R. (2018). 2018 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
4. Weahkee, R., & Mueller, R. (2019). 2019 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
5. Weahkee, R., & Mueller, R. (2020). 2020 Indian Health Service Urban Indian Health Organizations GPRA/GPRAMA Results. Rockville, MD; Indian Health Service.
6. Indian Health Services. (n.d.). 2011 GPRA Best Practices. 2011 GPRA Meeting. https://www.ihs.gov/california/tasks/sites/default/assets/File/GPRA/2011GPRAMtg-GPRABestPractices.pdf

Definitions:

• Adult Composite Immunizations: Percentage of adults age 19 and older who receive recommended age-appropriate vaccinations.
• Breastfeeding Rates: Percentage of patients who, at the age of 2 months, were either exclusively or mostly breastfed.
• Cancer Screening: Mammogram Rates: Percentage of women ages 52 to 74 years of age, who have had mammography screening within the previous two years.
• Diabetes: Statin Therapy to Reduce CVD Risk in Patients with Diabetes: Percentage of patients with diagnosed diabetes who received a prescription for statin therapy.
• Diabetes: Nephropathy Assessment: Percentage of patients with diagnosed diabetes assessed for nephropathy.
• Diabetes: Retinopathy: Percentage of patients with diagnosed diabetes who received an annual retinal exam
• Domestic (Intimate Partner) Violence Screening: Percentage of women who are screened for domestic violence at health care facilities.
• HIV Screening Ever: Percentage of patients who were ever screened for HIV.
• Statin Therapy for the Prevention and Treatment of Cardiovascular Disease: Percentage of patients with CVD or at high risk for CVD who receive a statin therapy prescription
• Topical Fluorides: Percentage of patients ages 1-15 who received one or more topical fluoride applications.