HONORING NATIONS: 1999 HONOREE

Institutionalized Quality Improvement Program
Puyallup Tribal Health Authority, Puyallup Tribe of Indians

Contact:
Lois Jacobs, QI Committee Coordinator
Puyallup Tribal Health Authority
2209 East 32nd St., Tacoma, WA 98404
Tel. (253) 593-0232 Fax (253) 272-6138 http://www.geocities.com/puyallup_tribe_of_indians

For years, members of the Puyallup Tribe suffered from serious health and social problems, many of which could be attributed to the reservation process, federal government neglect, and discrimination against Indians practiced by more recent settlers to the Pierce County, WA (Puget Sound) area. And the members of the Puyallup Tribe were not alone—the larger Native population in the county suffered from the same problems. In the early 1990s, for example, 95 percent of the Indians living on or near the Puyallup reservation had, or were affected by someone who had, a substance abuse problem. As recently as the 1970s, the Indian population on the reservation and in Pierce County generally had little or no health care. The Puyallup Tribe provided a few contract referral services through the Indian Health Service (IHS) and managed a small dental clinic and women’s health clinic in a church basement, but apart from these, there were virtually no other services available to meet local Indians’ health needs.

The Self-Determination Act of 1975 provided the Puyallup Tribe with an opportunity to change at least some of this picture. Under the provisions of the Act, the Tribe contracted with the IHS to self-manage tribal health programs. It secured additional IHS funding to establish a small, comprehensive medical clinic, and thus, in the late 1970s, the Tribe itself began to address the severe medical needs of the Indians in Pierce County.

Initially, the Tribe focused on self-management and program consolidation. By creating the Puyallup Tribal Health Authority (PTHA) and assuming greater responsibility for its own programs, the Tribe hoped to make significant progress against the dire health and social concerns of its client population. But in 1986, PTHA’s leaders determined that this approach was insufficient. While preparing for an accreditation review, PTHA staff agreed that to make truly substantial progress against the health needs of the community, it would be essential for the Health Authority to focus on providing high quality health care.

The Quality Improvement Program is the PTHA’s response to this challenge. The idea is simple—create a team of individuals charged with the task of making the health system as effective, efficient, and excellent as possible. This twelve-member team, called the Quality Improvement (QI) Committee, is comprised of representatives from the major service programs and select administrative staff—health care workers and program directors who know what improvements are needed and can determine how to meet them. The QI Committee meets once a month to determine health priorities, review performance, and implement policies and actions that will improve the overall effectiveness of the PTHA in each of its program and service areas. Because client satisfaction is a priority, the Committee also regularly administers patient health surveys to better respond to community needs.

The creation and implementation of the Quality Improvement Program has clearly improved the Puyallup Tribal Health Authority’s performance. The PTHA’s recent accreditation scores are one measure of the Program’s success. In 1998, the Authority received its first perfect score for services and its ambulatory care program scored 97 percent. Also in 1998, the PTHA exceeded standards in four of the five areas in which it sets clinical objectives—SIDS prevention, children’s immunizations, tobacco use documentation, and baby bottle tooth decay prevention. Even in the fifth area, pap smear compliance, the Health Authority’s achievements far exceeded those of other Northwest tribes.

Because the QI Program stresses outreach and prevention, visits to PTHA clinics are another measure of the Program’s impact. Since the QI Program’s inception, clinic visits have increased dramatically. Between 1994 and 1998, the number of visits to Puyallup clinics by Indians residing in the Pierce County increased from 4,978 to 7,553. By seeing more members of its service population and seeing them more often, the PTHA is better able to treat chronic problems and to address many other problems that, left unattended, could become serious.

The Program’s excellent human resources are a final measure of success. Despite the PTHA’s relatively small client population, it has funded positions for six full-time physicians, and it has managed both to recruit highly qualified practitioners and to limit their turnover. In the reservation context, these are remarkable feats. In total, the PTHA has 210 employees, and American Indians fill 45 percent of the positions.

The keys to the Quality Improvement Program’s success include sound administration, good communication, and a dedicated staff. An important additional factor is the PTHA’s full adherence to its mission “to provide quality health care and promote wellness in a culturally appropriate manner.” Puyallup traditions and practices are an integral part of the PTHA’s and QI Program’s functions and activities. These commitments are reflected not only in the physical surroundings of the Health Authority (for example, its facilities are decorated with exquisite native artwork and there is a meeting room modeled after a traditional Puyallup longhouse), but in its practices as well. Under the guidance of the QI Committee, the PTHA has pursued numerous opportunities to introduce Indian and Puyallup values and services into its offerings. For example, the mental health facility provides on-site sweat lodges, children’s counselors use Indian dolls and figurines, and the PTHA supports the use of traditional healers to complement Western medicine. Puyallup customs are even used to strengthen the Authority’s administrative systems. The PTHA staff is divided into cross-functional “clans” which meet weekly to coordinate services for patients who receive treatment from numerous programs, thereby encouraging a more holistic approach to healthcare.

The Puyallup Tribe’s institutionalized Quality Improvement Program provides solid evidence that tribes can not only assume responsibility over their own health care services, but also provide creatively managed, culturally appropriate, high quality health care. Since the Program’s implementation, the Puyallup Tribal Health Authority has significantly improved the quality and range of its health programs and positively affected the lives of its 8,000 clients.