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Section 2: Guiding Principles From the outset, it was decided that a set of guiding principles be used to keep the group’s task in focus. An undated memo that I acquired from meeting notes provided this rationale for adopting these principles as values. "Values set the organization’s standard for acceptable behavior. The subgroup decided that the Guiding Principles for Designing a New IHS set the values for the Agency and what it will be after its redesign" (Notes, 1995)

Twelve Guiding Principles were adopted by the IHDT in February 1995. Their importance cannot be understated. As the design process went into implementation, there were many impasses and disagreements. In a personal interview with one of the co-chairs of the IHDT, I asked him to comment in hindsight, how important these principles were. He answered:

During our first meeting, we listed our beliefs and our principles. And those beliefs and principles had to take precedence over our personal agendas. We would go back and constantly refer to those principles during the course of our planning. The principles got us through some rough times and tough times…it was funny, when we first did them, we never thought that they would come into play, but as it evolved, they were our guides. Someone would say, hey "remember, WE said this". I tried not to put my personal goals ahead of the group’s…We were here to do a job (Floyd, 1997).

In keeping with the "patient comes first" principle, input from the customers (patients) and the direct providers (employees) was solicited via a survey to guide the IHDT. The composition of the IHDT, consisting of 22 tribal or urban Indian health program representatives and 7 IHS administration delegates, was also consistent with the bottoms-up approach. Major recommendations of their report were to:

1.Redefine the Director’s role (and by extension, the role of headquarters) as a leader and advocate rather than an operational manager.

2. Change the role of all levels above the local units to that of support rather than control. This would mean consolidating the current 12 area offices into 3 or 4 units. They would then be responsible for payroll, personnel training, accounting services, technology and property/asset management.

3. The dollar savings effected from the above would be re-distributed to local units to carry out the function of service to customers. The red tape of reporting and administration would be streamlined in conjunction with the new support structure created above.

4. Most importantly, the IHDT recommends empowerment of local units to shape their own structure. It would provide flexibility in line item budgeting, authority for demonstration projects and allowing revisions in compensation to reward clinical expertise equal in value to management and supervisory skills.

The first two above points are well into the implementation stage. For point one, Headquarters have in fact been reduced. The downsizing of the twelve area offices in point two remains open. This is interesting to note because while the recommendation was made, it remains just a recommendation. As Tribal leaders convened to discuss the practical implications of consolidating twelve offices into three or four area offices, it was decided that this may not be the best idea. How this will eventually come out is yet to be decided.

Point three still stands as a basic tenet. Downsizing headquarters in the BIA plan did not state that any savings would be redirected to the local reservation delivery system. That was one reason for its downfall. That plan was blatantly a plan to cut the budget. There was no mechanism to "improve" the system. The IHDT plan specifically writes this out.

The empowerment of local units in point four is critical. While this step of implementation has not yet occurred, the decisions on how and how many services will be delivered will be made at the local level. An acronym, I/T/U, has emerged from the IHDT planning process. The "I" stands for local units operated by federal Indian Health Services. The "T" represents those units operated by tribes, and the "U" is for the local urban units.

IN SUMMARY, HERE ARE THE TWELVE PRINCIPLES

. Appendix 5: Guiding Principles for Restructuring

1. PATIENT CARE COMES FIRST.

2. BEING CUSTOMER-CENTERED. Being customer-centered shall become a core value in the mission of all Indian organizations along with the IHSI. Customers include all people, tribes and other Indian organizations dependent on a program’s service.

3. FOCUS ON HEALTH. Clinical, public health, and administrative functions shall be focused to promote high quality and cost effective patient care services. Any savings resulting from redesign shall be directed to patient care.

4. SOVEREIGNTY. The Federal government shall honor, uphold, protect, and advocate inherent sovereign rights and rights of the American Indian and Alaska Native Nations as evidenced by the treaty signing process, the content of those signed treaties by the signatory parties, and as afforded by the United States Constitution, Treaties, United States Statutes, Treaty Cessions, State Constitutional Disclaimer Provisions, Agreements, International Declarations of Indigenous Peoples Rights and Executive Orders.

5. CULTURAL SENSITIVITY & DIVERSITY. Structure, programs, and services shall be designed in partnership to respect cultural diversity at the local level.

6. TRUST RESPONSIBILITY. The Federal government has the trust responsibility to provide health services to Indian people.

7. EMPOWERMENT & ADAPTABILITY. Sufficient decision-making autonomy shall exist at the local level to enable capacity to address service delivery needs.

8. ACCOUNTABILITY. Accountability systems shall be designed to ensure efficiency, effectiveness, and patient and customer satisfaction regarding the achievement of IHS’s primary mission involving patient care, health promotion, and advocacy for tribal governments and Indian organizations.

9. FAIR TREATMENT OF EMPLOYEES. Employees shall be treated fairly and compassionately in all changes in the structure and programs of Indian health programs.

10. EXCELLENCE. Commitment to excellence shall be achieved and maintained in administrative, clinical, and public health programs and practices.

11. SYSTEM-WIDE SIMPLIFICATION. Administrative requirements and systems shall be simple and efficient for all Indian health programs operated through compacts, contracts, grants, as well as federal.

12. FULL DISCLOSURE & CONSULTATION. IHDT products shall be provided to stakeholders. Consultation shall be undertaken with tribes and Indian organizations to achieve knowledgeable participation in decision-making.

Approved by IHDT, 2/9/95