IHCRC26 Baldrige Application

2026 MALCOLM BALDRIGE NATIONAL QUALITY AWARD APPLICATION Journey of the Medicine Wheel

Table of Contents Glossary of Terms and Abbreviations................................................................................................. G1 Preface: Organizational Profile P.1 Organizational Description.................................................................................................................. i P.2 Organizational Situation.................................................................................................................... iv 1: Leadership 1.1 Senior Leadership................................................................................................................................ 1 1.2 Governance and Societal Contributions.............................................................................................. 3 2: Strategy 2.1 Strategy Development......................................................................................................................... 7 2.2 Strategy Implementation................................................................................................................... 10 3: Customers 3.1 Customer Expectations..................................................................................................................... 13 3.2 Customer Engagement...................................................................................................................... 14 4: Measurement, Analysis and Knowledge Management 4.1 Measurement, Analysis, Review, and Improvement of Organizational Performance......................... 15 4.2 Information and Knowledge Management....................................................................................... 15 5: Workforce 5.1 Workforce Environment.................................................................................................................... 17 5.2 Workforce Engagement..................................................................................................................... 18 6: Operations 6.1 Work Processes.................................................................................................................................. 20 6.2 Operational Effectiveness.................................................................................................................. 21 7: Results 7.1 Health Care and Process Results ...................................................................................................... 23 7.2 Customer Results ............................................................................................................................. 28 7.3 Workforce Results ............................................................................................................................ 31 7.4 Leadership and Governance Results ................................................................................................ 33 7.5 Financial, Marketplace, and Strategy Results ................................................................................... 34 Addendum A.1 CEO Strategic Vision...................................................................................................................... 37

G1 | Glossary of Terms and Abbreviations

Glossary of Terms and Abbreviations A AAAHC – Accreditation Association for Ambulatory Health Care

assistant developed by Microsoft, designed to enhance clinical workflows.

DV – Domestic Violence

AARP – American Association of Retired Persons

E EHR – Electronic Health Record

ADA – Americans with Disabilities Act

F

ADLI – Approach, Deployment, Learn, Integration

FDA – Food and Drug Administration

AI – American Indian B BH – Behavioral Health Birkman Assessment – identifies personality traits and work preferences to improve performance and collaboration.

C CARES – IHCRC's Values: Community, Accountability, Respect, Excellence, Stewardship CBHO – Chief Behavioral Health Officer

G GPRA – Government Performance and Results Act H HIPAA – Health Insurance Portability and Accountability Act HITECH – Health Information Technology for Economic and Clinical Health Act HIV – Human Immunodeficiency Virus HR – Human Resources

CDC – Centers for Disease Control and Prevention

I IHCRC – Indian Health Care Resource Center of Tulsa

CDIB – Certificate of Degree of Indian Blood

IHS – Indian Health Service

CEO – Chief Executive Officer

IPV – Intimate Partner Violence

CFO – Chief Financial Officer

IT – Information Technology

CHRO – Chief Human Resource Officer

COO – Chief Operating Officer

L Lean – a data-driven methodology that combines focus on eliminating waste with emphasis on reducing variation to improve processes, quality, and efficiency.

COVID-19 – Coronavirus Disease 2019 (Pandemic)

M MARTII – Medical Interpreter Service

CPR – Cardiopulmonary Resuscitation

MFA – Multi-factor Authentication

CQI – Continuous Quality Improvement

MH – Million Hearts Program

CVD – Cardiovascular Disease

MVV – Mission, Vision, and Values

D DM – Diabetes Management

N NACC – Native American Community Committee

CMS – Centers for Medicare and Medicaid Services

Dragon DAX Copilot – an AI-powered clinical Level 4 Application - 2026

Glossary of Terms and Abbreviations | G2

NRC Health – Patient Satisfaction Survey Platform O OB – Obstetric care OSHA – Occupational Safety and Health Administration OSU – Oklahoma State University OT – Occupational Therapy P PCMH – Patient-Centered Medical Home PCP – Primary Care Physician PDSA – Plan, Do, Check, Act PolicyStat – Policy Management Software PT – Physical Therapy Q Q&A – Questions and Answers R RPMS – Resource and Patient Management System S SBIRT – Screening, Brief Intervention, and Referral to Treatment SMART – Specific, Measurable, Attainable, Relevant, Time-bound SOP – Standard Operating Procedure SPTHB – Southern Plains Tribal Health Board ST – Speech Therapy SWOT – Strengths, Weaknesses, Opportunities, and Threats T Telehealth – the use of digital communication technologies to deliver healthcare service.

W WIC – Women, Infants, and Children

G3 | Glossary of Terms and Abbreviations

Preface: Organizational Profile P.1 Organizational Description P.1a Organizational Environment P.1a(1) Health Care Service Offerings Indian Health Care Resource Center of Tulsa (IHCRC) was founded in 1976 to address unmet healthcare needs for urban American Indians in Tulsa. Today, IHCRC serves more than 10,000 patients annually from over 130 federally recognized tribes, offering a wide array of services designed to meet medical, behavioral, and social needs.

IHCRC provides medical services that span the entire lifespan, including primary care, pediatrics, geriatrics, obstetrics, dentistry, optometry, lab services, and radiology. Preventive health is a major focus, with health and wellness screenings, diabetes management programs, and immunization campaigns. Special community events and health fairs further extend access to preventive care.

The Pharmacy Department supports both clinical care and patient education. In addition to prescription refills and fills, pharmacy staff provide medication counseling to improve patient understanding and adherence. IHCRC’s on-site pharmacy increases continuity of care by ensuring patients can obtain their medications at the same location as their medical visit. The pharmacy currently operates three robotic dispensing systems that together can label and deliver up to 250 medications per hour, significantly reducing wait times. With the completion of IHCRC 530, the pharmacy space has more than doubled in size and has added five drive-thru lanes for ease of access.

The Behavioral Health Department offers psychiatry, psychology, counseling, and case management. Services are grounded in evidencebased practices such as trauma-informed care, motivational interviewing, and integrated case management. The co-location of behavioral health within the medical home model ensures patients can seamlessly access mental health and primary care, improving overall health outcomes.

IHCRC also operates service units in diabetes education, nutrition, public health, fitness, youth development, and elder socialization. These Level 4 Application - 2026

services address chronic disease management and social determinants of health. For example, the diabetes program integrates nutrition counseling with culturally tailored education to support patients in achieving sustainable lifestyle changes.

The Elder Program, launched with United Health Foundation funding, includes social and community-based activities.

In 2025, IHCRC added physical therapy and began planning for occupational and speech therapy services in 2026. These services were identified as high-need areas through referrals and community feedback. These services strengthen IHCRC’s ability to provide comprehensive rehabilitation care under one roof, reducing delays and external referrals.

Revenue contributions demonstrate the importance of these offerings. Medical services generate approximately 26% of organizational revenue, pharmacy services generate 37.5%, while grants and contracts provide 35%, and private contributions account for the remaining 1.5%.

IHCRC delivers care through the PatientCentered Medical Home (PCMH) model, which emphasizes coordinated, team-based care. Patients are assigned to one of three provider teams, two adult teams and one pediatric team. Every effort is made for patients to see their primary provider; in recent years, this has occurred in 78% of visits. PCMH ensures care continuity and quality by emphasizing five attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Nurse case managers play a vital role by bridging communication between providers and patients.

Through this integrated model, IHCRC offers patients “one-stop access” to comprehensive, culturally competent care, positioning the organization as a trusted provider for the urban Native community.

P.1a(2) Mission, Vision, Values, and Culture — Mission: To empower the American Indian through exceptional healthcare!

— Vision: We will be the recognized leader in redefining primary healthcare for the American Indian.

— Values: Community, Accountability, Respect, Excellence, and Stewardship (CARES).

IHCRC sustains a values-driven culture Organizational Profile | i

emphasizing professionalism, continuous learning, and collaboration across departments.

The CARES values guide decision-making, performance expectations, and interactions with patients and staff. They are reinforced during hiring, orientation, training, and evaluations.

Leaders model transparency and accountability, and communication practices ensure employees understand priorities. Monthly staff meetings provide organizational updates, recognize achievements, and include training sessions. Development days emphasize crosstraining, teamwork, and problem-solving.

Cultural competence is fully integrated into IHCRC operations and service delivery.

The Teachings of the Medicine Wheel Cultural Competence Guide serves as a foundational framework, linking Native traditions, values, and whole-body perspectives on health to the care provided within the clinic. This guide helps employees understand the interconnectedness of physical, emotional, mental, and spiritual wellbeing, ensuring that services honor both cultural identity and medical best practices.

IHCRC has been named a Best Place to Work in Oklahoma multiple times, demonstrating the effectiveness of this culture in supporting both workforce engagement and patient care.

P.1a(3) Workforce Profile IHCRC employs approximately 170 staff members, with 39% identifying as American Indian. The workforce includes physicians, nurse practitioners, pharmacists, nurses, behavioral health clinicians, therapists, dentists, ancillary staff, administrative professionals, and leaders.

Workforce engagement is shaped by four drivers: 1. Mission alignment – Employees are motivated by the opportunity to serve the Native community.

2. Professional development – Continuing education reimbursement, skill training, and leadership pathways encourage growth.

3. Recognition – Staff contributions are celebrated in monthly meetings, annual events, and awards tied to CARES values.

4. Cultural pride – Staff find meaning in connecting cultural traditions to healthcare delivery.

Onboarding and Training: New hires ii | Organizational Profile

complete a structured four-day orientation covering compliance, safety, organizational policies, and cultural awareness. Annual training keeps staff current on clinical competencies, regulatory requirements, and cultural practices.

Performance and Feedback: Employees are evaluated at 30, 60, and 90 days, and annually thereafter, with evaluations tied to career progression and organizational goals. Leaders conduct rounding sessions to gather real-time staff feedback, which has led to workflow improvements and communication enhancements.

Engagement and Voice: IHCRC conducts annual workforce surveys and participates in the Best Places to Work in Oklahoma program.

Results drive improvements in communication, recognition, and professional development. Data from this survey supports trend analysis and ensures actions are evidence-based.

Diversity and Representation: Nearly 40% of staff identify as American Indian, reflecting the population served. This strengthens trust with patients and ensures care is culturally informed.

Recruitment emphasizes both professional expertise and cultural competency.

IHCRC’s workforce systems ensure employees are engaged, supported, and aligned with the mission. We recently integrated Birkman assessments into our workforce strategy to better align individual strengths with team goals. By embedding professional growth, recognition, and continuous feedback into daily practice, the organization sustains a capable and motivated workforce prepared to deliver exceptional healthcare.

P.1a(4) Assets IHCRC operates a multidisciplinary campus in Tulsa on Muscogee Creek land. The original facility, built in 1999 and expanded in 2011, remains a hub for services. In 2025, IHCRC opened IHCRC 530, a 62,000-square-foot addition housing Dental, Optometry, Fitness Education, and Pharmacy while introducing Physical Therapy, Occupational Therapy, Speech Therapy, as well as a same-day clinic.

The financing of IHCRC 530 was recently paid off in full, leaving the organization debt-free in facility investments. This strengthens long-term sustainability and enables resources to be directed

toward expanding programs and improving and promote continuous improvement. patient care.

The campus includes state-of-the-art P.1b Organizational Relationships diagnostic imaging, mammography, dental and P.1b(1) Organizational Structure optometry equipment, and automated pharmacy IHCRC operates under the oversight of a systems. Fitness education has a workout space Board of Trustees composed of community that rivals many professional gyms, supporting leaders and representatives from the American prevention and chronic disease management.

Indian community. The Board sets strategic IHCRC maintains a resilient IT infrastructure, direction, ensures alignment with IHCRC’s including redundant fiber internet, virtualized mission, vision, and values, and provides fiduciary servers, cloud-based backups, and 24/7 security oversight. Organizational Chart can be found in monitoring. The organization currently uses the Figure P.1-1.

IHS national electronic health record, RPMS, The Chief Executive Officer (CEO) leads and is preparing to transition to a new electronic daily operations and reports directly to the Board health record, as part of the future IHS technology of Trustees. Senior leaders report to the CEO or strategy.

COO and oversee operational areas including P.1a(5) Regulatory Environment IHCRC is Medical, Behavioral Health, Information accredited by the Accreditation Association for Technology, Finance, Human Resources, and Ambulatory Health Care (AAAHC), with Medical Marketing/Development. The Executive Team Home recognition since 2013 and Dental Home made up of senior leaders, manages strategic recognition since 2022. The organization complies planning, continuous quality improvement, and with CMS, HIPAA, OSHA, ADA, CDC, and FDA organizational learning processes. Managers requirements. Committees in pharmaceuticals, lead service units and ensure alignment with risk management, finance, development, and organizational strategy through departmental quality improvement ensure ongoing compliance metrics performance reviews.

INDIAN HEALTH CARE RESOURCE CENTER OFand TULSA, INC ORGANIZATIONAL CHART – 2026

Figure P.1-1 Organizational Chart MANAGEMENT of Functional Areas – Department Heads Board of Trustees

Chief Executive Officer Administrative Support

Chief Financial Officer *Baldrige Champion Compliance Officer Financial Audits Accounting & Purchasing Manager Accounts Payable Contracting Specialist

Chief Human Resource Officer *Baldrige Champion

Chief Operating Officer *Baldrige Champion

Employee Relations, Staff Development/Training, Job Descriptions/Payroll/DOL/EEOC Board Governance, Policy & Procedure, Compliance, Risk Management HR Manager, Benefits, OESC, Onboarding, Exit Interviews, FMLA

Director, Credentialing, Privileging, Accreditation, AAAHC Talent Acquisition Manager, Recruitment, Retention, AAP, Compensation

Chief Development Officer *Baldrige Champion

Fitness Program, Healthy Start Patient Risk Management Dental Services

Marketing & Communications Manager, Community Relations/ Media

Development Grants/ Fundraising DTM

Optometry Services

Director, Facilities Maintenance/ OSHA, Transportation, Housekeeping/ Security Director of Nursing Services, Infection Control, Public Health Nursing, PCMH- Nursing

Chief Information Officer *Baldrige Champion Systems Administration, Cyber Security

Interim Chief Behavioral Health Officer *Baldrige Champion

Chief Strategy Officer

Chief Medical Officer

*Baldrige Champion

*Baldrige Champion

Director, Behavioral Health Psychology Services NOPIP/Clinical Training Director, Pediatric BH Mental Health Counseling, Youth Support Services, Social Work Services

Psychiatry Services

Strategy

Quality Improvement

Primary Care Services, Pediatric Care Services, PCMH

Chief Administrative Officer *Baldrige Champion

HIPAA Privacy Officer

Medical Quality/ Peer Review, Integrated Health

Health Information Management

Nutritional Services, SDPI

Patient Business Office 3rd Party Contracting Patient Benefits, Referral Services, Coding

Integrated Health CAC/ RPMS

Pharmacy Services

RN- Utilization Review Nurse Accounts Receivable Manager

Lab/ Imaging Manager, Mammography, Ultrasound Therapy Physical Therapy, Occupational Therapy, Speech Therapy

Level 4 Application - 2026

Organizational Profile | iii

This governance and leadership system ensures accountability, transparency, and alignment of operations with IHCRC’s mission and vision.

P.1b(2) Patients, Other Customers, and Stakeholders IHCRC serves patients from more than 130 federally recognized tribes residing in Tulsa and across Oklahoma. Key market segments include children and youth, adults with chronic disease, elders, and individuals seeking behavioral health services. Patients represent diverse tribal affiliations, though the largest groups include Cherokee, Muscogee (Creek), Choctaw, Osage, and Chickasaw citizens.

Patients and families expect timely access, coordinated services, cultural competence, and high-quality care. Elders prioritize geriatric services and cultural engagement opportunities, while families value preventive services, youth development, and behavioral health support.

Stakeholders, including funding agencies and community partners, expect strong stewardship, measurable results, and collaboration.

IHCRC responds to these expectations through continuous feedback systems, including patient satisfaction surveys and workforce surveys. Leadership reviews this input to guide improvements in care delivery, communication, and programming.

P.1b(3) Suppliers, Partners, and Collaborators IHCRC depends on a diverse network of suppliers, partners, and collaborators to deliver exceptional care. Suppliers provide pharmaceuticals, dental and optometry equipment, IT infrastructure, payroll and workforce learning programs, and medical supplies, with requirements for reliability, regulatory compliance, and cost effectiveness.

Partners extend IHCRC’s impact by supporting prevention, education, and wellness initiatives. Collaborators include Tulsa Parks and Recreation, American Red Cross, LIFE Senior Services, Tulsa County Sheriff’s Office, Tulsa Fire Department, Tulsa Health Department, Tulsa Interagency Council, Tulsa City-County Library, Oklahoma Department of Health, AARP, and the Indian Health Service. These relationships support programs such CPR certification, public health initiatives, and cultural events. iv | Organizational Profile

IHCRC also partners with universities and training programs to host interns, especially in behavioral health, creating a pipeline for future workforce recruitment.

Through these relationships, IHCRC enhances its ability to deliver comprehensive, culturally competent, and innovative healthcare services while remaining responsive to patient and community needs.

P.2 Organizational Situation P.2a Competitive Environment IHCRC is one of only a few urban Indian health organizations in the nation, serving patients from more than 130 tribes. While 4.4% of Tulsa’s residents identify as American Indian, IHCRC’s reach extends across 60 of Oklahoma’s 77 counties and into surrounding states.

Competitors include Muscogee Creek Nation clinics, Cherokee Nation facilities, and the IHS Pawnee Indian Health Center. Unlike these tribal systems, IHCRC operates independently of tribal and federal governance, offering comprehensive integrated services on a single campus. This minimizes referrals, fosters provider collaboration, and ensures continuity of care.

P.2b Strategic Context IHCRC’s environment presents both challenges and advantages: • Challenges: Recruitment and retention of healthcare professionals, variability in funding, rising behavioral health needs, and chronic disease prevalence.

• Advantages: Strong reputation, integrated care model, culturally competent workforce, stable leadership, and repeated recognition as a Best Place to Work.

• Opportunities: Growth through IHCRC 530, expansion of PT/OT/ST services, further adoption of telehealth, stronger partnerships, and applying Baldrige principles to achieve performance excellence.

P.2c Performance Improvement System IHCRC’s Quality Improvement Plan provides the structure for evaluating and improving

processes and outcomes. The plan aligns with AAAHC standards and Baldrige principles, ensuring systematic improvements that are deployed, learned from, and integrated across the organization utilizing ADLI. • Approach: IHCRC uses Lean, PDSA, and Baldrige assessments to identify opportunities. Data include GPRA benchmarks, departmental dashboards, patient surveys, and workforce engagement results.

• Deployment: Projects are implemented through departmental key performance indicators, cross-functional committees, and monthly staff development sessions.

For example, new PT/OT/ST service units were deployed after patient referral data revealed gaps.

• Learning: Lessons are captured through staff rounding, workforce surveys, and patient feedback. Input from the Best Places to Work survey led to expanded professional development and new recognition programs. The MVV update process provided valuable learning in communication and strategic alignment.

• Integration: Performance data and improvement priorities are currently shared through an informal process, primarily with the Leadership Team. As data collection and reporting mature, IHCRC is working toward more consistent sharing of results across the organization to strengthen alignment, decision-making, and continuous improvement.

IHCRC demonstrates its identity as a learning organization. Telehealth and flexible scheduling developed during COVID-19 were refined with staff and patient feedback and made permanent.

Workforce survey data continues to guide engagement strategies, ensuring continuous adaptation and improvement.

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Organizational Profile | v

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vi |

1: Leadership 1.1 Senior Leadership 1.1a Mission, Vision, and Values 1.1a(1) Senior leaders at IHCRC establish the mission, vision, and values through a structured process involving the Executive Team. These leaders meet regularly and conduct strategic planning sessions quarterly where the MVV is reviewed in the context of the organization’s longterm goals, current environment, and community needs. The Executive Team are responsible for refining the language, confirming alignment with our culture and objectives, and presenting any updates to the Board of Trustees for approval.

Deployment of the MVV begins during onboarding, with a four-day orientation designed to introduce new employees to the history, mission, and operational philosophy of IHCRC. The MVV is also reinforced through our Cultural Competency Guide, The Teachings of the

Medicine Wheel, which connects key values like respect, balance, and responsibility to Native cultural teachings. Staff are expected to uphold these values in their daily work and interactions.

Leadership regularly reinforces the MVV in full-staff meetings, Leadership Team and Executive Team meetings, and rounding visits.

These values are actively used as filters for decision-making, hiring, and policy development.

During departmental planning and leadership conversations, the MVV is used as a standard to determine if new initiatives or decisions are in alignment. Patients are also introduced to the MVV through signage, educational materials, and interaction with staff who embody these principles.

1.1a(2) IHCRC promotes ethical behavior at every level through consistent leadership actions, formal training, clear policies, and accountability systems. Senior leaders model expected behavior by adhering to established codes of conduct

Figure 1.1-1 Leadership System Leadership Communication System Embedded Learning

Set Direction

Driven by Excellence & Respect

M I S S I O N

• • • • •

Organizational Learning System Knowledge Management System Workforce Development System Peer Review System Lean Engagement System

Driven by Excellence & Accountability • • • • •

Strategic Planning System MVV Integration System Governance Oversight System Board Engagement System Strategic Goal Deployment System

LEADING WITH CARES Establish Expectations Build Culture Driven by Stewardship & Accountability Driven by Community & Respect • • • • •

Performance Monitoring System Compliance & Ethics Reporting System Risk Management System Incident & Near-Miss Reporting System Policy & Procedure Alignment

• • • • •

Onboarding System Cultural Integration System Engagement & Recognition System Leadership Communication System Cultural Engagement System

V I S I O N

Performance Measurement System Core Values: IHCRC CARES Level 4 Application - 2026

Leadership | 1

and responding promptly to any concerns or violations.

All employees complete annual training in HIPAA, OSHA, Fraud, Waste, and Abuse, Antidiscrimination, diversity, sexual harassment, and corporate compliance. These trainings are tracked through the Relias Learning Management platform. In addition, IHCRC offers internal education on how to identify and report ethical concerns. Policies and expectations are included in staff handbooks, available online through Policystat policy management software, and reinforced through leadership communication.

When issues arise, they are addressed through an internal investigation process led by the Chief Human Resources Officer, often in collaboration with the Executive Team. Outcomes of investigations are reported to the CEO and may be escalated to the Executive Committee if serious or involving senior leadership/CEO. Findings result in corrective action, policy changes, or further training.

IHCRC also promotes transparency and accountability through its “near-miss” reporting system, which encourages staff to report errors

or risks before they become actual issues. Rather than being punitive, the system supports a culture of safety and continuous learning. IHCRC has an external Compliance Hotline where staff may report compliance issues anonymously.

1.1b Communication Communication is a strategic priority at IHCRC, with senior leaders using multiple methods to keep staff and stakeholders informed, engaged, and aligned. At the organizational level, IHCRC hosts a full-staff meeting on the first Wednesday of every month. These meetings, led by the HR department, CEO, CHRO, COO, and other leaders, offer updates on performance, highlight employee contributions, celebrate work anniversaries, introduce new hires, and reinforce the MVV. The meetings are interactive and often include presentations, training, or Q&A sessions to address concerns directly.

Midway through the month, the Chief Operating Officer produces “Operationally Speaking,” a video newsletter update that summarizes key developments, addresses ongoing initiatives, and spotlights high-performing teams

FigureLEADERSHIP 1.1-2 Leadership Communication System COMMUNICATION SYSTEM Frequency

Audience

Purpose

Direction

Onboarding

Method

Ongoing

E

BC

>

Board Meeting

Bi-Monthly

SL, E, B

SD

><

Weekly

SL

ALL

><

Senior Leadership Team Meetings Leadership Team Meetings

Monthly

SL, E

ALL

><

All-staff Meetings

Monthly

SL, E

ALL

><

Department Meetings

As Needed

E

ALL

><

Rounding

Bi-weekly

SL, E

BC, EL

><

Operationally Speaking (COO Update)

Monthly

SL, E

BC, EE

>

Organization Email

Ongoing

ALL

ALL

><

Telephone

Ongoing

ALL

ALL

><

Microsoft Teams

Ongoing

SL, E

ALL

><

Social Media

Ongoing

ALL

BC, EL

><

Website

Ongoing

ALL

BC, EL

><

Healthy Happenings Newsletter

Monthly

ALL

BC, EL

>

IHCRC Mobile App

Ongoing

ALL

BC

>

GoodHealth TV

Ongoing

SL, E, P

BC

>

Print Posters/Flyers/Handouts

Monthly

ALL

BC

>

Annual Report

Annual

ALL

BC

>

Audience: Board (B), Senior Leadership (SL), Employee (E), Community (C), Patients (P), Partners (PT) Purpose: Set Direction (SD), Build Culture (BC), Establish Expectations (EE), Embedded Learning (EL) Flow of Communication: Incoming (<), Outgoing (>), Bidirectional (><)

2 | Leadership

or individuals. This content is paired with written updates to ensure accessibility for all employees.

IHCRC leadership also engages in quarterly rounding across departments. During these informal visits, leaders speak directly with staff, asking what’s going well, what tools or support they need, and who they’d like to recognize. This feedback is digitally documented and reviewed collectively by the senior leadership team, with follow-up action taken when necessary.

Feedback loops are integrated into communication. Rounding feedback, staff surveys, and informal conversations are used to collect suggestions and surface concerns. Leaders maintain an open-door policy, and the CEO is known for being approachable and available to staff.

IHCRC leadership actively engages with patients by gathering feedback through multiple channels, including satisfaction surveys, communication forms, PCP change requests, social media, email, and phone outreach. These methods help ensure that patient voices are heard and integrated into continuous improvement efforts.

1.1c Focus on Organizational Performance 1.1c(1) IHCRC’s senior leaders create this environment through intentional leadership practices and structural systems designed to reinforce a culture of respect, safety, and empowerment. Rounding and full-staff meetings serve as engagement tools, while Lean and CQI frameworks allow employees at all levels to participate in performance improvement.

The organization’s commitment to cultural competency and equity is embedded in onboarding, policy development, and hiring.

IHCRC’s orientation process includes education on diversity and inclusion, the importance of cultural respect, and the foundational principles of patient-centered care. Staff are given the opportunity to understand and connect with the cultural needs of the Native community we serve.

Innovation is supported through near-miss reporting, informal process improvement projects, and other opportunities for staff to suggest, test, and implement changes. Staff have received Lean training and are applying improvement methods Level 4 Application - 2026

across the organization, although IHCRC is still working to capture and track these efforts more consistently.

A formal succession plan has been established for the CEO to ensure leadership continuity.

Looking ahead, the organization intends to broaden its succession planning efforts to include additional key roles across the company.

1.1c(2) Monthly reports are created by staff representatives of each individual Board of Trustees committee. These reports are shared with the board to maintain transparency and ensure accountability.

Performance data sharing is in the early stages of becoming more standardized across the organization. The intended approach is for each department to contribute goals and measures that leadership reviews during Executive Team meetings to guide decisions and adjust plans as needed.

Employees set individual goals with their supervisors each year, and these are reviewed during annual evaluations. Staff understand how their day-to-day work connects to IHCRC’s mission and broader goals. This alignment helps create a clear focus on action, where progress is measurable and accountability is shared.

Leaders demonstrate personal accountability by responding directly to staff concerns, celebrating milestones, and adapting when needed. If a goal or initiative stalls, senior leaders work to identify barriers and provide support or adjust strategies without shifting the focus away from results.

1.2 Governance and Societal Contributions 1.2a Organizational Governance 1.2a(1) IHCRC ensures responsible governance through a highly engaged and structured Board of Trustees that provides oversight of finances, operations, quality, risk, and strategic direction. The Board meets every two months and is supported by active committees including Finance, Governance, Executive, Development, CQI, and Facilities. Each committee reviews key organizational areas and brings forward motions and recommendations to Leadership | 3

the full board for approval.

The Governance Committee maintains policies regarding board roles and responsibilities, disclosure of conflicts, and expectations for ethical conduct. Board members participate in an onboarding process, receive regular updates, and have access to data related to quality, finances, patient satisfaction, and community impact.

Transparency is a priority. IHCRC undergoes an annual external financial audit and submits IRS Form 990, which is made publicly available.

Financial and performance summaries are included in the Annual Report and shared with the public. The organization also maintains accreditation through AAAHC, which involves a thorough review of operations, safety, and quality systems. Together, these measures ensure compliance and reinforce public trust.

When ethical or organizational concerns arise, the CHRO conducts an internal investigation in collaboration with the Executive Team. If necessary, findings are escalated to the CEO and then to the Executive Committee for further action or policy review. This chain of accountability helps IHCRC maintain integrity and transparency in both day-to-day operations and long-term planning.

1.2a(2) The CEO is evaluated annually by the Board President, with input from board members and strategic goal performance. Progress toward strategic goals, leadership behaviors, and organizational outcomes are all considered in this evaluation. In addition, the Governance Committee periodically reviews the board’s structure, participation, and effectiveness.

Board members are encouraged to engage in ongoing learning. Training opportunities are provided through the Oklahoma Center for Nonprofits, offering guidance on development, governance, oversight and management, recruitment, and strategic planning. This investment helps ensure that the governance system stays current with best practices and can provide strong oversight as the organization evolves.

1.2a(3) The governance system at IHCRC reviews strategic objectives through multiple channels. Strategic plan goals are assigned to leadership champions and measured with KPIs. 4 | Leadership

These KPIs are reviewed regularly during Executive Team meetings and are reported on every two months to the Board of Trustees.

Each board committee has a role in tracking specific elements of the strategic plan. For example, the Finance Committee reviews financial performance and resource alignment; the Development Committee supports community and fundraising goals; and the CQI Committee monitors progress on quality and safety measures.

Motions and action items from committees are presented to the full board for discussion and action.

The strategic plan itself is reviewed annually, and adjustments are made based on emerging needs, environmental shifts, or organizational performance. This process ensures the strategic plan remains actionable and responsive, and board members stay involved in its success.

To help ensure IHCRC is delivering evidencebased quality care, peer review and chart review are conducted for the medical, behavioral health, dental, and optometry departments. These reviews provide insights into provider performance, clinical practices, and areas for development.

Results are used to identify opportunities for professional growth and to maintain a high standard of care across all clinical services.

1.2b Legal and Ethical Behavior 1.2b(1) IHCRC has systems in place to proactively manage compliance with legal and regulatory requirements across all departments.

The organization maintains accreditation through the Accreditation Association for Ambulatory Health Care (AAAHC), which includes regular reviews of safety, quality, and operational standards.

Legal and compliance responsibilities are overseen by the Risk Management Committee and the Safety and Infection Control Committee.

These groups review regulatory updates and work with departments to update protocols. The CQI Department helps ensure data is collected, analyzed, and acted upon when needed.

IHCRC complies with CMS, HIPAA, IHS, and OSHA regulations, and conducts annual staff training to ensure all team members understand expectations and procedures. When regulations

change or new risks are identified, leadership provides immediate updates through all-staff communications.

Examples of proactive compliance include: • Updates to safety protocols based on infection control best practices.

• Frequent staff education on patient privacy and HIPAA. • IHS training on privacy, data security, and compliance with HITECH. When new programs or services are introduced, regulatory and risk assessments are conducted as part of the planning process to ensure compliance from the start.

1.2b(2) In addition, IHCRC uses an internal Incident Report document, which must be submitted immediately when incidents occur, including those involving potential ethics violations. This required process helps ensure timely awareness, thorough documentation, and appropriate response. “near-miss” forms are also available and widely used to report risks or concerns before harm occurs. These tools support proactive communication and continuous improvement in safety and operations. These practices directly reflect IHCRC’s core value of accountability, which means being responsible and transparent in our actions.

Staff are expected to uphold this value in every interaction, and leadership models it consistently in decision-making, communication, and follow-through. When a concern is submitted, the CHRO leads a confidential investigation in collaboration with the Executive Team when appropriate. Findings are reviewed with the CEO and may be elevated to the Governance Committee. This structured process ensures that ethical breaches are taken seriously, consistently addressed, and resolved promptly.

Ethical behavior is also encouraged through recognition and appreciation. Staff who go above and beyond to support IHCRC’s mission and values are highlighted in organizational communications, reinforcing a positive and principled workplace culture.

1.2c Societal Contributions 1.2c(1) IHCRC incorporates societal wellbeing into its strategy by promoting health Level 4 Application - 2026

equity, cultural connection, and long-term wellness through community-focused programs and events. These efforts are designed to reduce health disparities and strengthen the American Indian community in Tulsa.

Key examples include: • Family Fun & Fitness Day, a recurring public event that promotes physical activity, family engagement, and access to fitness supplies. It features fitness challenges, interactive booths, raffles, and health education. The event also includes community partners who provide resources and education.

• Resilience Through Tradition: Cultural Day, IHCRC’s annual cultural wellness event, supports youth and families by reinforcing cultural identity as a protective factor against behavioral health challenges.

The event includes traditional storytelling, language activities, dance, drumming, and craft stations, along with behavioral health education and supportive resources. It is designed to reconnect attendees with their heritage and strengthen intergenerational bonds.

In addition to programmatic work, IHCRC demonstrates environmental stewardship through its participation in the “Feed Mr. Murph” recycling program operated by Tulsa Waste Management. Clearly marked bins are located throughout the campus to encourage recycling among staff and visitors.

These activities are aligned with IHCRC’s mission to empower the American Indian through exceptional healthcare, while addressing community wellness at every level, physical, mental, spiritual, and cultural.

1.2c(2) IHCRC actively supports its key communities (primarily American Indians living in the Tulsa area) by offering culturally responsive programs, accessible care, and partnerships that extend services beyond what the clinic can provide alone.

IHCRC strengthens its key communities (primarily American Indians living in the Tulsa area) through accessible care, culturally rooted programs, strategic partnerships, and servicefocused values.

Leadership | 5

Community engagement efforts include: Running Strong, a walking and running club for youth and adults who are patients at IHCRC. Members attend weekly practices, set monthly movement goals, and participate in races and fitness events. The program supports physical health and builds a strong, supportive community among participants.

• Resilience Through Tradition: Cultural Day, which reconnects youth and families to Native traditions through a day of cultural celebration. The event promotes behavioral health by positioning culture as a source of strength, while also providing opportunities for education, art, movement, and social connection.

• Little Sparks, a prenatal program that prepares expectant Native mothers with culturally appropriate education, support, and resources. The program promotes maternal and infant health, strengthens family support systems, and empowers participants with knowledge and connection.

Cross-organizational partnerships include labor and delivery contract with OSU Center for Health Sciences and care coordination with other tribal health centers. These collaborations increase access to care and strengthen community impact.

Support of other nonprofits, such as Iron Gate, the Tulsa Day Center for the Homeless, the Community Food Bank of Eastern Oklahoma, and Family and Children Services through donations, food drives, and volunteer service.

While individual volunteer hours are not currently tracked, service is a core value upheld by staff across the organization.

•

6 | Leadership

2: Strategy 2.1 Strategy Development 2.1a Strategy Development Process 2.1a(1) IHCRC’s current strategic planning model reflects a cycle of learning from earlier strategic planning approaches. The process previously relied more heavily on development with the Board of Trustees, followed by approval and sharing with staff. Over time, IHCRC identified that board members may have gaps in information because they are not directly involved in day-to-day operations. This limited the ability of the planning process to fully account for operational realities.

As a result, IHCRC shifted to a model in which senior leaders develop the strategic plan and submit it to the Board for approval. This change helped move strategic planning from a more inactive process to a more active process.

Previously, the plan was approved and shared

with staff, but there was limited engagement after approval. IHCRC now reviews the strategic plan weekly during Executive Team meetings, creating a more consistent process for monitoring progress and responding to barriers.

IHCRC’s current process begins during quarterly offsite meetings of the Executive Team.

During these meetings, the Executive Team creates the strategic plan, identifies four to five strategic goals, ensures those goals align with key systems, and identifies champions for each goal.

Strategic objectives are then developed for each goal and reviewed for alignment with IHCRC’s CARES values. Champions then develop KPIs to measure each objective.

After board approval, the plan is shared with directors and managers and then with all staff during the monthly full-staff meeting. IHCRC creates a Strategic Scorecard to track progress on KPIs. Progress is reviewed during weekly Executive Team meetings, and lagging objectives

Figure 2.1-1 Strategic Planning System Strategic Goals and Objectives Selected SWOT Analysis Conducted

Environmental Scans as Needed

Board Approves Strategic Plan

Quarterly Offsite

Quarterly Offsite

Short and Longterm Action Plans Created

Executive Team Reviews Strategic Scorecard Weekly Strategic Plan Adjustments as Needed

Quarterly Offsite

Quarterly Offsite

Managers and Directors Create KPIs

Quarterly offsite meetings provide a structured opportunity for the Executive Team, and the Board of Trustees when appropriate, to review strategic performance, evaluate progress, and adjust priorities as needed.

Level 4 Application - 2026

Strategy | 7

are assessed during quarterly offsites. When an objective is not progressing as expected, an action plan is developed to address barriers.

Directors, managers, and staff are engaged as appropriate to resolve the lack of progress.

Progress on the action plan is reviewed weekly using the Strategic Scorecard until the objective is back on track. Final progress is reviewed at the last quarterly offsite of the year to inform the next planning cycle.

2.1a(2) Key inputs that inform IHCRC’s strategic planning include the community needs assessment, AAAHC accreditation and compliance requirements, benchmarking with other Baldrige organizations, and informal identification of internal strengths and weaknesses and external opportunities and threats. These inputs help IHCRC understand community needs, regulatory expectations, performance gaps, and opportunities to strengthen organizational systems.

IHCRC is also in the early stages of incorporating NRC Health survey results into strategic planning. These surveys give patients a voice in describing their overall experience and will provide additional data to help identify patient needs, expectations, and opportunities for improvement.

Through the current cycle of learning, IHCRC has recognized the need for more formalized SWOT analyses. This will increase feedback from staff, patients, and other stakeholders and help identify data to support impressions. IHCRC has also recognized the need to include more data from managers, directors, staff, patients, and other stakeholders in the development of the strategic plan.

The two most recent strategic plans provided a framework for the Executive Team to develop a plan that could be routinely evaluated for progress. Through this cycle of learning, it became apparent that IHCRC needs to incorporate more bottom-up feedback to create strategic goals and strategic objectives that provide directors, managers, and staff with KPIs to support broader organizational goals and objectives.

2.1a(3) IHCRC uses data and information to inform decision-making related to strategic 8 | Strategy

opportunities and innovations. For example, outside referral data has been used to measure the need for additional services. This type of data helped identify services that patients were already seeking outside the clinic and supported decisions about whether those services should be considered internally.

Through this process, IHCRC recognized that the most useful data and information was not always utilized and that more formalized systems are required for consistent data collection. This includes consistently using the same source when collecting and analyzing information. IHCRC has identified this need as an objective in the 20262027 Quality Improvement Plan.

IHCRC also identified gaps after benchmarking with another Baldrige organization that provides similar services. As a result, IHCRC is in the early stages of developing a formalized system for decision-making related to innovation. This includes the creation of a Staffing Needs Analysis to better evaluate staffing requests, financial impact, service demand, and the upstream and downstream effects of adding positions.

2.1a(4) Decision-making related to whether work should be completed internally or supported through outside vendors is currently an informal, case-by-case process. IHCRC considers factors such as financial cost, staff time, available expertise, service impact, and sustainability; however, this approach has not yet been uniformly rolled out across all areas of the organization.

A completed example of this process in action is IHCRC’s review of ADA-compliant documents and forms. IHCRC analyzed the staff time required to complete this work internally compared to the cost of using an outside vendor.

Based on that analysis, IHCRC determined that an outside vendor would provide cost savings and improve efficiency. This example reflects the type of decision-making process IHCRC intends to apply more consistently as the system is further developed.

IHCRC also considers the scope of services that can reasonably be provided within a primary care facility. While IHCRC provides comprehensive services on one campus, the

Figure 2.1-2 Strategic Planning 2026 Strategic Plan

Mission: To Empower the American Indian Through Exceptional Healthcare!

Strategic Goals

Strategic Objectives

Leadership Development

Workforce

Strategic Goal Champions:

Leadership Handbook - Accountability

Chief Human Resource Officer

Training Opportunities - Excellence

Chief Behavioral Health Officer (Interim)

Enhance the Quality of the Leadership Meeting - Excellence & Stewardship

Chief Development Officer

Mentorship - Excellence & Stewardship Volunteerism - Community

Improve/Expand Services

Operations and Strategy

Strategic Goal Champions:

Transportation - Community, Respect, & Excellence

Chief Medical Officer

Integrated Services - Excellence

Chief Operating Officer

Facility Development - Stewardship Add New Services - Excellence & Stewardship

Develop Quality Improvement Program

Measurement, Analysis, and Knowledge Management

Strategic Goal Champions:

AAAHC Studies and Department Studies - CARES

Chief Administrative Officer

NRC Surveys - CARES

Chief Strategy Officer

Monthly and Quarterly Reports - Accountability & Stewardship

Chief Financial Officer

LEAN - Accountability, Excellence, & Stewardship Data Validation - Accountability & Excellence

Enhance Community Engagement

Customers

Strategic Goal Champions:

Unified Community Engagement Strategy - CARES

Chief Development Officer

Native American Community Committee - Community & Respect

Chief Information Officer

Volunteerism - CARES

Board Development

Leadership/Governance

Strategic Goal Champions:

Board Education - Accountability, Excellence, & Stewardship

Board of Trustees

To Be Determined

Chief Executive Officer

Vision: We will be the recognized leader in redefining primary healthcare for the American Indian.

Core Values: Community, Accountability, Respect, Excellence, Stewardship (IHCRC Cares)

clinic has limitations on the types of clinical services it can offer. When patients need services outside IHCRC’s scope, the clinic utilizes outside facilities for referrals. IHCRC also collaborates with other facilities serving American Indian patients to identify opportunities for receiving referrals for clinical services.

These decisions help IHCRC balance stewardship, access, quality, and sustainability.

As the process becomes more formalized, IHCRC will consider keeping work in-house when it aligns with the mission, supports the clinic’s key systems, and can be managed with available staff and resources. Outside vendors or referral partners will be used when they provide needed expertise, improve efficiency, reduce cost, or support patient access to services that cannot be offered directly by IHCRC. 2.1b Strategic Objectives 2.1b(1) As IHCRC begins to implement Level 4 Application - 2026

strategic initiatives more systematically, a starting point was identified to connect strategic objectives to the strategic goals in the strategic plan. Because this process is in its early stages, IHCRC has focused on a one-year timeframe.

This allowed the organization to learn how to develop, implement, review, and refine a strategic plan in a manageable cycle.

IHCRC recognized gaps in long-term planning and how those gaps adversely affected opportunities for innovation. The clinic learned that effective long-term planning requires stronger systems for collecting input, evaluating data, setting priorities, and cascading objectives through the organization. IHCRC intends to incorporate long-term planning into quarterly offsites as the next step in the learning process.

The current one-year planning cycle has helped IHCRC strengthen the discipline of strategic planning. The next step is to expand strategic planning over multiple years so IHCRC Strategy | 9

can better evaluate strategic opportunities, future service needs, workforce needs, and innovation opportunities over a longer planning horizon.

2.1b(2)As IHCRC incorporates a higher level of strategic planning into operations, the focus has been on developing the process. This development started with short-term planning over a one-year timeframe and has centered around the highest levels of leadership, specifically the Executive Team.

Through refining the process, IHCRC recognized the need to more effectively cascade strategic planning through directors and managers and, ultimately, to staff. This became most apparent when a member of the Executive Team noted that a staff member referred to these initiatives as exclusive to the Executive Team.

This feedback helped IHCRC identify a gap in deployment and reinforced the need for broader engagement.

IHCRC has also recognized the need to incorporate more feedback from patients. The clinic is working on developing a systematic approach for utilizing patient satisfaction surveys, which is an objective in the 2026-2027 Quality Improvement Plan. This will allow patient feedback to more consistently inform strategic goals, strategic objectives, and improvement priorities.

IHCRC’s learning from recent planning cycles is that the strategic plan must be both leadershipdriven and organization-wide. Senior leaders are responsible for setting direction and ensuring alignment, but directors, managers, staff, patients, and other stakeholders must have meaningful input so that the plan reflects operational needs and can be deployed effectively.

2.2 Strategy Implementation 2.2a Action Plan Development and Deployment 2.2a(1) IHCRC attempted to deploy action plans through the organization in 2026. The strategic plan was shared with staff, and officers, directors, and managers were advised to have staff create SMART goals for the year that aligned with the strategic plan.

This approach helped IHCRC begin connecting individual and departmental work 10 | Strategy

to the broader strategic plan. It also revealed that additional structure was needed to make deployment more effective. As a result, IHCRC identified the need for clearer action plan templates, stronger director and manager involvement, and better alignment between strategic objectives and departmental KPIs. 2.2a(2) A significant barrier was discovered during deployment. In the process of creating KPIs for strategic objectives, it became clear that directors and managers had not provided sufficient input during the development of strategic goals and strategic objectives. As a result, directors and managers could not be fully utilized to create KPIs that were practical, measurable, and directly connected to departmental work.

Through this cycle of learning, IHCRC recognized that directors and managers need to be more involved in the strategic planning process before KPIs are finalized. IHCRC also identified that action plans have been used primarily as a response when progress is lagging on a strategic objective, rather than as an intentional step in the strategic planning process.

Going forward, strategic objectives will serve as the starting point for action planning. Directors and managers will help develop short- and longterm action plans to support each objective, and KPIs will be used to measure progress toward those action plans. This will create a more consistent structure for translating strategic objectives into departmental action, tracking progress, and identifying barriers.

Figure 2.2-1 Strategy Implementation MISSION - VISION - VALUES STRATEGIC PLAN ACTION ITEM SCORE CARD DATA EMPOWER EMPLOYEE

CQI EXECUTIVE

IHCRC also identified that directors and managers would benefit from an action plan template that closely resembles the Strategic Scorecard used by the Executive Team. This template will support a more consistent process for connecting strategic objectives, action plans, KPIs, responsible parties, timelines, and progress updates.

2.2a(3) IHCRC has become aware of a greater need to incorporate financial information into action planning. Two initiatives will serve as starting points to address this gap.

First, the Accounting Department has increased the amount of financial information Figure 2.2-2 Action Plan Modification

ISSUE IDENTIFIED MEET WITH LEADERSHIP/ FRONTLINE WORKERS DETERMINE ROOT CAUSE DEVELOP POSSIBLE SOLUTIONS IF SUCCESSFUL, IMPLEMENT NEW PROCESS

STANDARDIZE

shared with members of the Executive Team.

Accounting has also included officers, directors, and managers in the process of developing the annual budget for the entire facility. The next step is to develop departmental budgets to better inform decision-making about actions taken in each department.

Second, IHCRC is developing a process for a Staffing Needs Analysis that will include financial impact, both cost and revenue. This process will help leaders evaluate whether proposed staffing Level 4 Application - 2026

changes are financially sustainable and aligned with organizational priorities.

Together, these steps will help IHCRC better connect action planning to stewardship, resource allocation, and long-term sustainability.

2.2a(4) The Staffing Needs Analysis will also evaluate the upstream and downstream effects of adding staff. This includes the need for additional support staff, space, equipment, technology, training, and other resources required to support a new position.

By evaluating these effects before staffing decisions are made, IHCRC will be better positioned to understand the full operational impact of proposed changes. This process will also help ensure that new positions support strategic goals, strengthen key systems, and do not create unintended strain in other areas of the clinic.

2.2a(5) During a quarterly offsite meeting in June 2026, members of the Executive Team identified KPIs to measure the areas of the clinic within their chain of command. Additionally, the champions for each strategic goal will develop KPIs for each strategic objective.

This process is intended to create clearer ownership and improve alignment between the strategic plan, departmental performance, and organizational outcomes. The KPIs will also be incorporated into the Strategic Scorecard so the Executive Team can review progress during weekly meetings and identify objectives that are lagging.

2.2a(6) IHCRC will use the KPIs identified during the quarterly offsite and the strategic plan to project performance and monitor progress.

These KPIs will provide a baseline for evaluating whether strategic objectives are progressing as expected and whether action plans are having the intended impact.

2.2b Action Plan Modification The Strategic Scorecard is reviewed weekly during the Executive Team meeting. Any prolonged lag in meeting a strategic objective is examined during the next quarterly offsite. This process allows IHCRC to adapt action plans when unexpected challenges arise.

When an objective is lagging, the Executive Strategy | 11

Team assesses the barrier and develops an action plan to address the lack of progress. Directors, managers, and staff are engaged as appropriate based on the nature of the barrier. Progress on the action plan is then reviewed during weekly Executive Team meetings using the Strategic Scorecard.

Once the objective is back on track, the action plan may be discontinued or incorporated into standard work if the change needs to be sustained.

This creates a regular process for identifying lagging performance, responding to barriers, and modifying action plans based on current information.

This process represents an important cycle of learning for IHCRC. The clinic has moved from approving and sharing a strategic plan to actively reviewing progress, identifying gaps, and adjusting action plans throughout the year.

12 | Strategy

3: Customers 3.1 Customer Expectations 3.1a Listening to Patients and Other Customers 3.1a(1) IHCRC uses a variety of methods to obtain customer feedback, including patient satisfaction surveys, patient communication forms, PCP change requests, social media platforms, staff satisfaction surveys, and community outreach events. Our patients are a diverse group, and we value their input. We use feedback to identify and guide CQI projects and identify gaps in our services. For example, through an elders program grant, it was identified that many seniors needed home visits. One day per month, the elder care team conducts home visits to assure quality care is available for these valued patients. Also, in 2022, our patient satisfaction survey showed that only 92% of our patients felt the provider and care team showed respect for their culture. Over the next two years we implemented a cultural awareness and education program for the staff and improved our score to 99.36%, which was very rewarding to our staff.

3.1a(2) Social media is a key tool in how we engage with and listen to our community (customers).

Our marketing and communications team monitors comments, reactions, and direct messages across all communication channels to gather feedback and gauge sentiment. Our team reviews performance metrics on a monthly basis to identify top-performing posts, understand what resonates with our audience, and adjust our approach based on those insights. By regularly analyzing performance and engaging with our audience, we’re able to make informed, data-driven decisions that improve how we communicate and serve our community. Our increased engagement and steady growth in reach and interaction demonstrate that this approach is working and continuing to evolve.

We listened to both existing and potential customers through a Community Health Survey conducted through a partnership with the Southern Plains Tribal Health Board (SPTHB).

The results of the survey found that 61.2% of respondent indicated that they did not have Level 4 Application - 2026

reliable transportation. This led to including the improvement of transportation in the 2026-2027 Strategic Plan.

Figure 3.1-1 Transportation Access

3.1b Patient and Other Customer Segmentation and Service Offerings 3.1b(1) IHCRC assigns patients to PCMH care teams designed to meet the individual’s needs. The pink team serves the pediatric population, staffed by our three pediatricians, a nurse case manager, and other nursing staff. The adult PCMH teams are the blue and red teams.

Our empanelment policy determines when and how patients are assigned to a team. Patients can request a different provider once every 18 months.

PCMH teams collaborate with our specialty care services, including internal medicine, dental, optometry, nutrition and diabetes education, behavioral health, and physical therapy.

Occupational therapy and speech therapy services will be added soon.

3.1b(2) We continually analyze what services our patients receive by referral to providers outside of our clinic and determine which of these services we want to offer here, to better serve our patients. Most recently, we added PT, OT and ST because of the demand for these services.

Additionally, we recently expanded our pharmacy, dental, optometry, and fitness departments to meet our patients’ needs. This is monitored and assessed based on the number of referrals being made. Our Executive Team uses patient and financial data to determine if the services are financially viable and of benefit to the patients.

Customers | 13

3.2 Customer Engagement 3.2a Patient and Other Customer Experience 3.2a(1) We reach potential customers through our social media and website marketing. Our cultural competency guide, Teachings of the Medicine Wheel, provides guidance to our staff for understanding the IHCRC mission, vision, and values. With this knowledge and understanding, we can provide better service to our existing patients and potential customers.

The IHCRC Native American Community Committee (NACC) has been instrumental in widening our community base of support, bringing in numerous new business/organization supporters. Additionally, we host Dance of the Two Moons, our annual fundraiser, which brings together 500+ IHCRC supporters. Our Elders program offers Tea and Topics, Coffee Hour and a Half, Bingo, and other engagement opportunities for our elders. The elders enjoy the presentations and each other’s company. We prioritize a warm, welcoming clinic environment where front-desk, nursing, and provider staff are trained to recognize and respond to patient needs with empathy and cultural humility. Care teams engage in trauma-informed care and motivational interviewing to support long-term engagement.

3.2a(2) Customers can find IHCRC through our website or numerous social media sites. All patient registration forms are online and can be completed digitally, or patients may come to the clinic to complete forms. Appointment scheduling is available, but walk-in and same-day clinic is also available for emergent issues for both adults and children.

3.2a(3) IHCRC manages customer complaints through a structured and responsive process designed to ensure timely resolution and continuous improvement. Patients are encouraged to share concerns or feedback by completing a Patient Communication Form, which is readily available at multiple touchpoints within our facility and online.

Once submitted, the form is promptly reviewed by our Chief Operating Officer acting as our Patient Advocate. Each complaint is assessed for urgency, impact, and potential systemic implications. Based on this review, 14 | Customers

appropriate actions are taken, which may include direct service recovery, staff coaching, process adjustments, or escalation to the Executive Team or Board of Trustees if needed.

We prioritize transparent communication with the patient throughout the process.

Patients receive acknowledgment of their complaint, updates on the investigation, and a clear explanation of the resolution. This communication is documented and tracked to ensure closure and satisfaction.

3.2a(4) IHCRC is committed to health equality and develops processes and programs to reduce barriers to care and ensure fair treatment for all patients. As seen in our most recent Community Health Survey, transportation is a barrier to care for our patient population. IHCRC provides no cost transportation for our patients to ensure they get to and from their appointments.

IHCRC also delivers prescriptions to patients that have no other means to pick up prescriptions.

IHCRC also utilizes MARTII, a digital Medical Interpreter service that provides medially trained interpreters in over 250 languages, to assist patients that need interpretation services. IHCRC also has a dedicated Same Day clinic that allows all patients the ability walk in for a same day appointment if they are unable to get in with their empaneled provider.

3.2b Determination of Patient and Other Customer Satisfaction and Engagement We conduct ongoing patient satisfaction surveys for our Medical, Behavioral Health, Dental, Optometry, Nutritional Services, Rehabilitative Services, and Outpatient Testing (lab services). We utilize NRC Health patient satisfaction surveys as a key voice-of-thecustomer mechanism to capture real-time feedback across multiple service lines. These surveys provide actionable insights into patient perceptions of care, including communication, responsiveness, and overall experience. The patient will either receive a text message, phone call, or email depending on their communication preference. In addition, IHCRC does satisfaction surveys for various events including youth programs, camps, diabetes education programs, and others.

4: Measurement, Analysis, and Knowledge Management 4.1 Measurement, Analysis, Review, and Improvement of Organizational Performance 4.1a Performance Measurement 4.1a(1) IHCRC utilizes iCare dashboards and the Resource and Patient Management System (RPMS) system to systematically select and collect data to monitor daily operations and overall organizational performance. The CQI team and process owners collaborate to ensure that data aligns with organizational goals and reporting needs. GPRA metrics, departmental indicators, and strategic goal progress are key performance measures. These data are reviewed every two months by the Board of Directors and monthly by the Leadership Team.

4.1a(2)IHCRC primarily benchmarks performance with GPRA metrics, which provide a national level comparison with Indian Health Services (IHS).

4.1b Performance Analysis and Review, and Improvement 4.1b(1) Specific, time-limited goals are used

to measure progress on strategic goals, which are monitored and updated as needed. Initiatives lead by the CQI team or department-specific staff are implemented if performance issues arise. Specific departmental and program reports are used to analyze and review performance and capabilities.

Key financial performance indicators are revenues over expenditures, days cash on hand, and operating disbursements. These key financial indicators are calculated monthly and reported to the Board of Directors every two months. The revenues over expenditures are shared with the Executive Team each month.

4.1-b(2) IHCRC sets strategic goals and objectives at each strategic planning session.

Progress toward the goals are reviewed by the Executive Team weekly. A systematic review of the goals and objectives is conducted during a quarterly offsite. Strategic goals and objectives inform departmental goals which inform individual goals. IHCRC is in the early stages of cascading the goals from the Executive Team through the departments to individual goals.

As a result, there has been a gap in identifying key performance indicators that connect goals throughout all levels of the organization. During a quarterly offsite in June of 2026, Executive Team members identified key performance indicators

Figure 4.1-1 Measurement, Analysis, and Knowledge Management GPRA

Departmental Indicators

Strategic Objectives

From iCare Dashboards (Frequency: Monthly)

From iCare Dashboards & RPMS (Frequency: Monthly)

Progress Updates From Executive Team (Frequency: Weekly)

Compiled Into a Spreadsheet (Frequency: Monthly)

Compiled Into Board Report by Process Owners & Data (Frequency: Monthly)

Strategic Plan and Smart Goals Scorecards Updated (Frequency: Weekly)

Leadership Team Review (Frequency: Monthly)

Board Review (Frequency: Every Two Months)

Executive Team Review (Frequency: Quarterly)

INDICATORS

DATA/INFORMATION COLLECTION

DATA/INFORMATION COMPILATION

REVIEW PROCESS

Level 4 Application - 2026

Measurement, Analysis, and Knowledge Management | 15

that can be used to evaluate performance from the executive level to the individual staff level.

4.2 Information and Knowledge Management 4.2a Data and Information 4.2a(1) IHCRC utilizes training, SOPs, rolebased access, error reporting, and EHR validation to ensure the accuracy, validity and security of its data.

4.2a(2) Real-time data access is supported by RPMS and iCare.

4.2a(3) The IT team utilizes backup, patch management, and audit controls to maintain system integrity. A multi-level strategy that includes MFA, firewall monitoring, and annual cybersecurity training are used to maintain cybersecurity.

IHCRC is in the early stages of developing processes for innovation. Historically, changes have resulted from staff presenting ideas through their reporting chain in the hierarchy. The idea would then be presented to the CEO for final approval. IHCRC is currently incorporating the Executive Team in the process. However, a formalized system has not been developed.

4.2b Organizational Knowledge 4.2b(1) Knowledge is shared through departmental and team meetings, CQI reporting, and internal reports. Knowledge management is shifting away from being largely informal.

IHCRC has maintained a centralize program for storing all policies and procedures that are available to all clinic staff. An updated staff handbook was created on July 21, 2025 that was disseminated to all staff and provided to all newly hired staff. Many departments have outlines processes that are stored in different ways, including binders and electronic files. IHCRC is currently in the planning process for developing a centralized system for storing process to make them accessible to all staff.

4.2b(2) IHCRC relies heavily on benchmarking with similar organizations to develop best practices. This includes the ongoing back-and-forth sharing of information and one-on-one meetings between staff to discuss critical process. IHCRC consistently promotes collaboration with other facilities and organizations in the community via meetings and ongoing collaborations. These opportunities for collaboration are identified by members of the Executive Team and shared with the appropriate staff.

4.2c Pursuit of Innovation 16 | Measurement, Analysis, and Knowledge Management

5.1 Workforce Environment

WORKFORCE CAPABILITY Job Descriptions Align with department needs, reviewed annually.

Licensure & Certification Required for all clinical staff.

Tracked through HR and Credentialing System.

WORKFORCE CAPACITY Strategic Workforce Planning Align with Strategic Plan and Priority Action Plans. Adjusts to service demand and funding.

Cross-Training & Flexibility Enables coverage during absenses.

Credentialing & Privileging Required for licensed providers, aligned.

Turnover Monitoring HR tracks turnover and reasons. Data informs recruitment strategies.

Relias Learning System Online training modules.

Cultural competence, compliance, safety.

Use of Volunteers & Interns Supports non-clinical capacity.

Birkman Assessments Annual Performance Evaluations Ensures each employee has the knowledge, skills, and abilities to perform their role effectively.

Identify capability/ capacity gaps.

Inform training, recruitment, and strategic workforce planning.

Ensures the right number of people are available at the right time to meet patient and recruitment strategies.

workforce needs through succession planning, cross-training, and flexible scheduling. Strategic adjustments such as shifting staff to support telehealth during COVID-19 demonstrate the ability to respond quickly to workforce shortages Level 4 Application - 2026

Recruit

et

oard Onb

Figure 5.1-1 Workforce Capability & Capacity

Figure 5.1-2 Workforce Change Lifecycle

WORKFORCE CHANGE LIFECYCLE

R

5.1a Workforce Capability and Capacity 5.1a(1) IHCRC assesses workforce capability and capacity (see Figure 5.1-1) annually through departmental staffing plans, performance reviews, and workload analysis. Short-term needs are identified through operational data such as patient volumes and appointment wait times, while longterm needs are addressed in strategic planning and linked to growth initiatives such as IHCRC 530.

5.1a(2) Recruitment emphasizes both professional qualifications and cultural competence. Hiring processes ensure diversity of ideas and representation from Native communities. New staff complete a structured four-day orientation focused on compliance, safety, and cultural humility, aligning them with IHCRC’s mission and values from the beginning.

5.1a(3) IHCRC will prepare for changing

or new service demands. IHCRC's Workforce Change Lifecycle process address recruitment, onboarding, development, retention, and separation (see Figure 5.1-2).

Sepe rat e

5.1 Workforce

ain

el Dev

op

5.1a(4) The workforce is organized around IHCRC’s core competencies: integrated care, cultural competence, and continuous improvement. Work systems emphasize teambased care, with medical pods, case managers, and interdisciplinary teams reinforcing resilience, agility, and patient-centered outcomes.

IHCRC utilizes peer review processes, clinical competencies, and Birkman Assessments to align with and capitalize on organizational core competencies.

5.1b Workplace Climate 5.1b(1) IHCRC monitors workplace health and safety through annual safety audits, OSHA compliance, and patient safety training.

Accessibility is ensured through ADA-compliant facilities and workplace accommodations.

Employee well-being is further supported by initiatives such as wellness activities and development days.

5.1b(2) Compensation and benefits policies are structured to ensure fairness, alignment with industry standards, and equity across roles.

IHCRC values both external marketability and internal equity in our compensation program.

Benefits include health insurance, retirement plans, leave, and professional development Workforce | 17

support. We conduct periodic compensation reviews to ensure salary structures remain competitive with market benchmarks. These reviews incorporate regional and industry-specific data and are aligned with our workforce strategy to attract, retain, and reward high-performing talent. Adjustments are made as needed to maintain equity, support employee engagement, and reinforce our commitment to being an employer of choice.

5.2 Workforce Engagement 5.2a Assessment of Workforce Engagement 5.2a(1) Engagement drivers include mission alignment, professional development, recognition, and cultural pride. These vary by segment; for example, clinical staff emphasize training and scheduling support, while administrative staff value flexibility and communication.

5.2a(2) IHCRC measures engagement through the Best Places to Work in Oklahoma employee satisfaction survey, rounding feedback, and retention data. Because the organization did not participate in the Best Places to Work survey in 2021 due to COVID-19 vaccine mandates and transitioned to a different employee satisfaction survey provider in 2025 whose data collection did not produce comparable results, those years are excluded from trend reporting. The organization returned to the Best Places to Work survey in 2026 to maintain consistent, yearover-year benchmarking. Results are reviewed by the Executive Team to identify trends and opportunities for improvement. IHCRC has recently starting using the Birkman Assessment tool to bolster individual and team engagement.

5.2b Organizational Culture IHCRC fosters a culture of openness, respect, and high performance. Monthly staff meetings, leadership rounding, and ad hoc committees encourage two-way communication. The CARES values (Community, Accountability, Respect, Excellence, and Stewardship) are reinforced through recognition programs and integration into evaluations. This culture promotes empowerment, equity, and inclusivity, while benefiting from the diversity of ideas and traditions within the 18 | Workforce

workforce.

5.2c Performance Management and Development 5.2c(1) IHCRC’s performance management system links individual evaluations to organizational goals. Annual reviews include job description overview and updates, discussions of CARES values, training progress, and contributions to organizational outcomes.

5.2c(2) Learning and development opportunities include continuing education, cultural competence training and utilization of a robust learning management system called Relias.

Lean training has been implemented system-wide to support process improvement.

Figure 5.2-1 Workforce System Overview

Capability & Capacity • Recruitment • Classification • Scheduling

Workforce Climate • Safety • Diversity & Inclusion • Cultural Competence

WORKFORCE SYSTEM Workforce Policies • Policies • Onboarding • Benefits

Workforce Engagement • Drivers of Engagement • Learning & Development • Performance Evaluations • Best Places to Work Survey

5.2c(3) IHCRC is actively building the foundation for a formal succession planning process as part of our 1–2 year strategic workforce development goal. We currently support leadership readiness through mentoring, cross-training, and internal promotion pathways.

These efforts help identify and develop highpotential staff across departments. As we move forward, succession planning will be integrated into departmental reviews to ensure a systematic approach to leadership continuity and

organizational sustainability.

5.2c(4) Policies ensure equity in pay, development, and advancement. Workforce data are regularly reviewed to ensure representation across roles and leadership. Training in cultural humility and inclusion reinforces IHCRC’s commitment to equity for diverse workforce segments.

Level 4 Application - 2026

Workforce | 19

6. Operations 6.1. Work Processes 6.1a Service and Process Design 6.1a(1) IHCRC determines key health care service requirements through patient feedback, referral patterns, IHS benchmarks and strategic priorities. Our team-based approach utilizes Lean and PDSA methodologies to enable us to identify and refine service requirements.

Community health needs, clinical data, feedback from employees and leadership are incorporated through ongoing planning cycles and work groups.

6.1a(2) IHCRC applies PDSA principles and lean tools to design services that address key requirements. Our design steps include process mapping, feasibility studies and risk assessments. Evidence based practices and clinical guidelines are integrated into our care model, and collaboration across Medical, Behavioral Health and ancillary services support a whole person approach. IHCRC also has a robust peer review process that includes Medical, Dental, Optometry, and Behavioral Health that provides great value to our patients. New technologies are piloted and adopted based on alignment with our strategic goals. IHCRC recently implemented Dragon DAX Copilot to streamline documentation. We also use OneDrive to facilitate interdepartmental collaboration.

6.1a(3) Key work and support processes through strategic alignment, benchmarking, regulatory and legal compliance. Our core clinical processes include patient access and registration, primary care, behavioral health, pharmacy, dental, optometry, and care coordination. Support processes include HR, IT, compliance, marketing, finance, and facilities. Each process includes defined requirements centered around access, timeliness, effectiveness and safety guided by data from audits and stakeholder input. All work and support processes are developed and executed with IHCRC’s mission, vision and values in mind.

6.1a(4) IHCRC designs key work and support processes incorporating risk analysis, workflow mapping and stakeholder’s input. (Figure 6.11). We apply Lean methodologies, guided by the Plan–Do–Check–Act (PDSA) cycle, to 20 | Operations

pilot and evaluate new workflows across key operational areas. This structured approach supports continuous improvement and has been used to enhance processes such as patient flow between buildings, as well as coding and billing workflows. These initiatives improve efficiency, reduce errors, and ensure timely, accurate revenue cycle performance while maintaining a focus on patient-centered care. Processes are documented, tested and refined from lessons learned and results. Knowledge from implementation is captured and reviewed in team huddles and process reviews to enable organization wide learning.

Figure 6.1-1 Stakeholder Input Process Listen to our patients, suppliers, stakeholders, and employees.

Decipher and validate potential issues, challenges, and interpret data.

1. Collect

2. Analyze

4. Follow Up

3. Act

Communicate changes to customer and measure the impact.

Implement changes based on analysis.

6.1b Process Management and Improvement 6.1b(1) Day-to-day operations are guided by standard work practices, process dashboards and Lean improvement cycles. Key measures include patient satisfaction, error rates and outcome indicators. These measures are reviewed in departmental meetings and by senior leadership.

When performance gaps are identified, PDSA

cycles are used to improve processes.

6.1b(2) IHCRC is dedicated to providing culturally sensitive care in a patient centered environment. Through the development of Teachings of the Medicine Wheel Indian Health Care Resource Center of Tulsa’s Guide to Cultural Competency and the IHCRC Patient Handbook, patients are informed of patient expectations. We address patient expectations through transparent communication, culturally responsive care practices, and shared decision making. Patients receive clear expectations of procedures through printed and displayed materials, verbal discussion, and on the IHCRC website. Patient preferences are flagged in the EHR and updated regularly.

6.1b(3) Continuous improvement is embedded in daily work processes and operations. All staff are trained in Lean and are empowered to propose and implement lean improvements (Figure 6.1-2). We apply PDSA and Lean tools to improve clinical and administrative processes. Improvements are tracked, evaluated and shared through committees and staff communications.

Figure 6.1-2 Lean Engagement System Employee Involvement

Gather List of Problems/ Services

Start Small. Test or Pilot the Solution

Encourage Solutions, Choose an Idea.

Feasibility Study

Measure and Analyze

Adopt the Solution

Repeat

Level 4 Application - 2026

6.2 Operational Effectiveness 6.2a Operational Efficiency and Effectiveness IHCRC uses a balanced approach to ensure effective management of operations. We manage cost, efficiency, and effectiveness through a collaborative budgeting process, Lean principles, and performance monitoring. Department heads work with Finance to project and monitor costs.

Productivity metrics and clinical outcomes are tracked and reviewed. Standardized processes, including a multi-step purchase order and inventory system, help reduce waste, prevent redundancy, and control costs.

To reduce variability, IHCRC uses defined protocols, training and real time monitoring.

Rework and errors are reduced through upstream quality planning and root cause analysis.

Efficiency and value are designed to meet both clinical and financial objectives while focusing on our mission and the needs of the population we serve.

6.2b Supply-Network Management IHCRC manages our supply network by utilizing the National Supply Service Center and additional vetting for other suppliers. We prioritize vendors aligned with our mission, including Native-owned businesses. Vendors are evaluated for pricing, reputation, performance, and risk. For large purchases, a competitive bidding process is required for ensuring value.

Supplier performance is monitored through feedback loops.

6.2c Safety, Business Continuity and Resilience, and Risk Management 6.2c(1) IHCRC maintains a safe environment through education in new employee orientation, ongoing training, and active safety committees.

Our multidisciplinary Safety Committee meets quarterly and reviews safety trends. Safety expectations are reinforced through our Relias training platform and new hire orientation.

6.2c(2) Patient safety is addressed through verification protocols, medication reconciliation, and staff reporting of near-misses. The Safety Committee reviews safety data and recommends process changes.

Operations | 21

6.2c(3) Emergency preparedness is managed by our Safety and Infection Control Committee with quarterly drills, designated team captains, and scenario tracking. Lessons reviewed by the Safety and Infection Control Committee Chair and shared in leadership and safety meetings.

Technology systems and supply chains are accessed annually for resilience. We have a disaster recovery plan in place that addresses cyber security, natural disasters, and other disruptions. We work with Stericycle to ensure our infection control policies, hazard communication program, injury and illness prevention program and emergency preparedness program are in compliance. Stericycle provides an annual compliance audit and the recommendations are implemented.

6.2c(4) Risk is addressed through cross functional input and review by our Executive Leadership Committee, which serves as the Risk committee ultimately reporting to the CEO. Regular meetings include review of legal, compliance, financial, workforce and IT risks.

Lean tools help monitor trends and proactively manage concerns. Risks are escalated to the Board of Trustees as appropriate.

22 | Operations

7. Results

Figure 7.1-2 Controlled BP (>140/90)

7.1. Health Care and Process Results 7.1a Health Care and Customer-Focused Service Results IHCRC uses Government Performance and Results Act (GPRA) clinical quality measures Figures 7.1-1 through 7.1-28 to evaluate performance across chronic disease management, preventive screenings, behavioral health screenings, immunizations, oral health, and maternal/child health and more. These results demonstrate IHCRC’s focus on monitoring highimpact clinical outcomes and process measures that are especially important to the patients and communities the clinic serves. Strong or improving results indicate effective care delivery in several key areas, while measures below target or benchmark identify opportunities for focused improvement. IHCRC uses these results to guide quality improvement priorities, support clinical accountability, and ensure that healthcare performance is reviewed across a broad range of services rather than through a single measure of care.

Poor glycemic control is a key diabetes outcome measure, with lower results indicating better performance, as shown by the downward arrow. IHCRC’s improvement in this measure reflects progress in chronic disease management and continued focus on diabetes outcomes.

Figure 7.1-3 Statin Therapy (DM)

Figure 7.1-4 Nephropathy Assessed

Figure 7.1-1 Poor Glycemic Control (>9) Figure 7.1-5 Retinopathy Assessed

Level 4 Application - 2026

Results | 23

Figure 7.1-6 Mammogram Rates

Figure 7.1-10 Depression Screening (18+)

Figure 7.1-7 Pap Smear Rates

Figure 7.1-11 Depression Screening (12-17)

Figure 7.1-8 Colorectal Cancer Screening (50-75)

Figure 7.1-12 IPV DV Screening (14-46)

Figure 7.1-9 Tobacco Cessation Counseling

Figure 7.1-13 Alcohol Screening (9-75)

24 | Results

Figure 7.1-14 SBIRT

Figure 7.1-18 Universal HIV Screening

Figure 7.1-15 Childhood Weight Control

Figure 7.1-19 Influenza Immunization (6 mo -17 yrs)

Figure 7.1-16 Controlling High Blood Pressure - MH

Figure 7.1-20 Influenza Immunization (18+)

Figure 7.1-17 CVD Statin Therapy

Figure 7.1-21 Child Immunization

Level 4 Application - 2026

Results | 25

Figure 7.1-22 Adult Immunization Combo

Figure 7.1-26 Breastfeeding Rates

Figure 7.1-23 Dental Access General

7.1b Work Process Effectiveness Results 7.1b(1) IHCRC monitors key work process measures to evaluate access, continuity of care, operational efficiency, information security, and internal service responsiveness. Empaneled patient results show how effectively patients are connected to care teams, while no-show rates help the clinic monitor appointment access, provider capacity, and continuity of care. Cybersecurity measures, including MFA adoption and phishing results, along with IT ticket time, demonstrate the reliability and responsiveness of technology systems that support safe and efficient clinic operations.

Figure 7.1-24 Dental Sealants

Figure 7.1-27 Empaneled Patients

Figure 7.1-25 Topical Flouride

Figure 7.1-28 Chart Activity

26 | Results

Figure 7.1-29 Medicaid Enrollment

Figure 7.1-30 No-Show Rates

Figure 7.1-33 IT Ticket Response

Average IT Ticket response time measures how long it takes from the time a ticket is submitted until a technician responds and picks up the ticket. Excluded from this metric are office moves, IT maintenance (auto generated at midnight to check certain areas), and tickets that were put in while we are closed and could not be responded to until the following business day. The goal is to maintain an average response time of less than one hour.

Figure 7.1-34 Grant Activity

Figure 7.1-31 MFA Coverage

Multi-factor Authentication (MFA) metrics include workstation MFA percentages as well as applicable salaried users MFA percentages for mobile devices.

Figure 7.1-32 Phishing Click Rate

Level 4 Application - 2026

Grant activity reflects IHCRC’s selective approach to pursuing funding opportunities that align with the clinic’s mission and strategic priorities. Because applications are targeted rather than volume-driven, IHCRC has maintained a strong success rate. This data includes federal grants that require annual reapplication/ continuation.

7.1b(2) Emergency preparedness drills are used to evaluate workforce readiness, response processes, and continuity of operations. Results demonstrate structured preparedness activities that help protect patients, staff, visitors, and essential services during emergency situations.

Results | 27

Figure 7.1-35 Emergency Preparedness Drills

Figure 7.2-1 Behavioral Health Patient Satisfaction

Figure 7.1-36 Risk Management Results

Figure 7.2-2 Medical Patient Satisfaction

7.1c Supply-Network Management Results IHCRC does not currently have a formal process for monitoring supply-network management results. This has been identified as an opportunity to strengthen the clinic’s performance measurement system through future tracking of supplier reliability, supply availability, contract performance, and externally provided services.

Figure 7.2-3 Initial DM Satisfaction Survey 2025

7.2 Customer Results 7.2a Patient- and Other Customer-Focused Results 7.2a(1) IHCRC began reporting standardized NRC Health patient satisfaction results by service line in Quarter 2 of 2026 after an initial implementation period focused on refining reporting methods and identifying the most meaningful data to capture. Results are compared to national benchmarks when available to monitor service-line performance, evaluate the patient experience, and identify opportunities for continuous improvement. Patient complaint trends and the 2025 Diabetes Management satisfaction survey provide additional insight into satisfaction

28 | Results

Question 1

Information I received helped me manage my diabetes.

Questions 2

Educators explained materials in a way that I understood.

Question 3

Handout materials helped me learn and supported what I was taught.

Question 4

Educators helped me set realistic goals to manage my diabetes.

Question 5

Educators answered all my questions and concerns.

Question 6

I believe I can keep my blood sugars in better control as a result of my education.

Figure 7.2-4 Outpatient Testing Patient Satisfaction

Figure 7.2-5 Dental Patient Satisfaction

Figure 7.2-6 Nutrition Services Patient Satisfaction

Figure 7.2-8 Optometry Patient Satisfaction

and dissatisfaction across IHCRC. 7.2a(2) IHCRC’s digital communication strategy supports patient engagement by delivering timely, relevant, and accessible information through multiple communication channels. Social media platforms, the Healthy Happenings newsletter, and the IHCRC mobile app are used to strengthen relationships with patients, promote preventive health education, increase awareness of available services, and encourage ongoing interaction with the clinic.

Collectively, these measures demonstrate continued growth in digital audiences, strong engagement with clinic communications, and sustained performance relative to industry Figure 7.2-9 Customer Complaints

Figure 7.2-7 Rehabilitative Services Patient Satisfaction

Level 4 Application - 2026

Figure 7.2-10 Facebook Followers

Results | 29

Figure 7.2-11 Facebook Reach

organizational announcements.

Interaction rate represents the percentage of people reached who engaged with social media content. Calculated as total content interactions divided by total reach. Interaction across Facebook and Instagram indicate continued patient and community participation with the clinic's digital content.

Figure 7.2-15 Healthy Happenings Open Rate

benchmarks.

Fluctuations in Facebook reach correspond to community interest in activities and events, cultural education, awareness topics, and Figure 7.2-12 Instagram Followers

Figure 7.2-16 Healthy Happenings Unsubscribe

Figure 7.2-13 Instagram Reach

Healthy Happenings consistently exceeds the industry benchmark for email open rates, indicating strong patient engagement.

Figure 7.2-17 Mobile Application Users

Figure 7.2-14 Social Media Interaction Rate

The steady increase in IHCRC app users highlights growing patient adoption of digital tools that improve access to healthcare information and clinic services.

30 | Results

7.3 Workforce Results 7.3a Workforce-Focused Results Workforce-focused results are measured through staffing levels, employee turnover, and employee satisfaction data. Total employee counts provide insight into workforce capability and capacity as the clinic has grown, while turnover results help monitor workforce retention and organizational stability. Employee satisfaction is measured through Best Places to Work survey results, which provide feedback on workforce engagement, workplace climate, communication, leadership, and overall employee experience.

7.3a(1) Employee counts remained relatively stable from 2023 through 2025, demonstrating that the clinic maintained workforce capacity while continuing to support patient care and operational needs. This measure helps leadership evaluate whether staffing levels are aligned with service demand, organizational growth, and workforce planning needs.

environment and help leadership evaluate whether the clinic is maintaining a workplace where employees feel supported, safe, respected, and connected to the organization.

Figure 7.3-3 Commitment to Physical Safety

Figure 7.3-4 Culture of Diversity

Figure 7.3-1 Total Number of Employees

Figure 7.3-5 Commitment to Safety

7.3a(2) Workplace climate results are measured through Best Places to Work survey items related to employee well-being, safety, diversity, and compensation and benefits. These results provide insight into the quality of the work Figure 7.3-2 Leadership Cares

Level 4 Application - 2026

Figure 7.3-6 Benefits Satisfaction

Results | 31

7.3a(3) Turnover and Best Places to Work engagement results provide insight into employee commitment, satisfaction, trust, and intent to remain with the organization, helping the clinic monitor the strength of its workforce culture and employee experience over time.

Figure 7.3-10 Overall Satisfaction

Figure 7.3-7 Employee Turnover

Figure 7.3-11 Job Provides Meaning and Purpose

Figure 7.3-8 Trust in Communication

Figure 7.3-12 Organizational Pride

Figure 7.3-9 Role Importance to Success

Figure 7.3-13 Continue Career for 2 + Years

32 | Results

7.3a(4) IHCRC participated in Best Places to Work in 2019, 2020, 2022, 2023, and 2024. 2021 and 2025 results are not included because the clinic evaluated alternative tools, including Great Place to Work, and determined the data was not as applicable or actionable as intended. Based on this learning, the clinic made the decision to return to Best Places to Work as its primary employee satisfaction measurement tool to improve consistency, comparability, and usefulness of workforce results.

Figure 7.4-2 Sufficient Communication

Figure 7.3-14 Training Opportunities

Figure 7.4-3 Open to Input

Figure 7.4-4 Senior Leaders Live Core Values

7.4 Leadership and Governance Results 7.4a Leadership, Governance, Legal, Ethics, and Societal Contribution Results 7.4a(1) Senior leadership communication and engagement are measured through employee satisfaction survey results and internal communication analytics. Best Places to Work results show consistently strong employee confidence in leadership, with confidence remaining near or above 90% from 2019 through 2024 (Figure 7.4-1). Employees also report that senior leaders live the organization’s core values, with results remaining strong at 89% or higher

Figure 7.4-5 Employee Value

Figure 7.4-1 Confidence in Leadership

Level 4 Application - 2026

Results | 33

across the reporting period (Figure 7.4-4). These results reflect continued alignment between senior leadership behaviors, IHCRC’s mission, vision, and CARES values.

Employee feedback also shows strong results related to communication and leader responsiveness. Results for “leaders are open to input” improved from 82% in 2019 to 91% in 2022, with 2024 remaining above the 2019 baseline. Results for “enough communication” increased from 88% in 2019 to 91.8% in 2023, before decreasing in 2024. In response to the organization’s continued focus on communication, senior leaders strengthened internal communication through Operationally Speaking, full-staff meetings, and leadership updates.

Operationally Speaking open rates have increased significantly since early 2025, reaching more than 80% by June 2026 (Figure 7.4-7).

7.4a(2) IHCRC demonstrates governance and fiscal accountability through annual external Figure 7.4-6 Sufficient Training Opportunities

Figure 7.4-7 Operationally Speaking Open Rate

indicator of legal, regulatory, and accreditation Figure 7.4-8 Fiscal Accountability Audit Year External Financial Audit Unqualified Opinion Issued Significant Deficiency(ies) Identified

2021

2022

2023 2024 2025

Pass

Pass

Pass

None

None None None None

Pass

Pass

performance. Complaint volume (Figure 7.29) remains low compared to the total number of patients served, ranging from 2.6 to 7.1 complaints per 1,000 patients from 2020 through 2025. Complaints peaked in 2024 at 104, or 7.1 per 1,000 patients, before decreasing to 46, or 3.5 per 1,000 patients, in 2025. Because complaints are a low-volume measure, IHCRC evaluates them alongside accreditation outcomes, compliance reviews, and other regulatory indicators to identify trends and opportunities for improvement.

7.4a(4) Results for ethical behavior are being formalized as part of IHCRC’s continued development of key organizational measures.

While sufficient trend data is not yet available for display, ethical expectations are supported through policies, required training, leadership accountability, and established reporting processes. Future reporting will include measurable indicators such as training completion, reported concerns, substantiated findings, and external reported HIPAA complaints.

7.5 Financial, Marketplace, and Strategy Results

financial audits. From 2020 through 2025, IHCRC successfully passed each external financial audit. During the same period, no significant deficiencies were reported.

7.4a(3) IHCRC tracks complaints as one 34 | Results

7.5a Financial and Marketplace Results 7.5a(1) IHCRC uses revenue by fiscal year, payor mix, revenue over expenditures, operating disbursements, and days cash on hand to monitor financial performance, budget management, and overall financial stability. These measures show revenue trends by major payor source, changes in payor composition, positive year-to-date financial performance, consistent monitoring of operating expenses, and strong liquidity. The organization is continuing to refine how financial measures are

connected to specific market segments, patient groups, and service lines.

Figure 7.5-5 Revenue by Fiscal Year

Figure 7.5-1 Earnings over Expenditures

Figure 7.5-6 Annual Fundraising Performance Figure 7.5-2 Days Cash on Hand

Figure 7.5-3 Operating Disbursement Graph

Figure 7.5-4 Payor Mix

Level 4 Application - 2026

7.5a(2) Formal marketplace performance measures are not yet in place. While IHCRC can demonstrate expanded capacity and service growth through IHCRC 530, the organization does not currently have consistent data to measure market share, market growth, or market position by segment. This is an identified opportunity as the organization continues to strengthen its results and measurement systems.

7.5b Strategy Implementation and Innovation Results Strategy implementation is tracked through the Strategic Scorecard, which includes SMART goals, status updates, and revision notes for key organizational priorities. The scorecard excerpt (Figure 7.5-7) shows how progress is monitored, changes are documented, and priorities are adjusted when needed. Because the figure is an excerpt, it does not represent the full strategic scorecard, but it demonstrates IHCRC’s approach to maintaining accountability for strategy execution.

Results | 35

Figure 7.5-7 Strategic Scorecard Excerpt Measure

SMART Goals

Status

December 2025 full staff meeting - All staff will have been given a new handbook, requiring a Support Staff - Resource Guide signature form to be signed and turned into HR for inclusion in the personnel file. New handbook will be included in all new employee orientations.

Complete

Safe Work Environment

Add Core Services

Improve Integrated Services

Tell Our Story and History (Medicine Wheel)

Injury and Illness Prevention Program plan in Stericycle will be 100% updated by March 31, 2025, to prioritize a safe work environment.

Complete

Begin implementation of Physical Therapy, Occupational Therapy, and Speech Therapy services at IHCRC 530, with initial staff, space allocation, and equipment acquisition planned by On-Hold Q2 2025. Develop a phased rollout strategy and assess patient demand quarterly to refine services as needed.

Integrated encounters will increase by 5% when comparing initial 6 month period after initiation (October 2024 through March 2025) compared Complete to subsequent 6 month period (April though September 2025).

Ensure 100% of new staff members receive cultural competency training during New Employee Orientation (NEO) and distribute the Complete cultural competency manual to all new hires.

Gather feedback annually to improve training effectiveness.

Improve Processes and Critical Systems

By August 1, 2025, work with staff in at least three departments to guide process improvements and determine measures that can illustrate our commitment to our mission, vision, and values.

Complete

Deploy Key Systems in Six Baldrige Categories

By December 1, 2025, implement key systems in six Baldrige categories.

Complete

Deploy Lean White Belt Training

By June 1, 2025, at least 98% of IHCRC’s staff will have participated in the Lean training program that Complete results in each staff member having the knowledge and skills to conduct basic Lean projects.

July 1, 2025 - CHRO to research best practices Employee Succession Plans for for employee succession planning. Identify key All Directors and Above positions to be included in the succession plans.

Identify succession planning template to utilize.

Advocate for the American Indian at the Federal, State, Tribal, and Municipal Levels

36 | Results

Attend the National Council of Urban Indian Health (NCUIH) Conference in Washington, D.C., in April 2025, with leadership meeting with at least two federal representatives (or staff) to discuss key policy issues impacting urban Indian health.

Revisions/Notes

Removed

Complete

Moved to Q1 2026 Quarterly Offsite

Removed from Strategic Plan at Quarterly Offsite.

Addendum

contributing to their actions.

A.1 CEO Strategic Vision The CEO Strategic Vision comes from our CEO, Carmelita Skeeter. It outlines her desired outcomes for the clinic over the next decade.

Along with our Mission, Vision, and Values, the CEO Strategic Vision helps guide all strategic planning and innovation.

Looking to the future, we will be met with opportunities and challenges.

• The biggest opportunity is to become more systems-based because it makes us more resilient and adaptable. The systems-based approaches that are particularly successful are those that focus on using consistent processes and having staff cross-trained.

These approaches decrease disruptions when we have staffing changes.

• The biggest challenge we face is increasing competition from tribal healthcare facilities.

Focus on Growth Utilize the new services we offer to increase the volume of patients we see. Seeing more patients will, in turn, increase the types of services we can offer in the future.

Quality improvement initiatives will be essential for promoting growth.

Continue to Build on Systems-Based Approaches The Baldrige Excellence Framework has increased cohesion with staff in Senior Leadership. The next step is to expand this approach to all staff and increase their engagement in planning and innovation.

It is critical to maintain a culture of humility and recognize that titles do not make staff beyond reproach. We can all make mistakes. We can all CEO Strategic Vision learn. We can all have Coming Soon incredible ideas.

American Indians in Tulsa have more Continue to create systems that do not rely options than ever before. If we take patients on a single individual. We will benefit from for granted, they will stop coming. continuing to focus on cross training staff.

Make Our Patients Central Get Back to Our Roots Listen more to patients to ensure that we The clinic was founded with a focus on hear what they need and not assume their needs. addressing the needs of parents and children. It is Strategies for improving listening can include: important to get back to that focus. This includes: • Offer listening sessions with patients.

• Men’s health programing that addresses Doing so will provide continuous feedback chronic issues, such as alcohol abuse, and provide information on the most tobacco use, and heart disease. Core to this pressing issues people face. programming should be the promotion of • Continue developing our use of patient parent-child engagement. satisfaction surveys.

• Continue to build on treatment • Have more community activities that programming that promotes parent and connect staff with patients and provide child engagement. Treatment of children opportunities for education on important must include a parental component. healthcare topics. These activities can • Increase community activities that promote include things like potlucks and coffee parent-child interactions. hours.

Find a balance between accountability and compassion when dealing with patients.

It is critical to be less reactive to patient by recognizing situational factors that are Level 4 Application - 2026

Section Heading | 37

Mission: To Empower the American Indian Through Exceptional Healthcare!

Level 4 Application - 2026

Section Heading | 38