Purpose. This chapter revises policies and procedures, staffing responsibilities, priorities of care, services provided, and sets general standards of operation for the Indian Health Service (IHS) Eye Care Program. This chapter is a guide and not a substitute for communication with local eye care providers or Area eye care consultants or the IHS Eye Care Coordination Committee.

Policy. The IHS Eye Care Program will include the following:

Ocular health promotion activities.

General and specialty examinations.

Treatments and procedures.

Required prescription ophthalmic devices and associated dispensing services.

Ophthalmic surgery.

Goal.  The IHS Eye Care Program goal is to assure that comprehensive, culturally acceptable, eye care services are available and accessible to American Indian and Alaska Native (AI/AN) people.

Objective. The objective of the IHS Eye Care Program is to provide the highest possible level of eye care for AI/AN people, to the maximum extent possible, within the resources available.

Indian Health Service Eye Care Clinical Consultants.

Optometry Chief Clinical Consultant. The incumbent is Chief Consultant and spokesperson for IHS optometry and is appointed by the Director, Division of Clinical and Preventive Services, (DCPS), Office of Public Health (OPH), IHS.  However, all matters of an inter-professional nature or which have programmatic direction will first be discussed by the IHS Eye Care Coordination Committee. By virtue of being appointed to the position of Chief Clinical Consultant, the person becomes a required, voting member of the IHS Eye Care Coordination Committee (See 3-9.2B). Some specific responsibilities of the Chief Clinical Consultant are as follows:

Chief liaison to IHS Headquarters on special activities such as, IHS Loan Repayment Program, career development, Commissioned Officer Student Training and Extern Program (COSTEP), IHS Scholarship Program, etc.

Provides guidance and consultation to the Area optometry consultants.

Coordinates optometry committee activities.

Oversees the optometry externship and residency programs.

Coordinates optometry recruitment.

Participates in the development of IHS staffing and facilities planning documents.

Provides guidance for optometry credentialing, privileging, and peer review.

Is chief representative for IHS optometry at IHS and non-IHS professional meetings.

Deputy IHS Optometry Chief Clinical Consultants.  Several Deputy Optometry Consultants may be appointed to oversee a number of specific areas of concern. They will report periodically, as required, to the IHS Optometry Chief Clinical Consultant.

Ophthalmology Chief Clinical Consultant. The Ophthalmology Chief Clinical Consultant is appointed by the Director, DCPS. The selected person is the Chief Consultant and spokesperson for IHS ophthalmology. All matters of an inter-professional nature or matters which have programmatic direction will first be discussed by the Eye Care Coordination Committee. By virtue of being appointed to Ophthalmology Chief Clinical Consultant, the person is required to become a voting member of the IHS Eye Care Coordination Committee. Some specific areas of responsibility are as follows:

Chief liaison to IHS Headquarters on special activities such as the Loan Repayment Program, career development, and all other programs that impact upon IHS Ophthalmology services.

Participates in the development of IHS staffing and facilities planning documents.

Provides guidance, consultation, and troubleshooting to service units (SU) and IHS Ophthalmologists.

Comments on ophthalmology performance improvement, credentialing, billets, and privileging, research, ocular surgery, and primary care.

Liaison for the American Academy of Ophthalmology and other professional groups.

Deputy Ophthalmology Chief Clinical Consultant. A Deputy Chief Clinical Consultant for Ophthalmology may be appointed to assist the chief clinical consultant oversee certain areas of concern.

Area Consultants. It is recommended that each IHS Area appoint an Area Ophthalmology and an Optometry Consultant. All consultants, whether they are assigned to the national or Area level will provide consultative services to the appropriate governing body, SU, or tribe, in their areas of expertise. Input from eye care consultants may be needed in many areas of program management and should be consistent with IHS policy. Area Consultants may provide input on:

Program and facilities planning.

Clinical care.

Recruitment.

Program reviews.

Troubleshooting.

Communication/Reporting.

Performance Improvement/Peer Review.

Eye Care Coordination Committee. This committee consists of two optometrists and two ophthalmologists. The IHS Chief Clinical Consultants for Ophthalmology and Optometry are mandatory appointees to this committee. Each will appoint another member from his/her discipline. The purpose of this committee is to ensure inter-professional cooperation in the review and the recommendation to Headquarters of all important documents/policies effecting the delivery of eye care to AI/AN. This committee will meet in person or in teleconference, as much as necessary, and no less than three times annually. Specific responsibilities of this committee and the chairperson can be found in the committee's charter. See (Manual Exhibit 3-9-A.)

Service Unit Eye Care Organization.

Chief of Optometry, SU. Supervises the optometric staff within the SU. Acts as Chief Consultant for SU optometry matters.

Chief of Ophthalmology, SU. Supervises the ophthalmology staff within the SU. Acts as Chief Consultant for SU ophthalmology matters.

Chief of Eye Care SU.  Where optometry and ophthalmology services are provided at the same facility the program may be directed/coordinated by a Chief of Eye Care. Selection of an appropriate ophthalmologist or optometrist should be based upon possession of the proper credentials including administrative experience, availability, and willingness to do the job. Due to the politically sensitive relationship between the professions of optometry and ophthalmology, a background of successfully working in this environment is helpful. The Chief of Eye Care acts as an eye care consultant to the Clinical Director and Service Unit Director (SUD), integrates Area policy with SU policy and procedures, recommends SU eye care policy, promotes appropriate educational programs, directs eye screening services, acts as SU vision safety consultant, and monitors program effectiveness through an ongoing performance improvement program.

Staff Credentials. All eye care providers must be privileged/reprivileged to provide services at their local health care facilities per local credentialing requirements. The basic premise of the credentialing process is peer assessment of the providers' qualifications as presented in his/her application for clinical privileges and subsequent ongoing peer reviews. Guidance may be obtained from the Area Optometry Consultant or Area Ophthalmology Consultant, as appropriate.

Continuing Education. Continuing education is essential for the individual practitioner to maintain clinical competence and relicensure. It may be obtained through individual study and through a variety of mechanisms including local, regional, or national meetings within or outside IHS. The eye care professional must ^{meet the} continuing ^education requirements of the licensing board(s) to qualify for relicensure and satisfy local medical staff requirements, as appropriate. Financial support for this should be made available.

Committees. Committees are an avenue by which many issues and problems are resolved within the complex system of the IHS. Committees bring many people together with special interests or expertise that allow problems to be approached in a most democratic and efficient manner. Optometry and Ophthalmology have used committees for decades to deal with issues in many areas such as:

Diabetes

Pharmacotherapeutics

Research

Training

Career Development

Recruitment

Special Pay

Committees also create networking that is essential to the public/community health mission the IHS identifies with. The IHS encourages eye care professionals to participate in IHS committee activities. See (Manual Exhibit 3-9-B.)

Indian Health Service Direct Care.

Eligibility. All persons who are eligible for general medical care through the IHS health care delivery system are eligible for eye care, subject to expressed limitations in this section and in other IHS regulations.

Patients are encouraged to seek care at their respective SU.

Where direct care is not available and/or where supplemental or specialized care may be required, it may be procured under contractual arrangements by appropriate IHS authorizing officials, consistent with current priorities.

Frequency of Examination.  The frequency of eye examination shall be determined by the individual needs of each patient.

Screening.  Children (through age 18) should be adequately screened each year.

Complete Examinations.  Complete exams should be performed periodically for children and adults as indicated.  More frequent examinations are encouraged when:

Signs or symptoms of acute or chronic eye disease/conditions are known or apparent.

Instructed by a provider to return for a specific reason, such as diabetes, followup exam, or amblyopia therapy.

Written referral from a doctor, school nurse, or school screening.

Significant visual symptoms are apparent.

Diabetic Screening and Monitoring System.  A diabetic screening system will be maintained whereby every diabetic in the eligible population is encouraged to have an adequate ocular health screening/examination in accordance with the recommended protocol.

Provision of Direct Care Services for Active Duty United States Public Health Service Commissioned Corps Personnel and Their Dependents.  Direct care may be provided to active duty United States Public Health Service (PHS) Commissioned Corps personnel and their dependents if the provision of care does not interfere with the provision care to AI/AN beneficiaries.  This service is performed at the discretion of the SUD.  (Fees will be charged in accordance with IHS regulations.)

Emergency Care (Non-AI/AN). Emergency care can be provided to non-Indians for sight-threatening conditions. Where such care is provided, the patient will be billed directly, in accordance with applicable IHS regulations.

Contract Health Care. General, supplemental, and/or specialized care may be procured under contract consistent with current priorities. All IHS personnel who refer patients to non-direct care eye care providers must familiarize themselves with IHS Contract Health Services (CHS) rules, regulations, and priorities. Examination frequency may equal direct care, depending upon facility budgetary limitations.

Division of Services.

Primary Eye Care Services. Entry to eye care services generally occurs through the direct and contract care optometry/ophthalmology clinics. The level of services provided at any given direct care facility is dependent upon the eye care personnel available and the level of services provided.

Secondary Eye Care. Secondary level services are provided as needed and in accordance with medical priorities.

Management of complicated ocular condition and injuries.

Consultative services are available to other health care providers.

Contact Lens Examinations and Evaluation.

Non-elective contact lenses. When ocular conditions exist which preclude the successful use of ordinary spectacles, contact lens fitting may be authorized. Most commonly these applications are for keratoconus; irregular astigmatism correction; anisometropia (where symptoms are present or where it can be documented that binocularity will be significantly enhanced); and high refractive error. Written recommendation from an IHS optometrist or ophthalmologist may be required if a CHS provider is utilized.

Cosmetic or elective. All other contact lens examinations will be considered as elective. Elective contact lens fitting (including evaluation fees, materials, insurance, re-check visits, and the like) is not authorized by CHS priorities. Where direct IHS eye care is available, contact lens examinations and evaluations may be authorized. All costs incurred for lenses, insurance, and other accessories are the responsibility of the patient. If contact lenses are to be prescribed, adequate contact lens assessment equipment must be on hand.

Vision Therapy/Orthoptics. Vision therapy and/or orthoptics may be accomplished by or under the direction of an IHS optometrist or ophthalmologist where appropriate. Vision therapy/orthoptics scheduled to be performed by a contract provider should be first pre-approved by an IHS optometry or ophthalmology consultant and may be reviewed periodically for efficacy.

Eye Surgery.

Emergency eye surgery should be performed or referrals made as necessary.

Other eye surgery should be performed consistent with IHS priorities and PHS/IHS regulations See (Section 3-9.4B). Any CHS referrals should be consistent with the same priorities.

Low Vision Services. Low vision evaluation and the necessary devices will be available to patients based upon the available staffing and level of services provided.

Health Promotion/Disease Prevention.

Vision Safety/Employee Health. In accordance with Executive Order 12196, "Occupational Safety and Health Programs for Federal Programs", and Public Law (P.L.) 91-596, Part 29, Section 19, CFR 1960, "Occupational Safety and Health Act (OSHA), the IHS will establish and maintain a viable vision safety program for its employees. Each local program shall be in compliance and should incorporate this program into its Employee Health Plan.

Eye Screening.

Head Start and pre-school screening for Indian children through age 6 should be accomplished at all locations within IHS Areas under professional supervision or consultation.

Screenings of all Indian children or Indian children in selected grades at all area public and reservation schools should be conducted on a yearly basis. This screening should be accomplished, whenever the means are available, under professional supervision or consultation. See (Manual Exhibit 3-9-C, "Vision Screening Guidelines for School-Aged Children.)

Ocular health screening (generally dilated) of all diabetic patients in compliance with screening protocol is recommended. This screening may be provided by the primary medical providers as part of routine diabetic care. More advanced Diabetic Retinopathies need be monitored by eye care professionals. (Manual Exhibit 3-9-D "Diabetic Retinopathy Screening & Monitoring Procedures.")

Other types of ocular screening may be recommended by local eye care professionals based upon endemic need. The design and method of any screening performed should be appropriate to the target population.

Patient Education. Patient education is the cornerstone of health promotion and its impact on community health care cannot be overemphasized.  While a great deal of patient education occurs during the one on one encounter of provider and patient, a formal eye care educational program is required in each IHS facility and program area. In addition, AI/AN specific eye care education pamphlets and posters are available for distribution to patients through IHS health care programs.

Prescription Ophthalmic Devices. When prescription ophthalmic devices are provided, the following provides a reasonable and equitable guideline for utilization of these resources.

Spectacles. No spectacles will be ordered or replaced using IHS funds unless the ocular condition or the condition of the spectacles warrant such change or replacement. Care should be exercised in avoiding the use of glasses of low power which would provide minimum benefit.

Frequency of Spectacle Replacement.

Children through age 18 or through 12th grade will be allowed a maximum of one pair of spectacles in any 12-month period.

Adults will be limited to a maximum of one pair of spectacles in any 24-month period.

The 1 year/2-year limits of spectacle replacement at IHS expense applies within the context of current facility or Area policy.

Records must be maintained by all eye clinics/facilities indicating when a patient last received glasses at IHS expense.

Limitations in Spectacle Provisions.

A maximum frame cost limit will be established, consistent with the availability of a reasonable selection of functional, cosmetically acceptable frames.

Tints and other spectacle accessories are usually discouraged, but may be provided at the discretion of the provider when clinically indicated.

No cosmetic lenses will be routinely provided at IHS expense.

Before a non-IHS spectacle prescription is filled at IHS expense, the patient may be requested to have the prescribing doctor complete an information form or to supply added information on the prescription:

Prior prescription; condition of glasses.

Visual acuity without glasses, distance and/or near.

Visual acuity with old glasses, distance and/or near.

Visual acuity with new glasses, distance and/or near.

NOTE:

This information will be used to assure compliance with IHS policy and the judicious expenditure of IHS funding and to determine priority status when funding priorities are in effect.

Prescriptions that are current will generally be accepted. (Generally means under 9 months for children or under 18 months for adults; or renewals of prescriptions rewritten within these time limits.)

Glasses at IHS expense must be procured through appropriate government acquisition route(s). Exceptions may be allowed for individuals temporarily residing outside of and residing at a substantial distance from their SU, such as, at a college or vocational school, providing the person meets all qualifying IHS regulations.

Quality. All glasses will be verified for accuracy of prescription and quality of workmanship utilizing the ANSI 2-80 and/or 2-87 optical standards before dispensing.

Contact Lenses.

Therapeutically Indicated Contact Lens. Under conditions where therapeutically indicated contact lens must be purchased, the initial contact lenses and the minimum required accessories may be purchased with IHS funds, subject to priority limitations, within the following conditions:

Initial and replacement solutions may be provided consistent with pharmacy over-the-counter drug policy.

Lenses will be replaced as the individual patient's eye condition dictates.

Cosmetic/Elective Contact Lenses. Expenditure of IHS funds is not authorized, however, alternate funding is encouraged, i.e., patient-paid and Lion's Club.

Low Vision Devices.

Entry level low vision services should be available at all facilities where IHS clinics exist, if sufficient resources are available. Low vision devices for patients with documented low vision needs should be provided at IHS expense, if within IHS priorities of care, when these devices are an integral part of low vision rehabilitation.

Before the patient's or IHS resources are used for purchase of low vision devices, alternate resources should be carefully investigated. Alternate resources include:

State health authorities, state services for the blind, Lion's Club or other sources may be available to provide services and devices for low vision patients.

Prosthesis. Prosthetic eyes/shells/contact lenses, when integrally related to surgery or where there is gross (socially unacceptable) disfigurement, will be provided consistent with current priorities. Replacement is based upon the physiological needs of the patient and is at the discretion of the provider.

Optical Refabrication. When the patient fails to make normal adaptation to the prescribed ophthalmic device and new lenses have to be fabricated, such device may be replaced by the ordering facility, even when the original purchase was made at the patient's expense.

Payments. When funding is not available for purchase of an ophthalmic appliance, especially when this device is most appropriately ordered through specialty sources and is not otherwise available locally, the eye clinic or another facility department may act as an intermediary for purchase of the item by coordinating and facilitating payment by the patient to the source. The form of payment, i.e., cash, check, or money order, is determined by collections policy within each IHS Area. See Manual Exhibit 3-9-E for an "Optical Prescription Patient Paid Order" form.

Cooperative Efforts. At many IHS facilities, there is insufficient eye care staff to provide for all patients who need evaluation and treatment for medical and traumatic eye conditions. In order to meet the demand for these eye care services, it is necessary to form a close working relationship among health care providers. 

Cooperative decisions must be made on how to handle acute eye conditions in the clinic and how non-emergent, CHS eye referrals will be made. The eye care professional will function in a consultant role in direct care and CHS referral situations. This will allow for the maximum utilization of IHS resources to deal with eye problems of the AI/AN people.

This section describes the services which are provided in the IHS eye care delivery system. These services have been subdivided into five levels of services. The provisions of services necessary to treat emergency situations, those which are preventive, and those which promote eye health are classified higher than those which are corrective, rehabilitative, or supportive. For example: Level I services are the most necessary services, and Level V services are excluded services.

The schedule of services in Section 3-9.4B is intended to serve as a guide for: Eye care providers salaried by the Federal Government or tribal groups; fee-for-service eye care providers; administrators of direct IHS or tribal eye care programs; third party administrators; and IHS or tribal CHS personnel. No attempt has been made to differentiate the direct IHS Eye Care Program from tribal/P.L. 93-638 programs or the fee-for-service providers. Each are distinct and acceptable methods of eye care delivery to AI/AN people.
 

Indian Health Service Medical Priority System.

Whenever finances are insufficient, eye care providers are lacking, or a waiting list for eye care services must be maintained, a priority system for eligible patients should be established based upon the levels of services. If the need for services exceeds the available resources, services should be provided in the descending order of the level of care. When increasing services, each priority should be fully met before proceeding to the next lower priority within any given level. Adequate time/manpower must be available to permit associated performance improvement and statistical data activities required for program management relative to each level of services provided.

All facilities should develop a means to adequately screen all appointment requests in order to determine each patient's relative priority and to help reduce the chance of deferring a patient with an urgent or sight threatening eye condition.

The ability to provide eye care at a given priority level will vary significantly between Areas/SUs due to demand, staffing, and financial resources. The Area/SU priority level may need to be changed frequently in response to backlog and other factors. Each facility's current IHS Medical Priority System level shall be documented and approved by the SU/facility director. Documentation of these changes and changes in priorities will be forwarded to the Area Eye Care Consultants.

Schedule of Services. The elimination of any component of Levels I, II, or III, may significantly compromise the efficacy of any eye care program and create risk management and public health liabilities.

Level I. Services necessary for relief of acute conditions or services sufficiently urgent to warrant the highest level of priority.

Emergency Services. Services necessary to prevent the immediate loss of an eye or vision in an eye, i.e., penetrating injuries, open eye injury, chemical burns, central retinal artery occlusion, acute angle closure glaucoma, and retinal detachments threatening the macular area.

Urgent Services. Those services necessary for relief of acute, painful, or visually threatening conditions, i.e., corneal foreign body or abrasion, corneal ulcer, iritis, or any diagnosed/undiagnosed condition which could result in rapid vision loss if not given proper attention.

Specialty Consultations. In instances where no direct medical care is available, it may be necessary to authorize consultations to establish diagnoses (this is not a referral for treatment and/or monitoring). Once a diagnosis is confirmed, the patient will be treated consistent with the level of services currently being provided.

Level II (High Priority Restorative and Preventive Eye Care Services). Those services and activities designed to restore vision in the event of severe binocular vision loss, prevent the onset or progression of ocular disease or visual impairment, or services to advance the ability of people to become self-reliant.

Binocular Subnormal Vision. In the event of severe vision loss due to a progressive/degenerative bilateral eye condition, services to restore vision in one eye, i.e., visual acuity in the best-seeing eye approaching, equal to, or worse than 20/200 due to bilateral cataracts, bilateral corneal scarring, or a combination of several factors resulting in bilateral vision loss. Besides surgery, low vision aids, and protective eyewear for functionally monocular patients should be considered.

Children Screening Programs. Organized eye screening and treatment programs for children through age 6 .

Diabetic Screening. Diabetic retinopathy monitoring and treatment programs.

Glaucoma Management.

Management of Sub-acute or Chronic Conditions. Management of sub-acute or chronic conditions which can reasonably be expected to preserve vision, includes but is not limited to:

Keratoconus management.

Amblyopia/functional strabismus management.

Routine surgical care.

Medical eye services and followup of Level I services.

Therapeutically indicated contact lenses.

Level III (Other Primary Eye Care Services and Priority Secondary Eye Care Services).

Eye examinations for children ages 5-18 or 12th grade.

Eyeglasses for children through age 18 or through 12th grade.

Optical Refabrication (See item (8)of Section 3-9.3E).

Vision Safety Program.

Eye care for adults (prioritized):

Exams for patients ages 45 and over.

Exams for ages 19-44.

Eyeglasses for patients 45 and over.

Eyeglasses for patients ages 19-44.

Ocular prosthesis or other cosmetic restoration of badly disfigured patients.

Medically indicated refractive surgery, such as:

Refractive correction with anterior corneal stromal opacities where photo therapeutic keratectomy is already indicated.

Cases of extreme anisometropia where traditional optical correction is either not indicated or has failed.

Level IV (Other Rehabilitative Services and Elective Services). Optometrists and ophthalmologists are encouraged to perform a number of procedures within these services, consistent with their privileges, sufficient to maintain skills at an acceptable level. Those rehabilitative services which require more time, additional skill of the provider, or a higher cost to benefit ratio, to include but not limited to:

Minor and cosmetic surgical procedures.

Cosmetic contact lenses.

Perceptual-motor training.

Level V (Excluded Services). Services of an experimental/investigational nature or of questionable efficacy, or procedures that have an acceptable non-invasive alternative, such as: use of placebo spectacles.

Medical Records.

Strict adherence to the intent and the specific provisions of the Privacy Act is mandatory.

Adequate eye care records, as part of each patient's general health record, is essential.

The recording and coding of eye examinations must comply with IHS records requirements.

Scheduling. A patient scheduling policy should be available in writing in all facilities and should be strictly used to govern appointment/scheduling procedures. At minimum, this policy should include:

Clinic hours.

Availability of emergency care after hours.

Routine appointment making procedures.

Appointment priorities and justification if different from IHS or Area policies.

Walk-in policy.

Late and no-show policies.

Referral policy and sources; referral followup.

Specialty clinics.

Indian Health Service Eye Care Performance Improvement Program.  The intent of the IHS Eye Care Performance Improvement (PI) Program is to provide an active, organized, peer based procedure for maximizing the quality of patient care.  Among the goals of the PI program is adherence to the principles of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

The PI Program should include at least the following elements:

Program Review.  The Area Ophthalmology and Optometry Consultants are responsible for development, implementation, and application (at least on an annual basis) of a program review which addresses:

Assessment of the administrative direction of the program.

Organization and functioning of the eye clinic within the overall facility framework.

Policies and procedures (which must be documented and updated annually in a manual) of the eye clinic.

Staff membership status and clinical privileges of the professional staff of the eye clinic.

Physical facility and equipment.

Paraprofessional staffing and utilization.

Research and educational activities.

Continuing education program.

Peer review program.

Provider profiles.

Peer Review.  The Area Ophthalmology and Optometry Consultants are responsible for assuring that a peer review PI Program for each SU in the Are is developed and implemented.  Each provider and each facility within the Area discipline consultant, by other designated individuals or by a committee of peers in accordance with the local PI plan.  The PI audit program should include:

A Written Eye Care PI Plan.

Organized clinical criteria and standards against which performance may be objectively measured.

Objective, documented assessment to assure compliance with established criteria and standards.

Peer review of the appropriateness of care.

A mechanism to identify problem areas.

A procedure for developing a recommended plan of corrective action.

A feedback mechanism to assess whether identified problems are corrected by implementation of appropriate action.

A policy to deal with a disagreement with peer review.

Written documentation of each requirements (above) which requires the Eye Care Program to participate in the facility PI Program as directed through the facility PI Plan.

Service Unit Review.  The Chief of Eye Care, SU, is responsible for development and implementation of the SU Eye Care PI Program.  This program should include a written SU Eye Care PI Plan as outlined above, as well as, an ongoing assessment of the care provided through the use of generic screens, focused surveys, etc.

Screens and surveys are not intended as peer review, and the screener need not be a member of the eye clinic staff.

The screens should evaluate both the professional and ancillary staff.

There must be written documentation of ongoing assessments.

Formal problem are identification and resolution, usually within the framework of the facility's PI group, shall be documented.

Productivity standards will vary from clinic to clinic depending on the type of patient typical to that clinic, the equipment, and the support staff.  Assessment of levels of productivity should be done in collaboration with the appropriate discipline consultant.

Primary Care Eye Exam Standards.  Practice guidelines have been established for a primary care eye exam.  (See Manual Exhibit 3-9-G.)

Research.

Research on visual and ocular problems and conditions is encouraged.  Appropriate research which will increase the understanding of the visual ocular conditions of AI/AN people and/or improve the delivery of eye care is highly encouraged.

Under the guidance of the IHS Research Director, P.L. 94-437 funds may be available to any potential researcher.

All projects must follow protocol for approval as established by Part 1, Chapter 7, "Research Activities," Indian Health Manual (IHM).

Research activities shall not compromise or conflict with the provision of core services.

Equipment.

Standard Eye Care Equipment List.  The standard equipment list is the result of continuous evaluation and revision by Senior Clinicians and IHS specialty consultants.  The list was developed to aid in equipment acquisition for new facilities but will be useful as a guide to equip existing facilities.  By regulation the equipment purchased must be from government contract sources; a request for purchase from other sources must be accompanied by a detailed justification.

Standard Eye Care Equipment List Update.  Improvements in Ophthalmic equipment and technology require that the equipment list be subject to frequent review.  Suggested revisions must be directed by the Area Optometry and ophthalmology consultants, with recommendations, to the IHS Chief Clinical Consultant whose responsibility it is to update the ophthalmic equipment list.  (See Manual Exhibit 3-9-G.)

Preventive Maintenance.  An ongoing preventive maintenance program is essential to clinic efficiency, prevents interruption of patient care services due to equipment failure.  Generally, major ophthalmic equipment shall have biennial preventive maintenance, most effectively provided through an IHS Area level maintenance contract.

Repair and Replacement.  Monies should be made available on an ongoing basis for replacement and/or repair of specialized eye care equipment.

Optometric Clinical Training Program.  Although clinical training is not a primary function of the IHS, IHS facilities may participate in clinical training programs with accredited academic institutions when beneficial to patient care and program goals.

Optometric Student Externships.  Sites that have clinical space, i.e., an equipped examination room available full-time to the extern, and adequate patient case load are encouraged to host senior optometry students for clinical rotations.  A Memorandum of Agreement signed at the Area level and by the respective school(s) or college(s) of optometry from which students are assigned, governs the operation of these rotations.  Students are granted limited privileges requiring co-signature by fully privileged staff.  In addition to increasing access care for patients, these rotations create a positive reputation for IHS, enhance recruitment and stimulate staff morale and career satisfaction.

Optometric Post-Graduate Clinical Rotations.  Optometric post-graduate clinical rotations, also called Optometric residencies, may be sponsored by IHS optometry programs and must be affiliated with a school or college of optometry.  As with student extern programs, clinical space and clinical case load must be appropriate to support such programs and an agreement with the certifying academic institution signed at the IHS Area level delineates operation.  Residents are privileged to practice independently as members of the medical staff according to their licensure and credentials.  In addition to increasing access to care for patients and generating revenue for IHS facilities, these rotations create a positive reputation for the IHS, enhance recruitment, and stimulate optometric staff morale and career satisfaction.