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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

DFO Programs

Program Index

Realty -

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The Indian Health Service (IHS) Realty Management program implements the mandates of the Indian Health Care Improvement Act (P.L. 94-437), to provide the space necessary to achieve improved health care to American Indians and Alaska Natives.

The IHS Realty Management program assist in ensuring that federal owned lands and buildings are protected, managed, accounted for, developed, and utilized, in a timely and efficient manner.

The program’s transactions range from acquisitions, demolitions, transfers of IHS owned land and buildings, lease acquisitions and disposals of federal and commercial real property, the permitted use of IHS owned property for use by Federal agencies, tribes, and public and private entities, and asset management reporting.


The Realty program provides guidelines and procedures for the acquisition, utilization, and disposal of IHS owned assets and the acquisition and disposal of leased federal and commercial real property assets.

Fixed Asset Capitalization

Several laws enacted by the Congress require a new level of coordination between the federal real estate assets and overall financial records of all Federal agencies. These laws are the Chief Financial Officers Act of 1990 (P.L. 101-576), and the Federal Financial Management Act of 1994 (P.L. 103-356). As a result of these Acts, the Federal Accounting Standards Advisory Board (FASAB) developed Standard 6 – Accounting for Property, Plant, and Equipment (FASAB #6). This standard directs how Federal agencies account for its owned assets (i.e., newly constructed, additions and improvements, demolitions and transfers) and those assets acquired through capital leases and leasehold improvements. These actions are funded through a number of funding sources such as new construction, maintenance and improvement (M&I), Medicare and Medicaid, etc. It is not the funding source, but rather the resultant change to an asset’s value that requires an entry in the fixed asset module and subsequent reconciliation with the Agency’s general financial statements.

Healthcare Facilities Data System (HFDS)

The HFDS contains all IHS real estate holdings, the Federal Real Property Council Data Elements, maintenance, improvements, and equipment, FEDS and environmental self governance, energy and stewardship reporting data for IHS-held facilities.

Quarters Management

The IHS Quarters Management Program is designed to provide policy and guidance on quarter’s management issues; and provide procedures for effective implementation of IHS policy on quarter’s management. The program oversees the Area and Service Units implementation of the quarter’s policy to ensure the availability of safe, suitable housing for personnel essential to the continuity of the IHS health care delivery system.

This oversight of the quarter’s program’s operation and management includes maintaining reliable quarter’s occupancy and rental collections data. In coordination with the Department of Interior, Quarters Management Information System (QMIS), IHS realty officers and/or housing officers can enter Area and Service Units quarter’s occupancy and rental collections data in real time.

Leased Property

The HQ realty program is responsible for developing and issuing policies and internal procedures to implement DHHS policy in management of real property leases. Other responsibilities include coordination of the Lease Priority System to evaluate direct lease requests for new or expanded lease space requirements for IHS health care programs in assisting the Areas in obtaining approval for space acquisition. The realty program also tracks the expiration dates for all GSA-assigned and direct leases and coordinates all of IHS leasehold interests between the Areas, Engineering Services, and Service Unit.

Asset Management

Asset Management provides information and technical consultation on the planning, coordinating, evaluating, and management and accountability of IHS owned facilities. The program has oversight and control over the maintenance, repair and improvement of IHS facilities and the responsibility to assess, improve, correct, and report on the effective and economical management and utilization of IHS-held real property.

Clinical Engineering-Medical Equipment -

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Many health care services delivered by IHS require special medical equipment that must be acquired, installed, tested and calibrated, and maintained. Not only must each health care facility be equipped to meet its mission, but IHS continues to explore innovative methods, requiring new electronic technologies, to provide health care in rural settings. IHS acquires medical equipment for IHS and tribal health care facilities either as a part of construction of a new facility or with funds appropriated specifically to purchase equipment.   There are two components to the medical equipment program: management of existing biomedical devices, and funding/acquisition of new biomedical technologies.

Medical Equipment Management

In 1973, the IHS Biomedical Engineering Program was established.   Biomedical Engineers and technicians manage and service the complete spectrum of medical equipment in all IHS health care facilities.   These biomedical teams continue to manage device inventories in the midst of their rapid evolution, maintaining very rigid compliance with the requirements of the Joint Commission on Accreditation of Hospitals (JCAH, now known as JCAHO).

The Indian Health Service is moving rapidly in deploying state-of-the-art technology to bring primary care and specialty medicine to remote locations to reduce geographic barriers between remote, smaller communities and health care providers.    For example, clinical engineers are now equipping small remote villages in interior Alaska with telemedicine systems to provide transmission x-rays as well as digital images of patients’ ear drums, skin conditions, and even tonsils to distant health care providers.   Telemedicine also enables small rural communities to communicate during emergencies with social workers through video conferencing when transportation is difficult or impossible (especially in blizzard conditions in South Dakota).   Biomedical engineers manage devices associated with about forty telemedicine programs and partnerships within the IHS that are delivering health care to smaller, more isolated communities.

Picture of Medical Equipment

Medical Equipment Funding


The Congress also appropriates funds to modernize or replace existing equipment or provide newer equipment in existing programs.    Of these funds, the Congress provides approximately $14 million to be allocated, on a pro rata share basis, to provide ongoing replacement of existing medical equipment. The largest portion of funds appropriated for equipment is allocated among existing IHS and tribal health care facilities to replace existing infrastructure and add newer treatment modalities.   Funding amounts are based on workload and facility size using a standard formula.   Medical equipment is defined as any major or minor movable durable device, machine, apparatus that is solely intended for directly supporting the treatment or diagnosis of disease such as those regulated by the Food and Drug Administration.   Examples include sphygmomanometers, otoscopes, beds, bassinets, microscopes, centrifuges, laboratory equipment, portable whirlpool units, linen carts, patient monitoring equipment, x-ray systems, surgical instruments, various scopes, exam room equipment, office equipment/machines, and waiting room furniture, etc.   Medical equipment excludes fixed equipment that is usually attached to or integral to a building’s function such as elevators, utility systems, heating, ventilation, and air conditioning systems, electrical, systems, walk-in refrigerators, vaults, telecommunication systems, and are not funded with medical equipment funds.   Also, those equipment areas funded through other appropriations, such as IT networks, emergency medical service equipment, etc., are not funded from the medical equipment funding IHS budget line item. In addition, IHS sets aside some funds to procure, transport, and store excess Department of Defense (DOD) medical equipment so that it can be inventoried and provided to IHS facilities and tribes that need it (see next section on TRANSAM Medical Equipment Program).


Each year, congress appropriates approximately $5,000,000 to tribes for equipping their newly constructed expansion/replacement facilities when projects are funded using non-IHS funding sources.   Awarded funds can be used for purchasing waiting room and office furniture, x-ray and lab equipment, to lawn care equipment.   Each year tribes are invited to apply for equipment funding during the application submission period around the beginning of each fiscal year.   Awardees can receive up to 20% of their construction cost, depending on eligibility and the number of applications received during the funding cycle.   Each year the IHS receives approximately 30-60 applications, and funds are prorated after eligibility is determined.

For the purposes of this funding, Tribal general equipment is broadly defined as any major or minor movable durable device, machine or apparatus used in conjunction with operating a health program.   Examples include sphygmomanometers, otoscopes, beds, bassinets, microscopes, centrifuges, laboratory equipment, portable whirlpool units, linen carts, patient monitoring equipment, x-ray systems, surgical instruments, various scopes, exam room equipment, office equipment/machines, waiting room furniture, kitchen equipment, computer/IT systems, lawn care equipment, maintenance tools, etc.   Tribal General Equipment excludes fixed equipment that is usually attached to or integral to a building’s function such as elevators, utility systems, heating, ventilation, and air conditioning systems, electrical systems, walk-in refrigerators, vaults, telecommunications systems, etc.   For more information, please go to

Picture of Medical Equipment


The DoD makes excess medical equipment available to IHS before other federal agencies. Project TransAm originated by PL 103-335, National Defense Authorization Act of 1995, Section 8032 and works in partnership with the Air Force Reserves. To obtain this equipment, IHS need only acquire it through a DoD reutilization process (at no or minimal cost) and pay for its transportation and storage. After obtaining the equipment the IHS inventories it and makes lists available to tribes and IHS programs.    Because the DoD makes this equipment available only to Federal agencies, any tribe interested in obtaining equipment through his process must contact their respective Area Office Clinical Engineer.

Each Area develops a request for equipment based on the needs of tribes and service units.   Equipment can be selected on a first-come first-serve basis through a TransAm link on the website.   Registration on the website and coordination with respective Area Property Managers is required to meet accountability standards of government property.


IHS-GSA Shared Cost Program - Annually, the Indian Health Service allocates approximately $1 million for ambulances, which is used to subsidize the General Services Administration (GSA) rental rates for Tribal EMS programs. As a result the monthly operating costs for ambulances obtained through this program are approximately half the cost as the regular GSA rate. Ambulances are provided on a priority basis based upon mileage and maintenance histories as key factors in determining greatest replacement need. Currently, approximately 150 GSA ambulances serve 60 tribal and IHS Emergency Medical Service (EMS) programs.

Direct Lease through GSA - Tribes may lease ambulances directly from GSA rather than through the IHS-GSA Shared Cost Program.

Refurbished Ambulances- The TRANSAM program typically offers between seven and ten refurbished ambulances per year. The ambulance is delivered to the recipient program at no cost to the program. The tribal program owns the ambulance and is responsible for title, licensing, insurance, maintenance, fuel, and all costs associated with operating the ambulance. Tribes desiring an ambulance from TRANSAM should contact the IHS Office of Emergency Services. A priority list for refurbished ambulance is generated and maintained until all needs are met with priority given to those Tribal programs that have not taken EMS shares.

Facilities Engineering Deficiency System -

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The Facilities Engineering Deficiency System (FEDS) is a component of HFDS.   FEDS is a module used to manage all deficiencies including the Backlog of Essential Maintenance, Alteration, and Repair (BEMAR) and unmet space needs.   A deficiency is a need to repair, replace or alter buildings and structures or /projects.   These deficiencies are typically beyond the scope or capability of the Facility Managers and their staff or have been overlooked and discovered during a Facilities Condition Survey.   FEDS is used to:

  • Compare an installation’s condition to other IHS installations
  • Define regular maintenance requirements
  • Define capital repair and replacement projects
  • Develop cost estimates
  • Eliminate conditions that are either potentially damaging to the property or present life safety hazards
  • Identify energy conservation measures
  • Better forecast the facilities budget

  • Facility Condition Surveys

    This is a continuing program of comprehensive assessments of facilities.   The facilities require competent personnel examining all buildings, grounds, and building service equipment and evaluating their condition.   The physical condition of IHS-owned and most tribally-owned facilities are evaluated through Annual General Inspections (AGI) conducted by local personnel and IHS Area engineers and Architects.   In addition, comprehensive “Deep Look” surveys are conducted every 5 years by a team of engineers.   These surveys, together with routine observations by facilities personnel, identify deficiencies that are added to the BEMAR.   A report is generated that lists facility deficiencies, including physical condition deficiencies, violations of codes and standards, and needed program space utilization improvements.   This information is incorporated into a report that lists each deficiency along with a recommended corrective action and an associated budget cost estimate.   This data is entered into the FEDS module of the HFDS.   FEDS can then be used to help establish and prioritize projects for the upcoming fiscal years.   A yearly report, derived from FEDS, establishes a plan for corrective actions on the FEDS data.   This report is called the Facilities Engineering Plan (FEP).


    BEMAR is an acronym for Backlog of Essential Maintenance, Alteration and Repair.   BEMAR is derived from FEDS and consists of Public Law, Maintenance & Repair, and Improvements categories while excluding items which result from lack of deficiency code 6 – Unmet Supportable Space Needs and Deficiency Code 9 – Plant Management (Bench Stock, Service Contracts, and Training).    BEMAR is reported to Congress annually and it is the basis of supporting the need for M&I funding.

BEMAR for IHS chart
The identified BEMAR for IHS and reporting tribal facilities for FY2013 was $465.2 million.

Facilities Support Account (FSA) -

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Funds appropriated for the Facilities Support sub-activity are used to pay certain personnel and operating costs, including utilities, at the Area and service unit levels.   The personnel paid from this account operate and maintain health care facilities and staff quarters.   Staff functions supported by this sub-activity include management, operation, and maintenance of land, buildings, building systems, medical equipment technical support, and planning and construction management for new and replacement facilities projects.

In FY2008, Facilities Support provided Area offices and service units with staff to operate and maintain the health care buildings and grounds, and to service medical equipment.   This responsibility includes an inventory of approximately $320 million of medical equipment, hospitals, health centers, staff quarters, smaller health stations and satellite clinics, school health centers, and youth regional treatment centers.   The FY2014 Facilities Support Appropriation amounted to $124 million.

FSA for IHS chart

Maintenance and Improvement -

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The IHS maintains federal government owned buildings operated by the IHS and supports maintenance and improvement activities where tribally owned space is used for providing health care services pursuant to contract or compact arrangements executed under the provisions of the Indian Self Determination and Education Assistance Act (P.L. 93-638).

The Maintenance and Improvement (M&I) program objectives include:

  • Providing routine maintenance for facilities
  • Achieving compliance with buildings and grounds accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or other applicable accreditation bodies
  • Providing improved facilities for patient care
  • Ensuring that health care facilities meet building codes and standards
  • Ensuring compliance with Executive Orders and public laws relative to building requirements, e.g., energy conservation, seismic, environmental, handicapped accessibility, and security.

Continued funding is essential to ensure functional healthcare facilities that meet building/life safety codes, conform with laws and regulations and satisfy accreditation standards.

A total of $53.6 million was appropriated in FY2014 for M&I.

M&I for IHS chart

Program Management -

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Establishes, monitors, and routinely updates program objectives, policies, guidelines, criteria, and reporting systems for facilities planning, design and construction activities.

Energy Conservation and Sustainability -

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In 1973, the Federal government issued a comprehensive energy conservation policy.   The IHS began reporting quarterly on energy consumption at IHS facilities in compliance with the Energy Policy and Conservation Act of 1975.

In accordance with Executive Order 13123 Energy: Greening the Government through Efficient Energy Management, several actions were established.   A few of these significant actions include:

  • Greenhouse Gases Reduction - Reduce greenhouse gas emissions attributed to facility energy use by 30% by 2010 compared to 1990.
  • Energy Efficiency Improvement - Reducing energy consumption per gross square foot in facilities by 30% by 2005 and 3% by 2010 relative to 1985.
  • Industrial and Laboratory Facilities – reduce energy consumption per square foot, per unit of production, or per other unit as applicable by 20% by 2005 and 25% by 2010 relative to 1990.
  • Renewable Energy – Expand the use of renewable energy within facilities and in activities by implementing renewable energy projects and by purchasing electricity from renewable energy sources.
  • Million Solar Roofs – Install 2,000 solar energy systems by the end of 2000 and 20,000 solar energy systems by the end of 2010 at Federal facilities.
  • Petroleum – Reduce the use of petroleum within facilities.
  • Source Energy – Reduce total energy use and associated greenhouse gas and other air emissions, as measured at the source.
  • Water Conservation Goals – Reduce water consumption and associated energy use in facilities.  Also, establish water conservation goals for IHS facilities program.

From the Government’s perspective, energy is now essentially linked to overall environmental management.   Areas as well as facilities shall use life-cycle cost analysis in making decisions about their investments and planning.

Environmental Compliance and Remediation -

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Many IHS facilities were constructed before the existence of current environmental laws and regulations.    Compliance with current Federal, state, and local environmental regulations has been mandated by Congress.   Environmental assessments identify and evaluate potential environmental hazards.   These assessments form the basis of the IHS facilities environmental remediation plan.

Federal facility environmental planning is required by Executive Order 12088, Federal Compliance with Pollution Control Standards.   Under this order, Federal agencies are required to submit environmental plans to the Environmental Protection Agency (EPA) and the Office of Management and Budget (OMB).   IHS has established guidelines for funding environmental assessments and projects derived from the assessment process.   These procedures utilize a scoring process that considers the relative importance and acuteness of various priority ranking factors.   The work must be completed at IHS facilities or at tribally-owned health care facilities which provide IHS-funded services.

The Conference Report on IHS Appropriations for FY1993 stated that $3,000,000 should remain as a base in the IHS M&I Budget for the purpose of conducting environmental management program for all IHS and tribal health care facilities.   A total of $3 million was appropriated in FY2008 for funding of environmental assessments and remediation projects.

Accreditation -

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JCAHO - Management of the Environment of Care.   This standard measures how well a safe, functional and effective environment for patients, staff members, and other individuals in the organization is being maintained.   The following areas are addressed: emergency preparedness, security, safety, life safety, medical equipment, utility systems, hazardous materials and waste management.

JCAHO's Environment of Care standards for ambulatory care, assisted living, behavioral health care, critical access hospitals, home care, hospitals, laboratory and long term care facilities.

Facilities and Self Determination -

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Since 1975, when Congress enacted the Indian Self-Determination and Education Assistance Act, tribes have been able to assume control over the management of their health care services by negotiating contracts with the IHS.   The Indian Self-Governance Demonstration Project (SGDP), initially authorized in 1992, greatly expanded this partnership effort by simplifying the self-determination contracting processes and facilitating the assumption of IHS programs by tribal governments and organizations.    Finally, in 2000, the President signed the Self-Governance Amendments of 2000, which established a permanent authority for the IHS to enter into self-governance agreements with tribes.

Technical Handbook -

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The Office of Environmental Health and Engineering program routinely develops guidelines and procedures related to various environmental health and engineering topics.   This guidance is compiled in a comprehensive Technical Handbook for Environmental Health and Engineering in an organized form for easy reference and use.   The handbook consists of a series of separately issued “volumes”.   Each volume deals with a specific program within the Office of Environmental Health and Engineering (OEHE).   The volumes used and maintained by the Division of Facilities Operations are:

A.     Volume IV – Real Property Management provides information and guidance on procedures to direct, coordinate, and evaluate the real property management programs.   This includes accountability activities for federally owned land and improvements and IHS direct leased space.   It also discusses workplace management and provides technical interpretation of the laws, regulations, policies, procedures, and practices in realty management.

B.     Volume V – Clinical Engineering provides procedures and practices in the application of clinical engineering technology to support direct patient care.   It addresses the requirements for clinical equipment inspections, tests, calibrations, repairs, hazard/recall/alert notification, preventative maintenance, and electrical safety.   It also discusses user training for the safe use and application of medical devices, and the selection and evaluation process for purchasing clinical equipment.

C.     Volume VI – Facilities Engineering provides procedures, practices, and technical requirements to follow in the planning, coordinating, and implementing day-to-day operations of facilities maintenance and repair programs.   Topics include heating, ventilation, preventive maintenance, energy conservation, repairs and improvements to buildings and structures and non-clinical property, and operation of steam, air conditioning, water, and sewage plants.