The Indian Health Service (IHS) Realty Management program is designed to provide information and technical
consultation on control and management of realty assets/land and fixed improvements under the administrative jurisdiction of the IHS.
It also provides guidelines and procedures for the acquisition, utilization, and disposal of owned and leased realty assets.
The IHS Realty Management program also implements the mandate 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.
It is the policy of the IHS to develop, establish, assess, improve, correct, and report on the effective and
economical management and utilization of IHS-held realty.
Realty Asset Management
Realty Asset Management is responsible for the planning, coordinating and evaluating IHS realty management
and accountability activities.
Several laws enacted by the Congress require a new level of coordination between the Real Property Inventory
(RPI) 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 will track realty assets including those acquired through capital leases and leasehold
improvements in its RPI and requires the reconciliation of these Inventories (subsidiary ledger accounts) with the Agency’s general
In basic terms, land asset value is increased (capitalized), or possibly decreased (depreciated), by facilities
projects that improve or construct (build or improve an asset such as a facility, building, structure) or reduce (demolish or transfer)
the value of the asset.   These projects 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 RPI.
Real Property Inventory (RPI)
The Real Property Inventory contains all accountable data for IHS-held facilities.
The RPI is a subsidiary financial ledger to the IHS general ledger that documents all asset values for land and fixed improvements.
The ledger also includes actions involving acquisitions, improvements, transfers and disposal.
The HQ Realty program is responsible for developing and issuing policies and internal procedures to implement
Department of Health and Human Services (DHHS) policy in management of real property.   Other responsibilities include
formulating the rent and special cost services budget for all leased space from Area Office data and providing projections for space,
recurring and nonrecurring costs and assisting the Areas in obtaining approval for space acquisition.
It is IHS policy to ensure the availability of safe, suitable housing for personnel essential to the continuity
of the health care delivery system and for those personnel required to protect Government property.   The IHS Quarters
Management Program is designed to provide information and technical consultation on quarters management issues; provide procedures for
effective implementation of IHS policy; provide the minimum number of quality dwelling units to house essential employees efficiently
and effectively; maintain reliable quarters occupancy and rental collections data though the use of the IHS Quarters Tracking Information
System (QTIS); and provide guidelines for the management of resources generated by and required for implementation of the Quarters
Clinical Engineering-Medical Equipment - Back to Top
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.
Medical Equipment Funding
MEDICAL EQUIPMENT FUNDING FOR EXISTING IHS & TRIBAL PROGRAMS
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).
EQUIPMENT FUNDING FOR NEWLY CONSTRUCTED TRIBALLY BUILT REPLACEMENT FACILITIES
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 https://facilops.ihs.gov/erds
DOD EXCESS 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 http://www.ihs.gov website.   Registration on the website and coordination
with respective Area Property Managers is required to meet accountability standards of government property.
REFURBISHED AMBULANCE PROGRAM
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.
Healthcare Facilities Data System - Back to Top
Information management systems make instantaneous access to one central database possible from any geographical
location and from within any level of an organization.   In the mid 1990’s the Indian Health Service, like most
organizations, created and maintained large paper based reporting and data management systems.   A request for a change to
the RPI or the Facilities Engineering Deficiency System (FEDS) may have taken six months to formally complete.   Today, with
the Healthcare Facilities Data System (HFDS), these tasks can be completed in a matter of minutes.
The HFDS was developed to:
- Account for Federal and tribal real property assets within the IHS
- Assist in developing M&I and Equipment funds allocations
- Manage Supportable Space
- Manage deficiencies within FEDS
- Manage Projects
- Self Governance Table 4F, Tribal shares
- Track Energy Usage
- Report to Congress and other outside Agencies
- Justify level of funds or requests for increases
Over 140 personnel consisting of facility managers, area realty officers, Area facilities staff and HQ
facilities staff use HFDS.
Facilities Engineering Deficiency System - Back to Top
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.
The identified BEMAR for IHS and reporting tribal facilities for FY2008 was $336 million.
Facilities Support Account (FSA) - Back to Top
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 FY2008 Facilities Support Appropriation amounted to
Maintenance and Improvement - Back to Top
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 $52.9 million was appropriated in FY2008 for M&I.
Establishes, monitors, and routinely updates program objectives, policies, guidelines, criteria,
and reporting systems for facilities planning, design and construction activities.
Energy Conservation and Sustainability - Back to Top
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
- 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 - Back to Top
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.
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 - Back to Top
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.
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.