Following a major tribally-initiated restructuring in the early 1980s that created a quality improvement committee and a flatter organizational structure, the PTHA has increased patient access for urgent care visits, reduced "no show" rates, created clinical objectives, increased dental treatments, and incorporated the use of traditional healers into health care delivery. The Puyallup Tribe's Quality Improvement Program has enabled the PTHA to effectively address many of the health care needs of the community that were previously unmet under the Indian Health Service's management. With six full time physicians and a staff of 210, the PTHA has become a model for other Indian nations seeking to create and sustain health systems that meet the highest standard of excellence.