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Indian Health Service Facilities Made Progress Incorporating Patient Protection Policies, but Challenges Remain


In recent years, IHS had cases of health care providers abusing patients under facility care. In February 2019, the Deputy Secretary of the Department of Health and Human Services and the Senate Committee on Indian Affairs both requested that OIG review IHS policies for preventing, reporting, and addressing patient abuse in IHS facilities. In December 2019, OIG issued a report that found that IHS had strengthened its policies to protect children from sexual abuse by providers. Yet, we found gaps in IHS policies, such as not covering different types of abuse and circumstances, and some IHS facilities had not implemented the new agencywide policies. This study expands on that report, assessing facility implementation of the policies and identifying potential challenges to their effectiveness.


We based our findings on survey responses from 97 IHS-operated health care facilities, including hospitals, health centers, and health stations, and onsite interviews with leadership and staff at 16 of these facilities. We collected our data during February-March 2020. Topics for the survey and interviews included implementation of IHS patient protection policies and related challenges, training needs, communication and collaboration with IHS headquarters and Area Offices, and barriers to patient abuse reporting and improvement efforts.


Most IHS facilities (81 of 97) reported that they fully incorporated the agencywide patient protection policies, aimed at preventing and addressing child sexual abuse by health care providers, into their local policies and procedures, but some facilities are still early in implementation. All facilities reported that staff completed mandatory training on the new policies. Many facilities supplemented the training and expressed need for further training to support staff understanding of reporting requirements. We found that nearly two-thirds of facilities (62 of 97) reported encountering challenges in carrying out the policies. The most common challenges were providing chaperones during medical exams, due to staffing shortages and delays in background investigations; ensuring anonymity of victims and reporters; coordinating with law enforcement; and understanding the policies. All facilities said that they were generally confident that staff would report suspected patient abuse, but most (88 of 97) noted existing barriers that may deter staff and patients from reporting. We found that IHS has established avenues for reporting patient abuse and taken steps to promote an organizational culture of transparency, but the facilities reported remaining barriers, including fear of retaliation, stigma related to sexual abuse, and lack of awareness on what and how to report, among others. We identified some of the same barriers in our 2019 report.


To address the issues identified in this report and further protect patients from abuse, we recommend that IHS: (1) provide additional guidance and training to facilities on patient protection policies, including the role of law enforcement and the reporting process related to patient abuse; (2) improve the process and timeliness for conducting staff background investigations and notifying facilities when staff are approved; (3) examine and revise, as needed, the reporting structure in the policies and the incident reporting system to ensure that staff and patients can report anonymously; and (4) establish and enforce a deadline by which all facilities must fully incorporate the new requirements into their policies and procedures, and actively monitor facility adherence. IHS concurred with our recommendations.