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Indian Health Service Hospitals: More Monitoring Needed to Ensure Quality Care


We conducted this study and its companion, Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention to Support Quality Care (OEI 06 14 00011), in response to concerns about the care provided in IHS hospitals. Reports of inadequate health care services for American Indians and Alaska Natives (AI/ANs) have concerned the Federal Government for almost a century. IHS is responsible for providing health services to the 567 federally recognized tribes of AI/ANs. As part of its service, IHS directly operates 28 acute-care hospitals. IHS requires its hospitals to be accredited by a nationally recognized organization (or certified by Medicare) and to comply with the Medicare Hospital Conditions of Participation (CoPs). OIG is committed to continued work to improve patient care provided in IHS hospitals. Upcoming OIG work includes an IHS management review and a medical review focusing on patient safety in IHS hospitals.


We interviewed leadership staff at each IHS-operated hospital, the eight IHS Area Offices that oversee hospitals, and IHS headquarters regarding their processes for quality monitoring and oversight. Hospital interviews included the Chief Executive Officer (CEO) or Acting CEO, and Area Office interviews included the Area Director or Acting Director. Additional leadership staff, such as clinical directors and chief medical officers, were also present in most interviews. IHS headquarters interviews included the Chief Medical Officer, the Director of Field Operations, and the Director of the Hospital Consortium. We supplemented these interviews with document reviews and questionnaires. We also interviewed staff and reviewed select documents from CMS, which is the primary oversight agency for hospitals nationwide.


IHS may be missing opportunities to identify and remediate quality problems in its hospitals because it performed limited oversight regarding quality care and compliance with the CoPs. IHS relies on its Area Offices to monitor hospitals. However, Area Office staff have few sources of information about hospital quality, and most limit reviews of that information to infrequent meetings of each hospital's Governing Board. Further, CoP compliance surveys are not conducted by CMS with the frequency needed to make them a useful tool. Staffing shortages in Area Offices also limit the clinical support and guidance that they are able to provide, and the most promising efforts to improve hospital quality lack dedicated funding. Additionally, hospitals struggle to implement data-driven quality improvement methods as a result of limited information technology knowledge, a lack of resources, and difficulties with the electronic health record systems.


We recommend that IHS (1) implement a quality-focused compliance program; (2) establish standards and expectations for Area Office/Governing Board oversight activities; (3) work to identify new-and more meaningful-hospital performance metrics; and (4) continue to invest in training for hospital administration and staff. Additionally, we recommend that CMS assist IHS in its oversight efforts by conducting more frequent surveys of non-accredited hospitals, informing IHS leadership when hospitals are cited with deficiencies, and continuing to provide technical assistance and training. OS, IHS, and CMS provided a joint response to this report and its companion report. Collectively, these HHS agencies concurred with all recommendations in both reports.