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Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention to Support Quality Care


We conducted this study and its companion, Indian Health Service Hospitals: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010), 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 Medicare-certified) 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.


We interviewed leadership staff at each IHS-operated hospital, the eight Area Offices that oversee the 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, the Regional Human Resources Directors, and the Acting Deputy Director for Environmental Health and Engineering. We supplemented these interviews with questionnaires and with reviews of documents such as management reports and survey citations for deficiencies. We also interviewed staff and reviewed select documents from CMS, which is the primary oversight agency for hospitals nationwide.


IHS hospital administrators reported a range of interrelated challenges affecting their ability to provide quality care and maintain compliance with the CoPs. IHS hospitals face continual increases in the number of AI/ANs using their services, yet they provide a narrow scope of medical services and limited access to specialists and community support (e.g., nursing homes and home health). IHS hospitals particularly struggle to maintain the skills necessary to treat complex inpatient cases. Another significant concern among IHS hospital administrators is the inability to recruit and retain needed staff. The dependence on "acting" personnel and contracted providers to fill vacancies sometimes creates instability in IHS hospitals and weakens the continuity of care provided to patients. Further, hospital administrators reported that limited resources for maintaining old hospital structures and outdated equipment sometimes results in service interruptions and raises concerns about patient safety.


We recommend that OS lead an examination of the quality of care delivered in IHS hospitals as part of its newly formed Executive Council and use the findings to identify and implement innovative strategies to mitigate IHS's longstanding challenges. We also recommend that IHS conduct a needs assessment and develop an agencywide strategic plan with actionable initiatives and target dates to build a unified vision of IHS priorities and how to address them.

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.