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Organizational Challenges to Improving Quality of Care in Indian Health Service Hospitals


IHS provides comprehensive Federal health services to approximately 2.6 million American Indians and Alaska Natives. OIG and others have found significant problems in the quality of care and oversight of IHS hospitals. This study identifies underlying organizational challenges that may hamper IHS's ability to address critical longstanding problems. At times these issues have had serious consequences, including difficulty maintaining compliance with Federal quality-of-care requirements. IHS has made important new plans for improving the quality of care that it provides in its hospitals. However, if underlying organizational challenges are not addressed, they may prevent IHS from bringing its full organizational strength to these efforts.


We based our findings on interviews with IHS officials and other stakeholders, and on our observations of agency practices while we were conducting this and other OIG studies. Interview topics included challenges to the operations of IHS headquarters, Area Offices, and hospitals, and suggestions for accelerated progress. We did not independently verify the substance of the statements provided to us in these interviews. We also reviewed agency documents, including the Strategic Plan that IHS released in 2019. We conducted qualitative analysis to identify organizational challenges to IHS agency management of its hospitals, and to develop strategies for improvement.


OIG found three core organizational challenges that, if not addressed, could continue to limit IHS's ability to improve hospital operations and quality of care. First, IHS lacks formal structure, policies, and roles. IHS officials reported that they were often uncertain about their roles and those of other officials, including the authority to act in correcting problems. Consequences included lack of accountability and undermining of quality of care. The absence of clear roles was especially problematic with regard to the roles of IHS headquarters and Area Offices. Second, IHS lacks awareness and insight about Area Office and hospital performance, and IHS's organizational culture does not always encourage candid discussion of problems. Third, IHS officials lack confidence in the agency's ability to succeed. IHS officials consistently expressed a deep commitment to and passion for the agency's mission and beneficiaries, but also often expressed doubt in the agency's ability to make sustained improvements.


To address the underlying organizational challenges identified in this report and to take steps to improve IHS operations, IHS should incorporate the strategies we outline as it implements its new plans to improve hospital quality and agency operations. Specifically, IHS officials need to support an agency structure that outlines policies and roles; to cultivate a culture of continuous learning to support sustained improvements; and to inspire greater confidence in the agency's capacity to overcome longstanding challenges. Additionally, in other evaluations OIG has recommended specific actions for improving quality in IHS hospitals, such as establishing a comprehensive compliance program focused on quality of care. We continue to urge IHS to implement those recommendations.