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Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening


IHS provides comprehensive Federal health services to approximately 2.6 million American Indians and Alaska Natives. In 2016, OIG found significant problems in the quality of care and oversight of IHS-operated hospitals. Congressional testimonies in recent years and deficiency findings by the Centers for Medicare & Medicaid Services (CMS) also raised concerns about quality and patient access to care in IHS hospitals. During a 3-year period, IHS temporarily closed the emergency department (ED) at 4 of its 24 hospitals. The Rosebud Hospital ED remained closed for more than 7 months. We conducted this study to examine IHS's management of the closure and reopening of the Rosebud Hospital ED to identify lessons learned that IHS could apply should similar situations arise in the future.


This report provides a chronology of events and identifies factors that led to the closure of the Rosebud Hospital ED, improvement efforts to reopen the ED, and continued lapses in compliance. We interviewed leadership and staff at IHS headquarters, the Great Plains Area Office, and Rosebud Hospital, and other stakeholders, including administrators at CMS, receiving hospitals, and the Rosebud Sioux Tribe. We also reviewed both internal and publicly available documents from IHS and stakeholders.


After receiving citations during a CMS survey deemed of immediate jeopardy (IJ) to ED patients, IHS closed the Rosebud Hospital ED in December 2015. IHS diverted Rosebud patients to the nearest hospitals but did not provide the hospitals or the emergency medical services (EMS) adequate time to prepare. The receiving hospitals were overwhelmed by the volume and complexity of patients, and EMS struggled to meet demands with its limited staff and longer patient transports. To correct Rosebud Hospital's deficiencies and re-open the ED, IHS provided additional resources and support from across IHS, sought assistance from other agencies, and entered into a Systems Improvement Agreement (SIA) with CMS. IHS made improvements prompted by the SIA, which included updating policies and revising governing board bylaws. IHS completed the SIA to CMS's satisfaction in September 2017, but CMS cited Rosebud Hospital again with ED-related IJ deficiencies in July 2018.


To correct underlying problems and better serve its beneficiaries, we recommend that IHS, as a management priority, develop and implement a staffing program for recruiting, retaining, and training clinical and leadership staff in remote hospitals. This is a necessary first step to addressing quality issues long term; however, other actions are also needed, including taking steps to ensure that IHS intervenes early and effectively when problems emerge. To ensure better management of any future ED closures, we also recommend that IHS develop procedures for temporary ED closures and communicate those procedures with receiving hospitals and EMS to ensure that they are adequately prepared for such events. IHS concurred with our recommendations