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Indian Health Service Has Strengthened Patient Protection Policies but Must Fully Integrate Them Into Practice and Organizational Culture


In recent years, IHS has had a number of cases of healthcare providers abusing patients under facility care, including a pediatrician who was convicted of multiple counts of child sexual abuse. In February 2019, the Deputy Secretary of the Department of Health and Human Services requested that OIG assess IHS policies and procedures for preventing, reporting, and addressing patient abuse. In the same month, the Senate Committee on Indian Affairs also requested that OIG review applicable IHS policies, procedures, standards, and other requirements intended to prevent and address misconduct. This study identified strengths and gaps in IHS policies, and challenges to their early implementation.


We based our findings on document reviews and interviews with 45 officials and staff at IHS headquarters (HQ) and Area Offices, conducted in July-August 2019. We also reviewed IHS policies and other relevant documents and compared them to similar policies from three benchmark organizations: the American Academy of Pediatrics, the American Medical Association, and the National Council of State Boards of Nursing. Topics for our interviews with IHS officials and staff included implementation of IHS patient protection policies and procedures, strategies for and challenges to implementation, and other IHS improvement efforts related to preventing and addressing patient abuse in IHS facilities.


OIG found that IHS policies to prevent and address child sexual abuse included similar elements of policies developed by benchmark organizations. IHS included provisions for provider-patient boundaries, medical examination precautions, reporting responsibilities, and protections for patients and staff. In a few cases, IHS policies were stricter and more detailed than those of other organizations. However, IHS policies do not explicitly address other types of abuse, adult victims, or perpetrators who are not healthcare providers. Further, some IHS-operated healthcare facilities are early in implementation and have not updated their individual facility policies, largely due to staffing shortages and turnover of facility leadership. IHS has trained staff on its updated policies and provided outreach to Tribal communities, but faces challenges that may discourage reporting of abuse, including difficulty ensuring anonymity, fear of retaliation, and communication barriers (e.g., language, stigma), among others. In addition, we found significant shortcomings in IHS systems for storing and tracking patient abuse reports and confusion about roles and responsibilities related to such tasks. IHS has initiated efforts to strengthen systems and oversight.


To address these issues and further protect patients from abuse, we recommended that IHS: (1) extend policies to address more types of perpetrators, victims, and abuse; (2) ensure that the new incident reporting system is effective and addresses the risks identified in the current system; (3) designate a central owner in IHS HQ to ensure clear roles and responsibilities for shared ownership in implementing patient protection policies, and managing and responding to abuse reports; (4) continue to actively promote an organizational culture of transparency, and work to resolve barriers to staff reporting of abuse; and (5) conduct additional outreach to Tribal communities to inform them of patient rights, solicit community concerns, and address barriers to reporting of patient abuse. IHS concurred with our recommendations.