Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
I H S
NDIAN  EALTH  ERVICE 
 
 
H : L
OSPITALS    ONGSTANDING 
 
 
C W
HALLENGES  ARRANT 
 
 
F A
OCUSED  TTENTION TO 
S Q C  
UPPORT  UALITY  ARE 
 
Daniel R. Levinson  
Inspector General 
 
October 2016 
OEI-06-14-00011   
   
EXECUTIVE SUMMARY  INDIAN HEALTH SERVICE HOSPITALS:  LONGSTANDING 
CHALLENGES WARRANT FOCUSED ATTENTION TO SUPPORT QUALITY CARE  
OEI-06-14-00011 
 
WHY WE DID THIS STUDY  
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 Indian 
Health Service (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.   
 
HOW WE DID THIS STUDY 
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 the Centers for 
Medicare & Medicaid Services (CMS), which is the primary oversight agency for hospitals nationwide.   
 
WHAT WE FOUND 
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. 
 
WHAT WE RECOMMEND  
We recommend that the Office of the Secretary of Health and Human Services (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 IHSs longstanding challenges.  We 
also recommend that IHS conduct a needs assessment and develop an agency-wide 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.  
 
 
   
   
TABLE OF CONTENTS 
 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................5 
Findings........................................................................................................7 
Increasing numbers of outpatients, limited scopes of services,    
and geographic isolation restrict IHS hospitals ability to ensure  
patient access to care ........................................................................7 
Hospitals with low inpatient censuses may struggle to maintain       
clinical competence, which can result in patient harm ....................9 
Vacancies, use of acting positions, and dependence on     
contracted providers sometimes impair hospital service stability 
and continuity of care..................................................................... 11 
Outdated and insufficient buildings and equipment may further 
confound care .................................................................................14 
Recommendations ......................................................................................17 
Agency Comments and Office of Inspector General Response .....19  
Appendixes ................................................................................................21 
A:  Table A-1:  IHS Hospitals by Area ..........................................21 
B:  Table B-1:  Hospital Conditions of Participation .....................23 
C:  Methodology ............................................................................25 
D:  Agency Comments ...................................................................27 
Acknowledgments......................................................................................39
 
 
   
   
OBJECTIVE 
To examine the challenges affecting Indian Health Service (IHS) hospitals 
ability to provide quality care and comply with Medicare standards of 
care. 
BACKGROUND  
IHS is responsible for providing Federal health services to American 
Indians and Alaska Natives (AI/ANs).  IHSs mission is to raise the 
physical, mental, social, and spiritual health of AI/ANs to the highest 
level.  In partnership with the tribes, IHS provides free primary and 
preventive health care services for approximately 2.2 million AI/ANs 
living in the United States.  However, reports of health disparities and 
inadequate health care services for AI/ANs have been of concern to the 
Federal Government for almost a century.  
In 2010, Senator Byron Dorgan, then-Chairman of the Senate Committee 
on Indian Affairs, released a report citing problems in some IHS facilities 
related to credentialing and licensing of providers, accountability of 
controlled substances, and management of funds.  These problems were 
similar to those previously identified by the Office of Inspector General 
(OIG) and the U.S. Government Accountability Office (GAO).1  Prior to 
that, in 1999, and again in 2004, the U.S. Commission on Civil Rights 
found significant health disparities for AI/ANs as a result of structural 
barriers (e.g., insufficient staffing, aging facilities) and financial barriers 
(e.g., insufficient resources), many of which were similar to problems 
identified almost a century ago.  In 1928, a report requested by Federal 
oversight authorities regarding conditions of AIs found that their health 
and living conditions were bad, and that the lack of funding, personnel, 
and equipment prevented the development of an adequate system of 
public health administration and medical relief work for AIs.2, 3    
 
____________________________________________________________ 
1 U.S. Senate Committee on Indian Affairs, In Critical Condition:  The Urgent Need to 
Reform the Indian Health Services Aberdeen Area, December 28, 2010.  Accessed at 
http://www.indian.senate.gov/sites/default/files/upload/files/Chairman-s-Report-In-
Critical-Condition-12-28-10.pdf on February 12, 2015. 
2 The Institute for Government Research, The Problem of Indian Administration, 
February 21, 1928, ch. I.  Accessed at 
http://www.alaskool.org/native_ed/research_reports/IndianAdmin/Indian_Admin_Problm
s.html on November 3, 2014.  
3 U.S. Commission on Civil Rights, Broken Promises:  Evaluating the Native American 
Health Care System, September 2004, pp. 2-4.  Accessed at 
http://www.usccr.gov/pubs/nahealth/nabroken.pdf on November 3, 2014. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        1   
   
Indian Health Services 
IHS provides health care services to 567 federally recognized tribes 
primarily through outpatient clinics, but in some locations it also offers 
inpatient care and behavioral and community health services.  Depending 
on agreements with the particular tribes, IHS either provides services 
directly to AI/ANs through IHS-operated facilities or provides financial 
support for the tribes to operate their own health care systems.4  Currently, 
just under half of IHSs $1.8 billion appropriation to provide health care 
services is allocated to Federal operations serving tribes directly.  The 
other half of the hospital and health clinics portion of the budget goes to 
the individual Indian tribes or tribal organizations that have contracts 
and/or compacts with IHS.5 
IHS Area Offices 
Located in Rockville, Maryland, IHS headquarters provides general 
direction, policy development, and support for each of the 12 Area Offices 
and their health care delivery sites, which may include hospitals, urgent 
care clinics, and/or other types of facilities.  Area Offices oversee the 
delivery of health services and provide administrative and technical 
support to the federally operated hospitals and clinics for one or more of 
the 170 geographically defined service units.6  Each Area Office includes 
staff dedicated to common services, such as finance, administrative 
support, information technology (IT), public health programs, and 
environmental health.   
IHS maintains its current policies, procedures, and operating standards in 
the Indian Health Manual (IHM).  The IHM is the preferred reference 
for IHS staff regarding IHS-specific policy and procedural information.7 
____________________________________________________________ 
4 Pursuant to the Indian Self-Determination and Education Assistance Act, P.L. 
No. 93-638, IHS contracts and/or compacts with tribes or tribal organizations to deliver 
services. 
5 Department of Health and Human Services (HHS), IHS, Justification of Estimates for 
Appropriations Committees, Fiscal Year (FY) 2016, p. 6, 55.  Accessed at 
https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/documents/FY201
6CongressionalJustification.pdf on February 9, 2016.  Total IHS appropriations in 
FY 2015 were $4.6 billion.  In addition to the $1.8 billion appropriated for hospital and 
health clinic services, IHS supports programs such as dental services, public health, and 
purchased/referred care, among others.   
6 A service unit is an administrative subunit of an IHS Area, operated by IHS or a tribe, 
with responsibilities for providing IHS services within a particular geographic area.   
7 IHS, Indian Health Manual, pt. 1; ch. 1; section 1-1.2 (Indian Health Manual). 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        2   
   
IHS Hospitals 
IHS directly operates 28 acute-care hospitals in 8 States, many of which 
are in remote locations.  (See Appendix A for a listing of IHS-operated 
hospitals and Figure 1 for a map of their locations.)  These hospitals are 
typically small, with most having fewer than 50 beds.  IHS also contracts 
with tribes and tribal organizations to operate an additional 18 hospitals.  
Figure 1:  IHS Hospital Locations 
+ = IHS-operated hospital 
 
Although 1 IHS hospital is a Level III Trauma Center and cares for more 
than 40 inpatients a day, less than half of the 46 hospitals have operating 
rooms and many lack the equipment to do a computerized tomography 
(CT) scan.  Collectively, in FY 2013, IHS-run and tribally run hospitals 
had more than 13 million outpatient visits and a total of 44,677 inpatient 
admissions.  Nearly half of these admissions (20,469 inpatients) were to 
the 28 IHS-operated hospitals.    
 
IHS hospitals may be reimbursed by Medicare, Medicaid, and private 
insurance entities for services they provide to AI/ANs enrolled in these 
programs.8  In addition to the $1.8 billion that Congress appropriated for 
hospitals and health clinics operated by IHS and tribes for FY 2015, IHS 
was expected to collect approximately $1.1 billion from these three 
sources, and 90 percent of this amount was expected to be collected from 
the Medicare and Medicaid programs.9  
____________________________________________________________ 
8 Social Security Act  1880(a) and 1911(a), P.L. No. 94-437, Indian Health Care 
Improvement Act (codified at 25 U.S.C.  1621e). 
9 IHS, Justification of Estimates for Appropriations Committees, FY 2016, p. 6. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        3   
   
Purchased and Referred Care 
In certain circumstances, IHS may supplement the care available in 
a particular location by purchasing services for specific AI/AN patients 
from private health care providers.  This programformerly known as 
Contract Health Servicesis now known as Purchased and Referred Care 
(PRC).  Service units that have hospitals use the funds to refer patients for 
emergency or specialty care that is beyond their capacity.  However, the 
PRC programs do not have sufficient funds to cover all care needs and 
thus allocate health care on the basis of a medical-priority rating system.10   
Medicare Conditions of Participation 
IHS instructs its hospitals to be accredited by a nationally recognized 
organization (or certified by Medicare).  Accrediting organizations used 
by IHS must support the reimbursement requirements established by 
Medicare and Medicaid.11, 12  To meet this established criteria, hospitals 
must comply with the Medicare Conditions of Participation (CoPs), a set 
of minimum quality and safety standards.  The CoPs include requirements 
such as establishing an effective governing body legally responsible for 
the performance of the hospital, having an organized medical staff that is 
responsible for the quality of patient medical care, and maintaining a 
physical environment that avoids transmission of infections and 
communicable diseases.13  (See Appendix B for a descriptive list of CoPs.)   
The Centers for Medicare & Medicaid Services (CMS) and accreditation 
organizations such as The Joint Commission (TJC) monitor IHS-operated 
hospitals compliance with the CoPs through periodic onsite surveys.14  
Surveyors observe how hospitals provided care to patients, and assess 
whether that care met the needs of the patients and was in compliance with 
all requirements.  To indicate noncompliance, surveyors cite hospitals with 
deficiencies that hospitals must correct in a timely manner to continue 
participating in Medicare.   
Related Work 
This report expands on prior work by OIG in response to a congressional 
request.  In August 2015, OIG issued a reportOIG Site Visits to Indian 
Health Service Hospitals in the Billings, Montana Area  
____________________________________________________________ 
10 IHS, Purchased/Referred Care (PRC) History.  Accessed at 
http://www.ihs.gov/chs/index.cfm?module=chs_history on December 29, 2014. 
11 IHS, Circular No. 97-01.  Accessed at 
http://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_circ_main&circ=ihm_circ_9701 on 
January 22, 2014. 
12 Social Security Act  1880(a) and 1865 (a)(1). 
13 42 CFR  482.1, 482.12, 482.22, 482.41 and 482.42 
14 CMS, State Operations Manual (SOM), ch. 1,  1018A. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        4   
   
(OEI-09-13-00280)that identified problems related to staffing and 
continuity of care at two hospitals in the Billings Area.   
Companion Report.  OIG is concurrently issuing a companion report, 
Indian Health Service Hospitals:  More Monitoring Needed to Ensure 
Quality Care (OEI-06-14-00010).  The companion report found that IHS 
may be missing opportunities to identify and remediate quality problems 
in its hospitals because of a limited ability to provide rigorous oversight.  
(See below a summary of concerns cited in the companion report.)  
Insufficient Monitoring of IHS Hospitals 
Hospital monitoring practices differ significantly among Area Offices but in many cases, 
IHS lacks the necessary tools and/or infrastructure to provide robust oversight and 
proactive identification of quality or compliance problems.  Key concerns include: 
Few data sources  Because many IHS hospitals offer limited scopes of services and 
have limited experience with certain medical conditions, the quality indicators and 
metrics that most hospitals use are not always meaningful for quality monitoring. 
Infrequent review of quality metrics  Most Area Offices depend on infrequent 
Governing Board meetings to review quality metrics. 
Limited clinical support  Over time, staffing reductions and vacancies led several 
Area Offices to reduce clinical consulting services.  As a result, IHS hospital clinical 
directors rely on each other to solve problems with little support from the Area Office. 
Under-developed quality assurance programs  Many hospital programs fall short on 
requirements to be data-driven and hospital-wide, citing challenges in collecting, 
analyzing, and reporting data on quality and outcomes. 
 
Source:  OIG summary of the companion report, Indian Health Service Hospitals:  More Monitoring Needed to 
Ensure Quality Care (OEI-06-14-00010). 
 
Upcoming Work.  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.   
 
 
METHODOLOGY 
This study describes challenges affecting the 28 IHS-operated hospitals 
ability to provide quality care and maintain compliance with Medicare 
standards.  Report findings are based on multiple data sources, including 
telephone interviews, questionnaires, and document reviews.  We 
conducted in-depth telephone interviews with leadership staff at each 
IHS-operated hospital, the eight Area Offices that oversee the hospitals, 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        5   
   
and IHS headquarters.  We verified staff-reported issues when possible by 
reviewing documentation, such as internal management reports, survey 
deficiency citations, reports by an IHS-contracted consultant, and IHS data 
on user populations and facilities.15  In addition, we interviewed staff and 
reviewed select documents from CMS.  Information was collected 
between April and October 2014.  (See Appendix C for a full description 
of the methodology.) 
Limitations 
Although we reviewed supporting documentation when possible, many of 
the challenges described in this report are based on self-reported data, and 
may not reflect all of the pressing challenges affecting IHS hospitals.  We 
often relied on the perspectives of staff in leadership positions at IHS and 
CMS headquarters, at IHS Area Offices, and at IHS hospitals.  We did not 
interview patients, midlevel staff, lower level staff, or tribal 
representatives to gain their perspectives.  Additionally, the findings in this 
report pertain only to the 28 IHS-operated hospitals and cannot be 
generalized to other IHS providers, including the 18 hospitals operated by 
tribal organizations. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.
____________________________________________________________ 
15 The user population includes AI/ANs eligible for IHS services who have used those 
services at least once during the immediate 3-year period, and who are registered in a 
verifiable patient registration system.  IHS, Indian Health Service Headquarters 
Programs, Services, Functions and Activities Manual, June 2002.  Accessed at 
http://www.ihs.gov/tribalshares/includes/themes/newihstheme/display_objects/documents
/ITExcerptsPSFAManualJune2002.pdf on March 16, 2015. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        6   
   
FINDINGS 
The challenges presented below provide insight into the difficulties that 
IHS hospitals face meeting the care needs of AI/ANs.  As we assessed 
IHSs efforts to monitor and improve the quality of care, staff reported 
that a number of longstanding challenges compromise those efforts.  
Although we recognize that additional factors not presented in this report 
may also contribute to quality problems, it is important to highlight the 
challenges that emerged most prominently in our review.   
Increasing numbers of outpatients, limited scopes of 
services, and geographic isolation restrict IHS 
hospitals ability to ensure patient access to care   
Over the last 3 decades, federally operated IHS hospitals experienced a 
significant increase in their user populations as compared to the overall 
U.S. population growth.  (See Chart 1 for user population growth in IHS 
hospitals.)  Staff explained that the number of outpatients often exceeds 
the number of staff and space available to care for these patients, which 
ultimately affect patient access.  Similarly, limited types of services and 
constraints on funding further restrict IHS hospitals ability to provide 
necessary services, pay for patient referrals (i.e., through PRC), and ensure 
post-acute care.  Staff also reported that the geographic isolation of many 
hospitals plays a role in hospital access to specialists and community 
support such as nursing homes and home health services.  
Chart 1:  User Population Growth, by Fiscal Year (19862013) 
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
1986 1989 1992 1995 1998 2001 2004 2007 2010 2013
 
Note:  This chart shows the numbers of eligible AI/ANs who have used services in the federally operated service 
units.  It does not include AI/ANs who used services only in the tribally run facilities.                                    
Source:  OIG analysis of population data from IHSs Office of Environmental Health and Engineering, 2014. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        7   
   
Increasing numbers of users burden many hospitals and 
adversely affect patient access  
Between FYs 1986 and 2013, the collective population of registered users 
across the 28 IHS hospitals increased by 70 percent (from 695,941 users to 
1,181,613 users).  By comparison, the overall U.S. population increased 
by 32 percent during the same time period.  For 1 hospital and its satellite 
clinics alone, the user population more than doubled (from 26,797 users to 
68,838 users) during that time period.  IHS staff reported that such 
significant growth in patient population contributes to long waiting times 
in the hospitals and difficulty for patients in scheduling appointments, 
which are the most common complaints that hospitals receive regarding 
patient care. 
Limited scopes of services restrict hospitals ability to care for 
certain patients, and funding constraints restrict their ability to 
pay for patient referrals   
Administrators from all hospitals reported that service limitations cause 
them to refer patients to other non-IHS health care providers for medical 
services and procedures.  If approved, these services are paid for by IHSs 
PRC program.  Administrators from one hospital explained that the 
hospitals providers are primarily midlevel providers and family practice 
physicians who are not equipped to provide specialty care, causing them to 
rely heavily on PRC referrals.   
146,928 However, due to funding constraints, not all referrals are approved.  In 
 
FY 2013, PRC administrators denied over $760 million in referral requests 
Number of  for an estimated 146,928 services needed by eligible AI/ANs.  This 
represents almost half of the $1.56 billion total in referral requests made to 
referrals  
the PRC program and the Catastrophic Health Emergency Fund during 
for services denied 
FY 2013.16  
by IHS in 2013  
When the budget is insufficient to cover all needed services, IHS uses a 
medical-priority rating system to ensure that the most urgent requests are 
fulfilled first.  In FY 2013, 77 percent of IHS service unitsmany of 
which run hospitalscovered only referrals classified as acutely urgent 
care services (e.g., services necessary to prevent the immediate threat to 
life, limb, or senses).  Consequently, administrators denied most other 
referral requests, including those for preventive care services 
(e.g., mammography), primary and secondary care services (e.g., cardiac 
____________________________________________________________ 
16 IHS used the PRC program and a related program, the Catastrophic Health Emergency 
Fund (CHEF), to support $801 million in referral services.  The Indian Health Care 
Amendments of 1988, P.L. No. 100-713, established the Catastrophic Health Emergency 
Fund (CHEF) to cover solely extraordinary medical costs associated with treating AI/AN 
victims of disasters or catastrophic illnesses. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        8   
   
catheterization), and chronic tertiary and extended care services (e.g., joint 
replacement).  The Chief Executive Officer (CEO) at one of the 
geographically isolated hospitals reported that the hospital spent most of 
its limited PRC funds on emergency air transports because of its remote 
location, leaving little to spend on services that would otherwise be 
considered acutely urgent, such as a surgical intervention for a broken 
arm. 
Isolation limits access to specialists and community support, 
such as nursing homes and home health, but some hospitals 
have found alternative solutions   
Many hospitals are in remote locations, some as far as 200 miles from the 
nearest city, forcing patients to travel far for specialty care.  Staff from 
half of the hospitals (14 of 28) reported significant challenges resulting 
from limited access to specialists.  Administrators at one remotely located 
hospital reported that to better ensure continuity of care, the hospital 
partnered with a private hospital for telemedicine services for its pediatric 
patients.  Administrators from another hospital reported flying in 
specialists twice a month to increase patients access to specialty services.  
This hospital also reported forming agreements to provide mammogram 
services through mobile units that come on site once a month.  
For many hospitals, post-acute care and discharge planning are also 
substantial challenges affecting patient care.  Administrators from  
11 hospitals reported difficulties securing post-acute care for their patients 
because of limited placement options.  One administrator reported that 
patients must travel 100200 miles to receive post-acute care, which may 
be particularly problematic for patients at the end-of-life stage.  Another 
hospital administrator described how the lack of resources (e.g., nursing 
homes, rehabilitation clinics) in the community and the Third World 
living conditions (e.g., no running water or electricity) of many patients 
sometimes prevent the hospital from discharging patients, particularly 
during the winter months.   
Hospitals with low inpatient censuses may struggle to 
maintain clinical competence, which can result in 
patient harm 
Despite the growing number of outpatients, most IHS hospitals have 
exceedingly low numbers of patients admitted to inpatient wards.  These 
low inpatient censuses cause decreased staff recruitment, staff retention, 
and quality of care.  In 2013, the total number of inpatients across the 
28 IHS hospitals on any given day was approximately 221.  The average 
daily census for individual IHS hospitals was 8 inpatients; compared to the 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        9   
   
national daily average of 104 inpatients.17  (See Appendix A for 
3  
information on the average daily inpatient census at each IHS-operated 
hospital.)  Collectively, 7 hospitals cared for more than two-thirds of the 
Number of  IHS inpatients (151 of 221); while the remaining 21 hospitals had an 
inpatients  average daily census of 3 inpatients, with 5 hospitals caring for less than 
treated daily in  1 inpatient a day.  
most IHS  Two Area Directors reported that an ongoing problem for many IHS 
hospitals  hospitals is that their low inpatient censuses results in low volumes of 
high-risk conditions, affecting the quality of care provided to patients.    
As one Area Director explained it, a provider may receive appropriate 
training on intubation but intubate only one patient a year, which affects 
the providers comfort level and skill in performing such procedures.  
Further, an IHS official stated that specialist physicians, such as surgeons, 
are likely to leave a hospital if they are unable to perform enough 
procedures to maintain their skills.  Area Office staff also noted that 
hospitals may not always recognize inadequacies in their own providers.  
Similarly, empirical research has shown a link between low-volume 
hospitals/providers and poorer outcomes.18 
In one low-census IHS hospital, the lack of staff proficiency and inability 
to identify problems (among other issues) contributed to three patient 
deaths in 2014, according to CMS officials.  CMS surveyors found that 
hospital staff lacked training and knowledge on how to conduct 
emergency resuscitations and that the crash cart (a wheeled container 
carrying medicine and equipment that physicians and nurses use in 
emergency resuscitations) lacked essential medications and equipment.  
Surveyors also found that staff lacked knowledge on how to call 
emergency codes across the intercom system to summon assistance, were 
not adequately trained to recognize symptoms of a life-threatening 
condition, and failed to provide necessary stabilizing treatment.   
Administrators from another low-census hospital reported discontinuing 
some of its services, including labor and delivery, following a major flood 
affecting the hospital campus.  During the months in which the hospital 
was closed, many staff either left or struggled to maintain essential 
____________________________________________________________ 
17 The average daily census in hospitals nationwide was extrapolated from the American 
Hospital Associations (AHA) statistical compilation.  In 2013, there were 
5,686 hospitals in the United States, and the nations average daily hospital census was 
592,000.  Andis Robeznieks, Hospitals saw fewer admissions, more outpatients in 
2013, Modern Healthcare, January 27, 2015.  Accessed at   
http://www.modernhealthcare.com/article/20150127/NEWS/301279903 on June 16, 
2015. 
18 Harold S. Luft, John P. Bunker, and Alain C. Enthoven, Should Operations Be 
Regionalized?  The Empirical Relation between Surgical Volume and Mortality, New 
England Journal of Medicine, 301(1364-1369). 1979. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        10   
   
competencies, leaving insufficient numbers of qualified staff to treat 
patients.  Hospital administrators determined that it was no longer safe to 
continue providing certain services. 
Vacancies, use of acting positions, and dependence 
on contracted providers sometimes impair hospital 
service stability and continuity of care 
The CoPs require hospitals to have organized medical staffs that can 
 33%
provide quality medical care to patients.19  One of the biggest concerns, 
 
reported by most of the IHS-run hospitals (23 of 28), relates to difficulties 
Vacancy rate for  in recruiting and retaining staff.  Agencywide, vacancies are an issue.20  In 
physicians in IHS  2014, the vacancy rates across IHS for physicians and nurses were 
hospitals  23 percent and 17 percent, respectively.  However, for IHS hospitals alone, 
the physician vacancy rate was even higher, at 33 percent.21  In contrast, 
the national vacancy rate for hospital physicians was less than 18 percent 
in 2013.22 
According to staff, these vacancies have a significant impact on the 
continuity and quality of care.  Administrators from one hospital reported 
that staffing shortages sometimes force the hospital to turn patients away.  
In another hospital, administrators said that insufficient staffing was the 
cause of its recent immediate jeopardy citation for violating the 
Emergency Medical Treatment & Labor Act (EMTALA) in the emergency 
room.23  Not only did the hospital fail to properly staff the emergency 
room, it also failed to provide patients with adequate waiting areas and 
proper medical transfers.  According to CMS officials, EMTALA 
violations are serious problems in IHS hospitals and are closely linked to 
inadequate staffing.  In one hospital, administrators reported that staffing 
shortages not only resulted in deficiency citations for not meeting patient 
needs, but also affected staffs ability to meet performance standards and 
ensure a sanitary environment. 
____________________________________________________________ 
19 42 CFR  482.22. 
20 In 2014, there were 1,550 vacancies for health care professionals (e.g., physicians, 
dentists, nurses, pharmacists, physician assistants, and nurse practitioners) across IHS.  
HHS, IHS, FY 2015, op. cit., p. 9. 
21 Hospital-reported vacancies by IHS and tribal sites in the Physician and Nurse Position 
Reporting systems.   
22 AMN Healthcare, AMN Healthcare Survey:  Hospital Executives See Continued 
Shortage of Physicians, Nurses and Advanced Practitioners, December 12, 2013.  
Accessed at http://www.amnhealthcare.com/latest-healthcare-news/2147484592/1033/ on 
June 16, 2015.  
23 Congress enacted EMTALA in 1986 to ensure public access to emergency services 
regardless of ability to pay.  CMS, Emergency Medical Treatment & Labor Act 
(EMTALA).  Accessed at http://www.cms.gov/Regulations-and-
Guidance/Legislation/EMTALA/index.html?redirect=/emtala/ on March 12, 2015. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        11   
   
Hospitals attribute their staffing shortages to geographic 
isolation, limited incentives, noncompetitive pay, and a lengthy 
hiring process 
Administrators from nearly half of the hospitals (13 of 28) reported that 
the remoteness of their facilities affects their ability to recruit and retain 
staff.  Housing, amenities (e.g., stores, community activities, and schools), 
and job opportunities for accompanying family members are scarce in 
these areas.  One administrator reported that staff must commute a total of 
3 hours a day, without additional compensation, because of the lack of 
housing.  Administrators from another hospital described how insufficient 
housing not only affects staffing levels, but also impacts staff moralethe 
hospital prioritizes the limited number of housing units for physicians, 
which creates tension among staff members.    
Limited incentives and noncompetitive pay also play a significant role in 
causing hospital staffing shortages, according to hospital administrators.  
Although hospitals can use loan repayment and relocation bonuses to 
attract applicants, some of these bonuses exclude many essential staff, 
including nurses.  Administrators from one hospital described how its 
ability to compete for staff is affected by the lack of recruitment incentives 
(particularly, the lack of signing bonuses), the hospitals remote location, 
and the fact that its locality pay is the same as that for IHS hospitals in less 
rural areas.  In another hospital, administrators reported that although they 
can offer physicians a competitive salary using a special market pay 
authority, the hospital has lost applicants because of the lengthy approval 
process involved in such requests. 
Additionally, the length of the hospitals hiring process affects recruitment 
outcomes.  On average, it takes IHS hospitals 77 days to hire a new 
employee.  Although this timeframe is within the 80-day hiring standard 
set at the Federal level by the Office of Personnel Management, 
administrators from three hospitals reported that they have lost many 
suitable candidatesincluding doctors, nurses, and administrative staff
because of the lengthy hiring process.  Administrators at one of these 
hospitals stated that it sometimes takes as long as 6 months to hire new 
staff.  An IHS official reported that Human Resources (HR) can 
sometimes streamline the hiring process for key providers 
(e.g., physicians, dentists) by using direct hiring authority.  Under this 
authority, HR can post a continuous announcement to which providers can 
apply.  The applications are stored for 90 days, and as positions become 
available, HR staff can quickly pull a list of eligible candidates.  The use 
of this authority has sometimes shortened the hiring process for key 
providers to 30 days.    
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        12   
   
Hospital officials are often in an acting capacity, resulting in 
inconsistent facility leadership   
Administrators from 24 of the 28 hospitals reported having someone in an 
acting leadership position, such that vacant positions are filled by an 
interim person not intended to maintain the position long-term.  The most 
common acting position was that of the CEO (11 hospitals), followed by 
the clinical director (10 hospitals) and the director of nursing (9 hospitals).  
One administrator reported struggling with the constant change in 
leadership after having multiple acting CEOs; another administrator 
described that scenario as a historical dilemma for IHS.  In one case, 
described in a report by an IHS-contracted consultant, a hospital had three 
different acting CEOs within a 6-week span.  Administrators from another 
hospital reported that after several failed attempts to fill the position of 
clinical director, they had to assign two members of the medical staff to 
take turns doing 2-week stints as acting clinical director.  This created 
challenges and instability for those acting clinical directors and their staff. 
HR staff reported that hospitals often fail to inform them when using 
acting positions.  As a result, hospitals sometimes do not adhere to the 
necessary requirements for using such positions.  For example, 
administrators from one hospital reported that on two separate occasions, 
the hospital exceeded both the allowed 120-day timeframe and the allowed 
difference in pay grades when it assigned a nonsupervisory employee to 
the position of acting CEO.  In another hospital, the IHS-contracted 
consultant found that the hospital received a deficiency citation as a result 
of having six different acting CEOs in a year and failing to report the 
change in leadership to CMS or the accrediting organization.  
Hospital dependence on contracted providers to supplement 
permanent staff may affect quality and continuity of care 
The wide variation in the experience and training of contracted providers, 
combined with their short tenure, appear to make it difficult for hospitals 
that rely heavily on such providers to ensure that patients receive needed 
care.  For example, administrators from one hospital reported that it often 
has to refer patients out to other facilities for followup care because the 
contracted providers generally do not stay at the hospital long enough to 
see the patients in subsequent visits.  The administrators further explained 
that providing training to these providers can be a challenge because of 
their short tenure (which generally range from 3 days to 3 months) and 
IHS hospitals limited resources.   
Additionally, using contracted providers can be costly for hospitals.  
Administrators from one hospital reported that its dependence on 
contracted nurses and pharmacists to backfill vacancies has a significant 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        13   
   
impact on the hospitals operational budget.  The costly use of these 
providers prevents the hospital from expanding its facility (e.g., adding 
more exam rooms), which limits the hospitals ability to improve patient 
access to care.   
The constant rotation of contracted providers also led to problems with 
monitoring and oversight of these providers in some locations.  
Administrators from two hospitals raised concerns about poorly 
performing contracted providers who had rotated from one hospital to 
another.  In one of these hospitals, administrators reported that it had 
recently received two troublesome contracted providersone who had 
outstanding issues with the medical board in another State, and another 
who had been terminated by two other hospitals for inappropriate 
behavior.  
Outdated and insufficient buildings and equipment 
may further confound care  
The CoPs require hospitals to maintain a sanitary physical environment 
77 
that ensures patient safety and prevents the transmission of infections and 
communicable diseases.24  In more than half of the hospitals (15 of 28), 
Years since  administrators reported that old or inadequate physical environments 
last major  challenged their ability to provide quality care and maintain compliance 
renovation of the  with the CoPs.  For example, the aging structure in one IHS hospital 
two oldest IHS  caused sewage to leak into the operating room after its old pipes corroded.  
hospitals   The average age (or length of time since a major renovation) of IHS 
hospitals is 37 yearsnearly four times the average age of hospitals 
nationwide (which was 10 years in 2013).25, 26  The two oldest IHS 
hospitals are both 77 years old.  According to engineering staff at IHS, the 
oldest hospital structures were never designed to provide modern health 
care, and over time, health care practices and technology changed and 
outpaced many IHS hospitals.   
Further, according to administrators at most IHS hospitals (22 of 28), 
maintaining aging buildings and equipment is a major challenge because 
of limited resources.  In FY 2013, funding limitations for essential 
maintenance, alterations, and repairs resulted in backlogs totaling 
approximately $166 million.  Hospitals unmet maintenance and repair 
____________________________________________________________ 
24 42 CFR  482.41 and 482.42. 
25 The age of each hospital is calculated from the date of the most recent major 
renovation, not from the original construction date.  OIG interview with IHS Office of 
Environmental Health and Engineering (OEHE) staff on September 25, 2014. 
26 AHA, Chartbook: Trends Affecting Hospitals and Health Systems, ch. 4, Chart 4.10, 
Median Average Age of Plant 1993-2013.  Accessed at 
http://www.aha.org/research/reports/tw/chartbook/ch4.shtml on June 15, 2015. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        14   
   
needs in one Area accounted for nearly a third ($47 million) of the total 
backlog amount.  Staff from this Area Office reported that hospitals 
sometimes have to divert patients because of facility issues.  For example, 
one hospital has had to occasionally shut down its operating room because 
of mechanical problems. 
Nearly 35 percent (140 of 405) of all deficiencies cited in IHS hospitals 
during their most recent survey were related to the physical environment.27  
The deficiencies ranged from inappropriate air flow and pressure in certain 
areas (e.g., central sterile rooms), which are important infection control 
technologies, to malfunctioning emergency exit doors.  Staff from one 
Area Office attributed the large number of facility-based deficiencies to 
the age of the facilities and funding limitations.  Administrators from one 
hospital reported that their facility, which was built in the early 1900s, was 
not designed to be a hospital.  Despite the buildings poor layout, its 
historical significance prevents the hospital from expanding or changing 
its structure to better serve patients (e.g., tearing down walls, installing 
adequate fire sprinklers, and running necessary IT lines to support 
electronic health records).  The administrators also expressed concerns 
that the hospitals aging equipment posed a potential risk for infection.  At 
another hospital, administrators reported challenges in finding parts for its 
aging equipment.  Further, one Area Director stated that IHSs inability to 
modernize and keep up with technology also affects hospitals ability to 
recruit and retain providers because highly trained medical professionals 
want to provide care at the level they were trained to provide. 
Not only do hospitals face the challenge of being outdated, most have also 
outgrown their space.  Specifically, more than two-thirds of hospitals 
(19 of 28) have insufficient space; hospitals reported that these constraints 
most affected exam rooms, diagnostic services, and/or pharmacies.28  Of 
the 19 hospitals with insufficient space, 7 have less than half the estimated 
space needed to meet community needs.  When IHS recently replaced one 
of its older hospitals, the new structure was significantly larger in order to 
meet the needs of the growing user population.  The new structure was 
nearly five times larger than the old one, both in size and in the number of 
exam roomsthe hospital went from 38,481 square feet to 179,983 square 
feet, and from 13 exam rooms to 61. 
____________________________________________________________ 
27 We included the most recent survey that hospitals received during the period we 
studied.  As a result, hospitals may have received surveys after January 1, 2014, which 
occurred after our study period. 
28 This calculation is based on a comparison of each hospitals current space to the 
estimated space needed if a new facility was built today to meet the size of the current 
user population.  OIG interview with IHS OEHE staff on October 1, 2014. 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        15   
   
Administrators from another hospital reported that it had been built in 
1993 to meet the needs of the projected population for the next 15 years, 
but the population exceeded the hospitals capabilities by the year 2000
only 7 years later.  Because of space limitations, the administrators 
explained that they are unable to hire additional employees and expand 
services.  The administrators said that to meet patient needs and decrease 
waiting times, they would need an intensive care unit, space for physical 
therapy, a larger pharmacy department, and additional outpatient exam 
rooms.  Another hospital was constructed to handle 40,000 users; however, 
when it opened its doors, the user population immediately doubled after 
tribal clinics closed down and the criteria for tribal membership became 
more inclusive.  Administrators at another hospital reported that space 
issues not only affect the hospitals ability to ensure privacy in the 
emergency room and pharmacy department, but also prevent the hospital 
from establishing a triage room, which makes it more difficult for the 
hospital to comply with the EMTALA requirements.   
Although most IHS hospitals have outgrown their facilities, funding 
constraints prevent them from engaging in major renovation and 
construction.  IHS has a construction listdating back to 1992that 
includes 5 of the 28 hospitals.  No new construction projects may be added 
to this list until the existing items are completed.  The amount needed to 
complete the construction projects on the current list is nearly $2.3 billion.  
However, if IHSs annual construction budget were to remain at its 
FY 2015 level of $85 million, it would take the agency 24 years to 
complete all of the projects, including those involving the five IHS 
hospitals.   
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        16   
   
RECOMMENDATIONS 
Our review identified longstanding challenges that may affect IHS 
hospitals ability to provide quality care and comply with Medicare 
standards, including ensuring access to needed care, maintaining clinical 
competence, recruiting and retaining essential staff, and keeping patients 
safe despite outdated buildings and equipment.  Similar reports date back 
almost a century, and problems persist despite reported efforts to address 
them.  We also found in this studys companion reportIndian Health 
Service Hospitals:  More Monitoring Needed to Ensure Quality Care 
(OEI-06-14-00010)that IHS may lack important quality assurance 
infrastructure and active monitoring efforts.  Given the duration and extent 
of IHSs problems, we conclude that it may not be able to overcome these 
challenges without broad support from experts both within and outside 
HHS and consideration of different models for providing services.   
We recommend that the Office of the Secretary of Health and Human 
Services (OS): 
As part of OS newly formed Executive Council, lead an 
examination of the quality of care delivered in IHS hospitals 
and use the findings to identify and implement innovative 
strategies to mitigate IHSs longstanding challenges  
The Executive Councila new initiative led by HHSs Acting Deputy 
Secretary to leverage departmentwide resources in support of quality 
improvement within IHSshould undertake a concerted effort to examine 
and address the longstanding challenges facing IHS hospitals.  In the 
coming months, the council should develop its infrastructure and workplan 
to facilitate a smooth transition and continued progress during the shift to 
a new Presidential administration.   
To directly address IHSs most fundamental issues, the council should 
collaborate with IHS and leverage the councils organizational expertise in 
areas such as rural health, providing care to vulnerable populations, 
hospital management, performance metrics, and payment methodologies.  
The council should coordinate this effort with additional recommendations 
to IHS and CMS listed in the companion report.  For example, the council 
should work with IHS as IHS implements a quality-focused compliance 
program.  The council should also tackle broader issues, including 
managing the needs of a growing population; ensuring safe care at 
hospitals, particularly those with few inpatient beds and/or a limited scope 
of services; and ensuring compliance with Medicares hospital CoPs.  The 
council should consider a wide range of optionse.g., telemedicine and 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        17   
   
other alternative models of care deliverywith an eye toward identifying 
sustainable solutions and innovative ways to implement change. 
We recommend that IHS: 
Conduct a needs assessment culminating in an agencywide 
strategic plan with actionable initiatives and target dates 
Given that IHSs most recent strategic plan concluded in 2011, the agency 
needs a new strategic plan to build a unified vision of its priorities and 
how to achieve them.  IHS should clearly identify and articulate its goals 
and priorities for meeting the care needs of AI/ANs and develop a specific 
plan for achieving them.  As part of this effort, IHS should conduct a 
comprehensive needs assessment that reflects both broad goals for 
progress and the unique needs and obstacles of individual hospitals or 
groups of hospitals.  A full assessment of resources, capabilities, and 
challenges is necessary to ensure that the strategy is realistic and 
incorporates specific, actionable steps for improvement.   
The overarching priorities in the strategic plan should be agencywide, but 
how IHS achieves these priorities must be tailored to recognize the 
specific needs associated with some hospitals, such as those with very low 
inpatient censuses and those with ailing physical facilities.  The plan must 
address the underlying challenges to achieving quality and also expand the 
agencys priorities to include a commitment to quality monitoring and 
quality improvement.  For example, appropriate components of the 
strategic plan would be plans to relieve staffing challengessuch as 
streamlining the hiring process, establishing protocols for the practice of 
placing employees in acting positions, maximizing use of hiring 
incentives, improving recruitment practices, and systematically tracking 
the performance of contracted providers.  The strategic plan could also 
address topics including but not limited to: 
  maintaining clinical competence in hospitals with low censuses, 
  reducing denials of referrals for necessary services,  
  expanding referral networks,  
  ensuring maintenance and repair of buildings and equipment,  
  providing adequate IT support,  
  enhancing clinical support, and 
  evaluating physical security.   
 
The strategic plan should include short-term, midrange, and long-term 
priorities to ensure that as funding becomes available, it is spent on the 
most critical issues of health care quality.    
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        18   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Office of the Secretary, 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.  HHS also described 
efforts underway to address quality problems, especially concerns raised 
during a congressional hearing in February 2016 about the quality of care 
in the Great Plains Area and by CMS during certification surveys of 
several IHS hospitals.  These efforts, detailed in the Agency comments in 
Appendix D, include: 
  Departmentwide investment in IHSHHS created an Executive 
Council on Quality Care, currently led by the HHS Acting Deputy 
Secretary.  This Council, which includes health quality experts from 
across HHS, is working with IHS to examine the quality of care at 
IHS-operated hospitals.  HHS is currently targeting these efforts to 
respond to identified issues in the Great Plains Area.  The Councils 
work includes a mentorship program for administrators of select 
hospitals in the Great Plains Area, the development of a patient 
experience survey and data dashboards, new recruitment efforts in 
partnership with the National Health Service Corps, Health Resources 
and Services Administration, and the Peace Corps and a deployment of 
the U.S. Public Health Service Commissioned Corps.  
  Quality FrameworkIHS is developing a Quality Framework 
document that will establish a vision and a course of action for 
improving the care provided by IHS facilities.  IHS is assessing its 
policies and practices for quality and plans to add new policies for 
Governing Boards and hospital response to adverse events by the end 
of 2016.  IHS also plans to establish a new Office of Quality in its 
headquarters that will focus on standardizing processes and procedures 
across the IHS system of care. 
  Survey readiness and training initiativesIHS began a mock survey 
initiative to ensure that all IHS hospitals are assessed for compliance 
with the CoPs at regular intervals using standardized protocols. IHS 
plans to track performance data from these mock surveys and from 
accreditation or certification surveys centrally.  Additionally, IHS 
recently awarded a contract to TJC to assist hospitals in survey 
readiness, training, and education services.  The first TJC training 
sessions will cover Quality Assurance and Performance Improvement 
(QAPI) and the EMTALA requirements.  Additional training, 
prompted by a Systems Improvement Agreement with CMS, will 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        19   
   
address Governing Board practices and the Medicare CoP 
requirements more broadly.  Further, IHS recently began holding 
quarterly webinars with Area Office and service unit leaders to provide 
technical assistance and to share experiences. 
  Continuation and expansion of CMS technical assistance 
programsCMS will continue to support IHS hospital improvements 
through its Quality Improvement Network-Quality Improvement 
Organization (QIN-QIO) and Hospital Engagement Network (HEN) 
programs.  The QIN-QIO for the Great Plains Area will provide QAPI 
support with emphasis on leadership, staffing, data analytics, clinical 
standards, and quality.  Additionally, CMS and IHS are developing a 
task order for a single QIN-QIO to assist with quality improvement 
technical assistance in all IHS hospitals.  IHS hospitals will also 
participate in a HEN, which is a learning collaborative dedicated to 
preventing patient harm in hospitals.  This effort will continue as the 
HEN program transitions to the Hospital Improvement and Innovation 
Network (HIIN).  
HHS, IHS, and CMSs recent efforts provide a strong foundational 
response to the issues identified in this report.  Many of these activities, 
however, are currently localized to the Great Plains Area and it is unclear 
the extent to which these efforts will be applied to other Areas.  We 
encourage IHS to ensure that the lessons learned in the Great Plains Area 
will also be used to benefit the whole of IHS.  It is worth noting, also, that 
these efforts are extensive and full implementation will likely take years to 
achieve.  As such, we anticipate an extended timeframe for monitoring 
progress towards fulfillment of the recommendations.   
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        20   
   
APPENDIX A 
The table below provides basic demographic information, including the 
locations, of IHS hospitals.  We used publicly available 2010 Frontier 
and Remote Area data from the Department of Agriculture to identify 
remote locations and population density for the appropriate ZIP codes.  
Remote areas are at least 60 minutes from an urban area of 50,000 or more 
people.  IHS provided the hospital user populations and facility 
demographics for FY 2013.  We identified hospital survey agencies using 
both survey data provided by CMS and a review of information available 
on the TJC website. 
Table A-1:  IHS Hospitals by Area Office 
Avg. 
Remote  Pop.  User  Daily  Age of  Survey 
Hospital  City/State  Area  Density  Pop.  Census*  Facility  Agency 
Great Plains (formerly known as Aberdeen) Area Office 
Standing Rock/Fort Yates Hospital  Ft. Yates, ND  -  8.6  9,040  0.1  48  CMS 
Quentin N Burdick Memorial Hospital  Belcourt, ND  Remote  45.5  13,799  7.0  46  TJC 
Cheyenne River Hospital  Eagle Butte, SD  Remote  2.3  8,457  2.1  3  CMS 
Pine Ridge Hospital  Pine Ridge, SD  Remote  6.7  21,989  12.0  21  CMS 
Rapid City Indian Hospital  Rapid City, SD  -  103.5  14,819  0.9  76  CMS 
Rosebud Hospital  Rosebud, SD  Remote  8.9  12,482  6.8  24  CMS 
Winnebago Hospital  Winnebago, NE  -  24.4  5,213  2.2  10  TJC** 
 
Albuquerque Area Office 
Mescalero Service Unit  Mescalero, NM  Remote  5.0  4,705  2.0  46  TJC 
Acoma-Cononcito-Laguna Service Unit  Acoma, NM  -  3.3  11,035  2.8  35  TJC 
Santa Fe Service Unit  Santa Fe, NM  -  69.9  14,766  1.5  35  TJC 
Zuni Comprehensive Health Center  Zuni, NM  Remote  16.3  11,973  6.4  40  TJC 
Bemidji Area Office 
Cass Lake Hospital  Cass Lake, MN  Remote  18.1  10,589  0.7  77  CMS 
Red Lake Hospital  Red Lake, MN   Remote  45.9  8,046  2.8  33   TJC 
Billings Area Office 
Blackfeet Community Hospital  Browning, MT  Remote  7.0  11,571  11.0  77  CMS 
Crow/Northern Cheyenne Hospital  Crow Agency, MT  -  4.2  13,342  4.6  19  CMS 
Fort Belknap Hospital  Harlem, MT  Remote  3.5  4,662  0.1  16  CMS 
Continued on next page. 
.                                                                                                                                                  
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        21   
   
Table A-1:  IHS Hospitals by Area (Continued) 
Avg. 
Remote  Pop.  User  Daily  Age of  Survey 
Hospital  City/State  Area  Density  Pop.  Census*  Facility  Agency 
Navajo Area Office 
Chinle Comprehensive Health Care   Chinle, AZ  Remote  9.6  35,027  19.0  33  TJC 
Gallup Indian Medical Center  Gallup, NM  Remote  34.5  43,275  41.7  53  TJC 
Northern Navajo Medical Center  Shiprock, NM  -  8.3  53,915  5.8  20  TJC 
Crownpoint Health Care Facility  Crownpoint, NM  Remote  5.2  19,787  1.5  26  CMS 
Oklahoma Area Office 
Claremore Indian Hospital  Claremore, OK  -  196.5  100,801  6.8  37  TJC 
Lawton Indian Hospital  Lawton, OK  -  109.3  22,782  6.6  47  TJC 
Claremore, OK 
LPahwoteonni,x O AKr ea Office 
Parker Indian Hospital  Parker, AZ  -  16.6  9,275  4.6  13  TJC 
Hopi Health Care Center  Polacca, AZ  Remote  10.7  6,545  19.0  14  TJC 
Phoenix Indian Medical Center  Phoenix, AZ  -  3232.3  68,838  34.0  44  TJC 
San Carlos Hospital  San Carlos, AZ  Remote  2.7  12,323  0.7  52  TJC 
Whiteriver Hospital  Whiteriver, AZ   Remote  39.5  16,428  14.0  35  TJC 
Tucson Area Office 
Sells Indian Hospital  Sells, AZ    -  1.9  20,215  4.4  54  TJC 
*The average daily census includes inpatients only. 
**Winnebago Hospital lost accreditation and reverted to CMS certification during our evaluation.                    
Sources:  OIG compiled this table using information from the IHS Web site and the TJC Web site; Medicare provider data from the Certification and Survey Provider 
Enhanced Reporting; and interviews, surveys, and documents collected during this evaluation.  
   
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        22   
   
APPENDIX B 
Table B-1:  Hospital Conditions of Participation 
Condition  Regulation  Description 
Administrative Functions 
Compliance with Federal, State,   482.11  A hospital must comply with applicable federal laws on patient 
and Local Laws  health and safety and state and local laws on hospital and 
personnel licensing. 
Governing Body   482.12  A hospital must have a legally responsible governing body or 
persons charged with the responsibilities of a governing body. 
Patients Rights   482.13  A hospital must protect and promote patients rights. 
Basic Hospital Functions 
Quality Assessment and   482.21  A hospital must have an effective, hospitalwide quality assurance 
Performance Improvement  program. 
Program 
Medical Staff   482.22  A hospital must have an organized medical staff that abides by 
bylaws approved by the governing body and is responsible for the 
quality of patient medical care. 
Nursing Services   482.23  An organized nursing service must provide 24-hour nursing services 
that are supervised or furnished by registered nurses. 
Medical Record Services   482.24  A hospital must have a medical record service that has 
administrative responsibility for medical records. 
Pharmaceutical Services   482.25  The hospital must have pharmaceutical services that meet patient 
needs. 
Radiologic Services   482.26  The hospital must maintain, or have available, diagnostic radiologic 
services.  Therapeutic services provided must meet professionally 
approved standards for safety and personnel qualifications. 
Laboratory Services   482.27  The hospital must maintain, or have available, adequate laboratory 
services. 
Food and Dietetic Services   482.28  Dietary services must be organized, directed, and staffed by 
qualified personnel. Contracted services must meet certain 
requirements. 
Utilization Review   482.30  Utilization review plans must provide for review of the services that 
a hospital and its medical staff provide to Medicare and Medicaid 
patients. 
Continued on next page..                                                                                                                                                  
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        23   
   
Table B-1:  Hospital Conditions of Participation (Continued) 
Condition  Regulation  Description 
Physical Environment   482.41  Hospital construction, arrangements, and maintenance must ensure 
patient safety and provide diagnostic and treatment facilities and 
special hospital services appropriate to community needs. 
Infection Control   482.42  A hospitals sanitary environment must avoid sources and 
transmission of infections and communicable diseases.  It must have 
an active program to prevent, control, and investigate infections and 
communicable diseases. 
Discharge Planning   482.43  A hospital must have a discharge planning process applicable to all 
patients.  Policies and procedures must be in writing. 
Organ, Tissue, and Eye   482.45  The hospital must have and implement written protocols on 
Procurement  procurement and have adequate organ transplant policies. 
Surgical Services   482.51  Surgical services must be well organized and provided in 
accordance with acceptable standards of practice.  Outpatient 
services must be consistent with inpatient care quality in accordance 
with the complexity of services offered. 
Optional Services 
Anesthesia Services   482.52  Anesthesia services must be well organized and directed by a 
qualified doctor of medicine or osteopathy.  The service is 
responsible for all anesthesia administered. 
Outpatient Services   482.54  Outpatient services must meet patient needs consistent with 
acceptable standards of practice. 
Emergency Services   482.55  If emergency services are provided they must be organized under 
the direction of a qualified member of the medical staff and have 
adequate medical and nursing personnel qualified in emergency 
care to meet the needs anticipated by the facility. 
Rehabilitation Services   482.56  Rehabilitation, physical therapy, occupational therapy, audiology, or 
speech pathology services must be organized and staffed to ensure 
the health and safety of patients. 
Respiratory Services   482.57  Respiratory services must meet patient needs in accordance with 
acceptable standards of practice. 
Nuclear Medicine Services   482.53  Nuclear medicine services must meet the needs of the patients in 
accordance with acceptable standards of practice. 
 Sources:  42 CFR  482.11-482.57 CMS; SOM, Pub. No. 100-07, App. A. 
 
 
IHS Hospitals:  Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011)        24   
   
APPENDIX C 
METHODOLOGY 
This study describes challenges affecting the 28 IHS-operated hospitals 
ability to provide quality care and comply with the Medicare standards.  
We identified these challenges during our interviews with IHS staff for the 
companion report, IHS Hospitals:  More Monitoring Needed to Ensure 
Quality Care (OEI-06-14-00010).  Report findings are based on multiple 
data sources collected between April and October 2014.   
Telephone Interviews 
We conducted in-depth, semistructured telephone interviews with IHS 
leadership staff from federally operated hospitals, headquarters, Area 
Offices, and regional Human Resource Offices.  We also interviewed 
relevant staff from CMS. 
IHS Hospital Interviews.  We interviewed hospital CEOs from the 
28 IHS-operated hospitals.  The CEOs often opted to include additional 
members of their leadership team in the interviews (e.g., clinical directors, 
directors of nursing, and quality managers).  Interview questions focused 
on each hospitals ability to provide necessary care; challenges affecting 
quality care and compliance; and improvement efforts.  
IHS Area Office Interviews.  We interviewed the eight Area Directors 
responsible for overseeing federally run IHS hospitals.  Area Directors 
often opted to include additional members of their leadership team in the 
interviews as well.  We asked about the challenges that hospitals had 
identified and about the Area Offices functions.   
IHS Headquarters Interviews.  We interviewed a range of headquarters 
and specialized field staff including: 
  Chief Medical Officer (CMO)  We interviewed the CMO to 
discuss IHSs role in guidance, monitoring, and efforts to improve 
hospital quality and compliance with the CoPs. 
  Director of Field Operations (DFO)  We interviewed the DFO to 
better understand the relationship of Area Offices with both the 
hospitals and headquarters. 
  Regional HR Directors  We interviewed four regional directors to 
learn more about the hiring process, the use of acting positions, 
and any staffing-related challenges. 
  Acting Deputy Director of the Office of Environmental Health and 
Engineering (OEHE)  We interviewed the Acting Deputy Director 
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and other leadership staff from OEHE to better understand hospital 
challenges related to population growth, capacity, and buildings. 
CMS Interview.  We interviewed leadership staff in CMSs Consortium for 
Quality Improvement and Survey & Certification Operations.  We asked 
them about CMSs role in overseeing IHS hospitals and their experiences 
working with the hospitals. 
Questionnaires 
IHS Hospital Questionnaires.  For each of the 28 hospitals, we 
administered questionnaires regarding the hospitals average daily 
censuses, vacancies, referrals, and grievances during 2013.   
IHS Area Office Questionnaires.  We administered questionnaires to the 
eight Area Offices.  We asked about consultant programs, procedural 
information regarding how Area Office staff review quality information, 
and perceptions about which challenges most affected hospitals ability to 
provide quality care and maintain compliance.   
IHS Regional Human Resource Questionnaires.  We administered 
questionnaires to the four regional Human Resource Offices regarding 
vacancies and acting positions in Area Offices and hospitals.   
Document Reviews 
Based on interview and questionnaire responses, we requested documents 
to validate information shared by IHS staff. 
IHS Hospital Surveys.  Using survey data stored in the Automated Survey 
Processing Environment (ASPEN) and Accrediting Organization System 
for Storing User Recorded Experiences (ASSURE), we reviewed survey 
frequencies and deficiency citations from before January 1, 2014, for each 
of the 28 hospitals.  We also requested full survey reports from CMS and, 
when applicable, the accrediting organization, as well as an 
IHS-contracted report entitled Accreditation Survey Analysis that analyzed 
IHS hospital accreditation and certification surveys conducted from 
September 30, 2005, to July 15, 2013. 
IHS Headquarters Documents.  From IHS headquarters, we received 
several management-related documents including the Federal Managers 
Financial Integrity Act (FMFIA) Deficiency Analysis, and final reports of 
the Area Office reviews conducted in response to Senator Dorgans  
2010 report.  We also received the following from OEHE:  population data 
from FY 1986 through FY 2013, capacity projections (based on the size of 
hospital-user populations), and lists of building construction and 
renovation projects and needs. 
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APPENDIX D 
AGENCY COMMENTS 
   
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ACKNOWLEDGMENTS 
This report was prepared under the direction of Ruth Ann Dorrill, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office.  
Amy Ashcraft and Petra Nealy served as the team leaders for this study.  
Other Office of Evaluation and Inspections staff from the Dallas regional 
office who conducted the study include Patricia Chen and Malinda Hicks.  
Central office staff who provided support include Clarence Arnold, 
Lucia Fort, Kevin Golladay, Christine Moritz, and Sherri Weinstein.  
We would also like to acknowledge the contributions of other Office of 
Evaluation and Inspections regional office staff, including Blaine Collins, 
Camille Harper, Christina Lester, and China Tantameng.   
 
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Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS) programs, as  well  as the health  and welfare of individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.