U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
Organizational Challenges 
to Improving Quality of 
Care in Indian Health 
Service Hospitals  
 
 
 
 
OEI-06-16-00390  Suzanne Murrin 
August 2019  Deputy Inspector General  
  for Evaluation and Inspections 
oig.hhs.gov  Rep ort in Brief  U.S. Department of Health and Human Services 
August 2019 
Office  of Inspector General 
OEI-06-16-00390 
 
 
Organizational Challenges to Improving Quality  Why OIG Did This Review 
This study identifies underlying 
of Care in Indian Health Service Hospitals 
organizational challenges that 
may hamper IHSs ability to 
What OIG Found  address critical longstanding 
Key Takeaway 
OIG identified underlying issues that are  problems at its hospitals.  At 
IHS is at a crossroads.  The agency 
hindering the Indian Health Service (IHS)  times, these problems have 
has had longstanding problems 
from improving its management of its  had serious consequences, 
providing consistent high-quality 
hospitals, and recommends strategies for IHS  including difficulty maintaining 
hospital care.  In 201819, IHS 
as it implements new improvement plans.   compliance with Federal 
released promising plans for 
The issues represent core organizational  quality-of-care requirements.  
improvement.  However, to make 
challenges that, if not addressed, could  OIG and others have 
meaningful and lasting 
continue to limit IHSs ability to improve  previously analyzed these 
improvements, IHS needs to 
hospital operations and quality of care:  problems and recommended 
overcome underlying organizational 
corrective actions.  IHS has 
  Lack of Formal Structure, Policies, and  problems that have hampered its 
made important new plans for 
Roles: IHS officials reported that they  success.  This report identifies several 
improving the quality of care 
were often uncertain about their roles  organizational challenges to IHSs 
that it provides in its hospitals.  
and those of other officials, including the  management of its hospitals, and it 
However, if underlying 
authority to act in correcting problems.   offers strategies to overcome them 
organizational challenges are 
Consequences included lack of  for sustainable change. 
not addressed, they may 
accountability and undermining of   
prevent IHS from bringing its 
quality of care.  This absence of clear 
full organizational strength to 
roles was especially problematic with regard to the roles and responsibilities of 
these efforts.  
IHS headquarters (HQ) and Area Offices.     
How OIG Did This Review 
  Lack of a Clear View of Hospital Performance and Problems: We found that IHS 
We based our findings on 
HQ lacked awareness and insight about Area Office activities and hospital 
interviews with IHS officials 
performance.  In addition, IHSs organizational culture did not always encourage 
and other stakeholders, and 
candid communication, with what one official called a culture of niceness that 
our observations of agency 
sometimes impeded useful discussion of problems.   
practices while we were 
  Lack of Confidence in IHSs Ability to Succeed: IHS officials consistently  conducting this and other OIG 
expressed a deep commitment to and passion for the agencys mission and  studies.  Interview topics 
beneficiaries.  However, officials also expressed doubt in the agencys ability to  included challenges to the 
make sustained improvements.      operations of IHS HQ, Area 
Offices, and hospitals, and 
Addressing Organizational Challenges 
suggestions for accelerated 
To address these underlying organizational challenges, IHS should incorporate the   progress.  We did not 
strategies we outline in this report as it implements its new plans to improve operations:   independently verify the 
establish strong agency structures; ensure that leaders have a clear view of problems   substance of the statements 
and champion continuous learning in their work; and leverage the deep commitment   provided to us in interviews.  
of officials and staff to foster a greater confidence in the agency moving forward.  We also reviewed agency 
  documents, including the 
In other evaluations, OIG has recommended specific actions for improving quality in IHS   Strategic Plan that IHS 
hospitals, such as establishing a comprehensive compliance program focused on quality   released in 2019.  We 
of care.  We continue to urge IHS to implement those recommendations.  conducted q ualitative analysis 
to identify challenges to IHS 
Full r eport can be found at oig.hhs.gov/oei/reports/oei-06-16-00390.asp  agency management of its 
hospitals, and to develop 
strategies for improvement.   
TABLE OF CONTENTS 
BACKGROUND                                                                                                                             1 
Methodology                                                                                                                          8 
ORGANIZATIONAL CHALLENGES   
Challenge 1: Lack of Formal Structure, Policies, and Roles  11 
Strategy: Establish and follow formal structures and policies that define roles,   
responsibilities, and accountability 
Challenge 2: Lack of a Clear View of Hospital Performance and Problems  15 
Strategy: Ensure that leaders have a clear and comprehensive view of   
performance and problems, and champion continuous learning 
Challenge 3: Lack of Confidence in IHSs Ability To Succeed  18 
Strategy: Leverage the deep commitment to mission among IHS officials and   
staff, and foster greater confidence in the agencys capacity to make sustained 
improvements 
ADDRESSING ORGANIZATIONAL CHALLENGES   
Incorporate the organizational strategies outlined in this report as it implements its  21 
new plans to improve hospital quality and agency operations 
Take specific actions to improve quality and oversight of IHS hospitals, in line with  22 
OIGs recommendations and with the IHS Strategic Plan and Quality Framework 
APPENDICES   
Appendix A: Previous OIG Recommendations  23 
Appendix B: Interview Participants  24 
ACKNOWLEDGMENTS  26 
  
   
BACKGROUND 
 
Objective: To identify and propose methods to improve Indian Health 
  Service (IHS) management of hospitals.   
 
Indian Health  IHS is responsible for providing Federal health services to American Indians and 
Alaska Natives.  Its mission is to raise the physical, mental, social, and spiritual 
Service 
health of American Indians and Alaska Natives to the highest level.1  The Indian 
Health Care Improvement Act provides the legal authority for IHSs provision of 
health care to its beneficiaries.2  IHS has an annual budget of  
$5.6 billion, and in partnership with the 573 federally recognized tribes, it 
provides free primary and preventive health care services to approximately  
2.6 million beneficiaries living in the United States.3   
Within the Department of Health and Human Services (HHS), IHS is unique in its 
role as a direct provider of health care.  In addition to providing health care 
services directly through IHS-operated facilities, IHS also provides financial 
support for the tribes to operate their own health care systems.4  In fiscal year 
(FY) 2019, about 40 percent of IHSs $2 billion appropriation to provide health 
care services in hospitals and health clinics was allocated to Federal operations 
that serve tribes directly.  The remaining 60 percent was allocated to individual 
tribes or tribal organizations.5   
IHS headquarters (HQ), located in Rockville, Maryland, provides general 
direction, policy development, and support to each of 12 Area Offices and their 
sites for direct delivery of health care.  The IHS Area Offices are responsible for 
overseeing these IHS sites, including 24 acute-care hospitals, 50 health centers, 
 
1 IHS, Justification of Estimates for Appropriations Committees, FY 2020, p. CJ-1.  Accessed at  
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/
FY2020CongressionalJustification.pdf on August 19, 2019.   
2 P.L. No. 94-437, Indian Health Care Improvement Act.  25. U.S.C.  1601.   
3 IHS, Justification of Estimates for Appropriations Committees, FY 2020, pp. CJ-2, CJ-7.  See 
footnote 1 for URL information. 
4 Pursuant to the Indian Self-Determination and Education Assistance Act, P.L. No. 93-638, 
IHS contracts or compacts with tribal organizations to deliver services.  IHS, Quick Look 
(fact sheet).  Original link no longer works and is not archived online.  The current Quick Look fact 
sheet is online at https://www.ihs.gov/newsroom/factsheets/quicklook/. 
5 IHS, Justification of Estimates for Appropriations Committees, FY 2020, pp. CJ-16, CJ-56.  See 
footnote 1 for URL information.  IHS has a $2 billion appropriation for hospitals and health clinics, 
and the agency also supports programs such as dental services.  
Organizational Challenges to Improving Quality of Care in IHS Hospitals  1 
OEI-06-16-00390   
26 health stations, and 2 school health centers.6  IHS hospitals are generally 
small and rural; most have fewer than 30 beds.7   
The Great Plains Area Office is responsible for the oversight of one-fourth of 
IHS-operated hospitals (6 of 24 hospitals).  The Great Plains Area spans four 
States: Iowa, Nebraska, North Dakota, and South Dakota.8  (See Exhibit 1 for 
locations of the 24 IHS hospitals.) 
IHS maintains its policies, procedures, and operating standards in the Indian 
Health Manual (IHM).  IHS policy states that the IHM is the preferred reference 
for IHS staff regarding agency-specific policy and procedural information.9  The 
IHM dictates that Area Offices manage oversight of IHS hospitals.10  Area Offices 
oversee the delivery of health services and provide administrative and technical 
support to IHS facilities, including monitoring hospitals through a Governing 
Board process that requires hospitals to (1) report quality data and other 
performance and management data and (2) hold semiannual meetings of 
hospital and Area Office officials.   
Exhibit 1: Locations of the 24 IHS-Operated Hospitals, 2019 
 
 
6 IHS, Justification of Estimates for Appropriations Committees, FY 2020, pp. CJ-54, CJ-57.  Accessed 
online on April 8, 2019.  See footnote 1 for URL information. 
7 IHS, Fiscal Year 2017 Hospital Inpatient Statistics for IHS and Tribal Sites With Prior Fiscal Year 
Comparisons (FY 2016), July 13, 2018. 
8 IHS, Great Plains Area.  Accessed at https://www.ihs.gov/greatplains/ on August 19, 2019.  The 
number of hospitals that IHS operates in the Great Plains Area decreased from 7 to 6 hospitals 
after the Winnebago Tribe assumed operations of Winnebago Hospital in July 2018.  
9 IHS, IHM, pt. 1, ch. 4, Appendix 1-4-A. 
10 Ibid. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  2 
OEI-06-16-00390   
Longstanding Problems at IHS Hospitals 
Reports of health disparities and inadequate health care services for IHS 
beneficiaries have been a subject of concern for nearly a century.11  In recent 
years, much attention has focused on inadequacies at IHS hospitals in the Great 
Plains Area.  In February 2016, the Senate Committee on Indian Affairs held 
a hearing on the substandard quality of care in IHS hospitals in the Great Plains 
Area.  Testimony from the Centers for Medicare & Medicaid Services (CMS) and 
tribal representatives described quality-of-care concerns about several hospitals 
in the Area, including noncompliance with the Medicare Conditions of 
Participation and the requirements of the Emergency Medical Treatment and 
Labor Act.  Findings of noncompliance included deficiencies in critical 
capabilities such as maintaining staffing and equipment.  Subsequent hearings 
in 2017 and 2018 raised similar concerns about IHS hospitals, with testimony 
covering the following issues: problems with access to care, hospital closures, 
and difficultyparticularly in the Great Plains Areamaintaining staffing.12   
During this timeframe, IHS hospitals in the Great Plains Area continued to 
struggle with compliance.  CMS terminated one Great Plains hospital from the 
Medicare program in 2015 and another in 2017.  To avoid termination, another 
hospital completed a Systems Improvement Agreement (SIA)a corrective 
action contract that CMS may undertake with hospitals facing termination.13  
A fourth Great Plains hospital, which was at risk for termination, voluntarily 
stopped accepting inpatient admissions.14  Additionally, between 2014 and 2016, 
IHS temporarily closed the emergency departments at four hospitals, forcing 
patients to seek treatment elsewhere.15  Among these four hospitals were 
the hospital that completed the Systems Improvement Agreement and the 
hospital that stopped accepting inpatient admissions. 
 
11 The Institute for Government Research, The Problem of Indian Administration, February 21, 1928, 
ch. 1.  Accessed at http://www.alaskool.org/native_ed/research_reports/IndianAdmin/ 
Indian_Admin_Problms.html on January 14, 2019.  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 August 19, 2019. 
12 Committee on Indian Affairs, Oversight Hearing on the President's FY 2019 Budget Request for 
Indian Programs, Senate, 115th Congress (2018), April 11, 2018.  Accessed at  
https://www.indian.senate.gov/hearing/oversight-hearing-presidents-fy2019-budget-request-
indian-programs-0 on August 19, 2019. 
13 CMS terminated Pine Ridge Hospital and Winnebago Hospital; Rosebud Hospital completed 
a Systems Improvement Agreement; and Sioux San Hospital stopped inpatient admissions. 
14 IHS, Indian Health Service Report on Proposed Closure of the Sioux San Hospital Emergency and 
Inpatient Departments, July 2017.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/ReportT
oCongress_SiouxSanHospital_07282017.pdf on August 19, 2019. 
15 IHS temporarily closed the Acoma-Canoncito-Laguna Hospital emergency department on 
multiple occasions during a 5-month period in 2014; closed the Crownpoint Hospital emergency 
department for 2 months in 2015; and closed the Rosebud Hospital emergency department for 
7 months in 2015-2016.  The Sioux San Hospital emergency department has remained closed 
since September 2016.     
Organizational Challenges to Improving Quality of Care in IHS Hospitals  3 
OEI-06-16-00390   
Recent IHS Efforts To Improve Quality of Care in IHS Hospitals  
IHS has developed plans in recent years to improve hospital management and 
performance (see Exhibit 2), in particular creating a new office and program for 
improving quality and establishing a long-term strategic plan.   
Exhibit 2: Selected IHS Initiatives To Improve IHS Hospital Quality and Management Under IHS 
Quality Framework and Other  Initiatives, 20162019  
Initiative  Year  Actions 
    - Implemented telehealth consultation in some Areas 
Launched the  Quality Framework   2016  
    - Developed Accountability Dashboard for Quality 
Enhanced recruitment and retention policies  - Priority access to Commissioned Corps applicants    
2017  
and procedures   - Increased scholarship and loan repayment incentives   
- Awarded  system-wide accreditation  contract to  The  Joint  
Awarded  system-wide accreditation contract   2017  
 Commission for accreditation of all IHS hospitals  
- Purchased software  and hired contractor to  operate  new  
Revised  provider credentialing system   2018  
 credentialing system for enhanced  screening at hire  
- Established position for Deputy Director of  Quality  
Established Office of Quality     2019  
- Announced improvements to the quality  dashboard  
- Set goals  to improve access, quality, and management  
Released Strategic Plan, FY  20192023   2019  
- Revised  priorities and organizational structure 
Sources: IHS, The Principal Deputy Director writes to Tribal Leaders and Urban Indian Organization Leaders to provide the final 20162017 Quality 
Framework and Implementation Plan, November 16, 2016; IHS,  National Quality Accountability Dashboard Fact Sheet, February 2018; IHS,  
IHS Strategic Plan FY 20182022, July 2018; IHS, January 7, 2018; and IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2019, 
p. CJ-74,  December 2018.    
Quality Framework.  In November 2016, IHS began to develop the IHS Quality 
Framework.16  In December 2018, IHS announced the final provisions of the 
Quality Framework, including establishingeffective January 2019a new 
Office of Quality that would be responsible for the agencys quality- and safety-
related work, to be led by the Deputy Director of Quality Health Care.17  IHS said 
that it intends to establishunder this structurea Chief Quality Officer in each 
Area Office and a Quality Assurance and Performance Improvement Officer in 
each hospital.18    
 
16 IHS, Quality at IHS.  Accessed at https://www.ihs.gov/quality/  on August 19, 2019. 
17 IHS, Press Release, Indian Health Service Announces Office of  Quality, December 21, 2018.  
Accessed online on January 16, 2019.  Original  link no longer works; for an archived version, see 
https://web.archive.org/web/20190614222230/https://www.ihs.gov/newsroom/includes/themes/re
sponsive2017/display_objects/documents/PressRelease-
IndianHealthServiceAnnouncesNewOfficeofQuality_122118.pdf. 
18 IHS, Indian Health Service Quality Framework 20162017, October 2016.  Accessed online on 
January 26, 2019.  Original link  no longer works; see archived version at 
https://web.archive.org/web/20190614211420/https://www.ihs.gov/newsroom/includes/themes/ne
wihstheme/display_objects/documents/IHS_2016-2017_QualityFramework.PDF. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  4  
OEI-06-16-00390    
The Quality Framework seeks to centralize several IHS functions related to 
quality of care, such as physician credentialing, patient surveys, standards for 
wait times, and quality metrics.  Additionally, IHS has implemented new 
recruitment and retention strategies and developed a leadership training 
program for hospitals.19  Future plans include standardizing quality metrics, 
conducting mock accreditation surveys, and creating a new protocol for patient 
safety reporting.20  Additionally, the Quality Framework includes a plan to 
establish within the Office of Quality a new liaison position that will 
communicate directly with HHS OIG and the Government Accountability Office 
(GAO) to prioritize recommendations and corrective actions.21 
The IHS Office of Quality is divided into four divisions:22 
1.  Quality Assurance: Manages programs to promote compliance with Federal 
regulations, accreditation, and professional standards.  
2.  Innovation and Improvement: Manages quality improvement efforts 
throughout IHS, including measuring progress. 
3.  Patient Safety and Clinical Risk Management: Manages programs to 
promote patient safety and to identify risks to patient safety in hospitals. 
4.  Enterprise Risk Management: Manages progress of agency strategic 
planning and internal controls across IHS direct delivery of health care. 
Strategic Plan.  In February 2019, IHS released its IHS Strategic Plan FY 201923 
(Strategic Plan), the first such document since its last strategic plan ended in 
2011.23  The plan outlines three IHS-wide goals related to IHS hospitals and 
other IHS programs:  
1.  Access: To ensure that comprehensive, culturally appropriate personal and 
public health services are available and accessible to IHS beneficiaries. 
2.  Quality: To promote excellence and quality through innovation of IHS into 
an optimally performing organization. 
3.  Management: To strengthen IHS program management and operations. 
 
19 RADM Chris Buchanan, IHS Deputy Director, testimony before the U.S. House of 
Representatives Committee on Natural Resources, Subcommittee on Indian, Insular, and Alaska 
Native Affairs, June 21, 2017.  Accessed online on January 26, 2019.  Original link no longer works; 
see archived version at https://web.archive.org/web/20190614151309/https://www.ihs.gov/ 
newsroom/includes/themes/responsive2017/display_objects/documents/testimony/115/115th-
June-21-2017.pdf. 
20 IHS, Organization, Functions, and Delegations of Authority; Part G; Indian Health Service, 
83 Fed. Reg. 66284 (Dec. 26, 2018).  Accessed at https://www.federalregister.gov/documents/ 
2018/12/26/2018-27793/organization-functions-and-delegations-of-authority-part-g-indian-
health-service on August 19, 2019. 
21 Ibid. 
22 Ibid. 
23 IHS, Indian Health Service Strategic Plan FY 201923, February 27, 2019.  Accessed at 
https://www.ihs.gov/strategicplan/ihs-strategic-plan-fy-2019-2023/ on August 19, 2019. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  5 
OEI-06-16-00390   
The Strategic Plan references IHS hospitals specifically in a number of its 
provisions, including goals for compliance with the Medicare Conditions of 
Participation and plans to address longstanding issues with hospital and Area 
Office staffing.24   
OIG Work  OIG has long reported on IHS management of its hospitals and other agency 
operations.  Between 2001 and 2011, OIG released 26 audits and evaluations in 
Regarding 
three broad categories: financial management, quality of care, and program 
IHS Hospitals 
management.25  This work included IHS hospital operations as well as other 
agency functions.  Specific to hospitals, OIG found problems with IHS 
credentialing practices, facility management, and access to services.26  Since 
2016, OIG has focused largely on IHS management of hospitals, making multiple 
recommendations to IHS to improve operations and quality of care.  (See 
Appendix A for a list of outstanding OIG recommendations related to IHS 
hospital management.) 
IHS Hospital Challenges and Monitoring 
In 2016, OIG released two reports describing challenges faced by IHS hospitals 
and IHS monitoring of hospital quality and performance.27  OIG found that 
longstanding challenges affected IHS hospitals ability to provide quality care 
and comply with the Medicare requirementsspecifically, the requirements 
regarding ensuring access to needed care; maintaining clinical competence; 
recruiting and retaining essential staff; and keeping patients safe.  We also 
found that IHS was limited in its ability to provide rigorous quality oversight of 
hospitals, with few sources of information about hospital performance; had 
limited capacity to provide clinical support; and had insufficient procedures and 
infrastructure to maintain quality assurance and monitoring.   
We concluded that given the duration and extent of IHSs problems, the agency 
was unlikely to overcome its management challenges without broad support 
from experts within and outside HHS, and without consideration of different 
models for providing services.  We made recommendations to IHS and the HHS 
Office of the Secretary for them to identify and implement innovative strategies 
to mitigate IHSs longstanding challenges, and to develop an IHS-wide strategic 
plan and a quality-focused compliance program.   
 
 
24 Ibid. 
25 OIG, White Paper: Summary of OIG IHS Activities, October 5, 2011.  Accessed at 
https://oig.hhs.gov/newsroom/spotlight/2011/ihs-whitepaper.pdf on August 19, 2019. 
26 Ibid. 
27 OIG, Indian Health Service Hospitals: More Monitoring Needed to Ensure Quality Care 
(OEI-06-14-00010), October 2016, and Longstanding Challenges Warrant Focused Attention 
To Support Quality Care (OEI-06-14-00011), October 2016. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  6 
OEI-06-16-00390   
Case Study of IHS Management of the Closure and Reopening of the 
Rosebud Hospital Emergency Department 
In July 2019, OIG issued a case study examining IHS management of the  
7-month closure and subsequent reopening of the emergency department of 
Rosebud Hospital in the Great Plains Area.28  The case study provides 
a chronology of events and identifies the following: factors that led to the 
closure; improvement efforts to reopen the emergency department; and 
continued lapses in compliance.  We recommended that to correct underlying 
problems and prevent closures, IHSas a management prioritydevelop and 
implement a staffing program for recruiting, retaining, and training staff in 
remote hospitals.  We also recommended that IHS continue taking steps to 
ensure that it intervenes early when problems emerge at hospitals, and 
develops procedures for temporary closures of emergency departments.   
Adverse Events in IHS Hospitals 
OIG is in the process of determining the incidence of patient harm in IHS 
hospitals, using a panel of patient safety experts to conduct a medical record 
review of IHS hospitalizations.29  This work is one in a series of OIG studies 
identifying adverse events in different health care settings nationwide, including 
acute-care hospitals, skilled nursing facilities, rehabilitation hospitals, and long-
term care hospitals.  The resulting report will include incidence rates for patient 
harm events for a sample of IHS beneficiaries admitted to IHS hospitals, as well 
as a medical assessment of the preventability of the events and factors that 
contributed to the events.  An additional report will use cases from the patient 
harm study to examine whether care specific to maternal health; infant health; 
and labor and delivery at IHS hospitals met standards for quality. 
Patient Abuse in IHS Hospitals 
Following the conviction of an IHS pediatrician for sexual abuse, OIG is 
reviewing the sufficiency and implementation of IHSs current policies and 
procedures for preventing, reporting, and addressing patient abuse.  This work 
is also responsive to requests from the HHS Deputy Secretary and Congress.  
OIG Quality and Compliance Training 
OIG has also provided compliance training to support IHS and tribal officials in 
improving quality and management.  In 20172018, OIG hosted two compliance 
training conferences for tribal officials in South Dakota and Oklahoma.  These 
conferences gathered hundreds of representatives from OIG, CMS, IHS, and 
tribal organizations.  Conference sessions covered a variety of topics, including 
 
28 OIG, Case Study: Indian Health Service Management of Rosebud Emergency Department Closure 
and Reopening, OEI-06-17-00270, July 2019.     
29 OIG, Indian Health Service Hospitals: Incidence of Adverse Events, OEI-06-17-00450, report 
forthcoming. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  7 
OEI-06-16-00390   
guidance for complying with HHS program provisions and efforts to improve 
the quality of health care.  OIG is continuing these efforts in 2019 and 2020. 
Methodology  This study describes underlying organizational challenges that IHS faces as it 
seeks to improve hospital quality, including through implementation of its 
Quality Framework and its Strategic Plan.  We identified these issues primarily 
during interviews and other discussions with IHS officials and stakeholders in 
20162019.  Where possible, we supplemented this information with 
documentation from IHS, reports by other organizations such as GAO, 
congressional testimony, and previous and ongoing research by OIG regarding 
IHS policies and practices, and hospital quality of care.  Our data collection and 
analysis for this evaluation focused on IHS HQ and Area Office management of 
hospitals collectively, rather than facility-level management of specific hospitals.  
Interviews with IHS Officials and Other Stakeholders 
We conducted 16 in-depth, semistructured interviews with officials at IHS HQ 
and Area Offices.  We selected interview respondents on the basis of their 
agency responsibilities related to IHS hospitals and familiarity with hospital 
operations, particularly in the Great Plains Area.   
Interview topics included roles and responsibilities of IHS HQ management with 
respect to health care service and delivery; management challenges to 
improving IHS hospital care; and clinical standards at IHS facilities.  For example, 
we asked officials what would most improve their daily work and facilitate 
improvement.   
From 2017 to early 2019, we interviewed and consulted with IHS officials as part 
of two other OIG studies focused on the closure and reopening of the 
Rosebud Hospital emergency department, and on adverse events in IHS 
hospitals.  These meetings included discussion of the underlying organizational 
issues that this report describes.  Among the officials with whom we met were 
the individual who was serving as Acting Director and Principal Deputy Director, 
and the individual serving as Chief Medical Officer.  (IHS has not had a Director 
since 2015.  With the change in Administration in 2017, a new individual was 
named as Acting Director; this official then became the Principal Deputy 
Director in 2018.)  In addition to drawing on our notes from these interviews 
and discussions, we used our observations based on years of interaction with 
IHS officials and evaluations of IHS programs.   
We also met in December 2016 with officials from CMS and other members of 
the HHS Executive Council on Quality Care, formed by the then-Acting Deputy 
Secretary of HHS.  We interviewed representatives from 11 HHS agencies who 
served on this council.  (See Appendix B for a list of IHS officials we interviewed 
and HHS agencies that were represented in the meeting.)   
We did not independently verify the substance of the statements provided to us 
in these interviews.   
Organizational Challenges to Improving Quality of Care in IHS Hospitals  8 
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Document Reviews 
We reviewed supporting documents such as the IHS Quality Framework and 
organizational charts, and we added information that we had gleaned from our 
contact with IHS officials during other OIG studies.  In addition to reviewing 
information that we received directly from IHS and HHS, we also reviewed other 
reportssuch as congressional testimony and GAO reportsregarding 
IHS management and related issues.30   
These sources included a 2017 report by the Council of the Inspectors General 
on Integrity and Efficiency (CIGIE) that outlined management deficiencies that 
Inspectors General from multiple U.S. Government departments had found in 
programs serving American Indians and Alaska Natives.31  These deficiencies 
included failures to segregate staff responsibilities, maintain recordkeeping, and 
update infrastructure.  Lastly, we followed updates from across government 
regarding IHS hospital funding and areas that the Administrations 2020 budget 
raised as particular concerns, such as providing general health services, 
combating opioid abuse, and managing chronic diseases.32 
Analysis and Presentation 
We conducted qualitative analysis of interview and discussion notes, agency 
documents, and our own observations to identify underlying organizational 
challenges in how IHS manages its hospitals.  This analysis included comparing 
IHS operations to OIG-identified effective management practices in three areas: 
policy, leadership, and organizational culture.  Within each area, we provide 
examples to illustrate specific points.   
We also used quotations from IHS officials to provide insight and further 
illustrate our findings.  Most quotations come from the 2016 interviews, with 
additional information from later discussions and documents as noted.  
We identified the organizational challenges by analyzing IHS officials responses  
to our questions regarding IHSs hospital management, and considered updates 
provided by IHS to acknowledge recent efforts such as the Strategic Plan and 
Quality Framework.          
   
 
30 GAO, Indian Health Service: Actions Needed to Improve Oversight of Quality of Care, 
January 2017.  Accessed at https://www.gao.gov/assets/690/681951.pdf on August 19, 2019. 
31 CIGIE, Vulnerabilities and Resulting Breakdowns: A Review of Audits, Evaluations, and 
Investigations Focused on Services and Funding for American Indians and Alaska Natives, 
December 2017.  Accessed at https://www.ignet.gov/sites/default/files/files/ 
CIGIE_AIAN_Vulnerabilities_Report.pdf on August 19. 2019. 
32 IHS, Justification of Estimates for Appropriations Committees, FY 2020, p. CJ-2.  See footnote 1 
for URL information.   
Organizational Challenges to Improving Quality of Care in IHS Hospitals  9 
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Limitations 
OIG did not independently verify the information that we received from our 
interviews with IHS and HHS officials or from supplemental sources, beyond 
reviewing supporting documentation where available. 
Standards  We conducted this study in accordance with the Quality Standards for Inspection 
and Evaluation issued by the Council of the Inspectors General on Integrity and 
Efficiency.   
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ORGANIZATIONAL CHALLENGES and STRATEGIES 
IHS has had longstanding problems managing its hospitals and ensuring that 
they consistently provide high-quality care.  It has developed new plans for 
improving hospital operations and quality, which are promising.  However, to 
make meaningful and lasting improvements, IHS needs to overcome underlying 
organizational problems that have hampered its success.  From our interviews 
with IHS officials and our studies of the agency, we identified three 
organizational challenges that have impeded IHS's management and quality 
improvement efforts in recent years.  We encourage IHS to incorporate the 
following strategies to address these issues and bring its full organizational 
strength to plans for improving care. 
 
STRATEGY:   Challenge 1: Lack of Formal Structure, Policies, and Roles 
Establish and follow 
IHS needs to develop and support a clear agency structure and policies that 
formal structures and  outline roles and responsibilities, and to endeavor to maintain and enforce that 
policies that define  structure.  For this structure to be effective, it must meet the agencys needs 
and objectives; be practical and useful in directing daily work; be actionable by 
roles, responsibilities, 
officials and staff; and be supported by the expectation for adherence and 
and accountability 
accountability.    
IHS officials reported that they were often uncertain about their specific roles 
and responsibilities in relation to those of other officials, including the 
authority to act in correcting problems.  The most common issue that officials 
reported as negatively affecting their work was the lack of a solid organizational 
structure regarding management of IHS hospitals, including policies that would 
direct the work of IHS HQ, Area Offices, and hospitals, and distinguish their 
respective responsibilities.  Officials reported that the lack of structure could 
lead to frequent changes in policy as leadership changed.  In some cases, 
policies lacked detail and were not specific or prescriptive in mandating 
particular actions.  For example, the IHM does not delineate the actions that IHS 
HQ should take when it receives reports of problems from Area Office or 
hospital staff.  In other cases, IHS officials said that roles were described in 
agency documents but officials did not fully understand them, or officials 
assumed roles that may not be well-suited to their skills and abilities.  
Organizational Challenges to Improving Quality of Care in IHS Hospitals  11 
OEI-06-16-00390   
Repercussions of IHS's lack of clear and accountable roles, responsibilities, 
and policies included inefficiency, poor coordination, and lack of 
accountability.  Officials reported that in the absence of a solid structure, they 
were sometimes compelled to take action on their own, rather than in 
coordination.  This lack of coordination led to inefficienciesmultiple groups of 
officials and staff might be working on the same issue, but without a clear 
strategy or indication of which actions had been fruitful, how decisions would 
be made, or how to direct Area Offices and hospitals to take action.   
The lack of structure also resulted in actions getting mired in processes and 
taking longer to resolve.  Officials reported that in their confusion about who 
was responsible for various functions, they sometimes sought review and 
approval from multiple officials or groups which increased the bureaucratic 
hoops.  Another result of this confusion was that some divisions influenced 
decisions outside of their organizational scope.  One official pointed to an IHS 
organizational chart and said, That diagram does not describe how things 
work.  We build our own processes as we go, and hope that we are making 
progress.  Several officials described IHS management as a siloed structure 
wherein groups were working hard, but without a clear view of their objective or 
how their actions might achieve results.  Officials also noted that this separation 
of efforts led to effects downstream in the workplace; individuals selected 
camps to follow and competed to get others to support their proposed 
course of action.    
This lack of structure also resulted in an overreliance on the actions of a few 
strong leaders.  Several officials noted that what had held the agency together 
over the years was the leadership of a small number of impassioned individuals, 
rather than a strong set of agency policies that could be employed no matter 
who the specific leaders were.  For example, one official noted that in meetings, 
staff often quoted the statements of current or former leaders rather than 
referring to agency policies.   
Officials also reported that even when policies were in place, the policies were 
not always followed or fully enforced, including policies for critical functions 
such as hiring and contracting.  They said it was routine across IHS HQ to 
operate outside of stated policies and procedures, including for individuals to 
operate outside of their own position descriptions.  Consequently, when 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  12 
OEI-06-16-00390   
problems arose, it could be difficult to determine which official or group was 
responsible for taking corrective action.    
The absence of clear roles and accountability seemed particularly problematic 
with regard to the division of responsibilities between IHS HQ and Area 
Offices.  Perhaps most problematic in the agency structure is the lack of clarity 
and accountability in the relationship between IHS HQ and Area Offices.  
Although IHS policies state that Area Offices should oversee hospital 
operations, they lack specificity as to how Area Offices should execute that 
oversight and how IHS HQ should monitor Area Offices oversight.  Officials 
reported that Area Offices receive a great deal of discretion and flexibility in 
managing hospitals and providing assistance to them, but the result of this 
flexibility may be gaps in oversight and assistance.   
Further, some IHS officials reported that they oppose HQ oversight of Area 
Offices because the monitoring can bring with it added layers for approval and 
a greater bureaucracy that could hamper action.  These officials argued that the 
Area Offices and their related communities vary so substantially that IHS HQ 
could not effectively develop national practices that would serve all Areas.  They 
also believed that it was more important for IHS HQ to provide service and 
support to Area Offices than to provide oversightin essence, for HQ to put 
Area Offices on a more equal footing with agency leadership.  As one official 
explained, They prefer that we all be collegial, that we work side by side.  They 
dread the rumor mill saying HQ is taking over the Areas.  That would be 
a sledgehammer, and not perceived as a positive development from either 
group.   
OIG has recommended that IHS HQ impose greater accountability on, and 
greater uniformity among, Area Offices.  Specifically, OIG recommended that 
IHS establish standards and expectations for how Area Offices oversee 
hospitals, and that IHS monitor how Area Offices adhere to those standards.  
OIG based this recommendation on our findings that IHS may be missing 
opportunities to identify and remediate quality problems in its hospitals 
because IHS performed limited oversight regarding quality of care and 
compliance with the Medicare Conditions of Participation.  Area Office staff told 
OIG that they have few sources of information available regarding hospital 
quality; that staffing shortages in Area Offices limit the clinical support and 
guidance that they are able to provide; and that the most promising efforts to 
improve hospital quality lack dedicated funding.   
Organizational Challenges to Improving Quality of Care in IHS Hospitals  13 
OEI-06-16-00390   
Formal structures with clear roles and responsibilities could help mitigate the 
challenges posed by frequent changes in IHS leadership and personnel.  
During OIGs reviews of IHS hospital operations from 2013 to 2019, many 
leadership positions at IHS were vacant or occupied by officials who were in 
a temporary acting capacity.  These were often the top positions in the 
agencythe positions of Director, Deputy Director, Chief of Staff, and Chief 
Medical Officer.  Individuals who IHS assigned to serve in an acting capacity 
often held other positions in the agencyin some cases, requiring officials 
to serve in more than one capacity at the same time.   
Leaders also changed frequently in some Area Offices and hospitals, and 
sometimes officials from IHS HQ and other Area Offices had to fill those roles 
and divide their attention between their prior position and another in the field.  
IHS also filled positions temporarily with officials from other HHS agencies, such 
as the Healthcare Research and Services Administration (HRSA) and CMS.   
More clearly defining roles and responsibilities would help reduce the 
disruption and additional work associated with personnel changes.  It could also 
help new and acting officials better fulfill their responsibilities for performance 
oversight and accountability, which some reported to be a challenge.  For 
example, temporary leaders are sometimes unsure about their ability to institute 
policies.  As one official noted, individuals in acting positions can lack 
accountabilityand fail to enforce accountability in othersbecause their 
newness to the position and temporary status can make it difficult for them to 
understand and monitor job requirements and performance. 
   
   
Organizational Challenges to Improving Quality of Care in IHS Hospitals  14 
OEI-06-16-00390   
STRATEGY:   Challenge 2: Lack of a Clear View of Hospital Performance  
Ensure that leaders  and Problems   
have a clear and 
IHS leadership must encourage open communication about agency 
comprehensive view  performance and uncovering problems as they arise.  IHS officials need to do 
of performance and  the following: know fully and understand the agencys functions; gain 
a comprehensive view of organizational progress; candidly evaluate the efficacy 
problems, and 
of the agencys work; and establish an environment of continuous learning
champion continuous 
an environment that encourages identifying problems and monitoring results 
learning 
on an ongoing basis, and adapting methods as needed for improvement. 
IHS HQ has lacked needed awareness and insight into Area Office and 
hospital performance.  The lack of clear oversight responsibilities and Area 
Office accountability discussed above has frequently left IHS HQ without 
awareness of and insight into Area Office activities and hospital operations and 
performance.  As one HQ official said, It is difficult to even get a status check.  
The Areas sometimes act like it is voluntary to report.  Other HQ officials said 
that even if they preferred to exert greater oversight, they lacked the 
knowledge, insight, and tools to conduct such oversight.  Some officials stated 
that IHS HQ lacked understanding of Area operations, including accurate and 
up-to-date information about resources and policies.  One official reported, 
I couldnt tell you where to find data about AO [Area Office] staffing and facility 
numbers.  Officials also reported that they often received poor or incomplete 
information about operations, and that they did not feel that anyone in IHS HQ 
had a comprehensive view of Area Offices and hospitals. 
Our case study of the performance problems that led to the closure of the 
Rosebud hospital emergency department also raised concerns about lack of 
IHS HQ and Area Office insight into hospital problems.  Hospital staff reported 
poor relationships between the Great Plains Area Office and Rosebud Hospital, 
as well as communication breakdowns across IHS, which limited support to 
identify and correct problems.  This in turn resulted in a lack of knowledge 
within IHS regarding whether the agency was making progress, and a slowed 
sense of urgency.  We recommended that IHS ensure that its policies outline 
the necessary steps for closer monitoring and quicker intervention by Area 
Office and HQ leadership, given that these measures could avoid a potential 
crisis and ensure that IHS addresses in a timely and consistent manner any 
problems that may arise at its hospitals.   
   
Organizational Challenges to Improving Quality of Care in IHS Hospitals  15 
OEI-06-16-00390   
IHSs organizational culture has not always encouraged candid discussion of 
problems among HQ officials, or with Area Offices and hospitals.  In 
describing the agencys organizational culture, several officials cited the 
tendency to avoid conflict and frank discussion and feedback, and explained 
that problem-solving efforts can be superficial and sometimes do not squarely 
target the issues.  As one official said, Given the depth of some of the 
challenges, they may be difficult to truly overcome.  The first thing we must do 
is live in reality and hit where we are head-on.  Further, officials indicated that 
meetings often covered administrative topics rather than substantive ones.  One 
official complained that meetings often had too high-level of a focus; did not 
include practical discussions about operations and problems; and did not 
engage the IHS officials and staff most affected.   
IHSs history of problems, and the problems effects on morale, may also 
contribute to a feeling of being embattled that discourages candor about 
ongoing issues.  Recent headlines about poor performance in a relative few IHS 
hospitals may have contributed to feelings of pessimism IHS-wide.  Several 
officials said that it was unfair to the Area Offices and hospitals that were 
operating successfully that the media emphasis and the agencys image was 
forever wrapped around a few problem facilities.  They also stated that the 
problems and resulting poor image have caused a lack of trust among IHS 
beneficiaries and other stakeholders, which has left officials feeling constantly 
behind no matter how thoughtful their new plans.  
Frequent changes in leadership may also hinder open and candid 
communication.  Several officials reported that the frequent changes in 
leadership resulted in what one official called a culture of niceness that 
sometimes impeded useful discussion.  This occurred when individuals, 
particularly those who were new in their positions of authority, were unwilling to 
critique current practices and longtime officials, and chose collegiality over frank 
discussion of issues and concerns.  Officials said that as a result of agency 
employees desire not to offend each other, there was sometimes little focus on 
evaluating the efficacy of strategies; on viewing the organization and its actions 
comprehensively; or on making changes when warranted. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  16 
OEI-06-16-00390   
This lack of frank discussion about problems regarding quality of care and 
performance may have also created a cultural norm of avoiding negative 
reports of any sort, including allegations of serious misconduct.  In the instance 
of the IHS pediatrician who was convicted in 2018 for child sexual abuse, a few 
IHS staff had voiced serious suspicions about this pediatrician, but their 
concerns had gone unaddressed for years.33   
We feel we are all in this together, which is a good thing, but 
not when it means that we all hunker down to avoid reality.  We 
want to support each other, but that can lead to... hiding the 
facts.  We are a family, but we are also a business.  IHS Official
Cultivating continuous learning would support IHS in achieving sustained 
improvements.  In discussions with OIG in the course of our work, IHS 
leadership have expressed interest in building an environment of continuous 
learningi.e., making efforts to promote more open communication about 
problems and adapt methods in response.  IHS officials said that they openly 
encourage HQ and Area Office officials and staff to voice concerns, and have 
attempted to respond to problems more quickly.  IHS is in the process of 
establishing a new Quality Assurance and Risk Management Committee 
to convene and review allegations of patient abuse and other allegations or 
issues that affect patient safety or quality of care, and to determine appropriate 
responses.  This committee will consist of IHS senior officials, including the new 
Quality Director. 
This approach is promising, but some officials noted that prior IHS plans to 
improve operations were not fully executed.  As IHS further puts its new plans in 
operation, it should ensure that the policies are fully implemented in practice.  
Several officials said there may be a tendency by some in IHS to revert to prior 
policies and practices even when new ones are put into place.  They explained 
that officials who have been in positions at IHS for a long time, though small in 
number, could exhibit strong predispositions toward certain policies and 
practices, and may not be open to other viewpoints or new information.  As one 
IHS HQ official said, People stop listening.  The old school culture can be very 
strong.  This commitment to prior practices can lead some officials to take 
actions that may not be based on solid information and strategy.   
 
33 As this report mentioned previously, OIG is conducting additional work that examines the 
sufficiency and implementation of IHSs policies and procedures for preventing, reporting, and 
addressing patient abuse. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  17 
OEI-06-16-00390   
Promoting continuous learning as a management strategy would mean that IHS 
would encourage open communication, new information, and creative 
solutions, and that the organization would change course to address specific 
problems as needed.  This flexibility to learn and change does not eliminate the 
need for a solid organizational structure; that structure would allow IHS to 
incorporate new information and pivot more effectively by making clear the 
basics (policies, roles, responsibilities, and authority).  An environment of 
continuous learning is especially important when there is a great deal of 
complexity and variability to the enterprise, as with IHSs direct provision of 
health care.  
 
 
STRATEGY:   Challenge 3: Lack of Confidence in IHSs Ability To Succeed 
Leverage the deep 
IHS has the opportunity to use its strong commitment and important mission to 
commitment to  gain momentum toward improved practices.  Although IHS has a long history of 
mission among IHS  difficult problems, commitment to the mission remains strong and should serve 
as a foundation to bolster agency improvement and future success.   
officials and staff,  
and foster greater  IHS officials expressed deep commitment to and passion for the agencys 
mission and beneficiaries.  In interviews, all officials reported that despite the 
confidence in the 
challenges, they remained dedicated and committed to the mission of serving 
agencys capacity  
IHS beneficiaries.  As one official said, There are a lot of problems, but it is also 
to make sustained 
an agency full of people who really care about the program and who are 
improvements 
dedicated to making positive changes.   
This passion for the mission was notable to officials from other agencies, such 
as HRSA, who had been brought to IHS temporarily to fill vacant positions with 
experienced Federal staff.  Those we interviewed seemed surprised and 
sometimes overwhelmed by the difficulty of IHSs work, and praised long-time 
IHS staff for their dedication in spite of the many challenges.  An official detailed 
to IHS from another HHS agency said, If you ask people why they work at IHS, 
they will have a story for you.  It is usually a passion.  No one will say that they 
just needed a job.  A longtime IHS official agreed and said, Our mission is 
fantastic.  Even when things are lousy, even when things are rough, I will 
continue to give my best effort because I love our mission.   
 
 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  18 
OEI-06-16-00390   
To motivate and sustain improvements, IHS needs to inspire greater 
confidence in the agencys capacity to overcome longstanding challenges.   
Alongside the strong dedication to the organizations mission, officials often 
expressed discouragement about IHSs ability to carry out its mission and to 
make sustained improvements.  Many officials spoke enthusiastically about the 
communities they serve and their aspirations for improving outcomes, but they 
were far less enthusiastic about IHSs efficacy as an organization, citing 
protracted bureaucratic processes; lack of a clear vision for how to meet goals; 
lack of trust within IHS; and lack of trust between IHS and the broader 
beneficiary community.     
IHS leaders expressed optimism about the new Quality Framework and 
Strategic Plan, but some of them cautioned that much of the plans are still 
unfolding and it is unclear how they will differ from past efforts.  One official 
said that the long-term nature of the problems seemed to make them build on 
each other, and their combined effect made solutions more difficult.  Another 
official described the same phenomenon, calling it a malaise over agency 
operations, and attributing it to the sense that current and future actions may 
not result in meaningful change.  One long-time official said that action is 
difficult even after establishing plans: Sometimes I feel that we get ideas, but 
no real action.  Maybe action is not rewarded.  Maybe we are afraid.  But I can 
tell you for sure that we get paralyzed. 
Part of this paralysis appears to come from a perception that change is not fully 
possible.  Several officials said they believed that IHS and its hospitals had more 
difficult problems than other, non-IHS hospitals, and that as a result, the 
solutions developed by other systems would not work in IHS.  For example, 
officials expressed doubt that IHS efforts in the Great Plains Area and other 
heavily rural areas would ever be successful given the challenges of maintaining 
staff and competency with such low hospital occupancy.  One official said, We 
need to stop trying to do the things we shouldnt be doing, especially with 
workforce challenges.  A daily census of 0 or 1 [patients]?  How is that ever 
going to work?  However, others countered this sentiment, expressing 
frustration that IHS officials and staff were sometimes reluctant to learn from 
and adopt quality improvements that had proven to be successful in other 
health care systems.   
Organizational Challenges to Improving Quality of Care in IHS Hospitals  19 
OEI-06-16-00390   
Several officials said that IHS officials and staff have over the years thought of 
IHS as being uniquely burdened, which one official referred to as underdog 
status.  These officials described this sentiment as an aspect of IHS 
organizational culture that had become a barrier to success; the sense of futility 
hampered change.  Officials said that some in the agency have grown 
accustomed to having problems and feeling embattled, and might not be able 
to envision sustained success because they had never experienced stable, 
even-keeled operations.  Several officials noted that they could not recall any 
celebrations of success.  For example, one official said that meetings usually 
were just a recitation of longstanding problems without noting positive change 
or taking action toward solutions.   
When we spoke with officials in early 2019, in the midst of the initial rollout of 
the Quality Framework and Strategic Plan, there seemed to be a sense that 
these new policy and practice changes were different, and that officials 
expected them to be more substantial and lasting.  Certainly, the Quality 
Framework and Strategic Plan represent a deliberate and active effort to effect 
change, but embedding these changes in IHSs structures, practices, and 
organizational culture will be crucial to success.  According to some IHS officials, 
part of that change in organizational culture will be to recognize and address 
any sense of defeatism or lack of faith in the organization that could block 
   
progress.  
Organizational Challenges to Improving Quality of Care in IHS Hospitals  20 
OEI-06-16-00390   
ADDRESSING ORGANIZATIONAL CHALLENGES 
IHS has devoted substantial resources in recent years to assessing its policies 
and practices.  This scrutiny has led to long-term plans focused on improving 
quality of care and operations.  Realizing and sustaining these improvements in 
IHS hospitals will require intense focus and commitment to changenot only in 
the provision of care, but to the overall organization.   
This change should include progress in addressing the core foundational issues 
presented in this report: establishing strong organizational structures that are 
maintained throughout changes in leadership and other agency factors; 
obtaining a comprehensive and candid view of performance and problems; and 
leveraging the deep commitment of officials and staff to foster a greater 
confidence in the agency moving forward.   
OIG is committed to continuing our evaluation of IHS policies and 
management, and working with IHS and its stakeholders to improve the 
effectiveness of IHS's management and the quality of care it provides.   
To address the organizational challenges identified in this report and take 
further steps to improve IHS operations and quality, IHS should: 
Incorporate the organizational strategies outlined in this report as it 
implements its new plans to improve hospital quality and agency 
operations: 
  Establish and follow formal structures and policies that define roles, 
responsibilities, and accountability 
IHS must develop and support a clear agency structure and policies that 
outline roles and responsibilities; such a structure and policies are 
an essential framework for any organizations success.  For this structure to 
be effective, it must meet the agencys needs and objectives; be practical 
and useful in directing daily work; be actionable by officials and staff; and 
be supported by the expectation for adherence to policy and accountability 
for performance.    
  Ensure that leadership has a clear and comprehensive view of 
performance and problems, and champion continuous learning 
IHS leadership must encourage open communication about agency 
performance and uncovering problems as they arise.  This will require IHS 
officials to fully know and understand the agencys functions; gain 
a comprehensive view of organizational progress; candidly evaluate the 
efficacy of the agencys work; and hold themselves and others accountable 
for continuous learning and improvement. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  21 
OEI-06-16-00390   
  Leverage the deep commitment to mission among IHS officials and staff, 
and foster greater confidence in the agencys capacity to make sustained 
improvement 
Although IHS has a long history of difficult problems, commitment to the 
mission remains strong and should serve as a foundation to bolster agency 
improvement and future success.  IHS must use the strong commitment of 
its officials and staff to the agencys mission to effect improvement, and 
gain momentum from that to sustain improvements ongoing.  This will 
include recognizing barriers to success within IHSs organizational culture, 
such as defeatism and lack of belief in IHSs efficacy.  By diligently executing 
the new policies, IHS leadership can build a greater sense of confidence 
among officials and staff, and a sense that the goals are attainable will 
further strengthen the organization and improve operations.  
Take specific actions to improve quality and oversight of IHS hospitals, 
in line with OIGs recommendations and with the IHS Strategic Plan and 
Quality Framework 
In 2016, OIG made five recommendations to improve the quality and oversight 
of IHS hospitals (see Appendix A).  We recommended that IHS conduct a needs 
assessment and develop an IHS-wide strategic plan with actionable initiatives 
and target dates; implement a quality-focused compliance program; establish 
standards and expectations for Area Office oversight activities; work to identify 
new, more meaningful hospital performance metrics; and continue to invest in 
training for hospital administration and staff.   
IHS has made progress in implementing these recommendations with its 5-year 
Strategic Plan and Quality Framework.  To fully implement these plans, IHS must 
continue to work toward fleshing out the related policies and required actions, 
and include ongoing review of the effectiveness of implementation, such as its 
new hospital performance metrics and training initiatives.  IHSs plans, once fully 
executed, appear likely to address these five specific recommendations.   
In July 2019, OIG also made four recommendations in our case study of the 
closure and reopening of the Rosebud Hospital emergency department.  We 
recommended that IHS, as a management priority, develop and implement 
a staffing program for recruiting, retaining, and transitioning staff and 
leadership to remote hospitals; enhance training for new hospital leaders; 
continue to take steps to ensure early intervention when IHS identifies 
problems; and develop procedures for emergency department closures. 
Implementing these plans and recommendations will require IHS to work with 
urgency at all levels and across divisions and offices.  As IHS progresses toward 
implementation, it should monitor the impact and results of these changes in 
practices, and revise its approach as may be warranted to achieve and sustain 
improved quality of care. 
Organizational Challenges to Improving Quality of Care in IHS Hospitals  22 
OEI-06-16-00390   
APPENDIX A: Previous OIG Recommendations 
Exhibit A contains a list of prior OIG recommendations by report.  All recommendations remain 
unimplemented at the time of this reports release.   
 
Exhibit A: OIG Recommendations Regarding IHS Hospitals Directed to IHS October 2016June 2019   
OIG Recommendations by Report            Date of Report 
IHS Hospitals: More Monitoring Needed To Ensure Quality Care (OEI-06-14-00010)             October 2016 
IHS conduct a needs assessment culminating in an agency-wide strategic plan with actionable initiatives and  
target dates 
IHS Hospitals: Longstanding Challenges Warrant Focused Attention To Support                  October 2016 
Quality Care (OEI-06-14-00011)                                                                                                               
Implement a quality-focused compliance program to support Federal requirements for health care programs 
Establish standards and expectations for how Area Offices/Governing Boards oversee and monitor hospitals  
and monitor adherence to those standards 
Continue to seek new, meaningful ways to monitor hospital quality through the use of outcomes and/or  
process measures 
Continue to invest in training for hospital administration and staff, and assess the value and effectiveness of  
training efforts 
Case Study: IHS Management of Rosebud Hospital Emergency Department Closure                  July 2019          
and Reopening (OEI-06-17-00270)                                                                                                
As a management priority, develop and implement a staffing program for recruiting, retaining, and transitioning 
staff and leadership to remote hospitals 
Enhance training and orientation for new hospital leaders to ensure that they follow IHS directives and continue 
improvement efforts 
Continue to take steps to ensure early intervention when IHS identifies problems at hospitals  
Develop procedures for temporary closures of emergency departments and communicate those plans with 
receiving hospitals and Emergency Medical Services to ensure that they are adequately prepared to receive patients 
diverted during such events 
       
Organizational Challenges to Improving Quality of Care in IHS Hospitals  23 
OEI-06-16-00390   
APPENDIX B: Interview Participants 
Exhibit B contains a list of titles and dates for OIG interviews with IHS, HHS and CMS officials at the time of our 
interviews.  In all cases where the official is listed as a former official, the individual was still in an official 
position at IHS but speaking on behalf of their experience in the previous, recently held position.     
Exhibit B: Interview Participants from IHS and Other HHS Agencies  
Agency and Position         Date of Interviews 
IHS Officials Interviewed with Structured Interview Protocol                                                December 2016                                                                           
Acting Principal Deputy Director   
Former Deputy Director       
Acting Deputy Director of Field Operations       
Acting Deputy Director for Intergovernmental Affairs       
Former Deputy Director for Intergovernmental Affairs       
Deputy Director for Management Operations       
Special Assistant to the Deputy Director for Management Operations     
Acting Chief Medical Officer       
Clinical Quality Director       
Acting Chief of Staff       
Former Head of Contracting Authority       
Special Assistant to the Acting Principal Deputy       
Special Assistant to the Deputy Director       
Clinical Consultant to the Chief Medical Officer       
Former Area Office Director       
Current Area Office Director       
HHS Agencies Represented at Meeting of the Executive Council on Quality Improvement  December 2016 
Agency for Healthcare Research and Quality       
Assistant Secretary for Administration       
Assistant Secretary for Financial Resources       
Assistant Secretary for Health       
Assistant Secretary for Legislation       
Assistant Secretary for Planning and Evaluation       
Organizational Challenges to Improving Quality of Care in IHS Hospitals  24 
OEI-06-16-00390   
Agency and Position         Date of Interviews 
HHS Agencies Represented at Meeting of the Executive Council on Quality Improvement  December 2016 
(continued from previous page) 
Assistant Secretary for Public Affairs       
CMS       
HRSA       
Office of the National Coordinator       
Substance Abuse and Mental Health Services Administration       
CMS Officials                                                                                                                       December 2016 
Acting Principal Deputy Administrator and Chief Medical Officer         
Deputy Director of the Center for Clinical Standards and Quality       
Director of the Survey and Certification Group       
IHS Officials Engaged in Discussions Regarding Other OIG Studies                       June 2018February 2019 
Acting Principal Deputy Director       
Acting Deputy Director of Field Operations       
Acting Deputy Director for Intergovernmental Affairs       
Deputy Director for Quality of Care       
Deputy Director for Management Operations       
Chief Medical Officer       
Acting Chief of Staff       
Special Assistant to the Deputy Director       
 
 
   
Organizational Challenges to Improving Quality of Care in IHS Hospitals  25 
OEI-06-16-00390   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Ruth Ann Dorrill, Regional 
Inspector General for Evaluation and Inspections in the Dallas regional office, 
and Amy Ashcraft and Petra Nealy, Deputy Regional Inspectors General.  
Others in the Office of Evaluation and Inspections who provided support 
include Joe Chiarenzelli, Ben Gaddis, Evan Godfrey, and Christine Moritz. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
Organizational Challenges to Improving Quality of Care in IHS Hospitals  26 
OEI-06-16-00390   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, 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 beneficiaries served by those programs.  This statutory mission is 
carried out through a nation-wide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
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  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
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  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  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 Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
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 healthcare industry concerning 
the anti-kickback statute and other OIG enforcement authorities.