U.S. Department of Health and Human Services 
 
Office of Inspector General 
 
Indian Health Service Use of 
Critical Care Response Teams 
Has Helped To Meet Facility 
Needs During the COVID-19 
Pandemic
Suzanne Murrin 
Deputy Inspector General for Evaluation and Inspections 
September 2021, OEI-06-20-00700  U.S. Department of Health and Human Services 
O  ffice of Inspector General 
 
Report in Brief 
 
Se ptember 2021, OEI-06-20-00700 
   
Indian Health Service Use of Critical Care 
Why OIG Did This Review 
Coronavirus disease 2019 
Response Teams Has Helped To Meet Facility 
(COVID-19) is a highly contagious, 
sometimes fatal, disease that has  Needs During the COVID-19 Pandemic 
disproportionately affected 
American Indians and Alaska  What OIG Found 
Key Takeaway 
Natives (AI/ANs).  The Indian Health  IHS designed and launched the CCRT program 
Service (IHS) and Tribal health care  within a few months of COVID-19s reaching 
IHS developed the CCRT 
facilities are the main health care  the United States.  IHS awarded a contract in 
program as an innovative 
providers for the AI/AN population.   May 2020 to pilot the program and began 
capacity-building tool to 
Prior OIG work found that IHS  receiving facility requests for CCRT 
strengthen IHS and Tribal 
facilities often lacked sufficient staff  deployments shortly thereafter.  IHS expedited 
facilities response to the 
and had limited access to clinical  the credentialing and onboarding process, and 
COVID-19 pandemic.  
specialists, as well as finding other  the first team arrived onsite at a tribally 
The program is a positive 
quality-of-care concerns.  One  operated facility in June 2020.  CCRT teams 
step in IHSs efforts to 
recent IHS effort to address staffing  consisted of a critical care physician, one or 
promptly respond to the 
and quality concerns is its  two critical care nurses, and a respiratory 
immediate needs of 
development of Critical Care  therapist, all deployed on short notice.  At the 
facilities.  The CCRT 
Response Teams (CCRTs) to  time of our review, IHS had fulfilled all 
model also holds promise 
support IHS and Tribal facilities in  requests for CCRTs in a timely manner.   
for addressing 
caring for critically ill COVID-19 
longstanding challenges 
While onsite, the CCRTs provided hands-on 
patients.  This study examines IHSs 
facing some facilities 
training to strengthen staff skills and capacity 
first five deployments of the CCRTs, 
related to quality of care 
to handle surges of COVID-19 patients.  
which provided services to six IHS 
and staffing. 
Facility administrators found the deployments, 
facilities and three Tribal facilities 
 
which typically lasted 2 weeks, valuable.  In 
from June through September 
interviews, IHS officials and staff credited the CCRT training with saving lives 
2020.  
and stated that the teams presence boosted staffs confidence and skills.  
 
Although the CCRTs focused mostly on training staff, the teams also provided 
How OIG Did This Review 
direct patient care, particularly during patient surges.   
We based our findings on 
document reviews and interviews  Throughout each CCRT deployment, facilities provided close oversight and 
with 74 key officials and staff at IHS  communicated frequently with IHS headquarters and Area Offices about 
headquarters, IHS Area Offices, IHS- CCRT activities.  In January 2021, IHS awarded two contracts to extend the 
operated facilities, and tribally  program through the pandemic.  Although none of the facilities in our 
operated facilities, as well as with  sample planned to request another CCRT deployment, all facilities reported a 
contracted providers who served on  need for similar resources to assist with non-COVID-19-related care.  
the CCRTs.  We conducted data 
collection in December 2020 and  What OIG Recommends 
January 2021.  We reviewed  To further leverage the successes of the CCRT model in support of IHSs 
contracts and other documents  broader care improvement efforts, we recommend that IHS (1) solicit 
related to IHSs deployment of the  feedback from CCRTs regarding their observations of potential need for 
CCRTs.  Topics for the interviews  broader IHS-wide improvements beyond COVID-19-related care; (2) share 
included processes for deploying  the CCRTs recommendations across all IHS and Tribal facilities; and (3) assess 
the teams; roles and expectations;  whether IHS could use the CCRT model to provide support and training for 
and strategies used to address any  non-COVID-19-related care.  IHS concurred with our recommendations. 
challenges encountered during the 
   
deployments.     
TABLE OF CONTENTS 
 
 
 
 
BACKGROUND  1 
Methodology  6 
FINDINGS  8 
IHS designed and launched the CCRT program as a capacity-building resource to meet IHS  8 
and Tribal facility needs during the COVID-19 pandemic 
CCRTs assessed facility needs and trained staff on COVID-19-related care, which strengthened  11 
facilities ability to handle patient surges and reaped benefits beyond the deployment  
Facility administrators provided close oversight of the CCRTs during the deployments, and  17 
communicated frequently with IHS HQ and Area Offices about CCRT activities and progress 
IHS awarded new CCRT contracts in January 2021, extending the program through the  18 
pandemic, and facilities expressed the need for a similar program for non-COVID-19-related  
care 
CONCLUSION AND RECOMMENDATIONS FOR IHS  19 
Solicit feedback from CCRTs regarding their observations of potential need for broader IHS- 19 
wide improvements 
Compile the CCRTs recommendations to individual facilities and share them across all IHS  20 
and Tribal facilities 
Assess whether IHS could use the CCRT model to provide support and training to facilities  20 
needing assistance with non-COVID-19-related care 
AGENCY COMMENTS AND OIG RESPONSE  21 
APPENDIX  22 
Agency Comments   22 
ACKNOWLEDGMENTS AND CONTACT  24 
ABOUT THE OFFICE OF INSPECTOR GENERAL  25 
ENDNOTES  26 
   
BACKGROUND 
 
 
Objective 
To assess Indian Health Service (IHS) use of Critical Care Response Teams to 
support IHS and Tribal health care facilities during the coronavirus disease 2019 
(COVID-19) pandemic. 
Indian Health Service   
IHS is responsible for providing Federal health services to American Indians and 
Alaska Natives (AI/ANs) and has an annual budget of approximately $6 billion.1  In 
partnership with Tribes, IHS provides primary and preventive health care services to 
approximately 2.6 million AI/ANs who are members of the 574 federally recognized 
Tribes in the United States.2  IHS provides these services directly to AI/ANs through 
IHS-operated facilities or provides funding to Tribes through self-determination 
contracts and self-governance contracts to operate their own health care systems.3  
IHS also supports contracts and grants to Urban Indian Organizations (UIOs), which 
provide medical, dental, mental health, and other services to AI/ANs living  
off-reservation in urban locations.4, 5 
Health care challenges caused and exacerbated by the COVID-19 pandemic, such as 
staffing shortages and outdated equipment, have raised concerns about ensuring safe 
and accessible health care for AI/ANs.6  According to the Centers for Disease Control 
and Prevention (CDC), the incidence of laboratory-confirmed COVID-19 cases, as well 
as hospitalization and death rates, are higher among AI/ANs than among  
non-Hispanic white persons.7  As a response to those concerns, IHS took steps to 
bolster the capacity of IHS and Tribal facilities and developed the Critical Care 
Response Team (CCRT) program to assist facilities in caring for COVID-19 patients, 
among other efforts.8  The CCRTs are small teams of contracted critical care providers 
that can deploy, as needed, to support IHS and Tribal facilities that are experiencing 
or need assistance in preparing for surges of COVID-19 patients.9 
Organizational Structure 
IHS headquarters (HQ) provides general direction, policy development, and support 
for each of the 12 IHS Area Offices and their service units.  Area Offices oversee the 
delivery of health services and provide administrative and technical support to the 
service units health care delivery sites, which may include hospitals, health centers, 
and health stations, among other facility types.10, 11, 12, 13  As of August 2020, there 
were a total of 170 service units operated by IHS or Tribes, and within these service 
units were 24 IHS-operated hospitals, mostly in remote locations, and 22 tribally run 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Background | 1  hospitals, among other facility types.a  (See Exhibit 1 for a list of the number and type 
of facilities operated by IHS and Tribes.14) 
Exhibit 1: IHS and Tribal health care facilities by type 
Type of Facility  IHS  Tribal 
Hospital  24  22 
Health Center  51  279 
Health Station  24  79 
Alaska Village Center  0  59 
School Health Center  12  6 
Youth Regional Treatment Center  6  6 
Total  117  451 
Source: IHS, IHS Profile.  Accessed at https://www.ihs.gov/newsroom/factsheets/ihsprofile/ on September 30, 2020. 
Impact of COVID-19 Pandemic on IHS and Tribal Facilities 
SARS-CoV2 is a highly contagious coronavirus that causes the disease COVID-19, 
which can be fatal in some cases.15, 16  Common COVID-19 symptoms include fever, 
cough, shortness of breath, fatigue, and loss of taste or smell.17  The first U.S. patient 
with COVID-19 was reported on January 20, 2020, and on March 11, 2020, the World 
Health Organization declared COVID-19 to be a pandemic.18, 19  As of September 1, 
2021, there had been more than 39 million confirmed cases in the United States, with 
over 638,000 deaths.20 
 
The COVID-19 pandemic has disproportionately affected racial and ethnic minority 
groups in the United States, including AI/ANs.21  As of August 28, 2021, IHS had 
reported 226,953 cumulative positive COVID-19 tests and a 7-day rolling average 
positivity rate of 10.2 percent across IHS, Tribal, and UIO facilities.b, 22  According to 
CDC, the incidence of laboratory-confirmed COVID-19 cases was estimated to be  
1.6 to 3.5 times as high among AI/ANs than among non-Hispanic white persons.23, 24  
Similarly, hospitalization rates were 3.5 times as high and death rates were 2.4 times 
as high for AI/ANs than for non-Hispanic white persons.25  Moreover, for individuals 
aged 20-49 years, death rates are estimated to be 8 to 12 times as high for AI/ANs 
than for non-Hispanic white persons.26  However, CDC acknowledged limitations to 
_____________________________________________________________________________________________________________________________ 
a 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.  Each service unit may 
contain one or more health care facilities. 
b Tribes and UIOs are not required to report COVID-19 testing data to IHS; therefore, the number of 
positive tests may not represent the total number of positive COVID-19 cases across IHS, Tribal, and UIO 
facilities. 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Background | 2  these findings because of racial and ethnic misclassifications in epidemiologic and 
administrative data sets, and it has concluded that the numbers may underestimate 
actual AI/AN morbidity and mortality rates.  
The COVID-19 pandemic created and exacerbated challenges for the U.S. hospital 
system, including IHS and Tribal facilities.27, 28, 29  As front-line responders, hospitals 
have significant responsibilities in identifying and treating patients with COVID-19.  
IHS and Tribal facilities often serve as the main health care providers for AI/ANs, 
making them an integral part of the COVID-19 response, but many of those facilities 
have experienced challenges during the pandemicfrom difficulty in accessing 
personal protective equipment (PPE) to capacity limitations as a result of outdated 
buildings and equipment and staffing shortages.30, 31 
 
Historically, IHS has had sizable vacancy rates among its health care providers (e.g., 
physicians, nurses, dentists, and other clinical staff), with limited access to clinical 
specialistsa challenge that could worsen as providers become sick with COVID-19 
or leave their positions for any other reasons.  For physicians alone, IHS has had 
vacancy rates of 25 percent.32, 33, 34  The inability to secure sufficient staffing has been 
a concern for hospitals nationwide during the pandemic, and staffing shortages are 
expected to grow for years to come.35  It is estimated that by 2033, there will be a 
shortage of between 54,100 and 139,000 physicians in the United States, which could 
lead to further vacancies for IHS.36 
COVID-19 Funding 
As of March 2021, IHS had received approximately $9 billion in total supplemental 
funding to support its response to the COVID-19 pandemic, including funding from 
the Coronavirus Aid, Relief, and Economic Security (CARES) Act; the Paycheck 
Protection Program and Health Care Enhancement Act; the Families First Coronavirus 
Response Act; the Coronavirus Preparedness and Response Supplemental 
Appropriations Act; the Coronavirus Response and Relief Supplemental 
Appropriations Act; and the American Rescue Plan Act of 2021.37, 38, 39, 40, 41, 42, 43  
In deciding how to allocate the funding, IHS engaged in Tribal Consultation and 
Urban Confer sessions to ensure that funds would meet the needs of AI/ANs.44  IHS 
has used funding to purchase supplies and to support COVID-19 testing, contact 
tracing, and vaccine distribution, as well as to hire and support staff and maintain or 
improve facilities, among other efforts.45, 46, 47, 48  IHS has also used funding to expand 
and improve telehealth and has plans to use some of the funding to update its 
electronic health record system.49, 50 
IHS Response to COVID-19 Pandemic 
IHS has undertaken several efforts to support IHS and Tribal facilities during the 
pandemic, sometimes in collaboration with other Federal and State agencies.  These 
efforts have involved assisting facilities in coordinating emergency response activities; 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Background | 3  supplementing staffing; acquiring and distributing COVID-19 tests and supplies; and 
distributing and administering vaccines.  IHS established a section on its website 
dedicated to the agencys COVID-19 response, where it has provided frequent 
updates on its activities throughout the pandemic.51 
Incident Command and Coordination.  In March 2020, IHS activated its Incident 
Command Structure to respond to COVID-19 using the agencys pandemic response 
plan and facilities disaster plans.52  The purpose of the Incident Command Structure 
is to establish communication protocols to ensure comprehensive situational 
awareness and efficient deployment of resources across the agency.53  The Incident 
Command Structure is led by the Deputy Director of IHS and consists of leadership in 
IHS HQ and representatives from Area Offices, facilities, and other groups within the 
agency.  To enhance coordination during the pandemic, IHS trained staff in the Area 
Offices to serve as Emergency Management Points of Contact to facilitate the flow of 
resources, such as PPE and test kits, from centralized systems to the facilities.54  Area 
Offices also provided technical assistance and support to IHS, Tribal, and UIO facilities.  
In addition, IHS HQ held regular conference calls with Tribal leaders and UIOs to 
provide updates, answer questions, and hear concerns from Tribal communities to 
better coordinate response efforts.55 
Supplemental Staffing.  To alleviate staffing shortages during the pandemic, IHS took 
several steps to bolster staffing in facilities.  Those steps included using direct hire 
authority and instituting interim procedures for onboarding personnel.56  IHS also 
acquired temporary deployments from the Department of Veterans Affairs (VA), the 
Department of Defense (DoD), and the U.S. Public Health Service (USPHS) 
Commissioned Corps.57  IHS signed interagency agreements with VA and DoD that 
arranged for coordinated delivery of health care and other services from those 
agencies, including for IHS use of VA and DoD medical personnel and hospital  
beds.58, 59  IHS has a long history of receiving assistance from the USPHS, which 
comprises approximately 6,100 public health and safety professionals (e.g., doctors, 
nurses), assigned to various Federal agencies, and is available to the President and the 
HHS Secretary to rapidly respond to any public health emergency or crisis within or 
outside the United States.60, 61, 62 
Tests and Supplies.  To assist facilities in obtaining COVID-19 test kits and supplies, 
IHS used its National Supply Service Center, which manages the purchase and 
distribution of pharmaceuticals, medical, and other health-care-related supply items, 
and provides advice, consultation, and assistance to IHS, Tribal, and UIO facilities on 
supply management.63, 64  Tribes could also follow their usual processes for ordering 
supplies.65  As of April 14, 2021, IHS had distributed over 84 million units of PPE and 
other COVID-19-related products to IHS, Tribal, and UIO facilities, and as of  
August 28, 2021, those entities had performed nearly 2.8 million tests.66, 67  To 
administer the tests and vaccines, some facilities partnered with State National Guard 
units.68, 69, 70, 71 
Vaccines.  As of August 30, 2021, IHS had distributed more than 1.9 million COVID-19 
vaccine doses to IHS, Tribal, and UIO facilities.  As of the same date, these entities had 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Background | 4  together administered over 1.5 million of those doses.72  As of September 1, 2021, 
approximately 46 percent of all AI/ANs were fully vaccinated (i.e., had received one 
dose of a single-shot COVID-19 vaccine or the second dose in a two-dose COVID-19 
vaccine series)a higher vaccination rate than that of any other racial or ethnic group 
in the United States.73  In an effort to reduce the spread and impact of COVID-19 
across the country, many IHS, Tribal, and UIO facilities also provided vaccinations to 
nonbeneficiaries (i.e., individuals who are not members of a federally recognized 
Tribe), such as first responders, teachers, and other community members.74, 75, 76 
Critical Care Response Teams 
In May 2020, IHS awarded a contract to form the CCRT program to assist IHS and 
Tribal health care facilities in preparing for and responding to the pandemic.77, 78  The 
CCRT program is designed to provide facilities with short-term assistance focused on 
providing urgent medical care for COVID-19 patients through hands-on clinical 
training and consultation on facility operations by a small team of contracted staff.79  
IHS designated $5.8 million of its CARES Act funding to pilot the CCRT program and 
deployed the first team in June 2020.  During June through September 2020, IHS 
deployed five CCRTs that provided services to a total of nine facilities.  In January 
2021, IHS extended the CCRT program by awarding two Indefinite Delivery Indefinite 
Quantity contracts to continue assisting IHS and Tribal facilities with COVID-19-
related care throughout the pandemic. 
Related OIG Work 
OIG has a substantial body of work related to IHS and Tribal programs.  Since 2016, 
OIG has focused primarily on IHS management of hospitals.  Our work has included 
issuing reports describing lack of quality oversight and a number of challenges that 
affect IHS hospitals ability to provide quality care and maintain compliance with 
Federal requirements.80, 81, 82, 83  Recently published reports include a study examining 
the sufficiency of IHS policies for preventing, reporting, and addressing patient abuse 
and facility implementation of those policies; a medical record review examining 
adverse events (patient harm resulting from medical care) in IHS hospitals; and a 
companion report focusing on labor and delivery care.84, 85, 86, 87 
OIG has also undertaken extensive oversight work related to COVID-19.  See the OIG 
COVID-19 Portal for more information.  Two reportsone released in April 2020 and 
the other in March 2021outlined the challenges that a sample of U.S. hospitals 
reported facing in response to COVID-19 during the early weeks of the pandemic and 
1 year into the pandemic, respectively.88, 89  Other work includes toolkits detailing 
lessons learned from OIG reports published from 2002 to 2020 about health care 
facility and community emergency response.90, 91 
 
 
 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Background | 5  Methodology 
Scope of Inspection 
For this evaluation, we purposively selected a sample of IHSs CCRT deployments, 
which included the first five deployments.  During June through September 2020, 
these five CCRT deployments provided services to six IHS-operated facilities and  
three Tribal facilities.  (See Exhibit 2 for details about the facilities that received the 
five deployments.)  We collected data through interviews with selected key IHS 
officials; IHS and Tribal facility leadership and staff; and members of the CCRTs, as well 
as through document reviews, in December 2020 and January 2021.  We examined 
IHSs use of the CCRTs to meet facility needs; its management and oversight of the 
teams; any challenges encountered during the deployments; and lessons learned that 
IHS could apply to future CCRT deployments. 
Exhibit 2: Facilities that received a CCRT deployment during June through 
September 2020 
Source: OIG compiled this table using data obtained from IHS during September 2020 through January 2021. 
Data Collection and Analysis 
Interviews.  To assess IHS's use of the CCRTs to support facilities during the 
pandemic, we conducted in-depth telephone interviews with 74 respondents, 
individually or in small groups in December 2020.  The interview respondents included 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Background | 6  key officials and staff at IHS HQ and the five Area Offices that received the 
deployments (Billings, Great Plains, Nashville, Oklahoma City, and Tucson); leadership 
and staff at the selected IHS and Tribal facilities; and members of the CCRTs. 
During these interviews, we discussed the development of the CCRT program; the 
process for requesting deployments; and onboarding and oversight of the CCRTs at 
the facilities.  We also asked about the roles and expectations of the deployments; 
any challenges encountered and strategies used to address them; and facility needs 
for future CCRT deployments.  We employed semistructured interview protocols that 
allowed us to modify questions, as needed, and to follow up on additional issues as 
we learned new information and identified key issues. 
Document Reviews.  To determine the CCRTs responsibilities and obligations, we 
reviewed contracts, including statements of objectives; debriefing materials, including 
recommendations that CCRTs provided to facilities; and other documents related to 
the deployments.  To better understand the context surrounding the deployments, we 
also reviewed facility staffing data, capacity data, and other data obtained from IHS 
HQ and the facilities. 
Data Analysis.  We conducted a qualitative analysis of interview data and documents 
to identify themes and describe the IHS processes for developing, deploying, and 
managing the CCRTs; facilities perspectives on the effectiveness of the deployments; 
and any challenges in or lessons learned from the deployments.  We present this data 
in both aggregate analysis and individual quotations in this report. 
Limitations 
We did not independently verify the information reported by interview respondents 
or assess the extent to which facilities incorporated the CCRT recommendations 
provided to facilities during the deployments.  Further, in our review of the CCRT 
contract, we did not assess IHS invoices, cost estimates, or compliance with Federal 
Acquisition Regulations.  Lastly, this study focused only on the five deployments that 
occurred during June through September 2020 and did not include facilities that 
received deployments outside of that timeframe.  IHS has contracted with different 
staffing agencies since November 2020, and we recognize that the experiences of 
facility staff and CCRTs for those deployments may not reflect those described in this 
report. 
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.  
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Background | 7   
FINDINGS 
 
IHS designed and launched the CCRT program as a capacity-
building resource to meet IHS and Tribal facility needs during 
the COVID-19 pandemic 
In March 2020, shortly after the World Health Organization declared COVID-19 
a pandemic, IHS began to explore ways in which the agency could help prepare IHS 
and Tribal health care facilities in responding to the pandemic.  IHS officials reported 
that at the time, there were few COVID-19 cases in IHS and Tribal facilities, but there 
were concerns about facilities ability to adequately care for COVID-19 patients and 
handle a potential surge of such patients.  IHS officials and staff were concerned that 
as infections began to spread across the United States, it would become difficult for 
facilities to secure sufficient staffing, particularly critical care providers, especially 
because staffing was already a challenge in many facilities prior to the pandemic.  IHS 
officials and staff were also concerned that some facilities would experience difficulty 
in transferring critically ill patients to higher-level care because of limited availability 
of beds in intensive care units at receiving hospitals. 
Strategy for Success:  To assist IHS and Tribal facilities in preparing for and responding to the challenges 
Expedited  posed by COVID-19, IHS assembled a team of experts from within the agency who 
Development  developed the CCRT program, a capacity-building resource aimed at strengthening 
IHS tasked internal  facilities.  In interviews, IHS officials described how the team designed the CCRT 
experts to quickly  program to provide facilities with short-term assistance and hands-on training, based 
develop the CCRT 
on previous experience with hospital management and leadership development 
program and deploy 
teams and the USPHS Rapid Deployment Forces. 
the teams. 
 
  IHS awarded a contract in May 2020 to pilot the CCRT program 
and began receiving facility requests for CCRT deployments 
shortly thereafter 
In May 2020, IHS contracted with a staffing agency to pilot the CCRT program and 
worked with the contractor to finalize the specifics of the program before 
deployments could begin.  IHS designed the CCRTs to be small, typically consisting of 
a critical care physician; one or two critical care nurses; and a respiratory therapist.  As 
outlined by the contract, the CCRTs were to be deployed on short notice and to be 
available 24 hours a day, 7 days a week for no less than 3 to 5 consecutive working 
days per deployment.  To serve on the CCRTs, the team members had to have 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 8  academic knowledge and professional experience treating patients who were 
suspected or confirmed as having COVID-19.  
Strategy for Success:  In early June 2020, IHS leadership made agencywide announcements about the newly 
Accelerated Timeline  established CCRT program and informed IHS and Tribal facilities that they could begin 
March 2020  requesting deployments as needed.  IHS instructed facilities that to request a 
World Health  deployment, they should go through the Emergency Management Point of Contact in 
Organization declared 
the Area Office, who would then forward the request to IHS HQ.  Officials and staff in 
COVID-19 a pandemic 
IHS HQ would then review the request and consult with the facility to identify specific 
May 2020  needs and determine whether a CCRT deployment would meet those needs or 
IHS awarded the first  whether other resources would be better suited for the facility.  (See Exhibit 3 for 
CCRT contract  details about IHSs process for requesting a CCRT deployment; reviewing and 
June 2020  approving requests; and deploying a CCRT.) 
IHS announced that 
IHS officials reported that the agency received a request for a CCRT deployment 
CCRTs were available 
almost immediately after making the announcements.  In interviews, one facility 
and deployed the first 
team   reported requesting a deployment because it was experiencing a surge of COVID-19 
  patients at the time and needed help with caring for those patients.  Other facilities 
  explained that they wanted CCRT deployments to help prepare for anticipated future 
surges. 
Exhibit 3: The process for requesting a CCRT deployment, reviewing and 
approving requests, and deploying a CCRT  
 
Source: Documents provided by IHS to OIG, 2020.  
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 9  Facility administrators generally described the process for requesting and receiving 
approvals for deployments as quick and efficient and said that the timing of the CCRT 
deployments was helpful, as patient surges often occurred during or shortly after the 
deployment.  IHS officials reported that the agency had a process for prioritizing 
CCRT deployments if needed, but that it had been able to fulfill all requests in a timely 
manner without placing facilities on a waiting list.  
IHS expedited the credentialing and onboarding process to 
quickly deploy the CCRTs, and the first team arrived onsite in 
June 2020 
Strategy for Success:  To quickly get CCRTs onsite to facilities that requested deployments, IHS HQ reported 
Streamlined  working closely with Area Offices and facility administrators to expedite credentialing, 
Credentialing  privileging, and onboarding of the CCRT members.c  In interviews, IHS officials and 
IHS and facilities  staff credited IHSs new centralized credentialing system, implemented in the last few 
streamlined and 
years, for facilitating quick information-sharing (e.g., resumes, licenses) across 
expedited credentialing 
facilities, which sped up the credentialing process for CCRTs.  IHS had previously 
and onboarding of 
stored provider credential files at facilities or Area Offices, which did not allow for 
CCRTs to quickly begin 
easy agencywide access.  IHS HQ also reported that Area Offices held more frequent 
deployments. 
governing-board meetings with facilities to review CCRT candidates.d  One Area 
 
official noted that the credentialing approach used for CCRTs improved the agencys 
 
overall credentialing and privileging process because it forced IHS to examine its 
processes and make necessary adjustments.   
Facilities could also use emergency/disaster credentialing and privileging to get CCRT 
providers on board quickly if they were experiencing a surge and had activated their 
facility emergency plans.  To use emergency/disaster credentialing and privileging for 
CCRT providers, IHS required facilities to verify licensure and identification and check 
references and hospital affiliation as they would under normal circumstances,  
butunlike in the normal processIHS allowed facilities to complete those 
verifications up to 72 hours after the provider arrived onsite.  Two of the facilities in 
our sample reported using emergency/disaster credentialing and privileging, and IHS 
officials stated that several of the other facilities that received deployments after our 
study period used this type of credentialing and privileging process. 
To familiarize the CCRTs with the facilities, each facility provided new-employee 
orientation to the teams before or shortly after they arrived onsite.  The orientation 
_____________________________________________________________________________________________________________________________ 
c During credentialing, IHS verifies the providers education, training, licensure, and experience.  During 
privileging, IHS identifies the scope of the providers expertise and determines which medical functions 
the individual is permitted to perform at a particular facility.  IHS, Indian Health Manual, pt. 3; ch. 1; 
sections 3-1.1 (Introduction) and 3-1.4 (Procedures). 
d Each IHS-operated facility has a governing board that is chaired by the Area Director and includes 
leadership from the Area Office and the facility.  The governing board is the only authority that can grant 
full medical staff membership and clinical privileges, and it has the ultimate authority and responsibility 
for the oversight and delivery of health care rendered by practitioners who are credentialed and 
privileged.  IHS, Indian Health Manual, pt. 3, ch. 1, sections 3-1.2 (Responsibilities). 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 10  included trainings that covered facility-specific and agency-specific topics.  With the 
help from IHS HQ, facilities streamlined the trainings, which allowed providers to take 
the trainings virtually before they arrived or to complete them within 1 day when they 
arrived onsite.  
In June 2020, IHS deployed the first CCRT, which was to a Tribal facility that requested 
assistance because of to rising numbers of COVID-19 patients.  The team arrived at 
the facility within days of the request.  During June through September 2020, IHS 
deployed the CCRTs a total of five times, providing services to nine facilitiessix IHS 
facilities and three Tribal facilities.  (See Exhibit 2 on page 6 for details about the nine 
facilities.) 
The teams typically arrived onsite within a few weeks after facilities made their 
requests.  However, two facilities experienced slight delays in getting the full teams 
onsite.  An administrator at one of those facilities explained that the deployment was 
delayed, and had to begin virtually, because of overlap with the previous deployment 
and because one of the CCRT members had contracted COVID-19.   
CCRTs assessed facility needs and trained staff on COVID-19-
related care, which strengthened facilities ability to handle 
patient surges and reaped benefits beyond the deployment  
The CCRTs served several functions throughout the deployments to bolster facilities 
ability to care for COVID-19 patients and to protect staff and other patients from 
infection.  CCRT members reported that one of those functions was to assess facility 
needs and make recommendations to optimize patient flow and strengthen staff skills 
and capacity.  The CCRTs used these assessments to develop trainings specific to each 
facilitys needs, which they conducted for staff while onsite.  During some of the 
deployments, the CCRTs also assisted facilities in providing direct patient care, 
particularly if the facilities were experiencing a surge in patients.  The deployments, 
which typically lasted a couple of weeks, were well-received by facilities, a perspective 
that the CCRTs also shared. 
The CCRT assessments helped guide facilities in making changes 
to more effectively respond to the pandemic, such as revising 
policies and agreements; acquiring equipment and supplies; and 
conducting system updates  
Strategy for Success:   CCRT members reported that when they arrived onsite, they immediately began to 
Tailored Services  assess facilities capacity to handle COVID-19 cases.  During the assessments, the 
CCRTs assessed facility  CCRTs examined the facility layout and other logistics; reviewed facility policies and 
needs, layout, staff, and  procedures; and inventoried facility equipment and supplies.  In interviews, facility 
other logistics to tailor  administrators described these assessments as thorough, as they included most 
support and training. 
departments and examined a wide range of policies and procedures, from patient 
 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 11  care and infection control to emergency codes and equipment use.  CCRT members 
reported using the assessments to make recommendations to facilities for 
improvement and as a baseline to develop training for facility staff on  
COVID-19-related care.  Some of these recommendations included replacing 
outdated equipment; purchasing additional oxygen supply; reconfiguring space and 
erecting divider walls between patient beds; and instituting temporary ventilation 
systems.   
The CCRTs also helped revise facility policies and procedures.  For example, one Area 
Office reported that CCRT members helped a facility write policies for using 
Vapotherm, a noninvasive high-flow respiratory support system used to treat 
respiratory failure that the facility had not used before.92  In another facility that 
operated as an urgent care clinic, the CCRT helped establish a transfer agreement 
with a nearby IHS-operated hospital.  In interviews, the facility and the CCRT members 
described how the hospital had previously refused to accept patients from the facility, 
incorrectly believing that the facilitywhich was also operated by IHSprovided the 
same level of care and had the same capability as the hospital.    
The hospitals refusal to accept patients forced the facility to keep critically ill patients 
longer, without adequate equipment and staff, before the facility could locate another 
hospital further away that would accept the patients.  According to the CCRT 
members, this delay in care led to an adverse event (patient harm resulting from 
medical care or lack of medical care) for one patient.  To remedy this problem, the 
CCRT brought the facility and the hospital together along with the Area Office to 
clarify the capabilities and responsibilities of each and to establish a transfer 
agreement between them.  Under the agreement, the urgent care facility would 
transfer its critically ill patients to the hospital, which would care for the patients until 
they could be transferred out to higher-level care.    
The CCRTs also assisted facilities in conducting system updates to better handle 
Strategy for Success:  
Standardized EHR  suspected or confirmed COVID-19 cases.  Before IHS began deployments of the 
Templates  CCRTs, the agency developed a new COVID-19-specific graphical user interface in its 
IHS developed  electronic health record (EHR) system.  This new interface included templates with 
standardized EHR  instructions for admissions; transfers; discharges; medications; and other 
templates for COVID-19 
interventions, such as ventilator treatment.  One IHS official noted that these 
treatment to provide 
templates, which have been standardized across the facilities that received 
easy access and use for 
deployments, could be updated as the best practices for treating COVID-19 patients 
CCRTs and facility staff. 
continue to evolve.  Officials also explained that having a standardized template 
 
allowed easy access and use for the CCRT members as they deployed to different 
facilities.  When the CCRTs arrived onsite, they worked with the facilities to train staff 
on the new EHR templates; facilities indicated that this training was helpful.  One 
official in IHS HQ reported that the agencys response to COVID-19 and the CCRT 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 12  deployments was a catalyst for the agency to pursue EHR standardization across 
facilities and that the EHR templates helped drive the success of the CCRT program.e   
Throughout the deployments, CCRTs provided feedback to the facilities regarding 
their assessments and observations.  The CCRTs formalized this feedback into 
recommendations that they shared with facilities and IHS HQ both mid-deployment 
and laterduring a debriefing presentationat the end of each deployment.  The 
recommendations covered an array of topics, which the CCRTs grouped into  
six categories: facilities and equipment; clinical pathways; education and training; 
discharges and followup; staffing; and systems of care.  (See Exhibit 4 for a depiction 
of the CCRT categorization of the recommendations and related examples.) 
Exhibit 4: CCRTs made recommendations to facilities on the basis of their 
assessments, which they grouped into six broad categories.  
Examples: institute 
 
hospital response 
Facilities  Examples: purchase 
Clinical  teams, change 
and  equipment, modify   
Pathways  timing of 
Equipment  facility layout   
  medication 
administration 
             
Examples: draft  Examples: improve 
Education  protocols for  Discharges  discharge 
and  COVID-19    and  planning, improve 
Training  treatment, establish    Followup  followup 
 
super trainers*  telephone clinics 
             
Examples: develop 
Examples: 
strategies for 
streamline patient 
staffing during  Systems of 
Staffing    handoffs, review 
surges, streamline  Care 
  patient transfer 
  human resources 
arrangements  
processes 
Source: CCRT deployment debriefing documents, JuneSeptember 2020. 
*Super trainers are facility staff who are trained to provide training to other staff.   
Facility administrators and IHS officials expressed appreciation for the teams 
assessments and recommendations.  An administrator in one facility stated that 
having an extra set of eyes was beneficial because it provided a new perspective 
_____________________________________________________________________________________________________________________________ 
e In April 2021, IHSs then-Acting Director testified before the Subcommittee on Interior, Environment, 
and Related Agencies of the Senate Appropriations Committee that the pandemic highlighted challenges 
and risks posed by IHSs decentralized EHR structure and that the agency had recently begun the process 
to modernize its EHR system.  Accessed at 
https://www.appropriations.senate.gov/imo/media/doc/IHS%20Senate%20Interior%20Subcommittee%2
0COVID-19%20Hearing%20Testimony%20-%20Final%20042721.pdf on May 21, 2021. 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 13  different from that of the administrators and staff who may have worked at the facility 
for many years.  Although the CCRT feedback was well-received, one Area official 
reported that the CCRT members unfamiliarity with IHS made some 
recommendations difficult to implement, resulting in one facilitys tweaking the 
recommendations to better align with the facilitys needs and IHS processes.  In 
interviews, an Area Chief Medical Officer credited the CCRTs recommendations for 
helping facilities make long-term improvements to their processes and procedures, 
which had a positive impact on all patients and would likely continue beyond the 
pandemic.   
The CCRTs provided hands-on COVID-19-related training across 
facility departments and designated staff to continue the training 
after the team left, which facility administrators reported 
enhanced staff confidence in handling COVID-19 patients 
Shortly after the CCRTs arrived onsite and conducted their initial assessments of the 
facilities, the teams began to train facility staff on how to properly care for COVID-19 
patients, using best practices and personal experiences that the CCRT members had 
gained from working in COVID-19 units prior to the deployments with IHS.  The 
CCRTs tailored the training to address the needs of each facility and to enhance staffs 
individual and institutional knowledge.  In interviews, CCRT members and facility 
administrators described how they typically began the training sessions with a basic 
overview of COVID-19 care and then transitioned into advanced training, focusing 
specifically on emergency, inpatient, and critical care.  The training covered a wide 
range of topics, including handwashing; use of PPE; ventilation and airway 
management; Vapotherm therapy and other high-flow nasal oxygen therapy use; and 
proning of patientsthe process of turning a patient from lying on the back to lying 
face down to reduce respiratory distressamong other topics.93 
Strategy for Success:   The training was mostly interactive, with the CCRT members demonstrating and 
Hands-on Training  instructing staff at the bedside while attending to patients, or by using mannequins.  
CCRT members had  The CCRTs also covered training material through mock drills and lectures, virtually or 
expertise on COVID-19  in-person.  IHS officials and facility administrators reported that the hands-on training 
care and provided 
was the best way for staff to learn because it allowed them to observe and work 
hands-on training to 
side-by-side with providers who had experience caring for COVID-19 patients.  IHS 
nearly all facility staff on 
officials also stated that having the training in a team-based environment at the 
how to properly care for 
facility allowed the learning to occur collectively, which was more effective than 
COVID-19 patients.  
having a few staff at a time attend training at an offsite location where the training 
 
modules might be different each time. 
Although the CCRTs targeted specific departments, they also trained other clinical and 
nonclinical facility staff to increase the staffs understanding of the disease and 
treatment modalities and to strengthen the facilitys ability to respond to a potential 
surge of COVID-19 patients.  IHS officials and facility administrators explained that 
during a surge, facilities may need to pull staff from other departments to assist with 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 14  patient care, and therefore, those staff also had to be trained on skills that were 
essential to treating COVID-19 patients.   
According to facility administrators, nearly all clinical facility staff received training on 
COVID-19-related competencies during the deployments.  In interviews, a number of 
IHS officials and facility administrators noted that the training and the onsite presence 
of the CCRTs were crucial to instill skills and confidence in staff who often felt 
unprepared to manage COVID-19 patients.  CCRT members reported that they were 
sometimes met with resistance from staff who did not want to move away from their 
normal responsibilities and assist with COVID-19 patients, and the team had to work 
with facility leadership to build understanding and gain buy-in.  Several IHS officials 
and staff credited the CCRT training for saving lives because without it, the facilities 
would not have had the knowledge or skillset needed to adequately care for  
COVID-19 patients.   
The training was hugely valuable to staff in preparing for patients.  [The] level of 
confidence our staff has now in handling this and the level of care theyre able to 
provide... is much greater because of [the CCRTs] presence.  Facility Administrator 
 
To ensure that facility staff retained the new knowledge and kept up with COVID-19 
Strategy for Success:  
Super Trainers  competencies after the CCRTs left, the teams and facilities designated some staff as 
Facilities and CCRTs  super trainers to carry on the training post-deployment.  These super trainers 
designated super  received additional training from the CCRTs and were tasked with training other staff.  
trainers to continue  Several facility administrators reported that by assigning super trainerswho were 
staff training 
members of the facilities core staff and were unlikely to leave the facilitythe 
post-deployment and 
facilities could better ensure that staffs skills and comfort level were sustained over 
ensure retention of 
time.  Facilities could also extend this training to neighboring service units as a way to 
skills and knowledge 
strengthen the overall response to outbreaks in their geographic areas. 
over time. 
 
In some cases, the CCRTs also provided direct patient care and 
conducted community outreach on COVID-19 transmission and 
treatment, which helped relieve frontline staff and prepare Tribal 
communities for potential surges  
Although the CCRTs focused mostly on training staff, sometimes they also provided 
direct patient care while onsite.  In interviews, facility administrators and Area officials 
explained that in instances in which the CCRT provided direct patient care, the team 
would do so simultaneously with the training.  Administrators in one facility that was 
experiencing a surge when the team arrived described how the CCRT members 
quickly joined the frontline staff and worked side-by-side to care for the rising 
number of COVID-19 patients presenting at the facility, while also training staff.  
Administrators and staff stated that having the team onsite was a breath of fresh air 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 15  that provided relief and helped build confidence in staff who were exhausted from 
handling the many COVID-19 cases.   
[We] consistently heard how appreciative [staff] were of the team being there to 
help, elbow to elbow...  You feel more comfortable if you know you have an expert 
there next to you.  Area Chief Medical Officer 
 
The CCRTs also supported patient care through phone consultations with facility staff 
during deployment and post-deployment.  In interviews, one of the CCRT providers 
reported giving her personal contact information to the facility physicians and said 
that she had received frequent calls from the physicians, requesting consultations or 
wanting to share their success stories, long after the deployment ended.   
In addition to consultations with the CCRTs, facilities had access to a hotline if they 
needed advice on patient care.  The CCRT staffing agency subcontracted with a 
telehealth service provider to operate the hotline, which was staffed with critical care 
physicians and nurses.  All IHS and Tribal facilities had access to the hotline, which was 
available 24 hours a day, 7 days a week.  However, during the time period we 
reviewedJune through September 2020few facilities had used this resource.  In 
July 2021, IHS officials reported that the hotline had been discontinued when the 
contract for the service ended in May 2021.  Only one facility in our sample had used 
the hotline.   
In addition to providing direct patient care and training, CCRT members reported 
extending their services beyond the facility to the Tribal community.  Although 
community outreach was not part of the core responsibilities of the CCRTs, during 
one of the deployments, Tribal leaders invited the team to attend a Tribal council 
meeting to educate the community on COVID-19.  The meeting was held virtually and 
was broadcast on the local radio.  The team reported that they believed that similar 
meetings would be helpful to inform community members about the disease, and 
they said that they would have liked to conduct more outreach as part of their 
deployments.  Like the CCRT members, an IHS official also said that there was a need 
for additional outreach and education in Tribal communities to help prevent further 
spread of the virus and to mitigate capacity issues in the facilities. 
 
 
 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 16  Facility administrators provided close oversight of the CCRTs during 
the deployments, and communicated frequently with IHS HQ and 
Area Offices about CCRT activities and progress 
To monitor the progress of CCRT activities and to identify needed program 
Strategy for Success: 
Consistent Oversight   improvements, IHS provided oversight of the deployments both at the facility level 
IHS HQ held frequent   and the agency level.  Facility administrators reported providing direct oversight of 
meetings with facilities  the CCRTs, using the same chain of command as for other clinical staff in the facility.  
and CCRTs to monitor  At the HQ level, IHS designated a core group of officials and staff responsible for 
program challenges and  overseeing the CCRT program; these individuals were available to answer questions 
successes. 
and provide support to facilities throughout the deployment.  Members of this core 
 
group reported that they held calls with the facilities and the CCRTs pre-deployment, 
 
mid-deployment, and post-deployment to discuss and monitor the deployments.   
IHS officials and facility administrators explained that the pre-deployment calls were 
used for planning purposes to determine facility-specific needs and CCRT 
responsibilities, while the mid-deployment calls focused on the progress of the CCRT 
activities and any challenges that facilities and CCRTs encountered and changes they 
made as a result.  During the post-deployment calls, which were held at the end of 
each deployment, facilities and CCRTs gave debriefings on their experiences and the 
CCRTs presented their recommendations for facility improvements.  Members of the 
core group reported using the information from these calls, as well as from other 
sources, to modify the CCRT program and to improve future deployments.  For 
example, IHS officials noted that the CCRT program evolved over time to become 
more about building capacity of existing staff than about supplementing those staff. 
In interviews, facilities said that they found the frequent and open communication 
with the core group to be helpful.  The CCRT members also described the calls with 
the core group as valuable, but they said that they would have liked more 
opportunities to provide IHS with their overall observations and suggestions for 
improvements agencywide, beyond the individual facilities.  One observation that 
CCRT members reported was that facilities used different equipment, and they 
suggested that it would be more efficient if the agency used a blanket purchase 
agreement to standardize equipment across facilities.  The CCRT members noted that 
it was cumbersome for the teams and other temporary staff to learn and operate 
different equipment in each facility, particularly since the equipment was often old 
and outdated.  CCRT members also reported observingto their surprisethat IHS 
and Tribal facilities had many staff in administrative roles who were qualified to 
provide care but did not, and that facilities were quick to transfer patients to other 
facilities even though sometimes they had the capabilities to care for those patients 
themselves.  
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 17  IHS awarded new CCRT contracts in January 2021, extending the 
program through the pandemic, and facilities expressed the 
need for a similar program for non-COVID-19-related care 
Shortly after IHS began piloting the CCRT program, it decided to extend the program 
Strategy for Success:  
Program Continuity  through the pandemic, and in October 2020, IHS began soliciting proposals for an 
IHS awarded additional  Indefinite Delivery Indefinite Quantity (IDIQ) contract.  The IDIQ contract allowed IHS 
contracts to continue  to provide an indefinite quantity of services to facilities needing assistance with 
the CCRT program  COVID-19-related care through the duration of the pandemic.  To ensure continuity 
throughout the  of the CCRT program when the deployments of the initial CCRT contract ended in 
pandemic. 
November 2020, IHS officials reported using a transitional contractor to provide CCRT 
 
deployments while the agency was reviewing proposals for the IDIQ contract. 
 
In January 2021, IHS awarded the IDIQ contract to two separate staffing agencies and 
extended the CCRT program through at least the end of 2021.  The contract includes 
provisions that can extend the program through 2025, if needed, using 1-year 
increments.  In interviews, IHS officials and staff noted that having two contractors 
allows IHS to deploy multiple teams at the same time, and therefore, to better meet 
facility needs and train more staff on COVID-19 safeguards and treatment.  As of 
March 8, 2021, IHS had deployed CCRTs a total of 21 times to IHS and Tribal facilities, 
using the initial, transitional, and IDIQ contractors.  During these deployments, the 
CCRTs provided services to 15 IHS hospitals, 3 Tribal hospitals, and several satellite 
health centers and other facilities included in those deployments, and the teams 
trained a total of 1,255 facility staff.f   
None of the facilities in our sample indicated at the time of our review that they had 
plans to request another CCRT deployment.  However, we found that one of the 
facilities received a second deployment after our review period.  Further, several 
administrators and staff expressed interest in receiving additional consultation and 
COVID-19 training from the CCRTs.  Administrators in one facility reported that they 
wanted CCRT providers to review the facilitys progress in implementing the 
recommendations that the CCRT had provided during the deployment.   
In addition to reporting a need for more COVID-19 support, all facilities in our sample 
reported a need for resources similar to the CCRT program to assist facilities with 
training and consultation on non-COVID-19-related care, such as prevention, 
detection, and treatment of sepsis and high-risk obstetrics, among other topics.   
One facility reported that the CCRTs assistance in implementing the EHR templates 
for COVID-19 had been helpful, but more assistance was needed to standardize other 
IT-related templates in the facility.  In interviews, IHS officials indicated that they were 
open to providing additional non-COVID-19-related support to facilities, but they 
acknowledged that recurrent funding was needed to establish such a program and 
that it would need to be tailored to accommodate specific needs.  
_____________________________________________________________________________________________________________________________ 
f The 21 deployments that had occurred as of March 8, 2021, included the 5 deployments in our sample. 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Findings | 18   
CONCLUSION AND RECOMMENDATIONS 
 
 
The COVID-19 pandemic has been taxing on health care systems, and many U.S. 
hospitals have experienced shortages in both staffing and patient beds.  Given these 
challenges and the disproportionate numbers of AI/ANs affected by the disease, IHS 
developed the CCRT program to strengthen IHS and Tribal facilities response to the 
pandemic.  IHS designed the CCRTs as a resource for IHS and Tribal facilities to 
maximize their capacity to care for COVID-19 patients and effectively manage patient 
surges, even with limited staff.  The CCRT deployments provided facilities with 
assessments of their operations; hands-on training for staff; and assistance in 
implementing necessary changes to improve the care and outcome for critically ill 
COVID-19 patients.  The CCRTs used a comprehensive approach to involve as many 
departments and staff as possible in the assessments and trainings, so that facilities 
could more easily pull staff from their regular duties to assist with patient care during 
surges.   
Officials and staff across the agency and Tribal facilities have found this innovative 
resource to be successful, and IHS recently extended the program to continue 
deployments through the pandemic.  The CCRT program is a positive step in IHSs 
efforts to respond promptly to the immediate needs of facilities, and it also holds 
promise as a model for addressing some of the longstanding challenges that facilities 
face related to quality of care and staffing.  
To build on its successes and further leverage the CCRT model in support of IHSs 
broader care improvements efforts, we make three recommendations to IHS. 
We recommend that IHS: 
Solicit feedback from CCRTs regarding their observations of 
potential need for broader IHS-wide improvements  
To supplement the recommendations that CCRTs made to individual IHS and Tribal 
facilities, IHS should solicit feedback from the teams regarding their observations of 
potential need for broader agencywide improvements, which may extend beyond 
COVID-19-related care.  The frequent deployments and in-depth facility assessments 
provided the CCRTs with insight into common issues shared across facilities.  During 
the deployments, the CCRTs typically provided recommendations for improvement, 
but those recommendations were specific to individual facilities rather than agency-
focused.  To help IHS modify future deployments and identify needs and solutions for 
agencywide improvements beyond COVID-19-related care, IHS should provide 
opportunities for CCRTs to share their broader observations.  For example, IHS could 
host monthly or quarterly meetings with the CCRTs during which the teams could 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Conclusion and Recommendations | 19  present their observations and suggestions for improvements beyond the individual 
facilities. 
Compile the CCRTs recommendations to individual facilities 
and share them across all IHS and Tribal facilities 
To further strengthen facilities COVID-19 response, IHS should compile all CCRT 
recommendations into one resource and share it with facilities across the agency and 
Tribes.  This could be particularly beneficial for facilities that have not requested or 
have not yet received a CCRT deployment.  Although the recommendations are 
facility-specific, they could highlight improvement efforts that other facilities could 
replicate or use as guidance to make necessary changes that they might not 
otherwise have been aware of or considered. 
Assess whether IHS could use the CCRT model to provide 
support and training to facilities needing assistance with  
non-COVID-19-related care 
Given the programs success at helping meet facility needs during the pandemic and 
IHSs longstanding problems ensuring staffing and clinical expertise, IHS should 
consider the feasibility of building agencywide training on non-COVID-19-related 
issues using the CCRT model of hands-on training at the facility level.  The training 
could be tailored to specific facility needs and cover topics identified as high-risk by 
facilities and previous OIG reports, such as emergency care and labor and delivery 
(e.g., high-risk obstetrics).  Any new CCRT program should include components 
similar to those of the current CCRT programsuch as facility assessments; 
recommendations for policy and process improvements; training at the bedside; and 
other types of interactive trainingsand could also include direct patient care during 
crises.  We recognize that there might be budget constraints affecting IHS's ability to 
establish a similar program for non-COVID-19-related issues, as funding for the CCRT 
program is directly tied to the agencys COVID-19 response.  To launch a similar 
program, IHS would have to seek additional funds or shift funds from other areas.  
However, it is important to note that deployments of small, highly experienced teams 
assigned to train existing staff may be an efficient and effective way for IHS to expand 
facility capacity without paying for contracted providers or specialists at each facility 
and without having to send staff to offsite locations for trainings.   
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Conclusion and Recommendations | 20   
AGENCY COMMENTS AND OIG RESPONSE 
 
 
IHS concurred with our recommendations, and it reported its planned actions to 
implement the recommendations.   
In response to our first recommendationfor it to solicit feedback from CCRTs 
regarding their observations of potential need for broader IHS-wide improvements
IHS stated that it plans to solicit feedback from the current CCRT deployments to 
identify issues that may be applicable more broadly and that could be addressed 
throughout IHS. 
In response to our second recommendationfor it to compile the CCRTs 
recommendations to individual facilities and share them across all IHS and Tribal 
facilitiesIHS noted that it has compiled a document, which is currently under review, 
that summarizes all recommendations from previous CCRT deployments.  IHS stated 
that it plans to share this document with IHS and Tribal facilities, as appropriate, in 
October 2021. 
In response to our third recommendationfor it to assess whether IHS could use the 
CCRT model to provide support and training to facilities needing assistance with 
non-COVID-19-related care, IHS stated that it will assess other ongoing 
non-COVID-19 initiatives to determine whether the CCRT model could be used for 
such efforts.  IHS expects to complete its assessment by October 2021.  
 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Agency Comments and OIG Response | 21  APPENDIX:  Agency Comments
DEPARTMENT OF HEALTH & HUMAN SERVICES   Public Health Service 
______________________________________________________________________________________________________
Indian Health Service 
Rockville, MD  20857 
TO:  Inspector General 
FROM:  Acting Director 
SUBJECT:  IHS Response to Draft OIG Report, (OEI-06-20-00700), Indian Health Service 
Use of Critical Care Response Teams Has Helped to Meet Facility Needs During 
the COVID-19 Pandemic, dated June 2021 
We appreciate the opportunity to provide our official comments on the Draft Office of Inspector 
General (OIG) Report, (OEI-06-20-00700), Indian Health Service Use of Critical Care 
Response Teams Has Helped to Meet Facility Needs During the COVID-19 Pandemic, dated 
June 2021.  The Indian Health Service (IHS) concurs with the three OIG recommendations.  
Our responses and planned actions to the three OIG recommendations are discussed below.    
Recommendation No. 1:  IHS concurs with the recommendation 
Solicit feedback from CCRTs regarding their observations of potential need for broader 
agencywide improvements. 
Planned and completed actions: 
Feedback will be solicited from the current Critical Care Response Team (CCRT) contracts to 
identify issues that may be implemented on a broader basis throughout the IHS.  Feedback from 
current CCRT deployments will be shared within 30 days of the IHS receiving the CCRT 
contractors recommendations. 
Recommendation No. 2:  IHS concurs with the recommendation 
Compile CCRTs recommendations to individual facilities and share them across all IHS and 
Tribal facilities. 
Planned and completed actions: 
The IHS compiled a document summarizing all recommendations from previous CCRT 
deployments, which could be used by other facilities.  These recommended protocols are currently 
under Agency review and will be shared in October 2021, with IHS and Tribal facilities, as 
appropriate. 
Recommendation No. 3:  IHS concurs with the recommendation 
Assess whether IHS could use the CCRT model to provide support and training to facilities 
needing assistance with non-COVID-19 related care. 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
OEI-06-20-00700                           Appendix | 22 Page 2  Inspector General 
Planned and completed actions: 
The IHS will assess other ongoing non-COVID-19 initiatives to determine if using the 
CCRT model is appropriate for training and support activities by October 31, 2021. 
Thank you for the opportunity to review and comment on this draft OIG report.  Please refer any 
follow-up questions that you may have regarding our response to Ms. Athena Elliott, Chief 
Compliance Officer, IHS, by e-mail at athena.elliott@ihs.gov. 
Elizabeth A. Fowler 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
OEI-06-20-00700                           Appendix | 23  
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Petra Nealy served as the team leader for this study, and Charis Burger and 
Savanna Thielbar served as the lead analysts.  Office of Evaluation and Inspections 
staff who provided support include Joe Chiarenzelli, Althea Hosein, and 
Christine Moritz. 
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector 
General for Evaluation and Inspections in the Dallas regional office, and Petra Nealy, 
Deputy Regional Inspector General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Acknowledgments and Contact | 24   
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 nationwide 
network of audits, investigations, and inspections conducted by the following 
operating components: 
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 audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
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. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 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. 
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.
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  About OIG | 25   
EEEENNNNDDDDNNNNOOOOTTTTEEEESSSS    
 
 
1 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2021, p. CJ-2, 8.  Accessed at 
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf on 
April 2, 2020. 
2 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2021, pp. CJ-12.  Accessed at 
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf on 
April 2, 2020. 
3 Under the Indian Self-Determination and Education Assistance Act, P.L. No. 93-638, IHS contracts and compacts with Tribes or 
Tribal Organizations to deliver services. 
4 This support is given under the authority of Title V of the Indian Health Care Improvement Act, P.L. No. 94-437. 
5 IHS, Office of Urban Indian Health Programs: About Us.  Accessed at https://www.ihs.gov/urban/aboutus/ on April 6, 2021. 
6 Mark Walker, Pandemic Highlights Deep-Rooted Problems in Indian Health Service, The New York Times, updated January 3, 
2021.  Accessed at https://www.nytimes.com/2020/09/29/us/politics/coronavirus-indian-health-service.html on April 4, 2021. 
7 CDC, Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity.  Accessed (version updated April 23, 2021) at 
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html 
on May 21, 2021.  
8 IHS, COVID-19 Response, 100 Day Review.  Accessed at 
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on 
February 10, 2021. 
9 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2, 
2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021. 
10 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2021, p. CJ-179.  Accessed at 
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf on 
April 2, 2020. 
11 IHS, Locations.  Accessed at https://www.ihs.gov/locations/ on September 23, 2020. 
12 IHS, IHS Profile.  Accessed at https://www.ihs.gov/newsroom/factsheets/ihsprofile/ on September 24, 2020. 
13 IHS, Circular No. 88-02.  Accessed at https://www.ihs.gov/ihm/circulars/1988/service-unit-boundaries/ on September 30, 
2020. 
14 IHS, IHS Profile.  Accessed at https://www.ihs.gov/newsroom/factsheets/ihsprofile/ on September 24, 2020. 
15 Jiaye Liu et al., Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Shenzhen, China, 2020, 
Emerging Infectious Diseases, June 2020.  Accessed at https://wwwnc.cdc.gov/eid/article/26/6/20-0239_article on April 4, 2021. 
 
 
 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Endnotes | 26 
   
16 CDC, Risk for COVID-19 Infection, Hospitalization, and Death by Age Group.  Accessed (version updated February 18, 2021) at 
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html on April 4, 
2021.  
17 CDC, Symptoms of Coronavirus.  Accessed at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html 
on April 4, 2021.  [Page is now titled Symptoms of COVID-19.] 
18 Susie Neilson and Aylin Woodward, A comprehensive timeline of the coronavirus pandemic at 1 year, from Chinas first case 
to the present, Business Insider, December 24, 2020.  Accessed at https://www.businessinsider.com/coronavirus-pandemic-
timeline-history-major-events-2020-3 on April 4, 2021. 
19 WHO, WHO Director-Generals opening remarks at the media briefing on COVID-1911 March 2020, March 11, 2020.  
Accessed at https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-
briefing-on-covid-19---11-march-2020 on April 4, 2021. 
20 CDC, COVID Data Tracker, United States COVID-19 Cases, Deaths, and Laboratory Testing (NAATs [Nucleic Acid Amplification 
Tests]) by State, Territory, and Jurisdiction, updated September 1, 2021.  Accessed at https://covid.cdc.gov/covid-data-
tracker/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fcases-in-
us.html#cases_casesper100klast7days on September 1, 2021. 
21 Miriam E. Van Dyke et al., Racial and Ethnic Disparities in COVID-19 Incidence by Age, Sex, and Period Among Persons Aged 
<25 Years16 U.S. Jurisdictions, January 1December 31, 2020, CDC MMWR [Morbidity and Mortality Weekly Report], 
March 19, 2021.  Accessed at 
https://www.cdc.gov/mmwr/volumes/70/wr/mm7011e1.htm?s_cid=mm7011e1_w#suggestedcitation on April 4, 2021. 
22 IHS, Coronavirus (COVID-19), updated August 30, 2021.  Accessed at https://www.ihs.gov/coronavirus/ on September 1, 
2021.   
23 CDC, Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity.  Accessed (version updated April 23, 2021) at 
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html 
on May 21, 2021.  
24 Sarah M. Hatcher et al., COVID-19 Among Indian and Alaska Native Persons23 States, January 31-July 3, 2020, CDC 
MMWR, August 28, 2020.  Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/mm6934e1.htm on April 4, 2021. 
25 CDC, Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity.  Accessed (version updated April 23, 2021) at 
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html 
on May 21, 2021.  
26 Jessica Arrazola et al., COVID-19 Mortality Among American Indian and Alaska Native Persons14 States, January-June 
2020, CDC MMWR, December 11, 2020.  Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6949a3-H.pdf on 
February 12, 2021. 
27 OIG, Hospital Experiences Responding to COVID-19 Pandemic: Results of a National Pulse Survey March 2327, 2020 
(OEI-06-20-00330), April 2020. 
28 OIG, Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care Delivery, Results of a National 
Pulse Survey February 22-26, 2021 (OEI-09-21-00140), March 2021. 
 
 
 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Endnotes | 27 
   
29 Mark Walker, Pandemic Highlights Deep-Rooted Problems in Indian Health Service, The New York Times, updated 
January 3, 2021.  Accessed at https://www.nytimes.com/2020/09/29/us/politics/coronavirus-indian-health-service.html on 
April 4, 2021. 
30 HHS, HHS Announces $500 Million Distribution to Tribal Hospitals, Clinics, and Urban Health Centers, May 22, 2020.  Accessed 
at https://www.hhs.gov/about/news/2020/05/22/hhs-announces-500-million-distribution-to-tribal-hospitals-clinics-and-
urban-health-centers.html on September 4, 2020. 
31 Mark Walker, Pandemic Highlights Deep-Rooted Problems in Indian Health Service, The New York Times, updated 
January 3, 2021.  Accessed at https://www.nytimes.com/2020/09/29/us/politics/coronavirus-indian-health-service.html on 
April 4, 2021. 
32 IHS, IHS Recruitment.  Accessed at https://www.ihs.gov/dhps/programperformancedata/recruitment/ on September 30, 2020. 
33 OIG, Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention To Support Quality Care 
(OEI-06-14-00011), October 2016. 
34 Government Accountability Office (GAO), Indian Health Service: Agency Faces Ongoing Challenges Filling Provider Vacancies, 
GAO-18-580, August 2018.  Accessed at https://www.gao.gov/assets/gao-18-580.pdf on May 21, 2021. 
35 OIG, Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care Delivery, Results of a National 
Pulse Survey February 22-26, 2021 (OEI-09-21-00140), March 2021. 
36 Patrick Boyle, U.S. Physician Shortage Growing, Association of American Medical Colleges, June 26, 2020.  Accessed at 
https://www.aamc.org/news-insights/us-physician-shortage-growing on April 4, 2021. 
37 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2, 
2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021. 
38 IHS, Dear Tribal Leader and Urban Indian Organization Leader, May 19, 2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2020_Letters/DTLL_DUIOLL_0519202
0.pdf on September 4, 2020. 
39 HHS, HHS Announces $500 Million Distribution to Tribal Hospitals, Clinics, and Urban Health Centers, May 22, 2020.  Accessed 
at https://www.hhs.gov/about/news/2020/05/22/hhs-announces-500-million-distribution-to-tribal-hospitals-clinics-and-
urban-health-centers.html on September 4, 2020. 
40 IHS, Dear Tribal Leader and Urban Indian Organization Leader, January 15, 2021.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0115202
1.pdf on January 19, 2021. 
41 IHS, Dear Tribal Leader and Urban Indian Organization Leader, February 2, 2021.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0202202
1.pdf on February 10, 2021. 
42 IHS, Dear Tribal Leader and Urban Indian Organization Leader, March 8, 2021.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_03082021.pdf on 
April 5, 2021. 
 
 
 
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OEI-06-20-00700  Endnotes | 28 
   
43 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs, 
April 14, 2021.  Accessed at 
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15, 
2021. 
44 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs, 
April 14, 2021.  Accessed at 
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15, 
2021. 
45 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs, 
April 14, 2021.  Accessed at 
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15, 
2021. 
46 IHS, Dear Tribal Leader and Urban Indian Organization Leader, February 2, 2021.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0202202
1.pdf on February 10, 2021. 
47 IHS, Dear Tribal Leader and Urban Indian Organization Leader, May 19, 2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2020_Letters/DTLL_DUIOLL_0519202
0.pdf on September 4, 2020. 
48 IHS, press release, Biden Administration Invests Additional $1.8 Billion in American Rescue Plan Funding to Combat COVID-19 
in Indian Country, June 16, 2021.  Accessed at https://www.ihs.gov/newsroom/pressreleases/2021-press-releases/biden-
administration-invests-additional-1-8-billion-in-american-rescue-plan-funding-to-combat-covid-19-in-indian-country/ on 
June 21, 2021. 
49 IHS, Dear Tribal Leader and Urban Indian Organization Leader, March 26, 2021.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0326202
1.pdf on April 6, 2021. 
50 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs, 
April 14, 2021.  Accessed at 
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15, 
2021. 
51 IHS, Coronavirus (COVID-19), updated August 30, 2021.  Accessed at https://www.ihs.gov/coronavirus/ on September 1, 
2021.   
52 IHS, COVID-19 Response, 100 Day Review.  Accessed at 
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on 
February 10, 2021. 
53 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs, 
April 14, 2021.  Accessed at 
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15, 
2021. 
 
 
 
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OEI-06-20-00700  Endnotes | 29 
   
54 IHS, COVID-19 Response, 100 Day Review.  Accessed at 
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on 
February 10, 2021. 
55 IHS, FAQsFederal Response in Indian Country.  Accessed at https://www.ihs.gov/coronavirus/faqs-federal-response-in-
indian-country/ on April 4, 2021. 
56 IHS, COVID-19 Response, 100 Day Review.  Accessed at 
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on 
February 10, 2021. 
57 IHS, COVID-19 Response, 100 Day Review.  Accessed at 
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on 
February 10, 2021. 
58 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs, 
April 14, 2021.  Accessed at 
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15, 
2021. 
59 IHS, Dear Tribal Leader and Urban Indian Organization Leader, November 23, 2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2020_Speeches/RADM_Weahkee_Bi-
Weekly_Email_11.23.2020.pdf on April 22, 2021. 
60 GAO, Federal Personnel: Public Health Service Commissioned Corps Officers Health Care for Native Americans, 
GAO/GGD-97-111BR, August 1997.  Accessed at https://www.gao.gov/assets/ggd-97-111br.pdf on April 22, 2021. 
61 USPHS, Commissioned Corps of the U.S. Public Health Service: About Us.  Accessed at https://www.usphs.gov/about-us on 
April 2, 2021. 
62 USPHS, Fact Sheet: Rapid Deployment Forces.  Accessed at 
https://dcp.psc.gov/ccmis/RedDOG/FactSheets/RDF_Fact_Sheet_FINAL.pdf on February 9, 2021. 
63 IHS, FAQsFederal Response in Indian Country.  Accessed at https://www.ihs.gov/coronavirus/faqs-federal-response-in-
indian-country/ on April 4, 2021. 
64 IHS, National Supply Service Center: About.  Accessed at https://www.ihs.gov/nssc/about/ on April 4, 2021. 
65 IHS, FAQsFederal Response in Indian Country.  Accessed at https://www.ihs.gov/coronavirus/faqs-federal-response-in-
indian-country/ on April 4, 2021. 
66 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs, 
April 14, 2021.  Accessed at 
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15, 
2021. 
67 IHS, Coronavirus (COVID-19), updated August 30, 2021.  Accessed at https://www.ihs.gov/coronavirus/ on September 1, 
2021.   
 
 
 
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68 Richard Hoppe, Arizona National Guard Partners with Gila River Indian Community For Mass COVID-19 Vaccination Event, 
Luke Air Force Base Thunderbolt, February 24, 2021.  Accessed at https://www.aerotechnews.com/lukeafb/2021/02/24/arizona-
national-guard-partners-with-gila-river-indian-community-for-mass-covid-19-vaccination-event/ on April 4, 2021. 
69 CTUIR [Confederated Tribes of the Umatilla Indian Reservation] to hold mass vaccination event with aid of Oregon National 
Guard, East Oregonian, February 22, 2021.  Accessed at https://www.eastoregonian.com/coronavirus/ctuir-to-hold-mass-
vaccination-event-with-aid-of-oregon-national-guard/article_3d9feb94-7536-11eb-9531-db0d12fc9ccb.html on April 4, 2021. 
70 John Hughel, Washington Guard partners with Quinault Indian Nation, U.S. Army, May 27, 2020.  Accessed at 
https://www.army.mil/article/235977/washington_guard_partners_with_quinault_indian_nation on April 4, 2021. 
71 Emerson Marcus, Tribes, Nevada Guard combine efforts for COVID-19 testing, U.S. Army, August 19, 2020.  Accessed at 
https://www.army.mil/article/238292/tribes_nevada_guard_combine_efforts_for_covid_19_testing on April 4, 2021. 
72 IHS, Coronavirus (COVID-19), updated August 30, 2021.  Accessed at https://www.ihs.gov/coronavirus/ on September 1, 
2021.   
73 CDC, COVID Data Tracker, Vaccination Demographics, updated September 1, 2021.  Accessed at https://covid.cdc.gov/covid-
data-tracker/index.html#vaccination-demographics-trends on September 1, 2021. 
74 Pursuant to 25 U.S.C.  1680c(d)(2), IHS and Tribal health programs have the authority to vaccinate nonbeneficiaries to 
prevent communicable disease.  IHS, Coronavirus (COVID-19), section Frequently Asked Questions (FAQs) regarding the 
COVID-19 Vaccine, subsection Non-Beneficiaries, updated August 20, 2021.  Accessed at 
https://www.ihs.gov/coronavirus/vaccine/ on August 23, 2021. 
75 Mary Annette Pember, Most tribal clinics offer COVID-19 vaccines to non-Natives, Indian Country Today, March 11, 2021.  
Accessed at https://indiancountrytoday.com/news/most-tribal-clinics-offer-covid-19-vaccines-to-non-natives on August 23, 
2021. 
76 Erin Schumaker, Native tribes have expanded vaccines to everyone in Oklahoma, ABC News, March 17, 2021.  Accessed at 
https://abcnews.go.com/Health/native-tribes-expanded-vaccines-oklahoma/story?id=76509074 on August 23, 2021. 
77 IHS, IHS Contract Action with Fire Creek Services Company, May 22, 2020.  Accessed at 
https://www.fpds.gov/ezsearch/fpdsportal?indexName=awardfull&templateName=1.5.1&s=FPDS.GOV&q=75H70420P00027&
x=0&y=0 on September 29, 2020. 
78 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2, 
2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021. 
79 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2, 
2020.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021. 
80 OIG, Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention To Support Quality Care 
(OEI-06-14-00011), October 2016. 
81 OIG, Indian Health Service Hospitals: More Monitoring Needed To Ensure Quality Care (OEI-06-14-00010), October 2016. 
 
 
 
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic 
OEI-06-20-00700  Endnotes | 31 
   
82 OIG, Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening 
(OEI-06-17-00270), July 2019. 
83 OIG, Organizational Challenges to Improving Quality of Care in Indian Health Service Hospitals (OEI-06-16-00390), 
August 2019. 
84 OIG, Indian Health Service Has Strengthened Patient Protection Policies but Must Fully Integrate Them Into Practice and 
Organizational Culture (OEI-06-19-00330), December 2019. 
85 OIG, Indian Health Service Facilities Made Progress Incorporating Patient Protection Policies, but Challenges Remain 
(OEI-06-19-00331), December 2020. 
86 OIG, Incidence of Adverse Events in Indian Health Service Hospitals (OEI-06-17-00530), December 2020. 
87 OIG, Instances of IHS Labor and Delivery Care Not Following National Clinical Guidelines or Best Practices (OEI-06-19-00190), 
December 2020. 
88 OIG, Hospital Experiences Responding to COVID-19 Pandemic: Results of a National Pulse Survey March 2327, 2020 
(OEI-06-20-00330), April 2020. 
89 OIG, Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care Delivery, Results of a National 
Pulse Survey February 22-26, 2021 (OEI-09-21-00140), March 2021. 
90 OIG, Toolkit: Insights for Health Care Facilities From OIG's Historical Work on Emergency Response (OEI-06-20-00470), 
August 2020. 
91 OIG, Toolkit: Insights for Communities From OIG's Historical Work on Emergency Response (OEI-06-09-00440), August 2020. 
92 Ann M. Price et al., Using a high-flow respiratory system (Vapotherm) within a high dependency setting, Nursing in Critical 
Care, 13(6), 2008.  Accessed at https://pubmed.ncbi.nlm.nih.gov/19128313/ on April 5, 2021. 
93 Neal Wiggermann, Jie Zhou, and Dee Kumpar, Proning Patients With COVID-19: A Review of Equipment and Methods, 
Human Factors, 62(7), 2020.  Accessed at https://journals.sagepub.com/doi/10.1177/0018720820950532?url_ver=Z39.88-
2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed& on April 5, 2021. 
 
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OEI-06-20-00700  Endnotes | 32