Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
I H S
NDIAN  EALTH  ERVICE 
 
 
H : M
OSPITALS    ORE 
 
M  N
ONITORING  EEDED TO 
 
E Q C  
NSURE  UALITY  ARE 
 
Daniel R. Levinson  
Inspector General 
 
October 2016 
OEI-06-14-00010   
   
EXECUTIVE SUMMARY  INDIAN HEALTH SERVICE HOSPITALS:  MORE 
MONITORING NEEDED TO ENSURE QUALITY CARE  
OEI-06-14-00010 
 
WHY WE DID THIS STUDY 
We conducted this study and its companion, Indian Health Service Hospitals: Longstanding 
Challenges Warrant Focused Attention to Support Quality Care (OEI-06-14-00011), in response 
to concerns about the care provided in Indian Health Service (IHS) hospitals.  Reports of 
inadequate health care services for American Indians and Alaska Natives (AI/ANs) have 
concerned the Federal Government for almost a century.  IHS is responsible for providing health 
services to the 567 federally recognized tribes of  AI/ANs.  As part of its service, IHS directly 
operates 28 acute-care hospitals.  IHS requires its hospitals to be accredited by a nationally 
recognized organization (or certified by Medicare) and to comply with the Medicare Hospital 
Conditions of Participation (CoPs).  OIG is committed to continued work to improve patient care  
provided in IHS hospitals. Upcoming OIG work includes an IHS management review and a 
medical review focusing on patient safety in IHS hospitals.   
 
HOW WE DID THIS STUDY  
We interviewed leadership staff at each IHS-operated hospital, the eight IHS Area Offices that 
oversee hospitals, and IHS headquarters regarding their processes for quality monitoring and 
oversight.  Hospital interviews included the Chief Executive Officer (CEO) or Acting CEO, and 
Area Office interviews included the Area Director or Acting Director.  Additional leadership 
staff, such as clinical directors and chief medical officers, were also present in most interviews.  
IHS headquarters interviews included the Chief Medical Officer, the Director of Field 
Operations, and the Director of the Hospital Consortium.  We supplemented these interviews 
with document reviews and questionnaires. We  also interviewed staff and reviewed select 
documents from the Centers for Medicare & Medicaid Services (CMS), which is the primary 
oversight agency for hospitals nationwide. 
 
WHAT WE FOUND 
IHS may be missing opportunities to identify and remediate quality problems in its hospitals 
because it performed limited oversight regarding quality care and compliance with the CoPs.  
IHS relies on its Area Offices to monitor hospitals.  However, Area Office staff have few sources 
of information about hospital quality, and most limit reviews of that information to infrequent 
meetings of each hospitals Governing Board.  Further, CoP compliance surveys are not 
conducted by CMS with the frequency needed to make them a useful tool.  Staffing shortages in 
Area Offices also limit the clinical support and guidance that they are able to provide, and the 
most promising efforts to improve hospital quality lack dedicated funding.  Additionally, 
hospitals struggle to implement data-driven quality improvement methods as a result of limited 
information technology knowledge, a lack of resources, and difficulties with the electronic health  
record systems.   
 
 
 
 
 
   
   
WHAT WE RECOMMEND  
We recommend that IHS (1) implement a quality-focused compliance program; (2) establish 
standards and expectations for Area Office/Governing Board oversight activities; (3) work to 
identify newand more meaningfulhospital performance metrics; and (4) continue to invest 
in training for hospital administration and staff.  Additionally, we recommend that CMS assist 
IHS in its oversight efforts by conducting more frequent surveys of non-accredited hospitals, 
informing IHS leadership when hospitals are cited with deficiencies, and continuing to provide 
technical assistance and training.  The Office of the Secretary, IHS, and CMS provided a joint 
response to this report and its companion report.  Collectively, these HHS agencies concurred 
with all recommendations in both reports. 
   
 
 
   
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................7 
              Findings........................................................................................................9 
Area Offices performed limited oversight of IHS hospital  
quality of care and compliance with the CoPs .................................9 
Lack of routine surveys by CMS limits the                             
information available to IHS regarding hospital quality................12 
Staff reductions limit the clinical support and CoPs guidance  
that Area Offices provide ...............................................................13 
The Hospital Consortium provided a much needed focus on                               
quality improvement, but uncertainties remain about its influence 
and funding ....................................................................................14 
IHS hospitals struggle to implement data-driven quality 
improvement methods and to adapt to new technology.................15 
Recommendations ......................................................................................18 
            Agency Comments and Office of Inspector General Response .....21 
Appendixes ................................................................................................23 
A:  Table A-1:  IHS Hospitals by Area ..........................................23 
B:  Table B-1:  Hospital Conditions of Participation .....................25 
C:  Methodology ............................................................................27 
D:  Agency Comments ...................................................................29 
            Acknowledgments........................................................................................41
 
 
   
   
OBJECTIVE 
To assess the Indian Health Services (IHS) efforts to monitor and ensure 
that IHS hospitals provide quality care and comply with Medicare 
standards of care. 
BACKGROUND  
IHS is responsible for providing Federal health services to American 
Indians and Alaska Natives (AI/ANs).  IHSs mission is to raise the 
physical, mental, social, and spiritual health of AI/ANs to the highest 
level.  In partnership with the tribes, IHS provides free primary and 
preventive health care services for approximately 2.2 million AI/ANs 
living in the United States.  However, reports of health disparities and 
inadequate health care services for AI/ANs have been of concern to the 
Federal Government for almost a century. 
In 2010, Senator Byron Dorgan, then-Chairman of the Senate Committee 
on Indian Affairs, released a report citing problems in some IHS facilities 
related to credentialing and licensing of providers, accountability of 
controlled substances, and management of funds.  These problems were 
similar to those previously identified by the Office of Inspector General 
(OIG) and the U.S. Government Accountability Office (GAO).1  Prior to 
that, in 1999, and again in 2004, the U.S. Commission on Civil Rights 
found significant health disparities for AI/ANs as a result of structural 
barriers (e.g., insufficient staffing, aging facilities) and financial barriers 
(e.g., insufficient resources), many of which were similar to problems 
identified almost a century ago.  In 1928, a report requested by Federal 
oversight authorities regarding the conditions of AIs found that their health 
and living conditions were bad, and that the lack of funding, personnel, 
and equipment prevented the development of an adequate system of 
public health administration and medical relief work for AIs.2, 3     
 
____________________________________________________________ 
1 U.S. Senate Committee on Indian Affairs, In Critical Condition:  The Urgent Need to 
Reform the Indian Health Services Aberdeen Area, December 28, 2010.  Accessed at 
http://www.indian.senate.gov/sites/default/files/upload/files/Chairman-s-Report-In-
Critical-Condition-12-28-10.pdf on February 12, 2015. 
2 The Institute for Government Research, The Problem of Indian Administration, 
February 21, 1928, ch. I.  Accessed at 
http://www.alaskool.org/native_ed/research_reports/IndianAdmin/Indian_Admin_Problm
s.html on November 3, 2014.  
3 U.S. Commission on Civil Rights, Broken Promises:  Evaluating the Native American 
Health Care System, September 2004, pp. 2-4.  Accessed at 
http://www.usccr.gov/pubs/nahealth/nabroken.pdf on November 3, 2014. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        1   
   
Indian Health Services 
IHS provides health care services to 567 federally recognized tribes 
primarily through outpatient clinics, but in some locations it also offers 
inpatient care and behavioral and community health services.  Depending 
on agreements with the particular tribes, IHS either provides services 
directly to AI/ANs through IHS-operated facilities or provides financial 
support for the tribes to operate their own health care systems.4  Currently, 
just under half of IHSs $1.8 billion appropriation to provide health care 
services is allocated to Federal operations serving tribes directly.  The 
other half of the hospital and health clinics portion of the budget goes to 
the individual Indian tribes or tribal organizations that have contracts 
and/or compacts with IHS.5 
IHS Area Offices 
Located in Rockville, Maryland, IHS headquarters provides general 
direction, policy development, and support for each of the 12 Area Offices 
and their health care delivery sites, which may include hospitals, urgent 
care clinics, and/or other types of facilities.  Area Offices oversee the 
delivery of health services and provide administrative and technical 
support to the federally operated hospitals and clinics for one or more of 
the 170 geographically defined service units.6  Each Area Office includes 
staff dedicated to common services, such as finance, administrative 
support, information technology (IT), public health programs, and 
environmental health.   
IHS maintains its current policies, procedures, and operating standards in 
the Indian Health Manual (IHM).  The IHM is the preferred reference 
for IHS staff regarding IHS-specific policy and procedural information.7 
IHS Hospitals 
IHS directly operates 28 acute-care hospitals in 8 States, many of which 
are in remote locations.  (See Appendix A for a listing of IHS-operated 
hospitals and Figure 1 for a map of their locations.)  These hospitals are 
____________________________________________________________ 
4 Pursuant to the Indian Self-Determination and Education Assistance Act, P.L. No. 93-
638, IHS contracts and/or compacts with tribes or tribal organizations to deliver services. 
5 Department of Health and Human Services (HHS), IHS, Justification of Estimates for 
Appropriations Committees, Fiscal Year (FY) 2016, p. 6, 55.  Accessed at 
http://www.ihs.gov/budgetformulation/includes/tehemes/newihstheme.documents/FY201
6Congressional Justification.pdf on February 9, 2016.  Total IHS appropriations in 
FY 2015 were $4.6 billion.  In addition to the $1.8 billion appropriated for hospital and 
health clinic services, IHS supports programs such as dental services, public health, and 
purchased/referred care, among others.   
6 A service unit is an administrative subunit of IHS Area, operated by IHS or a tribe, with 
responsibilities for providing IHS services within a particular geographic area.   
7 IHS, Indian Health Manual, pt. 1; ch.1; section 1-1.2 (Indian Health Manual). 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        2   
   
typically small, with most having fewer than 50 beds.  IHS also contracts 
with tribes and tribal organizations to operate an additional 18 hospitals.   
 
Figure 1: IHS Hospital Locations 
 
+ = IHS-operated hospital 
Although 1 IHS hospital is a Level III Trauma Center and cares for more 
than 40 inpatients a day, less than half of the 46 hospitals have operating 
rooms and many lack the equipment to do a computerized tomography 
(CT) scan.  Collectively, in fiscal year (FY) 2013, IHS-run and tribally run 
hospitals had more than 13 million outpatient visits and a total of 
44,677 inpatient admissions.  Nearly half of these admissions  
(20,469 inpatients) were to the 28 IHS-operated hospitals.    
 
IHS hospitals may be reimbursed by Medicare, Medicaid, and private 
insurance entities for services they provide to AI/ANs enrolled in these 
programs.8  In addition to the $1.8 billion that Congress appropriated for 
hospitals and health clinics operated by IHS and tribes for FY 2015, IHS 
was expected to collect approximately $1.1 billion from these three 
sources, and 90 percent of this amount was expected to be collected from 
the Medicare and Medicaid programs.9  
Quality of Care in Hospitals 
Over the past decade, the Federal Government has progressively increased 
its focus on health care quality, placing new requirements on hospitals 
____________________________________________________________ 
8 Social Security Act  1880(a) and 1911(a), P.L. No. 94-437, Indian Health Care 
Improvement Act (codified at 25 U.S.C.  1621e). 
9 IHS, Justification of Estimates for Appropriations Committees, FY 2016, p. 6. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        3   
   
data systems and quality departments.  Hospitalspublic and private
began submitting quality data to the Centers for Medicare & Medicaid 
Services (CMS) in 2004 as part of a pay-for-reporting program.10, 11  
In 2006, CMS began developing a plan to link hospital payments to 
qualitya data-driven concept known as Value-Based Purchasingand 
added new requirements for reporting of hospital quality data.12, 13  In 
2009, the Federal Government created an incentive program granting 
$27 billion in funding for hospitals and other providers to adopt electronic 
health record (EHR) systems that were expected to reduce adverse drug 
events, decrease mortality rates, and lower health care costs.14, 15  (This 
incentive program is often referred to as Meaningful Use.)  In 2010, the 
Affordable Care Act tied payment to quality by including a provision that 
rewards or penalizes providers on the basis of quality performance.16  In 
2011, CMS launched Partnership for Patients, an initiative to improve the 
quality, safety, and affordability of health care by reducing preventable 
hospital-acquired conditions and readmissions.17  In January 2015, HHS 
announced specific measurable goals for participation in Value-Based 
Purchasing programs. HHS expected that by 2016, 85 percent of Medicare 
payments should be tied to programs such as the Hospital Value-Based 
Purchasing program and the Hospital Readmissions Reduction Programs.  
HHS expects 90 percent of payments to be tied to these programs by 
2018.18     
____________________________________________________________ 
10 P.L. No. 108-173, Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003  501(b). 
11 CMS, Medicare Hospital Value-Based Purchasing Plan Development Issues Paper, 
January 17, 2007.  Accessed at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/Downloads/Hospital_VBP_Plan_Issues_Paper.pdf on 
December 22, 2014.   
12 Ibid. 
13 P.L. No. 109-171, Deficit Reduction Act of 2005  5001(a) and 5001(b). 
14 See Titles IV and XIII of the American Recovery and Reinvestment Act of 2009.  P.L. 
No. 111-5.  
15 Office of the National Coordinator for Health Information Technology, EHR Incentives 
& Certification.  Accessed at http://www.healthit.gov/providers-professionals/ehr-
incentives-certification on March 3, 2015. 
16 Patient Protection and Affordable Care Act of 2010  3001(a). 
17 CMS, Press release:  Partnership for patients to improve and lower costs for 
Americans, April 12, 2011.  Accessed at 
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2011-Press-
Releases-Items/2011-04-12.html on March 5, 2015. 
18 HHS, News, Better, Smarter, Healthier: In historic announcement, HHS sets clear 
goals and timeline for shifting Medicare reimbursements from volume to value, 
January 26, 2015.  Accessed at 
http://www.hhs.gov/news/press/2015pres/01/20150126a.html  on January 26, 2015. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        4   
   
Quality Data Reported to Congress 
Pursuant to the Government Performance and Results Act of 1993 
(GPRA), IHS must report to Congress annually on the quality of health 
care provided to AI/ANs.19  In 2014, IHS reported more than 20 GPRA 
measures.  These measures focus on overall health of the AI/AN 
population, reporting almost exclusively rates of diagnostic screenings and 
preventive care.20 
Medicare Conditions of Participation 
IHS instructs its hospitals to be accredited by a nationally recognized 
organization (or certified by Medicare).  Accrediting organizations used 
by IHS must support the reimbursement requirements established by 
Medicare and Medicaid, including Medicares Conditions of Participation 
(CoPs).21, 22  The CoPs are a set of minimum quality and safety standards 
and include requirements such as establishing an effective governing body 
legally responsible for the conduct of the hospital, having an organized 
medical staff that is responsible for the quality of patient medical care, and 
maintaining a physical environment that avoids transmission of infections 
and communicable diseases.23 Additionally, hospitals should have an 
effective quality assurance and performance improvement (QAPI) 
program.24, 25  Hospital leaders may customize QAPI programs to best suit 
their individual needs, but the programs should be data-driven and 
hospital-wide, and should result in specific interventions designed to 
____________________________________________________________ 
19 IHS, Government Performance and Results Act Plus.  Accessed at 
http://www.ihs.gov/cio/GPRAPlus/gpra-plus-reporting.asp on December 7, 2015. 
20 IHS, GPRA FY 14 through FY 16 Performance Measures Matrix.  Accessed at 
https://www.ihs.gov/crs/includes/themes/newihstheme/display_objects/documents/gpra/2
016/2014-2016_Matrix.pdf  on September 9, 2016. 
21 IHS, Circular No. 97-01.  Accessed at 
http://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_circ_main&circ=ihm_circ_9701 on 
January 22, 2014. 
22 Social Security Act  1880(a) and 1865 (a)(1). 
23 42 CFR  482.1, 482.12, 482.22, 482.41 and 482.42. 
24 42 CFR  482.21.  
25 CMS, Survey & Certification (S&C) 03-16, Interim Guidance for the Hospital Quality 
Assessment and Performance Improvement Condition of Participation.  Accessed at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/downloads/SCLetter03-16.pdf on March 18, 
2015. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        5   
   
improve health outcomes for patients.26, 27  (See Appendix B for a 
descriptive list of all CoPs.)   
Hospital Surveys 
CMS and accreditation organizations monitor IHS-operated hospitals 
compliance with the CoPs through periodic onsite surveys.28  Surveyors 
observe how hospitals provided care to patients, and assess whether that 
care met the needs of the patient and was in compliance with all 
requirements.  To indicate noncompliance, surveyors cite hospitals with 
deficiencies that hospitals must correct in a timely manner to continue 
participating in Medicare.  Accreditation organizations conduct full 
surveys of accredited hospitals approximately every 3 years, but there is 
no regulatory timeframe requirement for CMS-conducted surveys.29  In 
addition to conducting these routine surveys, accreditation organizations 
and CMS conduct abbreviated surveys in response to complaints.  These 
complaint surveys substantiate or dismiss third-party allegations of 
noncompliance or poor quality.30   
Related Work 
This report expands on prior work by OIG in response to a congressional 
request.  In August 2015, OIG issued a reportOIG Site Visits to Indian 
Health Service Hospitals in the Billings, Montana Area  
(OEI-09-13-00280)that identified problems related to staffing and 
continuity of care at two sites in the Billings Area.  
Companion Report.  OIG is concurrently issuing a companion report, 
Indian Health Service Hospitals:  Longstanding Challenges Warrant 
Focused Attention to Support Quality Care (OEI-06-14-00011).  The 
companion report describes a range of interrelated challengessuch as 
low inpatient censuses (number of patients), access limitations, difficulty 
maintaining clinical competence, staffing instability, and outdated 
facilitiesthat affect IHS hospitals ability to provide quality care and 
maintain compliance with the CoPs.  (See a summary below of the 
challenges cited in the companion report.) 
____________________________________________________________ 
26 42 CFR  482.21. 
27 CMS, S&C 12-32, Patient Safety Initiative Pilot Phase  Revised Draft Surveyor 
Worksheets.  Accessed at http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-12-32.pdf 
on March 24, 2015. 
28 CMS, State Operations Manual (SOM), ch. 1, Sec. 1018A. 
29 Each accrediting organization describes its standard on the application for deeming 
authority, which is approved by CMS.  Survey frequency standards for non-accredited 
hospitals are not currently defined in Federal regulation. 
30 CMS, SOM, Chapter 5  5100.1, and 5200. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        6   
   
Staff-Reported Challenges Affecting IHS Hospitals 
IHS hospitals report facing significant and longstanding challenges that restrict their 
ability to provide quality care and meet Federal requirements. These challenges, 
summarized below, underscore the importance of robust oversight.  
Access limitations  Hospitals trying to meet the needs of a growing patient 
population are hampered by their small scopes of services and limited access to 
specialists. 
Difficulty maintaining clinical competence  With many hospitals treating few 
inpatients with complex conditions, providers lack the practice and repetition to 
maintain necessary skill sets for some procedures. 
Staffing instability  Difficulty recruiting and retaining staff has led to a dependence 
on acting personnel and contracted providers, weakening both leadership stability and 
the continuity of care provided to patients. 
Outdated buildings and equipment  Limited resources for maintaining or updating 
hospital structures and equipment has created service interruptions and concerns 
about patient safety. 
 
Source: OIG summary of companion report, Indian Health Service Hospitals:  Longstanding Challenges Warrant 
Focused Attention to Support Quality Care (OEI-06-14-00011). 
 
Upcoming Work.  OIG is committed to continued work to improve patient 
care provided in IHS hospitals.  Upcoming OIG work include an IHS 
management review and a medical review focusing on patient safety in 
IHS hospitals.  
 
METHODOLOGY 
This study describes IHSs efforts to ensure that the 28 IHS-operated 
hospitals provide quality care and comply with Medicare standards of 
care.  Report findings are based on multiple data sources, including 
telephone interviews, questionnaires, and document reviews.  We spent 
numerous hours conducting in-depth telephone interviews with leadership 
staff at each IHS-operated hospital, the eight Area Offices that oversee the 
hospitals, and IHS headquarters.  We verified staff reported issues when 
possible by reviewing documentation, such as internal management 
reports, contracts, meeting agendas, and survey deficiency reports.  In 
addition, we interviewed staff and reviewed select documents from CMS.  
Information was collected between April and October 2014.  (See 
Appendix C for a full description of the methodology.) 
Limitations 
Although we reviewed supporting documentation when possible, we often 
relied on the perspectives of staff in leadership positions and did not 
interview patients, midlevel or lower level staff, or tribal representatives to 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        7   
   
gain their perspectives.  Additionally, the findings in this report pertain 
only to the 28 IHS-operated hospitals and cannot be generalized to other 
IHS providers, including the 18 hospitals operated by tribal organizations. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        8   
FINDINGS 
Area Offices performed limited oversight of IHS 
hospital quality of care and compliance with the CoPs 
Eight of the twelve Area Offices oversee the twenty-eight IHS hospitals, 
and these offices are charged with an important role in quality oversight.  
IHS has established Governing Boards for each of its hospitals.  
Governing Board membership is composed of staff from the respective 
Area Offices, making them the primary parties responsible for the 
performance of the hospitals, including compliance with the CoPs and the 
quality of care provided to patients.31  However, Area Offices vary in the 
extent to which they monitor and oversee hospital performance.   
Area Offices have few sources of information about hospital 
quality 
Each of the eight Area Offices reported that they conduct activities to 
monitor quality, yet those efforts are minimal in some Areas.  Even the 
Area Offices that are most engaged in monitoring activities acknowledged 
limitations in the comprehensiveness and usefulness of the information 
they collected.    
A small number of complaints and patient harm reports are the primary 
source of information Area Offices use to detect quality problems.  Five of 
the eight Area Offices stated that they are most likely to detect quality 
problems at hospitals through complaints by patients, patient families, or 
staff.32  However, according to hospital administrators, most patient 
complaints relate to customer service and wait times, rather than medical 
care.  Further, most hospitals (20 of 28) receive fewer than 100 complaints 
per year for inpatient and outpatient visits combined, averaging about  
1 complaint per 1,000 patient visits.   
Patient harm is rarely recorded by staff in an IHS hospitals incident 
reporting system.  According to a recent internal report by IHS, 4 hospitals 
reported no patient harm data during a 16-month reporting period and 
another 10 hospitals reported rates of fewer than 5 harm events per  
1,000 risk opportunities each month.33  Considering the quantity and 
____________________________________________________________ 
31 See 42 CFR  482.12; See also CMS, SOM, App. A  482.12. 
32 The other three Area Offices said they usually detect problems through mock surveys, 
data trends, or peer reviews.   
33 A risk opportunity is the number of patient harm events to which an inpatient is 
considered susceptible.  IHS limits its harm rate to a list of 10 hospital-acquired 
conditions, and some of these harm events are not applicable to every patient.  For 
example, only patients who undergo surgery are at risk for surgical infections.  On 
average, patients have approximately five risk opportunities per admission.  
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        9   
subject matter of complaints and patient harm reports, they are unlikely to 
provide hospital staff with the breadth of information needed to identify 
and diagnose systemic quality or compliance breakdowns.   
Half of Area Offices do not routinely conduct mock surveys, which provide 
insight regarding hospital quality practices.  Mock surveys typically 
include methods similar to those that CMS uses during certification 
surveys or that accrediting organizations use during accreditation surveys.  
These methods include direct observations, policy reviews, and medical 
record reviews.  Although they are not required to do so, four of the eight 
Area Offices reported conducting mock surveys to assess hospital quality 
and compliance between accreditation or certification surveys.  These 
mock surveys vary in frequency, but most hospitals in these four Areas 
receive such surveys annually.  Three Area Directors described mock 
surveys as the best way to ensure that hospitals are meeting national 
standards of care.   
Area Offices that reported that they did not conduct mock surveys stated 
that they lacked either appropriate staff or sufficient funding to perform 
this type of oversight.  The Area Directors reported occasionally hiring 
consultants to fill that role, but stated that they primarily rely on hospitals 
to self-monitor.  Consequently, these Area Offices must depend on the less 
frequent surveys conducted by accrediting organizations or CMS and/or 
meeting benchmarks with reported data metrics, such as CMSs Hospital 
Compare, to gauge whether hospitals are meeting national standards of 
care.  
Data monitoring is both difficult and less useful for small IHS hospitals.  
Traditional metrics for monitoring qualitysuch as those found in CMSs 
Hospital Compare and in the Core Measures developed by the Joint 
Commission (TJC), an accrediting organizationare often not applicable 
to IHS hospitals.  Too often, these metrics relate to procedures or services 
that are either not performed or are performed so infrequently that quality 
measures cannot be used for comparison to other hospitals.  Inpatient 
censuses for small IHS hospitals can be as few as one or two patients per 
day, and the hospitals may not have sufficient opportunities to perform 
procedures that are commonly used for outcomes comparisons.  For 
example, several hospitals do not perform surgery and therefore cannot 
provide rates of postsurgical infections.  Treatment for other conditions 
may be in the scope of services offered at the hospital (e.g., treatment for 
heart failure or pressure ulcers), but these conditions may be so seldom 
seen that an outcomes comparison to other hospitals is not meaningful. 
GPRA measures are widely reviewed by IHS hospital administrators and 
are the quality data that the Area Offices most frequently review, but these 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        10   
measures emphasize health screening and prevention activities for the 
AI/AN population and are not specific to the services provided at the 
hospitals.  GPRA measures include data regarding immunization rates, 
cancer screenings, and smoking cessation education, all of which hospitals 
may perform (see Table 1).  However, these measures have little bearing 
on the most critical hospital-management issues, such as infection control 
practices or patient outcomes (e.g., mortality rates). 
Table 1: Topics Covered by GPRA Performance Measures (FY 2014) 
Topics Covered by GPRA Performance Measures 
Clinical tests or screenings (8) 
  Cholesterol testing for diabetic patients    Retinopathy assessment for diabetic patients 
  Mammography    Colorectal cancer screening 
  Depression screening    Domestic violence screening 
  Risk assessments for cardiovascular patients    HIV testing for pregnant women 
Prevention activities (7) 
  Access to dental services    Use of dental sealants for children 
  Use of topical fluoride for children    Childhood immunization rates 
  Influenza vaccines for senior adults    Tobacco cessation interventions 
  Breastfeeding rates 
Administration (3) 
  Implementation of tribal recommendations    Documentation of public health nursing activities 
  Suicide surveillance reporting 
Patient outcomes (2) 
  Glycemic control for diabetic patients    Blood pressure control for diabetic patients 
Accreditation (2) 
  Hospital accreditations    Youth Regional Treatment Center accreditations* 
Source:  OIG summary of IHS's GPRA performance measures reported in FY 2014. 
*Youth Regional Treatment Centers are tribally and federally operated centers that address substance abuse and co-occurring disorders 
among AI/AN youth. 
Most Area Offices depend on infrequent Governing Board 
meetings to review quality metrics 
All but one Area Office identified their respective Governing Board 
meetings as an important component of their quality oversight efforts.  
(The remaining Area Office began holding these meetings in January 
2015, after our review.)  OIG states in its guidance to Governing Boards 
that it views the quality-improvement function of Governing Boards as 
critical for minimizing the risk of patient harm.  In addition, industry 
research suggests that Governing Board practices are strongly related to 
hospital quality performance.34, 35  In addition to providing opportunities 
____________________________________________________________ 
34 HHS, OIG, et al., Practical Guidance for Health Care Governing Boards on 
Compliance Oversight.  April 20, 2015.  Accessed at http://oig.hhs.gov/newsroom/news-
releases/2015/guidance-release2015.asp on April 20, 2015. 
35 Tsai, Thomas, et al., Hospital Board and Management Practices are Strongly Related 
to Hospital Performance on Clinical Quality Metrics.  Health Affairs, August 2015. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        11   
for reviews of financial statements and administrative responsibilities, 
Governing Board meetings give Area Offices an opportunity to inquire 
about hospitals quality challenges and performance on various quality 
metrics.  The nonprofit Institute for Healthcare Improvement recommends 
that Governing Boards review quality data weekly, or at a minimum, 
monthly.36 
In one Area Office, staff reported that the only time they routinely review 
hospital quality datasuch as incident reports, peer reviews, or statistics 
about patient outcomesis during their twice-yearly Governing Board 
meetings.  Four other Area Offices reported reviewing the vast majority of 
quality data only at their Governing Board meetings, with the exception of 
a few items that they review more frequently.  For example, one Area 
Office reviews incident reports and complaints as it receives them and 
conducts more frequent monitoring of its Special Diabetes Program, but 
leaves all other programmatic reviews until its Governing Board meetings. 
Despite the importance of Governing Board meetings, they are 
infrequent.37  Although IHS has not established a specific requirement for 
the frequency of meetings, the two Area Offices with the highest number 
of scheduled Governing Board meetings per year met on a quarterly basis.  
Four other Area Offices reported meeting two to three times per year, and 
one Area Office held only one Governing Board meeting each year.  
Lack of routine surveys by CMS limits the information 
available to IHS regarding hospital quality  
Administrators from four hospitals described accreditation or certification 
surveys as the most useful source of information to determine whether 
hospitals are following acceptable standards of care.  Of the  
28 IHS-operated hospitals, CMS was responsible for conducting CoP 
compliance surveys for 10.38  (The other 18 hospitals were deemed 
compliant on the basis of their good standing with an approved accrediting 
organization.)  CMS does not have a written requirement as to how often it 
must survey these non-accredited hospitals, but a staff member described 
an unofficial goal of conducting certification surveys of IHS hospitals at 
least once every 5 to 6 years.  CMS met this modest benchmark for 9 of 
____________________________________________________________ 
36 Institute for Healthcare Improvement, 5 Million Lives Campaign.  Getting Started Kit: 
Governance Leadership Boards on Board How-to Guide.  Cambridge, MA; 2008.  
Accessed at 
http://www.ihi.org/resources/Pages/Tools/howtoGuideGovernanceLeadership.aspx on 
April 3, 2015. 
37 In addition to holding full Governing Board meetings, some Boards hold separate 
meetings to address ad-hoc issues and/or to give formal approval for the credentialing of 
medical staff.  These meetings were not included in our frequency analysis. 
38 CMS, SOM, Pub. 100-97, ch. 1,  1018A. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        12   
the 10 hospitals that it surveyed.  The remaining hospital had not been 
surveyed since 2005, which was 8 years prior to our review.  By 
comparison, all of the 18 accredited hospitals were surveyed during the  
3-year timeframe of our review (20112013).  During the same timeframe, 
CMS recertified only two nonaccredited hospitals.   
In an interview, CMS officials expressed concern that some IHS hospitals 
had incomplete or outdated knowledge of the CoPs and lacked expertise 
with methodologies for quality improvement.  As a result, CMS decided to 
use its limited funds towards training and hands-on technical assistance, 
rather than increasing the number of surveys it conducted.  As part of this 
effort, CMS staff went onsite to assist hospitals with significant problems 
and extended CMSs CoPs training (originally designated for State survey 
agencies) to IHS staff.  Administrators from all but 1 of the 28 hospitals 
reported receiving some kind of education or technical assistance from 
CMS or a CMS-funded Quality Improvement Organization (QIO) during 
the prior year.   
Complaint surveys are another source of information about hospital 
compliance; however, delayed CMS investigations may limit their 
usefulness.  Administrators from one hospital explained that when CMS 
finally came onsite to conduct a survey after a long interlude, it reviewed 
multiple complaints dating back as far as 5 years.  CMSs policy for 
investigating complaints allows for less serious complaints to be addressed 
during the next onsite survey.39  However, according to these hospital 
administrators, the lag between the complaints and the CMS investigation 
made it impractical to identify the breakdowns and to make timely 
improvements. 
Staff reductions limit the clinical support and CoPs 
guidance that Area Offices provide  
Tribal contracting, Sequestration, reorganizations, and the difficulty of 
filling positions affected staffing in most Area Offices.40  Five of the eight 
Area Directors described significant decreases in the number of staff 
positions during the past decade; two Area Offices reported losing over 
50 percent of their staff positions in recent years.  These losses were 
____________________________________________________________ 
39 CMS, SOM, ch. 5  5075.9, Maximum Time Frames Related to the Federal Onsite 
Investigation of Complaints/Incidents, Updated 9-19-14.  Accessed at 
http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107c05.pdf on February 9, 2015. 
40 Pursuant to the Indian Self-Determination and Education Assistance Act, P.L. No. 93-
638, tribes may contract with IHS to provide health services directly to their members, 
taking significant portions of Area Office budgets with them. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        13   
further compounded by a high vacancy rate (13 percent) for remaining 
positions across the eight Area Offices.  
Staffing reductions and vacancies led several Area Offices to shift services 
towards administrative matters and to conduct less community outreach 
and clinical consulting.  One Area Office reported having only four staff 
members with clinical expertise remaining in the Area.  As a result, the 
hospital clinical directors in this Area rely on each other to identify and 
solve problems with little support from the Area Office.  They had 
previously consulted the Area Office for some clinical and other issues.  
Two other Area Offices reported no longer employing clinical consultants 
to manage the Areas nursing and quality assurance programs, which are 
important components of ensuring hospital quality.   
From the hospitals perspective, the lack of clinical support staff 
sometimes limits Area Offices ability to assist hospitals.  For example, 
administrators from two hospitals reported that lack of staffparticularly 
clinical consultantsand lack of funding are the reasons their Area 
Offices no longer conduct hospital program reviews or mock surveys.41 
Administrators from another hospital described its Area Office as being 
overwhelmed, with too many facilities to oversee and not enough staff, 
and reported difficulties receiving timely assistance. 
The Hospital Consortium provided a much needed 
focus on quality improvement, but uncertainties 
remain about its influence and funding 
Prompted by quality concerns and requests for assistance with compliance 
with the CoPs, some Area Offices combined efforts to create a 
collaborative group dedicated to achieving and maintaining hospital 
quality standards of care.  Organized at the national level circa 2012, this 
groupthen known as the Hospital Consortium (the Consortium)
included representatives from each Area.  During its first 2 years, the 
Consortium laid groundwork for future improvements, including 
facilitating training for hospital staff, collecting baseline quality metrics, 
and earmarking topics for research.   
Despite these positive efforts, the ability of this group to improve quality 
is unclear.  Consortium leaders reported that not all Areas are fully 
engaged in the Consortium activities and that IHS leadership has yet to 
find funding to hire a permanent Consortium director.  One IHS official 
____________________________________________________________ 
41 Like mock surveys, program reviews evaluate program priorities, strengths, 
deficiencies, and unmet needs for specific functional areas.  However, program reviews 
are typically conducted by Area Office consultants for a single programmatic topic.  IHS, 
Indian Health Manual, pt. 3; ch. 8; section 3-8.2B. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        14   
explained that the financial cost of providing basic patient care leaves few 
resources to devote to other activities, such as the Consortium. 
The Consortiums lack of dedicated funds may also affect the future of 
this group.  Through interagency agreements connected to CMSs 
Partnership for Patients initiative, CMS provided over $2.3 million in 
2013 and 2014 to support the efforts of the Consortium.  However, no 
subsequent funding agreements were made to continue this support in 
2015.  Although the Consortium was in place before CMS funding, it 
could not have completed the bulk of its work without CMSs support.  
The funding supported the cost of four staff to lead the Consortium in 
2013 ($450,000).  It also allowed for several contracts, with the largest 
contracts (totaling $700,000) dedicated to hospital performance 
assessmentsevaluating current processes and providing onsite 
assistance.  Another $450,000 was dedicated to the development of Web-
based training on quality-related topics and to travel costs for select staff 
to attend CMS training on the hospital CoPs.  Additional contracts were 
let for conducting a needs assessment ($400,000) and improving data 
analytic capacities ($300,000).  As the Consortium continues, leaders have 
identified new goals for standardization of Governing Board bylaws and 
credentialing, as well as exploring opportunities for annual accreditation 
surveys.   
IHS hospitals struggle to implement data-driven 
quality improvement methods and to adapt to new 
technology 
Although all IHS hospitals report having a QAPI program, under-
developed programs and IT challenges in many hospitals result in 
difficulties meeting new and evolving expectations for quality.  Current 
standards place a high emphasis on hospitals use and reporting of quality 
statistics, which is dependent on accurate data collection and the ability to 
extract information from the relevant IT and EHR systems.  An IHS 
official who oversees the Area Offices described hospital staffs lack of 
IT-related knowledge and training as one of the top barriers to quality and 
compliance in IHS hospitals.   
Administrators from nearly half of hospitals reported 
significant challenges in collecting, analyzing, or reporting 
quality or patient outcomes data 
Of the 28 hospitals, 12 reported difficulties collecting, analyzing, or 
reporting data related to quality or outcomes.  These data challenges stem 
from staff shortages, lack of expertise, low inpatient censuses, and 
competing priorities.  For example, although IHS expects hospitals to have 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        15   
at least one staff member specialized in extracting information from 
EHRs, administrators from two hospitals reported extended periods (up to 
10 years) without such a person.  Other hospitals described the 
requirements for reporting data (to Area Offices and external groups) as 
onerous and expressed the need for more direction from the Area 
Offices on how to prepare the reports.  Further, as described previously, 
smaller hospitals may not treat a sufficient number of patients with 
particular conditions or conduct enough of certain procedures to make 
meaningful comparisons to other hospitals.   
Difficulties using EHR systems contribute to wait times and 
create potential for quality problems in some IHS hospitals  
The adoption of EHR systems was intended to improve patient care in 
hospitals.  However, administrators from nine hospitals reported that the 
current systems are cumbersome and outdated and have significantly 
increased patient wait times.  For example, administrators from one 
hospital reported difficulties completing EHR documentation in real time 
because of a slow system and the lack of the ability to record information 
in examination rooms.  These problems are particularly pronounced in the 
hospitals emergency department where staff and providers must often 
move quickly from patient to patient.  Hospital administrators reported 
that the lag in documentation combined with the urgency of patient care 
sometimes resulted in patient visits that were not recorded and the transfer 
of emergency patients without the electronic portion of the medical record.  
In another hospital, administrators explained that it does not use EHRs in 
the emergency department out of concern with not being able to use them 
effectively.  Other concerns included frustration and delays related to the 
use of parallel systems, such as requiring multiple logins to access certain 
information (e.g., x-rays and outside referrals), and problems with the 
systems freezing.  
Hospital Quality Assurance and Performance Improvement 
programs fall short on requirements to be data-driven and 
hospital-wide 
Although CMS added the QAPI requirement to the hospital CoPs more 
than a decade ago (2003), several IHS staff members explained that 
hospital QAPI efforts are relatively new or have been recently enhanced to 
reflect the new emphasis.  The addition of the QAPI requirement was an 
effort to bring about a data-driven, proactive approach to improving 
patient care.42  This requirement combines quality assurance, which is a 
retrospective effort to examine why a facility failed to comply with certain 
____________________________________________________________ 
42 CMS, S&C 03-16, Interim Guidance for the Hospital Quality Assessment and 
Performance Improvement Condition of Participation. (See footnote 26 for URL.) 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        16   
standards, and performance improvement, which is a proactive and 
continuous effort to prevent problems by addressing underlying causes of 
systemic problems.43  One Area Office reported that its hospitals began 
QAPI efforts only 212 years ago.  Another Area Office indicated that 
a basic QAPI infrastructure is only now being required of its hospitals.  
Administrators from a hospital within one of these Areas described its 
QAPI program as small and indicated that the hospital needs to dedicate 
more time to it.  Other hospitals indicated that they have functioning QAPI 
programs, but struggle with certain required aspects, such as managing 
data and ensuring that the improvement efforts are hospital-wide. 
The lack of QAPI-dedicated staff in Area Offices may affect hospitals 
ability to instill a culture of continuous performance improvement.  
Although most hospital administrators reported having a dedicated quality 
manager on staff to identify and address quality problems, only four Area 
Offices reported having a dedicated staff member (i.e., a clinical 
consultant) to provide direction and assistance to hospital staff regarding 
QAPI.  Several hospital administrators from the remaining Areas 
expressed a desire for more assistance and direction on QAPI compliance. 
The projects selected for QAPI efforts are sometimes related to 
administrative or customer satisfaction, rather than being driven by 
patient-harm data, as required.  When asked about current and recent 
performance improvement efforts, leadership staff from several hospitals 
reported administrative improvement efforts such as provider productivity, 
privileging, or billing processes, or physical improvement such as 
renovating buildings.  Others identified efforts to improve customer 
satisfaction generally or as it related to long wait times, inadequate seating 
in the waiting room, a drab institutional appearance, or noise problems 
during evening hours.  Additionally, administrators from three hospitals 
reported that they try to comply with the requirement that QAPI efforts be 
hospitalwide by requiring each clinical department to identify a project.  In 
the absence of data to guide the selection of projects, staff may be 
introducing a great deal of subjectivity into what should be primarily a 
data-driven process.   
____________________________________________________________ 
43 CMS, QAPI Description and Background.  Accessed at 
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/qapidefinition.html on October 27, 2014. 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        17   
RECOMMENDATIONS 
IHS staff told usand our review of documentation supportsthat IHS 
hospitals attempt to meet new revised requirements for quality while also 
struggling to meet patients basic care needs.  A companion reportIndian 
Health Service Hospitals:  Longstanding Challenges Warrant Focused 
Attention to Support Quality Care (OEI-06-14-00011)identifies 
longstanding challenges:  ensuring access to needed care, maintaining 
clinical competence, recruiting and retaining essential staff, and keeping 
patients safe despite outdated buildings and equipment.  These issues 
elevate the importance of IHSs efforts to ensure a strong infrastructure for 
quality and proactive monitoring efforts.  However, IHS has few sources 
of information on its hospitals performance and a limited capacity to 
provide clinical support.  CMS surveys could be a valuable source of 
information to assist IHS in improving quality, but CMS does not conduct 
these surveys with the frequency needed for IHS to rely on them as a key 
management tool.  Additionally, the lack of dedicated funding within IHS 
means there is a risk of curtailing the most promising efforts to improve 
hospital quality.  As a result, IHS may be missing opportunities to identify 
and remediate quality problems in its hospitals.   
We recommend that IHS: 
Implement a quality-focused compliance program to support 
Federal requirements for health care programs 
IHS should establish an agencywide compliance program thatin 
addition to including other elements of an effective compliance program
oversees the analysis of risk areas, investigation of reported concerns, and 
development of efforts to improve program quality.  The program should 
be supported by a committee that is chaired by a compliance officer and 
includes members of IHS senior management and physician executives, as 
well as representatives from Area Offices and service units.  This program 
should coordinate and support the compliance efforts of the Area 
Offices/Governing Boards and hospitals.  The program should include 
mechanisms for staff at all levels to confidentially report concerns 
regarding quality and/or compliance and should ensure timely 
investigations of such reports.  The committee should address quality care 
matters such as patient safety, peer review, and credentialing and 
privileging, and it should meet at least quarterly. 
   
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        18   
Establish standards and expectations for how Area Offices/ 
Governing Boards oversee and monitor hospitals and monitor 
adherence to those standards 
Area Offices/Governing Boards should review and oversee matters related 
to quality and compliance with Federal requirements for health care 
programs.  IHS should provide guidance to Area Offices/Governing 
Boards on both minimum standards and best practices for quality 
oversight.  This should include minimum standards for the content and 
frequency of Governing Board meetings, the review of quality metrics, 
and the use of mock surveys and/or peer review processesall of which 
were found to be inconsistent among IHS Areas.  When IHS develops 
these standards, it should consult OIG for guidance on the role of 
Governing Boards.  Additional guidance may be warranted for standards 
regarding intake of patient complaints and staff reporting of patient harm.  
IHS should incorporate such standards into the Indian Health Manual, 
periodically assess whether its expectations are being met, and it should 
hold Area Offices/Governing Boards accountable.   
Continue to seek new and meaningful ways to monitor 
hospital quality through the use of outcomes and/or process 
measures   
IHS should partner with Federal agencies that have expertise in 
developing health care quality indicators, such as the Agency for 
Healthcare Research and Quality, and strive to develop more suitable 
quality metrics for small rural hospitals.  IHS should consider the use of a 
customized panel of quality metrics for each hospital to ensure that it 
observes the most meaningful measures for that hospital.  
In addition, given hospital and Area Office focus on GPRA reporting, IHS 
should develop additional GPRA measures to monitor hospital 
performance.  GPRA appears to be the most widely used tool for quality 
improvement in IHS, yet only one GPRA measure specifically addresses 
hospital performance.  This measure, which is the percentage of hospitals 
that are accredited (or certified by Medicare), does not reflect serious 
and/or extended compliance deficiencies with the CoPs.  New quality 
measures could include the number of survey deficiencies cited, number 
of serious reportable events, and/or numbers of patient harm indicators, 
such as unexpected mortality.  Additional measures related to management 
could include measures of staff turnover and use of acting positions or 
percentage of providers who are contracted. 
 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        19   
Continue to invest in training for hospital administration and 
staff, and assess the value and effectiveness of training efforts 
IHS recently began a training initiative that includes developing a series of 
Web-based trainings and funding staff attendance at CMS-sponsored 
training on the hospital CoPs.  Although these efforts appear to align with 
IHSs current needs, IHS should study the value and effectiveness of these 
efforts to ensure the best use of limited training resources.  Further, IHS 
should continue to invest in training efforts and ensure that the content 
covers both quality improvement methodologies and training to correct 
specific deficits, such as difficulties in extracting and reporting data from 
the EHR system.   
We recommend that CMS: 
Assist IHS in its oversight efforts by conducting more frequent 
surveys of IHS hospitals, informing IHS leadership of 
deficiency citations, and continuing to provide technical 
assistance and training 
CMS should elevate the priority of conducting CoP compliance surveys 
for IHS hospitals that are non-accreditedof which there are currently 
10to ensure that it surveys these hospitals at intervals similar to those 
used by accrediting organizations.  When hospitals are cited with 
deficiencies, CMS should inform IHS leadership immediately to allow for 
early intervention.  Further, for any IHS hospital with a recent history of 
serious compliance problems, CMS should consider giving the hospital 
heightened attentionfor example, conducting surveys more frequently 
and investigating complaints quickly.  Lastly, CMS should continue to 
provide technical assistance and training opportunities to IHS as 
opportunities arise, and should provide formal communication to IHS 
leadership regarding its perception of IHS training needs. 
   
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        20   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Office of the Secretary, IHS, and CMS provided a joint response to 
this report and its companion report.  Collectively, these HHS agencies 
concurred with all recommendations in both reports.  HHS also described 
efforts underway to address quality problems, especially concerns raised 
during a congressional hearing in February 2016 about the quality of care 
in the Great Plains Area and by CMS during certification surveys of 
several IHS hospitals.  These efforts, detailed in the Agency comments in 
Appendix D, include: 
  Departmentwide investment in IHSHHS created an Executive 
Council on Quality Care, currently led by the HHS Acting Deputy 
Secretary.  This Council, which includes health quality experts from 
across HHS, is working with IHS to examine the quality of care at 
IHS-operated hospitals.  HHS is currently targeting these efforts to 
respond to identified issues in the Great Plains Area.  The Councils 
work includes a mentorship program for administrators of select 
hospitals in the Great Plains Area, the development of a patient 
experience survey and data dashboards, new recruitment efforts using 
assistance from the National Health Service Corps, Health Resources 
and Services Administration, and the Peace Corps, and a deployment 
of the U.S. Public Health Service Commissioned Corps.  
  Quality FrameworkIHS is developing a Quality Framework 
document that will establish a vision and course of action for 
improving the care provided by IHS facilities.  IHS is assessing its 
policies and practices for quality and plans to add new policies for 
Governing Boards and hospital response to adverse events by the end 
of this calendar year.  IHS also plans to establish a new Office of 
Quality in its headquarters that will focus on standardizing processes 
and procedures across the IHS system of care. 
  Survey readiness and training initiativesIHS began a mock survey 
initiative to ensure that all IHS hospitals are assessed for compliance 
with the CoPs at regular intervals and using standardized protocols. 
IHS plans to centrally track performance data from these mock surveys 
and from accreditation or certification surveys.  Additionally, IHS 
recently awarded a contract to TJC to assist hospitals in survey 
readiness, training, and education services.  The first TJC training 
sessions will cover QAPI and the Emergency Medical Treatment and 
Labor Act (EMTALA) requirements.  Additional training efforts, 
prompted by a Systems Improvement Agreement with CMS, will 
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        21   
address Governing Board practices and the Medicare CoP 
requirements more broadly.  Further, IHS recently began holding 
quarterly webinars with Area Office and service unit leaders to provide 
technical assistance and to share experiences. 
  Continuation and expansion of CMS technical assistance 
programsCMS will continue to support IHS hospital improvements 
through its Quality Improvement Network-Quality Improvement 
Organization (QIN-QIO) and Hospital Engagement Network (HEN) 
programs.  The QIN-QIO for the Great Plains Area will provide QAPI 
support with emphasis on leadership, staffing, data analytics, clinical 
standards, and quality.  Additionally, CMS and IHS are developing a 
task order for a single QIN-QIO to assist with quality improvement 
technical assistance in all IHS hospitals.  IHS hospitals will also 
participate in a HEN, which is a learning collaborative dedicated to 
preventing patient harm in hospitals.  This effort will continue as the 
HEN program transitions to the Hospital Improvement and Innovation 
Network (HIIN).  
HHS, IHS, and CMSs recent efforts provide a strong foundational 
response to the issues identified in this report.  Many of these activities, 
however, are currently localized to a single Area and it is unclear the 
extent to which these efforts will be applied to other Areas.  We encourage 
IHS to ensure that the lessons learned in the Great Plains Area will also be 
used to benefit the whole of IHS.  We wish to provide additional clarity 
regarding our recommendation to implement a compliance program.  A 
compliance program would provide internal controls to govern IHSs 
ethical and business policies, and help create a culture that promotes 
prevention, detection, and resolution of unlawful or unethical conduct.  It 
is worth noting, also, that the efforts described by HHS are extensive, and 
full implementation will likely take years to achieve.  As such, we 
anticipate an extended timeframe for monitoring progress towards 
fulfillment of the recommendations.  
   
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        22   
APPENDIX A 
The table below provides basic demographic information, including the 
locations, of IHS hospitals.  We used publicly available 2010 Frontier 
and Remote Area data from the U.S. Department of Agriculture to 
identify remote locations and population density for the appropriate ZIP 
Codes.  Remote areas are at least 60 minutes from an urban area of 
50,000 or more people.  IHS provided the hospitals user populations and 
facility demographics for FY 2013.  We identified hospitals respective 
surveying agency using both survey data provided by CMS and a review 
of information available on the TJC website.  
Table A-1:  IHS Hospitals by Area 
Avg. 
Remote  Pop.  User  Daily  Age of  Survey 
Hospital  City/State  Area   Density   Pop.  Census*  Facility  Agency 
Great Plains (formerly known as Aberdeen) Area Office 
Standing Rock/Fort Yates Hospital  Ft. Yates, ND  -  8.6  9,040  0.1  48  CMS 
Quentin N Burdick Memorial Hospital  Belcourt, ND  Remote  45.5  13,799  7.0  46  TJC 
Cheyenne River Hospital  Eagle Butte, SD  Remote  2.3  8,457  2.1  3  CMS 
Pine Ridge Hospital  Pine Ridge, SD  Remote  6.7  21,989  12.0  21  CMS 
Rapid City Indian Hospital  Rapid City, SD  -  103.5  14,819  0.9  76  CMS 
Rosebud Hospital  Rosebud, SD  Remote  8.9  12,482  6.8  24  CMS 
Winnebago Hospital  Winnebago, NE  -  24.4  5,213  2.2  10  TJC** 
 
Albuquerque Area Office 
Mescalero Service Unit  Mescalero, NM  Remote  5.0  4,705  2.0  46  TJC 
Acoma-Cononcito-Laguna Service Unit  Acoma, NM  -  3.3  11,035  2.8  35  TJC 
Santa Fe Service Unit  Santa Fe, NM  -  69.9  14,766  1.5  35  TJC 
Zuni Comprehensive Health Center  Zuni, NM  Remote  16.3  11,973  6.4  40  TJC 
Bemidji Area Office 
Cass Lake Hospital  Cass Lake, MN  Remote  18.1  10,589  0.7  77  CMS 
Red Lake Hospital  Red Lake, MN   Remote  45.9  8,046  2.8  33  TJ C 
Billings Area Office 
Blackfeet Community Hospital  Browning, MT  Remote  7.0  11,571  11.0  77  CMS 
Crow/Northern Cheyenne Hospital  Crow Agency, MT  -  4.2  13,342  4.6  19  CMS 
Fort Belknap Hospital  Harlem, MT  Remote  3.5  4,662  0.1  16  CMS 
Continued on next page. 
   
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        23   
Table A-1:  IHS Hospitals by Area (Continued) 
Avg. 
Remote  Pop.  User  Daily  Age of  Survey 
Hospital  City/State  Area  Density  Pop.  Census*  Facility  Agency 
Navajo Area Office 
Chinle Comprehensive Health Care   Chinle, AZ  Remote  9.6  35,027  19.0  33  TJC 
Gallup Indian Medical Center  Gallup, NM  Remote  34.5  43,275  41.7  53  TJC 
Northern Navajo Medical Center  Shiprock, NM  -  8.3  53,915  5.8  20  TJC 
Crownpoint Health Care Facility  Crownpoint, NM  Remote  5.2  19,787  1.5  26  CMS 
Oklahoma Area Office 
Claremore Indian Hospital  Claremore, OK  -  196.5  100,801  6.8  37  TJC 
Lawton Indian Hospital  Lawton, OK  -  109.3  22,782  6.6  47  TJC 
Claremore, OK 
LPahwoteonni,x O AKr ea Office 
Parker Indian Hospital  Parker, AZ  -  16.6  9,275  4.6  13  TJC 
Hopi Health Care Center  Polacca, AZ  Remote  10.7  6,545  19.0  14  TJC 
Phoenix Indian Medical Center  Phoenix, AZ  -  3232.3  68,838  34.0  44  TJC 
San Carlos Hospital  San Carlos, AZ  Remote  2.7  12,323  0.7  52  TJC 
Whiteriver Hospital  Whiteriver, AZ   Remote  39.5  16,428  14.0  35  TJC 
Tucson Area Office 
Sells Indian Hospital  Sells, AZ    -  1.9  20,215  4.4  54  TJC 
  *The average daily census includes inpatients only. 
     **Winnebago Hospital lost accreditation and reverted to CMS certification during our evaluation. 
  Sources:  OIG compiled this table using information from the IHS website and the TJC website; Medicare provider data from the Certification and Survey Provider 
Enhanced Reporting; and interviews, surveys, and documents collected during this evaluation. 
   
IHS Hospitals:  More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010)        24   
APPENDIX B 
Table B-1:  Hospital Conditions of Participation 
Condition  Regulation  Description 
Administrative Functions 
Compliance with Federal, State,   482.11  A hospital must comply with applicable federal laws on patient 
and Local Laws  health and safety and state and local laws on hospital and 
personnel licensing. 
Governing Body   482.12  A hospital must have a legally responsible governing body or 
persons charged with the responsibilities of a governing body. 
Patients Rights   482.13  A hospital must protect and promote patients rights. 
Basic Hospital Functions 
Quality Assessment and   482.21  A hospital must have an effective, hospitalwide quality assurance 
Performance Improvement  program. 
Program (QAPI) 
Medical Staff   482.22  A hospital must have an organized medical staff that abides by 
bylaws approved by the governing body and is responsible for the 
quality of patient medical care. 
Nursing Services   482.23  An organized nursing service must provide 24-hour nursing services 
that are supervised or furnished by registered nurses. 
Medical Record Services   482.24  A hospital must have a medical record service that has 
administrative responsibility for medical records. 
Pharmaceutical Services   482.25  The hospital must have pharmaceutical services that meet patient 
needs. 
Radiologic Services   482.26  The hospital must maintain, or have available, diagnostic radiologic 
services.  Therapeutic services provided must meet professionally 
approved standards for safety and personnel qualifications. 
Laboratory Services   482.27  The hospital must maintain, or have available, adequate laboratory 
services. 
Food and Dietetic Services   482.28  Dietary services must be organized, directed, and staffed by 
qualified personnel. Contracted services must meet certain 
requirements. 
Utilization Review   482.30  Utilization review plans must provide for review of the services that 
a hospital and its medical staff provide to Medicare and Medicaid 
patients. 
Continued on next page..                                                                                                                                                  
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Table B-1:  Hospital Conditions of Participation (Continued) 
Condition  Regulation  Description 
Physical Environment   482.41  Hospital construction, arrangements, and maintenance must ensure 
patient safety and provide diagnostic and treatment facilities and 
special hospital services appropriate to community needs. 
Infection Control   482.42  A hospitals sanitary environment must avoid sources and 
transmission of infections and communicable diseases.  It must have 
an active program to prevent, control, and investigate infections and 
communicable diseases. 
Discharge Planning   482.43  A hospital must have a discharge planning process applicable to all 
patients.  Policies and procedures must be in writing. 
Organ, Tissue, and Eye   482.45  The hospital must have and implement written protocols on 
Procurement  procurement and have adequate organ transplant policies. 
Surgical Services   482.51  Surgical services must be well organized and provided in 
accordance with acceptable standards of practice.  Outpatient 
services must be consistent with inpatient care quality in accordance 
with the complexity of services offered. 
Optional Services 
Anesthesia Services   482.52  Anesthesia services must be well organized and directed by a 
qualified doctor of medicine or osteopathy.  The service is 
responsible for all anesthesia administered. 
Outpatient Services   482.54  Outpatient services must meet patient needs consistent with 
acceptable standards of practice. 
Emergency Services   482.55  If emergency services are provided they must be organized under 
the direction of a qualified member of the medical staff and have 
adequate medical and nursing personnel qualified in emergency 
care to meet the needs anticipated by the facility. 
Rehabilitation Services   482.56  Rehabilitation, physical therapy, occupational therapy, audiology, or 
speech pathology services must be organized and staffed to ensure 
the health and safety of patients. 
Respiratory Services   482.57  Respiratory services must meet patient needs in accordance with 
acceptable standards of practice. 
Nuclear Medicine Services   482.53  Nuclear medicine services must meet the needs of the patients in 
accordance with acceptable standards of practice. 
 Sources:  42 CFR  482.11-482.57 CMS, SOM, Pub. No. 100-07, App. A. 
 
 
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APPENDIX C 
METHODOLOGY  
This study describes CMSs and IHSs efforts to ensure that IHS hospitals 
provide quality care and comply with Medicare standards of care.  Report 
findings are based on multiple data sources collected between April and 
October 2014.   
Telephone Interviews 
We conducted in-depth, semistructured telephone interviews with IHS 
leadership staff from federally operated hospitals, headquarters, and Area 
Offices.  We also interviewed staff from CMS. 
IHS Hospital Interviews.  We interviewed hospital CEOs from the  
28 IHS-operated hospitals.  The CEOs often opted to include additional 
members of their leadership team in the interviews (e.g., clinical directors, 
directors of nursing, and quality managers).  Interview questions focused 
on hospitals ability to provide necessary care; challenges affecting quality 
care and compliance; improvement efforts; and assistance received from 
Area Offices, IHS headquarters, CMS, and accrediting organizations.  
IHS Area Office Interviews.  We interviewed the eight Area Directors 
responsible for overseeing federally run hospitals.  Area Directors often 
opted to include additional members of their leadership team in the 
interview.  We asked about the Area Offices functions, hospital oversight 
activities, and collaboration with CMS and accrediting organizations.   
IHS Headquarters Interviews.  We interviewed a range of headquarters 
and specialized field staff including: 
  Chief Medical Officer (CMO)  We interviewed the CMO to 
discuss IHSs role in guidance, monitoring, and efforts to improve 
hospital quality and compliance with the CoPs for inpatient care. 
  Director of Field Operations (DFO)  We interviewed the DFO to 
better understand the relationship of Area Offices with both the 
hospitals and headquarters. 
  Director of the Hospital Consortium  We interviewed the Director 
of the Hospital Consortium, a cross-Area workgroup, to learn 
about the Consortiums efforts to improve hospital quality and 
promote CoPs compliance. 
CMS Interview.  We interviewed leadership staff in CMSs Consortium for 
Quality Improvement and Survey & Certification Operations.  We asked 
about CMSs role in overseeing IHS hospitals and their experiences 
working with them. 
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Questionnaires 
IHS Hospital Questionnaires.  For each of the 28 hospitals, we 
administered questionnaires regarding the hospitals average daily 
censuses, vacancies, referrals, and grievances during 2013.   
IHS Area Office Questionnaires.  We administered questionnaires to the 
eight Area Offices.  We asked questions about consultant programs, 
procedural information regarding how the Area Office staff reviews 
quality information, and perceptions about which challenges most affected 
hospitals ability to provide quality care and maintain compliance.   
Document Reviews 
Based on interview and questionnaire responses, we requested documents 
to validate information shared by IHS staff. 
IHS Hospital Surveys.  Using survey data stored in the Automated Survey 
Processing Environment (ASPEN) and Accrediting Organization System 
for Storing User Recorded Experiences (ASSURE), we reviewed survey 
frequencies and deficiency citations from before January 1, 2014, for each 
of the 28 hospitals.  We also requested full survey reports from CMS and, 
when applicable, the accrediting organization, as well as an 
IHS-contracted report entitled Accreditation Survey Analysis that included 
an analysis of IHS hospital accreditation and certification surveys 
conducted from September 30, 2005, to July 15, 2013. 
Area Office Questionnaires and Documents.  From each Area Office, we 
received documents from Governing Board meetings (e.g., agenda, list of 
attendees), quality-related reports or dashboards (e.g., incident reports, 
infection control reports), and reports from mock surveys conducted 
during FYs 20132014.  (Mock surveys simulate certification and 
accreditation surveys.)   
IHS Headquarters Documents.  From IHS headquarters, we received 
several management-related documents including the Federal Managers 
Financial Integrity Act (FMFIA) Deficiency Analysis, and final reports of 
the Area Office reviews conducted in response to Senator Dorgans 2010 
report.  Additionally, we received the proposed charter for the Hospital 
Consortium; interagency agreements relating to the Partnership for 
Patients initiative; and, contracts, deliverables, and related budget 
information regarding the Quality Improvement Organization (QIO)  
Special Innovation Project.   
   
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APPENDIX D 
AGENCY COMMENTS 
 
   
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ACKNOWLEDGMENTS 
This report was prepared under the direction of Ruth Ann Dorrill, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office. 
Amy Ashcraft and Petra Nealy served as the team leaders for this study.  
Other Office of Evaluation and Inspections staff from the Dallas regional 
office who conducted the study include Patricia Chen and Malinda Hicks.  
Central office staff who provided support include Clarence Arnold, 
Lucia Fort, Kevin Golladay, Christine Moritz, and Sherri Weinstein.  
We would also like to acknowledge the contributions of other Office of 
Evaluation and Inspections regional office staff, including Blaine Collins, 
Camille Harper, Christina Lester, and China Tantameng.   
 
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Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS) programs, as  well  as the health  and welfare of individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.