Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

INDIAN HEALTH SERVICE 

HOSPITALS: LONGSTANDING 

CHALLENGES WARRANT 

FOCUSED ATTENTION TO

SUPPORT QUALITY CARE

Daniel R. Levinson

Inspector General

October 2016

OEI-06-14-00011
 

 

EXECUTIVE SUMMARY – INDIAN HEALTH SERVICE HOSPITALS: LONGSTANDING 

CHALLENGES WARRANT FOCUSED ATTENTION TO SUPPORT QUALITY CARE 

OEI-06-14-00011 

WHY WE DID THIS STUDY 

We conducted this study and its companion, Indian Health Service Hospitals: More Monitoring Needed 

to Ensure Quality Care (OEI-06-14-00010), in response to concerns about the care provided in Indian 

Health Service (IHS) hospitals. Reports of inadequate health care services for American Indians and 

Alaska Natives (AI/ANs) have concerned the Federal Government for almost a century. IHS is 

responsible for providing health services to the 567 federally recognized tribes of AI/ANs. As part of its 

service, IHS directly operates 28 acute-care hospitals. IHS requires its hospitals to be accredited by a 

nationally recognized organization (or Medicare-certified) and to comply with the Medicare Hospital 

Conditions of Participation (CoPs). OIG is committed to continued work to improve patient care 

provided in IHS hospitals. 

HOW WE DID THIS STUDY 

We interviewed leadership staff at each IHS-operated hospital, the eight Area Offices that oversee the 

hospitals, and IHS headquarters regarding their processes for quality monitoring and oversight. Hospital 

interviews included the Chief Executive Officer (CEO) or Acting CEO, and Area Office interviews 

included the Area Director or Acting Director. Additional leadership staff, such as clinical directors and 

chief medical officers, were also present in most interviews. IHS headquarters interviews included the 

Chief Medical Officer, the Director of Field Operations, the Regional Human Resources Directors, and 

the Acting Deputy Director for Environmental Health and Engineering. We supplemented these 

interviews with questionnaires and with reviews of documents such as management reports and survey 

citations for deficiencies. We also interviewed staff and reviewed select documents from the Centers for 

Medicare & Medicaid Services (CMS), which is the primary oversight agency for hospitals nationwide. 

WHAT WE FOUND 

IHS hospital administrators reported a range of interrelated challenges affecting their ability to provide 

quality care and maintain compliance with the CoPs. IHS hospitals face continual increases in the 

number of AI/ANs using their services, yet they provide a narrow scope of medical services and limited 

access to specialists and community support (e.g., nursing homes and home health). IHS hospitals 

particularly struggle to maintain the skills necessary to treat complex inpatient cases. Another significant 

concern among IHS hospital administrators is the inability to recruit and retain needed staff. The 

dependence on “acting” personnel and contracted providers to fill vacancies sometimes creates instability 

in IHS hospitals and weakens the continuity of care provided to patients. Further, hospital administrators 

reported that limited resources for maintaining old hospital structures and outdated equipment sometimes 

results in service interruptions and raises concerns about patient safety. 

WHAT WE RECOMMEND 

We recommend that the Office of the Secretary of Health and Human Services (OS) lead an examination 

of the quality of care delivered in IHS hospitals as part of its newly formed Executive Council and use the 

findings to identify and implement innovative strategies to mitigate IHS’s longstanding challenges. We 

also recommend that IHS conduct a needs assessment and develop an agency-wide strategic plan with 

actionable initiatives and target dates to build a unified vision of IHS priorities and how to address them. 

OS, IHS, and CMS provided a joint response to this report and its companion report. Collectively, these 

HHS agencies concurred with all recommendations in both reports. 
 

 

TABLE OF CONTENTS

Objective ......................................................................................................1

Background..................................................................................................1

Methodology................................................................................................5

Findings........................................................................................................7

Increasing numbers of outpatients, limited scopes of services, 

and geographic isolation restrict IHS hospitals’ ability to ensure 

patient access to care........................................................................7

Hospitals with low inpatient censuses may struggle to maintain 

clinical competence, which can result in patient harm ....................9

Vacancies, use of “acting” positions, and dependence on 

contracted providers sometimes impair hospital service stability 

and continuity of care.....................................................................11

Outdated and insufficient buildings and equipment may further 

confound care.................................................................................14

Recommendations......................................................................................17

Agency Comments and Office of Inspector General Response.....19

Appendixes ................................................................................................21

A: Table A-1: IHS Hospitals by Area ..........................................21

B: Table B-1: Hospital Conditions of Participation.....................23

C: Methodology ............................................................................25

D: Agency Comments...................................................................27

Acknowledgments......................................................................................39
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 1

OBJECTIVE

To examine the challenges affecting Indian Health Service (IHS) hospitals’ 

ability to provide quality care and comply with Medicare standards of 

care.

BACKGROUND

IHS is responsible for providing Federal health services to American 

Indians and Alaska Natives (AI/ANs). IHS’s mission is to raise the 

“physical, mental, social, and spiritual health of AI/ANs to the highest 

level.” In partnership with the tribes, IHS provides free primary and 

preventive health care services for approximately 2.2 million AI/ANs 

living in the United States. However, reports of health disparities and 

inadequate health care services for AI/ANs have been of concern to the 

Federal Government for almost a century. 

In 2010, Senator Byron Dorgan, then-Chairman of the Senate Committee 

on Indian Affairs, released a report citing problems in some IHS facilities 

related to credentialing and licensing of providers, accountability of 

controlled substances, and management of funds. These problems were 

similar to those previously identified by the Office of Inspector General 

(OIG) and the U.S. Government Accountability Office (GAO).1 Prior to 

that, in 1999, and again in 2004, the U.S. Commission on Civil Rights 

found significant health disparities for AI/ANs as a result of structural 

barriers (e.g., insufficient staffing, aging facilities) and financial barriers 

(e.g., insufficient resources), many of which were similar to problems 

identified almost a century ago. In 1928, a report requested by Federal 

oversight authorities regarding conditions of AIs found that their health 

and living conditions were “bad,” and that the lack of funding, personnel, 

and equipment “prevented the development of an adequate system of 

public health administration and medical relief work” for AIs.2, 3 

____________________________________________________________ 

1

 U.S. Senate Committee on Indian Affairs, In Critical Condition: The Urgent Need to 

Reform the Indian Health Service’s Aberdeen Area, December 28, 2010. Accessed at 

http://www.indian.senate.gov/sites/default/files/upload/files/Chairman-s-Report-InCritical-Condition-12-28-10.pdf on February 12, 2015. 

2

 The Institute for Government Research, The Problem of Indian Administration, 

February 21, 1928, ch. I. Accessed at 

http://www.alaskool.org/native_ed/research_reports/IndianAdmin/Indian_Admin_Problm

s.html on November 3, 2014. 

3

 U.S. Commission on Civil Rights, Broken Promises: Evaluating the Native American 

Health Care System, September 2004, pp. 2-4. Accessed at 

http://www.usccr.gov/pubs/nahealth/nabroken.pdf on November 3, 2014. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 2

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 IHS’s $1.8 billion appropriation to provide health care 

services is allocated to Federal operations serving tribes directly. The 

other half of the hospital and health clinics portion of the budget goes to 

the individual Indian tribes or tribal organizations that have contracts 

and/or compacts with IHS.5

IHS Area Offices

Located in Rockville, Maryland, IHS headquarters provides general 

direction, policy development, and support for each of the 12 Area Offices 

and their health care delivery sites, which may include hospitals, urgent 

care clinics, and/or other types of facilities. Area Offices oversee the 

delivery of health services and provide administrative and technical 

support to the federally operated hospitals and clinics for one or more of 

the 170 geographically defined service units.6 Each Area Office includes 

staff dedicated to common services, such as finance, administrative 

support, information technology (IT), public health programs, and 

environmental health. 

IHS maintains its current policies, procedures, and operating standards in 

the Indian Health Manual (IHM). The IHM is the “preferred reference” 

for IHS staff regarding IHS-specific policy and procedural information.7

____________________________________________________________ 

4

 Pursuant to the Indian Self-Determination and Education Assistance Act, P.L. 

No. 93-638, IHS contracts and/or compacts with tribes or tribal organizations to deliver 

services. 

5

 Department of Health and Human Services (HHS), IHS, Justification of Estimates for 

Appropriations Committees, Fiscal Year (FY) 2016, p. 6, 55. Accessed at 

https://www.ihs.gov/budgetformulation/includes/themes/newihstheme/documents/FY201

6CongressionalJustification.pdf on February 9, 2016. Total IHS appropriations in 

FY 2015 were $4.6 billion. In addition to the $1.8 billion appropriated for hospital and 

health clinic services, IHS supports programs such as dental services, public health, and 

purchased/referred care, among others. 

6

 A service unit is an administrative subunit of an IHS Area, operated by IHS or a tribe, 

with responsibilities for providing IHS services within a particular geographic area. 

7

 IHS, Indian Health Manual, pt. 1; ch. 1; section 1-1.2 (Indian Health Manual). 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 3

IHS Hospitals

IHS directly operates 28 acute-care hospitals in 8 States, many of which 

are in remote locations. (See Appendix A for a listing of IHS-operated 

hospitals and Figure 1 for a map of their locations.) These hospitals are 

typically small, with most having fewer than 50 beds. IHS also contracts 

with tribes and tribal organizations to operate an additional 18 hospitals. 

Although 1 IHS hospital is a Level III Trauma Center and cares for more 

than 40 inpatients a day, less than half of the 46 hospitals have operating 

rooms and many lack the equipment to do a computerized tomography 

(CT) scan. Collectively, in FY 2013, IHS-run and tribally run hospitals 

had more than 13 million outpatient visits and a total of 44,677 inpatient

admissions. Nearly half of these admissions (20,469 inpatients) were to 

the 28 IHS-operated hospitals. 

IHS hospitals may be reimbursed by Medicare, Medicaid, and private 

insurance entities for services they provide to AI/ANs enrolled in these 

programs.8 In addition to the $1.8 billion that Congress appropriated for 

hospitals and health clinics operated by IHS and tribes for FY 2015, IHS 

was expected to collect approximately $1.1 billion from these three 

sources, and 90 percent of this amount was expected to be collected from 

the Medicare and Medicaid programs.9

____________________________________________________________ 

+ = IHS-operated hospital 

Figure 1: IHS Hospital Locations 

8

 Social Security Act §§ 1880(a) and 1911(a), P.L. No. 94-437, Indian Health Care 

Improvement Act (codified at 25 U.S.C. § 1621e). 

9

 IHS, Justification of Estimates for Appropriations Committees, FY 2016, p. 6. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 4

Purchased and Referred Care

In certain circumstances, IHS may supplement the care available in 

a particular location by purchasing services for specific AI/AN patients 

from private health care providers. This program—formerly known as 

Contract Health Services—is now known as Purchased and Referred Care 

(PRC). Service units that have hospitals use the funds to refer patients for 

emergency or specialty care that is beyond their capacity. However, the 

PRC programs do not have sufficient funds to cover all care needs and 

thus allocate health care on the basis of a medical-priority rating system.10 

Medicare Conditions of Participation 

IHS instructs its hospitals to be accredited by a nationally recognized 

organization (or certified by Medicare). Accrediting organizations used 

by IHS must support the reimbursement requirements established by 

Medicare and Medicaid.11, 12 To meet this established criteria, hospitals 

must comply with the Medicare Conditions of Participation (CoPs), a set 

of minimum quality and safety standards. The CoPs include requirements 

such as establishing an effective governing body legally responsible for 

the performance of the hospital, having an organized medical staff that is 

responsible for the quality of patient medical care, and maintaining a 

physical environment that avoids transmission of infections and 

communicable diseases.13 (See Appendix B for a descriptive list of CoPs.) 

The Centers for Medicare & Medicaid Services (CMS) and accreditation 

organizations such as The Joint Commission (TJC) monitor IHS-operated 

hospitals’ compliance with the CoPs through periodic onsite surveys.14 

Surveyors observe how hospitals provided care to patients, and assess 

whether that care met the needs of the patients and was in compliance with 

all requirements. To indicate noncompliance, surveyors cite hospitals with 

deficiencies that hospitals must correct in a timely manner to continue 

participating in Medicare. 

Related Work

This report expands on prior work by OIG in response to a congressional 

request. In August 2015, OIG issued a report—OIG Site Visits to Indian 

Health Service Hospitals in the Billings, Montana Area 

____________________________________________________________ 

10 IHS, Purchased/Referred Care (PRC) History. Accessed at 

http://www.ihs.gov/chs/index.cfm?module=chs_history on December 29, 2014.

11 IHS, Circular No. 97-01. Accessed at 

http://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_circ_main&circ=ihm_circ_9701 on 

January 22, 2014. 

12 Social Security Act §§ 1880(a) and 1865 (a)(1). 

13 42 CFR §§ 482.1, 482.12, 482.22, 482.41 and 482.42 

14 CMS, State Operations Manual (SOM), ch. 1, § 1018A. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 5

(OEI-09-13-00280)—that identified problems related to staffing and 

continuity of care at two hospitals in the Billings Area. 

Companion Report. OIG is concurrently issuing a companion report, 

Indian Health Service Hospitals: More Monitoring Needed to Ensure 

Quality Care (OEI-06-14-00010). The companion report found that IHS 

may be missing opportunities to identify and remediate quality problems 

in its hospitals because of a limited ability to provide rigorous oversight. 

(See below a summary of concerns cited in the companion report.) 

Insufficient Monitoring of IHS Hospitals 

Hospital monitoring practices differ significantly among Area Offices but in many cases, 

IHS lacks the necessary tools and/or infrastructure to provide robust oversight and 

proactive identification of quality or compliance problems. Key concerns include: 

Few data sources – Because many IHS hospitals offer limited scopes of services and 

have limited experience with certain medical conditions, the quality indicators and 

metrics that most hospitals use are not always meaningful for quality monitoring. 

Infrequent review of quality metrics – Most Area Offices depend on infrequent 

Governing Board meetings to review quality metrics. 

Limited clinical support – Over time, staffing reductions and vacancies led several 

Area Offices to reduce clinical consulting services. As a result, IHS hospital clinical 

directors rely on each other to solve problems with little support from the Area Office. 

Under-developed quality assurance programs – Many hospital programs fall short on 

requirements to be data-driven and hospital-wide, citing challenges in collecting, 

analyzing, and reporting data on quality and outcomes. 

Source: OIG summary of the companion report, Indian Health Service Hospitals: More Monitoring Needed to 

Ensure Quality Care (OEI-06-14-00010). 

Upcoming Work. OIG is committed to continued work to improve patient 

care provided in IHS hospitals. Upcoming OIG work includes an IHS 

management review and a medical review focusing on patient safety in 

IHS hospitals. 

METHODOLOGY

This study describes challenges affecting the 28 IHS-operated hospitals’ 

ability to provide quality care and maintain compliance with Medicare 

standards. Report findings are based on multiple data sources, including 

telephone interviews, questionnaires, and document reviews. We 

conducted in-depth telephone interviews with leadership staff at each 

IHS-operated hospital, the eight Area Offices that oversee the hospitals, 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 6

and IHS headquarters. We verified staff-reported issues when possible by 

reviewing documentation, such as internal management reports, survey 

deficiency citations, reports by an IHS-contracted consultant, and IHS data 

on user populations and facilities.15 In addition, we interviewed staff and 

reviewed select documents from CMS. Information was collected 

between April and October 2014. (See Appendix C for a full description 

of the methodology.)

Limitations

Although we reviewed supporting documentation when possible, many of 

the challenges described in this report are based on self-reported data, and 

may not reflect all of the pressing challenges affecting IHS hospitals. We 

often relied on the perspectives of staff in leadership positions at IHS and 

CMS headquarters, at IHS Area Offices, and at IHS hospitals. We did not 

interview patients, midlevel staff, lower level staff, or tribal 

representatives to gain their perspectives. Additionally, the findings in this 

report pertain only to the 28 IHS-operated hospitals and cannot be 

generalized to other IHS providers, including the 18 hospitals operated by 

tribal organizations.

Standards

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency.

____________________________________________________________ 

15 The user population includes AI/ANs eligible for IHS services who have used those 

services at least once during the immediate 3-year period, and who are registered in a 

verifiable patient registration system. IHS, Indian Health Service Headquarters 

Programs, Services, Functions and Activities Manual, June 2002. Accessed at 

http://www.ihs.gov/tribalshares/includes/themes/newihstheme/display_objects/documents

/ITExcerptsPSFAManualJune2002.pdf on March 16, 2015. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 7

FINDINGS

The challenges presented below provide insight into the difficulties that 

IHS hospitals face meeting the care needs of AI/ANs. As we assessed

IHS’s efforts to monitor and improve the quality of care, staff reported 

that a number of longstanding challenges compromise those efforts. 

Although we recognize that additional factors not presented in this report 

may also contribute to quality problems, it is important to highlight the 

challenges that emerged most prominently in our review. 

Increasing numbers of outpatients, limited scopes of 

services, and geographic isolation restrict IHS 

hospitals’ ability to ensure patient access to care 

Over the last 3 decades, federally operated IHS hospitals experienced a 

significant increase in their user populations as compared to the overall 

U.S. population growth. (See Chart 1 for user population growth in IHS 

hospitals.) Staff explained that the number of outpatients often exceeds 

the number of staff and space available to care for these patients, which

ultimately affect patient access. Similarly, limited types of services and 

constraints on funding further restrict IHS hospitals’ ability to provide 

necessary services, pay for patient referrals (i.e., through PRC), and ensure 

post-acute care. Staff also reported that the geographic isolation of many 

hospitals plays a role in hospital access to specialists and community 

support such as nursing homes and home health services. 

Chart 1: User Population Growth, by Fiscal Year (1986–2013) 

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

Note: This chart shows the numbers of eligible AI/ANs who have used services in the federally operated service 

units. It does not include AI/ANs who used services only in the tribally run facilities. 

Source: OIG analysis of population data from IHS’s Office of Environmental Health and Engineering, 2014. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 8

146,928

Number of 

referrals 

for services denied 

by IHS in 2013 

Increasing numbers of users burden many hospitals and 

adversely affect patient access

Between FYs 1986 and 2013, the collective population of registered users 

across the 28 IHS hospitals increased by 70 percent (from 695,941 users to 

1,181,613 users). By comparison, the overall U.S. population increased 

by 32 percent during the same time period. For 1 hospital and its satellite 

clinics alone, the user population more than doubled (from 26,797 users to 

68,838 users) during that time period. IHS staff reported that such 

significant growth in patient population contributes to long waiting times 

in the hospitals and difficulty for patients in scheduling appointments, 

which are the most common complaints that hospitals receive regarding 

patient care.

Limited scopes of services restrict hospitals’ ability to care for 

certain patients, and funding constraints restrict their ability to 

pay for patient referrals 

Administrators from all hospitals reported that service limitations cause 

them to refer patients to other non-IHS health care providers for medical 

services and procedures. If approved, these services are paid for by IHS’s 

PRC program. Administrators from one hospital explained that the 

hospital’s providers are primarily midlevel providers and family practice 

physicians who are not equipped to provide specialty care, causing them to 

rely heavily on PRC referrals. 

However, due to funding constraints, not all referrals are approved. In 

FY 2013, PRC administrators denied over $760 million in referral requests 

for an estimated 146,928 services needed by eligible AI/ANs. This 

represents almost half of the $1.56 billion total in referral requests made to 

the PRC program and the Catastrophic Health Emergency Fund during 

FY 2013.16

When the budget is insufficient to cover all needed services, IHS uses a 

medical-priority rating system to ensure that the most urgent requests are 

fulfilled first. In FY 2013, 77 percent of IHS service units—many of 

which run hospitals—covered only referrals classified as acutely urgent 

care services (e.g., services necessary to prevent the immediate threat to 

life, limb, or senses). Consequently, administrators denied most other 

referral requests, including those for preventive care services 

(e.g., mammography), primary and secondary care services (e.g., cardiac 

____________________________________________________________ 

16 IHS used the PRC program and a related program, the Catastrophic Health Emergency 

Fund (CHEF), to support $801 million in referral services. The Indian Health Care 

Amendments of 1988, P.L. No. 100-713, established the Catastrophic Health Emergency 

Fund (CHEF) to cover solely extraordinary medical costs associated with treating AI/AN 

victims of disasters or catastrophic illnesses. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 9

catheterization), and chronic tertiary and extended care services (e.g., joint 

replacement). The Chief Executive Officer (CEO) at one of the 

geographically isolated hospitals reported that the hospital spent most of 

its limited PRC funds on emergency air transports because of its remote 

location, leaving little to spend on services that would otherwise be 

considered acutely urgent, such as a surgical intervention for a broken 

arm.

Isolation limits access to specialists and community support, 

such as nursing homes and home health, but some hospitals 

have found alternative solutions 

Many hospitals are in remote locations, some as far as 200 miles from the 

nearest city, forcing patients to travel far for specialty care. Staff from 

half of the hospitals (14 of 28) reported significant challenges resulting 

from limited access to specialists. Administrators at one remotely located 

hospital reported that to better ensure continuity of care, the hospital 

partnered with a private hospital for telemedicine services for its pediatric 

patients. Administrators from another hospital reported flying in 

specialists twice a month to increase patients’ access to specialty services. 

This hospital also reported forming agreements to provide mammogram 

services through mobile units that come on site once a month. 

For many hospitals, post-acute care and discharge planning are also 

substantial challenges affecting patient care. Administrators from 

11 hospitals reported difficulties securing post-acute care for their patients 

because of limited placement options. One administrator reported that 

patients must travel 100–200 miles to receive post-acute care, which may 

be particularly problematic for patients at the end-of-life stage. Another 

hospital administrator described how the lack of resources (e.g., nursing 

homes, rehabilitation clinics) in the community and the “Third World” 

living conditions (e.g., no running water or electricity) of many patients 

sometimes prevent the hospital from discharging patients, particularly 

during the winter months. 

Hospitals with low inpatient censuses may struggle to 

maintain clinical competence, which can result in 

patient harm

Despite the growing number of outpatients, most IHS hospitals have 

exceedingly low numbers of patients admitted to inpatient wards. These 

low inpatient censuses cause decreased staff recruitment, staff retention,

and quality of care. In 2013, the total number of inpatients across the 

28 IHS hospitals on any given day was approximately 221. The average 

daily census for individual IHS hospitals was 8 inpatients; compared to the 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 10

3 

Number of 

inpatients 

treated daily in 

most IHS 

hospitals

national daily average of 104 inpatients.17 (See Appendix A for 

information on the average daily inpatient census at each IHS-operated 

hospital.) Collectively, 7 hospitals cared for more than two-thirds of the 

IHS inpatients (151 of 221); while the remaining 21 hospitals had an 

average daily census of 3 inpatients, with 5 hospitals caring for less than 

1 inpatient a day. 

Two Area Directors reported that an ongoing problem for many IHS 

hospitals is that their low inpatient censuses results in low volumes of 

high-risk conditions, affecting the quality of care provided to patients. 

As one Area Director explained it, a provider may receive appropriate 

training on intubation but intubate only one patient a year, which affects 

the provider’s comfort level and skill in performing such procedures. 

Further, an IHS official stated that specialist physicians, such as surgeons, 

are likely to leave a hospital if they are unable to perform enough 

procedures to maintain their skills. Area Office staff also noted that 

hospitals may not always recognize inadequacies in their own providers. 

Similarly, empirical research has shown a link between low-volume 

hospitals/providers and poorer outcomes.18

In one low-census IHS hospital, the lack of staff proficiency and inability 

to identify problems (among other issues) contributed to three patient 

deaths in 2014, according to CMS officials. CMS surveyors found that 

hospital staff lacked training and knowledge on how to conduct 

emergency resuscitations and that the “crash cart” (a wheeled container 

carrying medicine and equipment that physicians and nurses use in 

emergency resuscitations) lacked essential medications and equipment. 

Surveyors also found that staff lacked knowledge on how to call 

emergency codes across the intercom system to summon assistance, were 

not adequately trained to recognize symptoms of a life-threatening 

condition, and failed to provide necessary stabilizing treatment. 

Administrators from another low-census hospital reported discontinuing 

some of its services, including labor and delivery, following a major flood 

affecting the hospital campus. During the months in which the hospital 

was closed, many staff either left or struggled to maintain essential 

____________________________________________________________ 

17 The average daily census in hospitals nationwide was extrapolated from the American 

Hospital Association’s (AHA) statistical compilation. In 2013, there were 

5,686 hospitals in the United States, and the nation’s average daily hospital census was 

592,000. Andis Robeznieks, “Hospitals saw fewer admissions, more outpatients in 

2013,” Modern Healthcare, January 27, 2015. Accessed at 

http://www.modernhealthcare.com/article/20150127/NEWS/301279903 on June 16, 

2015.

18 Harold S. Luft, John P. Bunker, and Alain C. Enthoven, “Should Operations Be 

Regionalized? – The Empirical Relation between Surgical Volume and Mortality,” New 

England Journal of Medicine, 301(1364-1369). 1979. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 11

33%

Vacancy rate for

physicians in IHS 

hospitals

competencies, leaving insufficient numbers of qualified staff to treat 

patients. Hospital administrators determined that it was no longer safe to 

continue providing certain services.

Vacancies, use of “acting” positions, and dependence 

on contracted providers sometimes impair hospital 

service stability and continuity of care

The CoPs require hospitals to have organized medical staffs that can 

provide quality medical care to patients.19 One of the biggest concerns, 

reported by most of the IHS-run hospitals (23 of 28), relates to difficulties 

in recruiting and retaining staff. Agencywide, vacancies are an issue.20 In 

2014, the vacancy rates across IHS for physicians and nurses were 

23 percent and 17 percent, respectively. However, for IHS hospitals alone, 

the physician vacancy rate was even higher, at 33 percent.21 In contrast, 

the national vacancy rate for hospital physicians was less than 18 percent 

in 2013.22

According to staff, these vacancies have a significant impact on the 

continuity and quality of care. Administrators from one hospital reported 

that staffing shortages sometimes force the hospital to turn patients away. 

In another hospital, administrators said that insufficient staffing was the 

cause of its recent “immediate jeopardy” citation for violating the 

Emergency Medical Treatment & Labor Act (EMTALA) in the emergency 

room.23 Not only did the hospital fail to properly staff the emergency 

room, it also failed to provide patients with adequate waiting areas and 

proper medical transfers. According to CMS officials, EMTALA 

violations are serious problems in IHS hospitals and are closely linked to 

inadequate staffing. In one hospital, administrators reported that staffing 

shortages not only resulted in deficiency citations for not meeting patient 

needs, but also affected staffs’ ability to meet performance standards and 

ensure a sanitary environment.

____________________________________________________________ 

19 42 CFR § 482.22. 

20 In 2014, there were 1,550 vacancies for health care professionals (e.g., physicians, 

dentists, nurses, pharmacists, physician assistants, and nurse practitioners) across IHS. 

HHS, IHS, FY 2015, op. cit., p. 9. 

21 Hospital-reported vacancies by IHS and tribal sites in the Physician and Nurse Position 

Reporting systems. 

22 AMN Healthcare, AMN Healthcare Survey: Hospital Executives See Continued 

Shortage of Physicians, Nurses and Advanced Practitioners, December 12, 2013. 

Accessed at http://www.amnhealthcare.com/latest-healthcare-news/2147484592/1033/ on 

June 16, 2015. 

23 Congress enacted EMTALA in 1986 to ensure public access to emergency services 

regardless of ability to pay. CMS, Emergency Medical Treatment & Labor Act 

(EMTALA). Accessed at http://www.cms.gov/Regulations-andGuidance/Legislation/EMTALA/index.html?redirect=/emtala/ on March 12, 2015. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 12

Hospitals attribute their staffing shortages to geographic 

isolation, limited incentives, noncompetitive pay, and a lengthy 

hiring process

Administrators from nearly half of the hospitals (13 of 28) reported that 

the remoteness of their facilities affects their ability to recruit and retain 

staff. Housing, amenities (e.g., stores, community activities, and schools), 

and job opportunities for accompanying family members are scarce in 

these areas. One administrator reported that staff must commute a total of 

3 hours a day, without additional compensation, because of the lack of 

housing. Administrators from another hospital described how insufficient 

housing not only affects staffing levels, but also impacts staff morale—the 

hospital prioritizes the limited number of housing units for physicians, 

which creates tension among staff members. 

Limited incentives and noncompetitive pay also play a significant role in 

causing hospital staffing shortages, according to hospital administrators. 

Although hospitals can use loan repayment and relocation bonuses to 

attract applicants, some of these bonuses exclude many essential staff, 

including nurses. Administrators from one hospital described how its 

ability to compete for staff is affected by the lack of recruitment incentives 

(particularly, the lack of signing bonuses), the hospital’s remote location, 

and the fact that its locality pay is the same as that for IHS hospitals in less 

rural areas. In another hospital, administrators reported that although they 

can offer physicians a competitive salary using a special “market pay” 

authority, the hospital has lost applicants because of the lengthy approval 

process involved in such requests.

Additionally, the length of the hospitals’ hiring process affects recruitment 

outcomes. On average, it takes IHS hospitals 77 days to hire a new 

employee. Although this timeframe is within the 80-day hiring standard 

set at the Federal level by the Office of Personnel Management, 

administrators from three hospitals reported that they have lost many 

suitable candidates—including doctors, nurses, and administrative staff—

because of the lengthy hiring process. Administrators at one of these 

hospitals stated that it sometimes takes as long as 6 months to hire new 

staff. An IHS official reported that Human Resources (HR) can

sometimes streamline the hiring process for key providers 

(e.g., physicians, dentists) by using direct hiring authority. Under this 

authority, HR can post a continuous announcement to which providers can 

apply. The applications are stored for 90 days, and as positions become 

available, HR staff can quickly pull a list of eligible candidates. The use 

of this authority has sometimes shortened the hiring process for key 

providers to 30 days. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 13

Hospital officials are often in an “acting” capacity, resulting in 

inconsistent facility leadership 

Administrators from 24 of the 28 hospitals reported having someone in an 

“acting” leadership position, such that vacant positions are filled by an 

interim person not intended to maintain the position long-term. The most 

common acting position was that of the CEO (11 hospitals), followed by 

the clinical director (10 hospitals) and the director of nursing (9 hospitals). 

One administrator reported struggling with the constant change in 

leadership after having multiple acting CEOs; another administrator 

described that scenario as a “historical dilemma for IHS.” In one case, 

described in a report by an IHS-contracted consultant, a hospital had three 

different acting CEOs within a 6-week span. Administrators from another 

hospital reported that after several failed attempts to fill the position of 

clinical director, they had to assign two members of the medical staff to 

take turns doing 2-week stints as acting clinical director. This created 

challenges and instability for those acting clinical directors and their staff.

HR staff reported that hospitals often fail to inform them when using 

acting positions. As a result, hospitals sometimes do not adhere to the 

necessary requirements for using such positions. For example, 

administrators from one hospital reported that on two separate occasions, 

the hospital exceeded both the allowed 120-day timeframe and the allowed 

difference in pay grades when it assigned a nonsupervisory employee to 

the position of acting CEO. In another hospital, the IHS-contracted 

consultant found that the hospital received a deficiency citation as a result 

of having six different acting CEOs in a year and failing to report the 

change in leadership to CMS or the accrediting organization.

Hospital dependence on contracted providers to supplement 

permanent staff may affect quality and continuity of care

The wide variation in the experience and training of contracted providers, 

combined with their short tenure, appear to make it difficult for hospitals 

that rely heavily on such providers to ensure that patients receive needed 

care. For example, administrators from one hospital reported that it often 

has to refer patients out to other facilities for followup care because the 

contracted providers generally do not stay at the hospital long enough to 

see the patients in subsequent visits. The administrators further explained 

that providing training to these providers can be a challenge because of 

their short tenure (which generally range from 3 days to 3 months) and 

IHS hospitals’ limited resources. 

Additionally, using contracted providers can be costly for hospitals. 

Administrators from one hospital reported that its dependence on 

contracted nurses and pharmacists to backfill vacancies has a significant 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 14

77

Years since 

last major 

renovation of the 

two oldest IHS 

hospitals 

impact on the hospital’s operational budget. The costly use of these 

providers prevents the hospital from expanding its facility (e.g., adding 

more exam rooms), which limits the hospital’s ability to improve patient 

access to care. 

The constant rotation of contracted providers also led to problems with 

monitoring and oversight of these providers in some locations. 

Administrators from two hospitals raised concerns about poorly 

performing contracted providers who had rotated from one hospital to 

another. In one of these hospitals, administrators reported that it had 

recently received two troublesome contracted providers—one who had

outstanding issues with the medical board in another State, and another 

who had been terminated by two other hospitals for inappropriate 

behavior. 

Outdated and insufficient buildings and equipment 

may further confound care 

The CoPs require hospitals to maintain a sanitary physical environment 

that ensures patient safety and prevents the transmission of infections and 

communicable diseases.24 In more than half of the hospitals (15 of 28), 

administrators reported that old or inadequate physical environments 

challenged their ability to provide quality care and maintain compliance 

with the CoPs. For example, the aging structure in one IHS hospital 

caused sewage to leak into the operating room after its old pipes corroded. 

The average age (or length of time since a major renovation) of IHS 

hospitals is 37 years—nearly four times the average age of hospitals 

nationwide (which was 10 years in 2013).25, 26 The two oldest IHS 

hospitals are both 77 years old. According to engineering staff at IHS, the 

oldest hospital structures were never designed to provide modern health 

care, and over time, health care practices and technology changed and 

outpaced many IHS hospitals. 

Further, according to administrators at most IHS hospitals (22 of 28), 

maintaining aging buildings and equipment is a major challenge because 

of limited resources. In FY 2013, funding limitations for essential 

maintenance, alterations, and repairs resulted in backlogs totaling 

approximately $166 million. Hospitals’ unmet maintenance and repair 

____________________________________________________________ 

24 42 CFR §§ 482.41 and 482.42. 

25 The age of each hospital is calculated from the date of the most recent major 

renovation, not from the original construction date. OIG interview with IHS Office of 

Environmental Health and Engineering (OEHE) staff on September 25, 2014. 

26 AHA, Chartbook: Trends Affecting Hospitals and Health Systems, ch. 4, Chart 4.10, 

Median Average Age of Plant 1993-2013. Accessed at 

http://www.aha.org/research/reports/tw/chartbook/ch4.shtml on June 15, 2015. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 15

needs in one Area accounted for nearly a third ($47 million) of the total 

backlog amount. Staff from this Area Office reported that hospitals 

sometimes have to divert patients because of facility issues. For example, 

one hospital has had to occasionally shut down its operating room because 

of mechanical problems.

Nearly 35 percent (140 of 405) of all deficiencies cited in IHS hospitals 

during their most recent survey were related to the physical environment.27 

The deficiencies ranged from inappropriate air flow and pressure in certain 

areas (e.g., central sterile rooms), which are important infection control 

technologies, to malfunctioning emergency exit doors. Staff from one 

Area Office attributed the large number of facility-based deficiencies to 

the age of the facilities and funding limitations. Administrators from one 

hospital reported that their facility, which was built in the early 1900s, was 

not designed to be a hospital. Despite the building’s poor layout, its 

historical significance prevents the hospital from expanding or changing 

its structure to better serve patients (e.g., tearing down walls, installing 

adequate fire sprinklers, and running necessary IT lines to support 

electronic health records). The administrators also expressed concerns 

that the hospital’s aging equipment posed a potential risk for infection. At

another hospital, administrators reported challenges in finding parts for its 

aging equipment. Further, one Area Director stated that IHS’s inability to 

modernize and keep up with technology also affects hospitals’ ability to 

recruit and retain providers because highly trained medical professionals 

want to provide care at the level they were trained to provide.

Not only do hospitals face the challenge of being outdated, most have also 

outgrown their space. Specifically, more than two-thirds of hospitals 

(19 of 28) have insufficient space; hospitals reported that these constraints 

most affected exam rooms, diagnostic services, and/or pharmacies.28 Of 

the 19 hospitals with insufficient space, 7 have less than half the estimated 

space needed to meet community needs. When IHS recently replaced one 

of its older hospitals, the new structure was significantly larger in order to 

meet the needs of the growing user population. The new structure was 

nearly five times larger than the old one, both in size and in the number of 

exam rooms—the hospital went from 38,481 square feet to 179,983 square 

feet, and from 13 exam rooms to 61.

____________________________________________________________ 

27 We included the most recent survey that hospitals received during the period we 

studied. As a result, hospitals may have received surveys after January 1, 2014, which 

occurred after our study period. 

28 This calculation is based on a comparison of each hospital’s current space to the 

estimated space needed if a new facility was built today to meet the size of the current 

user population. OIG interview with IHS OEHE staff on October 1, 2014. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 16

Administrators from another hospital reported that it had been built in 

1993 to meet the needs of the projected population for the next 15 years, 

but the population exceeded the hospital’s capabilities by the year 2000—

only 7 years later. Because of space limitations, the administrators 

explained that they are unable to hire additional employees and expand 

services. The administrators said that to meet patient needs and decrease 

waiting times, they would need an intensive care unit, space for physical 

therapy, a larger pharmacy department, and additional outpatient exam 

rooms. Another hospital was constructed to handle 40,000 users; however, 

when it opened its doors, the user population immediately doubled after 

tribal clinics closed down and the criteria for tribal membership became 

more inclusive. Administrators at another hospital reported that space 

issues not only affect the hospital’s ability to ensure privacy in the 

emergency room and pharmacy department, but also prevent the hospital 

from establishing a triage room, which makes it more difficult for the 

hospital to comply with the EMTALA requirements. 

Although most IHS hospitals have outgrown their facilities, funding 

constraints prevent them from engaging in major renovation and 

construction. IHS has a construction list—dating back to 1992—that

includes 5 of the 28 hospitals. No new construction projects may be added 

to this list until the existing items are completed. The amount needed to

complete the construction projects on the current list is nearly $2.3 billion. 

However, if IHS’s annual construction budget were to remain at its 

FY 2015 level of $85 million, it would take the agency 24 years to 

complete all of the projects, including those involving the five IHS 

hospitals. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 17

RECOMMENDATIONS

Our review identified longstanding challenges that may affect IHS 

hospitals’ ability to provide quality care and comply with Medicare 

standards, including ensuring access to needed care, maintaining clinical 

competence, recruiting and retaining essential staff, and keeping patients 

safe despite outdated buildings and equipment. Similar reports date back 

almost a century, and problems persist despite reported efforts to address 

them. We also found in this study’s companion report—Indian Health 

Service Hospitals: More Monitoring Needed to Ensure Quality Care 

(OEI-06-14-00010)—that IHS may lack important quality assurance 

infrastructure and active monitoring efforts. Given the duration and extent 

of IHS’s problems, we conclude that it may not be able to overcome these 

challenges without broad support from experts both within and outside 

HHS and consideration of different models for providing services. 

We recommend that the Office of the Secretary of Health and Human 

Services (OS):

As part of OS’ newly formed Executive Council, lead an 

examination of the quality of care delivered in IHS hospitals 

and use the findings to identify and implement innovative 

strategies to mitigate IHS’s longstanding challenges 

The Executive Council—a new initiative led by HHS’s Acting Deputy 

Secretary to leverage departmentwide resources in support of quality 

improvement within IHS—should undertake a concerted effort to examine 

and address the longstanding challenges facing IHS hospitals. In the 

coming months, the council should develop its infrastructure and workplan 

to facilitate a smooth transition and continued progress during the shift to 

a new Presidential administration. 

To directly address IHS’s most fundamental issues, the council should 

collaborate with IHS and leverage the council’s organizational expertise in 

areas such as rural health, providing care to vulnerable populations, 

hospital management, performance metrics, and payment methodologies. 

The council should coordinate this effort with additional recommendations 

to IHS and CMS listed in the companion report. For example, the council 

should work with IHS as IHS implements a quality-focused compliance 

program. The council should also tackle broader issues, including 

managing the needs of a growing population; ensuring safe care at 

hospitals, particularly those with few inpatient beds and/or a limited scope 

of services; and ensuring compliance with Medicare’s hospital CoPs. The 

council should consider a wide range of options—e.g., telemedicine and 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 18

other alternative models of care delivery—with an eye toward identifying 

sustainable solutions and innovative ways to implement change.

We recommend that IHS:

Conduct a needs assessment culminating in an agencywide 

strategic plan with actionable initiatives and target dates

Given that IHS’s most recent strategic plan concluded in 2011, the agency 

needs a new strategic plan to build a unified vision of its priorities and 

how to achieve them. IHS should clearly identify and articulate its goals 

and priorities for meeting the care needs of AI/ANs and develop a specific 

plan for achieving them. As part of this effort, IHS should conduct a 

comprehensive needs assessment that reflects both broad goals for 

progress and the unique needs and obstacles of individual hospitals or 

groups of hospitals. A full assessment of resources, capabilities, and 

challenges is necessary to ensure that the strategy is realistic and 

incorporates specific, actionable steps for improvement. 

The overarching priorities in the strategic plan should be agencywide, but 

how IHS achieves these priorities must be tailored to recognize the 

specific needs associated with some hospitals, such as those with very low 

inpatient censuses and those with ailing physical facilities. The plan must 

address the underlying challenges to achieving quality and also expand the 

agency’s priorities to include a commitment to quality monitoring and 

quality improvement. For example, appropriate components of the 

strategic plan would be plans to relieve staffing challenges—such as 

streamlining the hiring process, establishing protocols for the practice of 

placing employees in “acting” positions, maximizing use of hiring 

incentives, improving recruitment practices, and systematically tracking 

the performance of contracted providers. The strategic plan could also 

address topics including but not limited to:

 maintaining clinical competence in hospitals with low censuses,

 reducing denials of referrals for necessary services, 

 expanding referral networks, 

 ensuring maintenance and repair of buildings and equipment, 

 providing adequate IT support, 

 enhancing clinical support, and

 evaluating physical security. 

The strategic plan should include short-term, midrange, and long-term 

priorities to ensure that as funding becomes available, it is spent on the 

most critical issues of health care quality. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 19

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 IHS―HHS 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 Council’s 

work includes a mentorship program for administrators of select 

hospitals in the Great Plains Area, the development of a patient 

experience survey and data dashboards, new recruitment efforts in 

partnership with the National Health Service Corps, Health Resources 

and Services Administration, and the Peace Corps and a deployment of 

the U.S. Public Health Service Commissioned Corps. 

 Quality Framework―IHS is developing a Quality Framework 

document that will establish a vision and a course of action for 

improving the care provided by IHS facilities. IHS is assessing its 

policies and practices for quality and plans to add new policies for 

Governing Boards and hospital response to adverse events by the end 

of 2016. IHS also plans to establish a new Office of Quality in its 

headquarters that will focus on standardizing processes and procedures 

across the IHS system of care.

 Survey readiness and training initiatives―IHS began a mock survey 

initiative to ensure that all IHS hospitals are assessed for compliance 

with the CoPs at regular intervals using standardized protocols. IHS 

plans to track performance data from these mock surveys and from 

accreditation or certification surveys centrally. Additionally, IHS 

recently awarded a contract to TJC to assist hospitals in survey 

readiness, training, and education services. The first TJC training 

sessions will cover Quality Assurance and Performance Improvement 

(QAPI) and the EMTALA requirements. Additional training, 

prompted by a Systems Improvement Agreement with CMS, will 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 20

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 

programs―CMS 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 CMS’s recent efforts provide a strong foundational 

response to the issues identified in this report. Many of these activities, 

however, are currently localized to the Great Plains Area and it is unclear 

the extent to which these efforts will be applied to other Areas. We 

encourage IHS to ensure that the lessons learned in the Great Plains Area 

will also be used to benefit the whole of IHS. It is worth noting, also, that 

these efforts are extensive and full implementation will likely take years to 

achieve. As such, we anticipate an extended timeframe for monitoring 

progress towards fulfillment of the recommendations.
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 21

APPENDIX A

The table below provides basic demographic information, including the 

locations, of IHS hospitals. We used publicly available “2010 Frontier 

and Remote Area” data from the Department of Agriculture to identify 

remote locations and population density for the appropriate ZIP codes. 

Remote areas are at least 60 minutes from an urban area of 50,000 or more 

people. IHS provided the hospital user populations and facility 

demographics for FY 2013. We identified hospital survey agencies using 

both survey data provided by CMS and a review of information available 

on the TJC website. 

Table A-1: IHS Hospitals by Area Office 

Hospital City/State

Remote 

Area

Pop. 

Density

User 

Pop.

Avg. 

Daily 

Census*

Age of 

Facility

Survey 

Agency

Great Plains (formerly known as Aberdeen) Area Office

Standing Rock/Fort Yates Hospital Ft. Yates, ND - 8.6 9,040 0.1 48 CMS

Quentin N Burdick Memorial Hospital Belcourt, ND Remote 45.5 13,799 7.0 46 TJC

Cheyenne River Hospital Eagle Butte, SD Remote 2.3 8,457 2.1 3 CMS

Pine Ridge Hospital Pine Ridge, SD Remote 6.7 21,989 12.0 21 CMS

Rapid City Indian Hospital Rapid City, SD - 103.5 14,819 0.9 76 CMS

Rosebud Hospital Rosebud, SD Remote 8.9 12,482 6.8 24 CMS

Winnebago Hospital Winnebago, NE - 24.4 5,213 2.2 10 TJC**

Albuquerque Area Office

Mescalero Service Unit Mescalero, NM Remote 5.0 4,705 2.0 46 TJC

Acoma-Cononcito-Laguna Service Unit Acoma, NM - 3.3 11,035 2.8 35 TJC

Santa Fe Service Unit Santa Fe, NM - 69.9 14,766 1.5 35 TJC

Zuni Comprehensive Health Center Zuni, NM Remote 16.3 11,973 6.4 40 TJC

Bemidji Area Office

Cass Lake Hospital Cass Lake, MN Remote 18.1 10,589 0.7 77 CMS

Red Lake Hospital Red Lake, MN Remote 45.9 8,046 2.8 33 TJC

Billings Area Office

Blackfeet Community Hospital Browning, MT Remote 7.0 11,571 11.0 77 CMS

Crow/Northern Cheyenne Hospital Crow Agency, MT - 4.2 13,342 4.6 19 CMS

Fort Belknap Hospital Harlem, MT Remote 3.5 4,662 0.1 16 CMS

Continued on next page. 

. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 22

Table A-1: IHS Hospitals by Area (Continued)

Hospital City/State

Remote 

Area

Pop. 

Density

User 

Pop.

Avg. 

Daily 

Census*

Age of 

Facility

Survey 

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

Claremore, OK - 196.5 100,801 6.8 37 TJC

Lawton Indian Hospital

Lawton, OK

Lawton, OK - 109.3 22,782 6.6 47 TJC

Phoenix Area Office

Parker Indian Hospital Parker, AZ - 16.6 9,275 4.6 13 TJC

Hopi Health Care Center Polacca, AZ Remote 10.7 6,545 19.0 14 TJC

Phoenix Indian Medical Center Phoenix, AZ - 3232.3 68,838 34.0 44 TJC

San Carlos Hospital San Carlos, AZ Remote 2.7 12,323 0.7 52 TJC

Whiteriver Hospital Whiteriver, AZ Remote 39.5 16,428 14.0 35 TJC

Tucson Area Office

Sells Indian Hospital Sells, AZ - 1.9 20,215 4.4 54 TJC

*The average daily census includes inpatients only. 

**Winnebago Hospital lost accreditation and reverted to CMS certification during our evaluation. 

Sources: OIG compiled this table using information from the IHS Web site and the TJC Web site; Medicare provider data from the Certification and Survey Provider 

Enhanced Reporting; and interviews, surveys, and documents collected during this evaluation. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 23

APPENDIX B

Table B-1: Hospital Conditions of Participation 

Condition Regulation Description

Administrative Functions

Compliance with Federal, State,

and Local Laws

§ 482.11 A hospital must comply with applicable federal laws on patient 

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

Performance Improvement 

Program

§ 482.21 A hospital must have an effective, hospitalwide quality assurance 

program.

Medical Staff § 482.22 A hospital must have an organized medical staff that abides by 

bylaws approved by the governing body and is responsible for the 

quality of patient medical care.

Nursing Services § 482.23 An organized nursing service must provide 24-hour nursing services 

that are supervised or furnished by registered nurses.

Medical Record Services § 482.24 A hospital must have a medical record service that has 

administrative responsibility for medical records.

Pharmaceutical Services § 482.25 The hospital must have pharmaceutical services that meet patient 

needs.

Radiologic Services § 482.26 The hospital must maintain, or have available, diagnostic radiologic 

services. Therapeutic services provided must meet professionally 

approved standards for safety and personnel qualifications.

Laboratory Services § 482.27 The hospital must maintain, or have available, adequate laboratory 

services.

Food and Dietetic Services § 482.28 Dietary services must be organized, directed, and staffed by 

qualified personnel. Contracted services must meet certain 

requirements.

Utilization Review § 482.30 Utilization review plans must provide for review of the services that 

a hospital and its medical staff provide to Medicare and Medicaid 

patients.

Continued on next page.. 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 24

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 hospital’s 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 

Procurement

§ 482.45 The hospital must have and implement written protocols on 

procurement and have adequate organ transplant policies.

Surgical Services § 482.51 Surgical services must be well organized and provided in 

accordance with acceptable standards of practice. Outpatient 

services must be consistent with inpatient care quality in accordance 

with the complexity of services offered.

Optional Services

Anesthesia Services § 482.52 Anesthesia services must be well organized and directed by a 

qualified doctor of medicine or osteopathy. The service is 

responsible for all anesthesia administered.

Outpatient Services § 482.54 Outpatient services must meet patient needs consistent with 

acceptable standards of practice.

Emergency Services § 482.55 If emergency services are provided they must be organized under 

the direction of a qualified member of the medical staff and have 

adequate medical and nursing personnel qualified in emergency 

care to meet the needs anticipated by the facility.

Rehabilitation Services § 482.56 Rehabilitation, physical therapy, occupational therapy, audiology, or 

speech pathology services must be organized and staffed to ensure 

the health and safety of patients.

Respiratory Services § 482.57 Respiratory services must meet patient needs in accordance with 

acceptable standards of practice.

Nuclear Medicine Services § 482.53 Nuclear medicine services must meet the needs of the patients in 

accordance with acceptable standards of practice.

Sources: 42 CFR §§ 482.11-482.57 CMS; SOM, Pub. No. 100-07, App. A.
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 25

APPENDIX C

METHODOLOGY

This study describes challenges affecting the 28 IHS-operated hospitals’ 

ability to provide quality care and comply with the Medicare standards. 

We identified these challenges during our interviews with IHS staff for the 

companion report, IHS Hospitals: More Monitoring Needed to Ensure 

Quality Care (OEI-06-14-00010). Report findings are based on multiple 

data sources collected between April and October 2014. 

Telephone Interviews

We conducted in-depth, semistructured telephone interviews with IHS 

leadership staff from federally operated hospitals, headquarters, Area 

Offices, and regional Human Resource Offices. We also interviewed 

relevant staff from CMS.

IHS Hospital Interviews. We interviewed hospital CEOs from the 

28 IHS-operated hospitals. The CEOs often opted to include additional 

members of their leadership team in the interviews (e.g., clinical directors, 

directors of nursing, and quality managers). Interview questions focused 

on each hospital’s ability to provide necessary care; challenges affecting 

quality care and compliance; and improvement efforts. 

IHS Area Office Interviews. We interviewed the eight Area Directors 

responsible for overseeing federally run IHS hospitals. Area Directors 

often opted to include additional members of their leadership team in the 

interviews as well. We asked about the challenges that hospitals had 

identified and about the Area Offices’ functions. 

IHS Headquarters Interviews. We interviewed a range of headquarters 

and specialized field staff including:

 Chief Medical Officer (CMO) – We interviewed the CMO to 

discuss IHS’s role in guidance, monitoring, and efforts to improve 

hospital quality and compliance with the CoPs.

 Director of Field Operations (DFO) – We interviewed the DFO to 

better understand the relationship of Area Offices with both the 

hospitals and headquarters.

 Regional HR Directors – We interviewed four regional directors to 

learn more about the hiring process, the use of “acting” positions, 

and any staffing-related challenges.

 Acting Deputy Director of the Office of Environmental Health and 

Engineering (OEHE) – We interviewed the Acting Deputy Director 
 

IHS Hospitals: Longstanding Challenges Warrant Focused Attention (OEI-06-14-00011) 26

and other leadership staff from OEHE to better understand hospital 

challenges related to population growth, capacity, and buildings.

CMS Interview. We interviewed leadership staff in CMS’s Consortium for 

Quality Improvement and Survey & Certification Operations. We asked 

them about CMS’s role in overseeing IHS hospitals and their experiences 

working with the hospitals.

Questionnaires

IHS Hospital Questionnaires. For each of the 28 hospitals, we 

administered questionnaires regarding the hospital’s average daily 

censuses, vacancies, referrals, and grievances during 2013. 

IHS Area Office Questionnaires. We administered questionnaires to the 

eight Area Offices. We asked about consultant programs, procedural 

information regarding how Area Office staff review quality information, 

and perceptions about which challenges most affected hospitals’ ability to 

provide quality care and maintain compliance. 

IHS Regional Human Resource Questionnaires. We administered 

questionnaires to the four regional Human Resource Offices regarding 

vacancies and acting positions in Area Offices and hospitals. 

Document Reviews

Based on interview and questionnaire responses, we requested documents 

to validate information shared by IHS staff.

IHS Hospital Surveys. Using survey data stored in the Automated Survey 

Processing Environment (ASPEN) and Accrediting Organization System 

for Storing User Recorded Experiences (ASSURE), we reviewed survey 

frequencies and deficiency citations from before January 1, 2014, for each 

of the 28 hospitals. We also requested full survey reports from CMS and, 

when applicable, the accrediting organization, as well as an 

IHS-contracted report entitled Accreditation Survey Analysis that analyzed 

IHS hospital accreditation and certification surveys conducted from 

September 30, 2005, to July 15, 2013.

IHS Headquarters Documents. From IHS headquarters, we received 

several management-related documents including the Federal Managers 

Financial Integrity Act (FMFIA) Deficiency Analysis, and final reports of 

the Area Office reviews conducted in response to Senator Dorgan’s 

2010 report. We also received the following from OEHE: population data 

from FY 1986 through FY 2013, capacity projections (based on the size of 

hospital-user populations), and lists of building construction and 

renovation projects and needs.
 

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APPENDIX D

AGENCY COMMENTS
 

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ACKNOWLEDGMENTS

This report was prepared under the direction of Ruth Ann Dorrill, 

Regional Inspector General for Evaluation and Inspections in the Dallas 

regional office. 

Amy Ashcraft and Petra Nealy served as the team leaders for this study. 

Other Office of Evaluation and Inspections staff from the Dallas regional 

office who conducted the study include Patricia Chen and Malinda Hicks. 

Central office staff who provided support include Clarence Arnold, 

Lucia Fort, Kevin Golladay, Christine Moritz, and Sherri Weinstein. 

We would also like to acknowledge the contributions of other Office of 

Evaluation and Inspections regional office staff, including Blaine Collins, 

Camille Harper, Christina Lester, and China Tantameng.
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 OIG’s 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.