Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

INDIAN HEALTH SERVICE 

HOSPITALS: MORE 

MONITORING NEEDED TO 

ENSURE QUALITY CARE

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 hospital’s 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 new—and more meaningful—hospital 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
 

IHS Hospitals: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 1

OBJECTIVE

To assess the Indian Health Service’s (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). 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 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 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: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 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

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) 3

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 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. 

Figure 1: IHS Hospital Locations

+ = IHS-operated hospital 
 

IHS Hospitals: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 4

data systems and quality departments. Hospitals—public 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 

quality—a data-driven concept known as Value-Based Purchasing—and 

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-ServicePayment/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/ehrincentives-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-PressReleases-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) 5

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 Medicare’s 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-andCertification/SurveyCertificationGenInfo/downloads/SCLetter03-16.pdf on March 18, 

2015.
 

IHS Hospitals: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 6

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 report—OIG 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 challenges—such as 

low inpatient censuses (number of patients), access limitations, difficulty 

maintaining clinical competence, staffing instability, and outdated 

facilities—that 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-andCertification/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) 7

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 IHS’s 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 

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.
 

IHS Hospitals: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 8

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) 9

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 hospital’s 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) 10

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 CMS’s 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 quality—such as those found in CMS’s 

Hospital Compare and in the Core Measures developed by the Joint 

Commission (TJC), an accrediting organization—are 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) 11

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

 Mammography

 Depression screening

 Risk assessments for cardiovascular patients

 Retinopathy assessment for diabetic patients

 Colorectal cancer screening

 Domestic violence screening

 HIV testing for pregnant women

Prevention activities (7)

 Access to dental services

 Use of topical fluoride for children

 Influenza vaccines for senior adults

 Breastfeeding rates

 Use of dental sealants for children

 Childhood immunization rates

 Tobacco cessation interventions

Administration (3)

 Implementation of tribal recommendations

 Suicide surveillance reporting

 Documentation of public health nursing activities

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/newsreleases/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) 12

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 data—such as incident reports, peer reviews, or statistics 

about patient outcomes—is 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) 13

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 (2011–2013). 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 CMS’s 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. CMS’s 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-andGuidance/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) 14

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 Area’s 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 staff—particularly 

clinical consultants—and 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 

group—then 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) 15

explained that the financial cost of providing basic patient care leaves few 

resources to devote to other activities, such as the Consortium. 

The Consortium’s lack of dedicated funds may also affect the future of 

this group. Through interagency agreements connected to CMS’s 

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 CMS’s 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 

assessments—evaluating current processes and providing onsite 

assistance. Another $450,000 was dedicated to the development of Webbased 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, underdeveloped 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 staff’s 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) 16

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 

hospital’s 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) 17

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 21⁄2 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-andCertification/QAPI/qapidefinition.html on October 27, 2014. 
IHS Hospitals: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 18

RECOMMENDATIONS

IHS staff told us—and our review of documentation supports—that IHS 

hospitals attempt to meet new revised requirements for quality while also 

struggling to meet patients’ basic care needs. A companion report—Indian 

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 IHS’s 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 that—in 

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) 19

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 processes—all 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) 20

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 

IHS’s 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-accredited—of which there are currently 

10—to 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 attention—for 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) 21

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 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 Framework―IHS 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 initiatives―IHS 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) 22

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 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 IHS’s 

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) 23

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

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: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 24

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 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) 25

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 (QAPI)

§ 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: More Monitoring Needed to Ensure Quality Care (OEI-06-14-00010) 26

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.
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APPENDIX C

METHODOLOGY

This study describes CMS’s and IHS’s 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 IHS’s 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 Consortium’s efforts to improve hospital quality and 

promote CoPs compliance.

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

Quality Improvement and Survey & Certification Operations. We asked 

about CMS’s 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 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 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 2013–2014. (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 Dorgan’s 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.
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.