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[Federal Register Volume 89, Number 249 (Monday, December 30, 2024)]
[Notices]
[Pages 106537-106539]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-31273]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Indian Health Service

Organization, Functions, and Delegations of Authority; Part G; 
Indian Health Service; Headquarters, Office of the Director, Office of 
Quality

AGENCY: Indian Health Service, Department of Health and Human Services.

ACTION: Final notice.

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SUMMARY: Part G of the Statement of Organization, Functions, and 
Delegations of Authority of the Department of Health and Human Services 
(HHS) is hereby amended to reflect a reorganization of the Indian 
Health Service (IHS). The purpose of this reorganization proposal is to 
update the current approved IHS, Office of the Director (GA), 
Congressional and Legislative Affairs Staff (GA1) and the Office of 
Quality (GAP) in their entirety and replace with the following:

SUPPLEMENTARY INFORMATION: The IHS is an Operating Division within the 
Department of Health and Human Services (HHS) and is under the 
leadership and direction of a Director who is directly responsible to 
the Secretary of Health and Human Services. The IHS Headquarters is 
proposing to reorganize the following major component: Office the 
Office of Quality (OQ).
    Part G of the Statement of Organization, Functions, and Delegations 
of Authority was most recently amended at 89 FR 61126, July 30, 2024.

[[Page 106538]]

Office of the Director, IHS (GA)

Congressional and Legislative Affairs Staff (CLAS) (GA1)

    (1) Serves as the principal advisor to the IHS Director on all 
legislative and congressional relations matters; (2) advises the IHS 
Director and other IHS officials on the need for changes in legislation 
and manages the development of IHS legislative initiatives; (3) serves 
as the IHS liaison office for congressional and legislative affairs 
with Congressional offices, the HHS, the Office of Management and 
Budget (OMB), the White House, and other federal agencies; (4) tracks 
all major legislative proposals in the Congress that would impact 
Indian health; (5) ensures that the IHS Director and appropriate IHS 
and HHS officials are briefed on the potential impact of proposed 
legislation; (6) develops legislative strategy for key policy and 
legislative initiatives; (7) provides technical assistance and advice 
relative to the effect that initiatives/implementation would have on 
the IHS; (8) provides support and collaborates with the Office of 
Finance and Accounting relative to IHS appropriations efforts; (9) 
directs the development of IHS briefing materials for congressional 
hearings, testimony, and bill reports; (10) analyzes legislation for 
necessary action within the IHS; (11) develops appropriate legislative 
implementation plans; (12) coordinates with IHS HQ and Area Offices as 
appropriate to provide leadership, advocacy, and technical support to 
respond to requests from the public, including tribal governments, 
tribal organizations, and Indian community organizations regarding IHS 
legislative issues.

Office of Quality (GAP)

    The Office of Quality (OQ) provides leadership and direction for 
quality improvement and patient safety activities and oversees 
compliance and risk management throughout the agency. Specifically, the 
office (1) advises the Indian Health Service (IHS) Director on assuring 
quality health care, maximizing the patient experience, and 
systematizing quality improvement activities to improve clinical 
outcomes and administrative processes; (2) develops and implements a 
strategic quality framework; (3) oversees accreditation readiness 
activities and compliance with accreditation requirements at all IHS 
Direct Service facilities; (4) conducts performance improvement, 
quality assurance, innovative thinking, and risk management trainings; 
(5) oversees IHS facilities and staff in intra-agency quality 
improvement activities; (6) advises on development and monitoring of 
quality assurance and governance metrics for health care delivery 
processes and outcomes; (7) develops programs to assess, address, and 
improve systems and processes to improve health care quality; (8) 
advises on compliance with relevant federal regulations and 
accreditation and professional standards; (9) provides guidance for 
standardization of health care delivery policies, protocols, and 
governance; (10) advises and guides IHS patient-centered care 
processes, ensuring engagement of patients as partners in care; (11) 
oversees the IHS Enterprise Risk Management (ERM) vision, culture, 
strategy, and framework and clinical risk management; (12) oversees and 
coordinates the agency's efforts to establish and maintain proper 
internal controls; (13) ensures requirements are met under OMB Circular 
A-123; (14) develops programs to promote patient safety management and 
reporting systems and processes, sentinel event investigations/root 
cause analysis; and (15) participates in cross-cutting issues and 
processes, including but not limited to, emergency preparedness/
security, quality assurance, recruitment, budget formulation, self-
determination issues, and resolution of audit findings as may be needed 
and appropriate.

Division of Quality Assurance and Patient Safety (GAPA)

    (1) Develops and implements programs to promote sustained 
compliance with relevant federal regulations related to accreditation 
and professional standards for health care facilities; (2) manages and 
coordinates continuous accreditation compliance programs using 
multidisciplinary integration of survey readiness activities; (3) 
coordinates health care accreditation resource management; (4) tracks 
health care accreditation and certification survey reports; (5) 
develops and implements programs to manage credentialing standards and 
policy, acquires and maintains centralized credentialing software 
system, promotes unification of medical staff professionals (MSP), and 
promotes standardized training and support resources for MSP; (6) 
develops and implements policies and procedures to promote patient 
safety, infection control practices, and environment of care and life 
safety practices; (7) establishes policies and guidelines to reduce 
adverse events; (8) develops education and training related to the 
application of established patient safety and adverse event reporting 
systems and metrics; (9) establishes and maintains oversight mechanisms 
for incident identification and reporting, adverse events and good 
catches, comprehensive systemic analysis/root cause analysis process 
and documentation; (10) implements strategies to improve patient and 
workforce safety; (11) enhances collaborative communication to 
facilitate the sharing of best practices and learning related to 
identified risks and mitigation actions across the agency; (12) 
identifies IHS and National patient safety trends and investigates 
positive and negative patient safety outcomes across the agency; and 
(13) provides patient safety consultation regarding industry standards, 
best practices, and development of policy, processes, and procedures.

Division of Enterprise Risk Management (GAPB)

    (1) Oversees and coordinates the IHS ERM vision, culture, strategy, 
and framework; (2) develops goals and objectives for the ERM program, 
integrated with broader IHS-wide strategic goals/objectives, and tracks 
progress toward achieving them; (3) coordinates the development of risk 
policy, including a risk appetite statement, to guide Agency decision-
making and documentation related to risk; (4) advises and collaborates 
in the development of the IHS ERM portfolio of enterprise risks and 
ensures appropriate and effective management by accountable individual 
risk owners; (5) integrates risk assessment activities across the IHS 
risk portfolio; (6) advises on ERM and provides expertise, advice, and 
assistance to the agency leadership on compliance matters; (7) provides 
guidance and training on the risk management process and 
prioritization; (8) facilitates the governance policy, process, and 
reporting to establish consistency and quality of documentation of 
fiduciary responsibilities of governing bodies; (9) oversees tracking 
of high-risk administrative, clinical, or personnel incidents to ensure 
appropriate local and agency-wide response, timely closure, assessment 
of internal controls, and review of case studies to promote a safety 
culture based on risk-awareness; (10) collaborates with key HQ Offices 
to ensure consistency in cross-cutting agency strategic planning, ERM, 
and management of internal controls across IHS; (11) collaborates with 
strategic planning process to integrate risk management and strategic 
thinking; (12) reviews tort claims files; (13) represents the IHS when 
claims are presented for review by the Malpractice Claims

[[Page 106539]]

Review Panel chartered by the HHS, and assists providers with 
Malpractice Claims Review Panel interactions; (14) submits payment 
reports to the National Practitioner Data Bank; (15) maintains case 
files and a malpractice claims database; (16) provides case summaries, 
peer review, outcome information, and feedback of risk management 
recommendations; (17) disseminates information about the review 
process; (18) responds to outside organizations requesting tort claim-
involvement histories on former employees; and (19) responds to Tort 
Claims inquiries from governmental agencies, media, Tribal and Urban 
Indian organizations, and advocacy groups with the Office of General 
Council guidance.

Division of Innovation and Improvement (GAPC)

    (1) Provides trainings on innovative thinking and performance 
improvement techniques; (2) provides training on empathy and relational 
intelligence to better understand colleagues and stakeholders and 
maximize teamwork; (3) integrates innovative thinking into quality 
improvement and policy formation processes to stimulate rapid idea 
generation; (4) oversees training programs to increase quality 
improvement capacity and standardize improvement methodology to test 
small-scale changes at the local level; (5) reviews use of health 
information technology and data to improve performance, quality and 
service; (6) monitors patient and staff satisfaction with health care 
service delivery; (7) leads change management for practice 
transformation to embrace new models of care delivery and to enhance 
efficiency of the care delivery process; (8) develops programs to 
promote the implementation of patient-centered care models; (9) 
coordinates sharing of best practices between Area Quality Managers and 
Service Unit Quality Assurance and Performance Improvement officers; 
and (10) supports and promotes patient-centered care including Patient 
and Family Engagement, and promotes unification of Area Quality 
Managers and Service Unit Quality Assurance and Performance Improvement 
Officers.

Division of Compliance (GAPD)

    (1) Coordinates the IHS's compliance program; (2) administers the 
agency's internal control program in accordance with the Federal 
Managers' Financial Integrity Act, OMB Circular No. A-123, GAO Green 
Book, and other applicable requirements; (3) oversees and coordinates 
the agency's efforts to establish and maintain proper internal 
controls; (4) oversees and institutionalizes a continuous compliance 
review process; (5) manages goals and objectives for the Compliance 
program, integrates them with broader IHS-wide strategic goals/
objectives, and tracks progress toward achieving them; (6) evaluates 
and monitors systems of internal control across IHS and uses the 
assessments of the internal control program as an integral part of ERM 
to effectively manage risks across IHS; (7) Serves as the IHS liaison 
office to the Government Accountability Office (GAO) and Office of 
Inspector General (OIG); (8) coordinates the development, clearance, 
and transmittal of IHS responses and follow-up to reports issued by the 
OIG, the GAO, and other federal internal and external authorities 
reviewing risk management and internal controls; (9) provides 
leadership and direction on activities for continuous improvement of 
management accountability and administrative systems for effective and 
efficient program support services IHS-wide; and (10) oversees and 
coordinates the annual development and submission of the agency's 
federal Activities Inventory Reform Act report to the HHS.

Section GA-30, Indian Health Service--Delegations of Authority

    All delegations of authority and re-delegations of authority made 
to IHS officials that were in effect immediately prior to this 
reorganization, and that are consistent with this reorganization, shall 
continue in effect pending further re-delegation.

Roselyn Tso,
Director, Indian Health Service.
[FR Doc. 2024-31273 Filed 12-27-24; 8:45 am]
BILLING CODE 4166-14-P
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