Indian Health Service: Continued Efforts Needed to Help Strengthen Response to Sexual Assaults and Domestic Violence
Published: 2011-10-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Justice Department has reported that Indians are at least twice as likely to be raped or sexually assaulted as all other races in the United States. Indians living in remote areas may be days away from health care facilities providing medical forensic exams, which collect evidence related to an assault for use in criminal prosecution. The principal health care provider for Indians, which operates or funds tribes to operate 45 hospitals, is the Department of Health and Human Services' Indian Health Service (IHS). In response to a Tribal Law and Order Act of 2010 mandate, GAO examined (1) the ability of IHS and tribally operated hospitals to collect and preserve medical forensic evidence involving cases of sexual assault and domestic violence, as needed for criminal prosecution; (2) what challenges, if any, these hospitals face in collecting and preserving such evidence; and (3) what factors besides medical forensic evidence contribute to a decision to prosecute such cases. GAO surveyed all 45 IHS and tribally operated hospitals and interviewed IHS and law enforcement officials and prosecutors..
section_title: What GAO Found
paragraphs: GAO's survey of IHS and tribally operated hospitals showed that the ability of these hospitals to collect and preserve medical forensic evidence in cases of sexual assault and domestic violence--that is, to offer medical forensic services--varies from hospital to hospital. Of the 45 hospitals, 26 reported that they are typically able to perform medical forensic exams on site for victims of sexual assault on site, while 19 reported that they choose to refer sexual assault victims to other facilities. The hospitals that provided services began to do so generally in response to an unmet need, not because of direction from IHS headquarters, according to hospital officials. Partly as a result, levels of available services have fluctuated over time. GAO found that the utility of medical forensic evidence in any subsequent criminal prosecution depends on hospital staff's properly preserving an evidentiary chain of custody, which depends largely on coordinating with law enforcement agencies. IHS has made significant progress since 2010 in developing required policies and procedures on medical forensic services for victims of sexual assault; nevertheless, challenges in standardizing and sustaining the provision of such services remain. In March 2011, IHS took a sound first step in what is planned to be an ongoing effort to standardize medical forensic services by issuing its first agencywide policy on how hospitals should respond to adult and adolescent victims of sexual assault. Remaining challenges include systemic issues such as overcoming long travel distances between Indian reservations or Alaska Native villages and IHS or tribal hospitals and developing staffing models that overcome problems with staff burnout, high turnover, and compensation, so that standardized medical forensic services can be provided over the long term. In addition, other challenges include establishing plans to help ensure that IHS hospitals consistently implement and follow the March 2011 policy, such as with training guidelines, and developing policies on how IHS hospitals should respond to domestic violence incidents and sexual abuse involving children who have not yet reached adolescence--neither of which is included in the March 2011 policy. GAO found that IHS is aware of these challenges and has initiatives under way or under consideration to address them. Decisions to prosecute sexual assault or domestic violence cases are based on the totality of evidence, one piece of which is medical forensic evidence collected by hospitals. In some cases, medical forensic evidence may be a crucial factor; in other cases, however, it may not be relevant or available. Law enforcement officers and prosecutors said that they also consider several other factors when deciding to refer or accept a case for prosecution. For example, some victims in small reservations or isolated villages may refuse to cooperate or may retract their initial statements because of pressure from community members who may depend on the alleged perpetrator for necessities. As a result, the victim may be unavailable to testify. Several prosecutors also told us that the availability to testify of the providers who perform medical forensic exams is an important factor, because such testimony can help demonstrate that an assault occurred or otherwise support a victim's account. IHS's March 2011 policy, however, does not clearly and comprehensively articulate the agency's processes for responding to subpoenas or requests for employee testimony.
section_title: What GAO Recommends
paragraphs: GAO is making five recommendations aimed at improving IHS's response to sexual assault and domestic violence, including to develop an implementation and monitoring plan for its new sexual assault policy and to modify sections of the policy regarding required training and subpoenas or requests to testify. The Department of Health and Human Services and the state of Alaska generally agreed with GAO's findings and recommendations.

section_title: Letter
paragraphs: The Department of Justice has reported that Indians are at least twice as  likely to be raped or sexually assaulted as all other races in the United  States and that one in three Indian women have reported being raped at  some time in their life. Similarly, over one-third of Indian women and  one-eighth of Indian men in the United States will experience domestic  violence. Some Indians who are victims of sexual assault, domestic  violence, or child abuse live in urban areas, but many live on rural  reservations or in remote, isolated Alaska Native villages. For people in  rural or remote areas, it can take hours—and sometimes days—to reach  the closest medical provider who can not only treat their injuries, but also  perform a medical forensic exam to collect assault-related evidence for  use in the criminal justice system.
The Department of Health and Human Services’ Indian Health Service  (IHS) is the principal federal health care provider for approximately  1.9 million Indians across 35 states. IHS headquarters oversees 12 area  offices representing the agency’s different regions and either directly  operates or provides funding to tribes or tribal organizations to operate  approximately 1,200 facilities. These facilities include hospitals, clinics,  health centers, school health centers, health stations, dental clinics,  alcohol substance abuse treatment facilities, behavioral health facilities,  and others. Across the United States, IHS provides direct medical care at  its facilities, including primary care services and some specialty services,  such as treatment and prevention of diabetes, and operates or provides  funding to tribes to operate 45 hospitals, providing services to Indians  from over 560 tribes.
IHS defines sexual assault as sexual contact without consent, and it  defines domestic violence as abusive behavior involving intimate partners  or family members or household members that is used to gain or maintain  power and control over another intimate partner or family member or  household member. Victims of sexual assault and domestic violence can  typically receive a sexual assault medical forensic examination in a  hospital. A 2007 report by the human-rights organization Amnesty  International USA called for Congress to increase IHS funding to ensure  that victims of sexual assault and domestic violence can receive more  timely medical forensic examinations and that proper protocols are  followed for collecting and preserving evidence related to these crimes.
Tribal, state, or federal governments may each have jurisdiction to  prosecute those who commit crimes in Indian country, depending on  several factors, including the nature of the crime and whether the victim  or alleged perpetrator is Indian. For example, the federal government and  tribal governments have jurisdiction to prosecute sexual assault crimes  committed by Indians in Indian country in almost all states in which IHS  has hospitals. For crimes prosecuted by the federal government,  investigating agencies include Justice’s Federal Bureau of Investigation  (FBI) or the Department of the Interior’s Bureau of Indian Affairs, and the  crimes are prosecuted by 1 of the 94 U.S. Attorneys’ Offices.
Victims of sexual assault or domestic violence may arrive at an IHS  hospital in various ways: an ambulance may transport them, law  enforcement officers may bring them, or they may arrive on their own.  They may arrive immediately after an assault (such cases are typically  referred to as acute cases) or weeks, months, or years later (delayed or  nonacute cases). Thus begins a series of steps that—if proper protocols  are followed, and the appropriate “chain of custody” of the evidence is  maintained, among other factors—may ultimately lead to a decision to  prosecute (see fig. 1).
Given consent by the victim, medical providers generally collect medical  forensic evidence through a medical forensic examination that may follow  steps and use supplies from a sexual assault evidence collection kit; the  collected evidence is preserved until law enforcement takes possession  of it. Under Justice’s national protocol for sexual assault medical forensic  exams, medical providers may collect a range of physical evidence,  including but not limited to clothing, foreign materials on the body, hair  (including head and pubic hair samples and combings), body swabs, and  a blood or saliva sample for DNA analysis and comparison. In addition,  medical forensic exams typically include documenting biological and  physical findings such as cuts or bruises, through either writing or  photographs, and recording a victim’s medical forensic history such as  the time and nature of the assault. This exam can take several hours.  Once the exam is completed, medical providers preserve the collected  evidence according to jurisdictional policies, which may include  procedures for packaging, labeling, and sealing evidence collection kits  and storing the kits in a secure location (see fig. 2). For cases of domestic  violence, medical providers typically do not perform a sexual assault  medical forensic exam unless a sexual assault has also occurred.
Instead, medical providers, and sometimes law enforcement officers,  generally record a victim’s statement of the incident and document  injuries through writing or photographs.
The Tribal Law and Order Act of 2010—whose purpose was, among  other things, to combat sexual and domestic violence against American  Indian and Alaska Native women—mandated that we study the capability  of IHS facilities in remote Indian reservations and Alaska Native villages  to collect, maintain, and secure evidence of sexual assaults and domestic  violence, as required for criminal prosecution. In response to the  mandate and subsequent discussion with offices of the relevant  congressional committees of jurisdiction, this report examines (1) the  ability of IHS and tribally operated hospitals to collect and preserve  medical forensic evidence for use in criminal prosecution in sexual  assault and domestic violence cases; (2) what challenges, if any, these  hospitals face in collecting and preserving such evidence, particularly remote Indian reservations and Alaska Native villages; and (3) what  factors besides medical forensic evidence collected by these hospitals  contribute to a decision to prosecute such cases.
For all three objectives, we collected and analyzed laws, regulations, a agency policies relevant to the collection and preservation of medical  forensic evidence by IHS and tribally operated hospitals in cases of  sexual assault and domestic violence, and we interviewed and gathered  relevant documentation from headquarters officials at IHS, the Bureau of  Indian Affairs, Justice, and the state of Alaska. In addition, we conducte d  over 60 semistructured interviews with several groups of stakeholders,  including staff from IHS and tribally operated hospitals, victim advocacy groups, prosecutors, and law enforcement. Specifically, we conducted  semistructured interviews with stakeholders (1) from hospital staff during  site visits to a nonprobability sample of 8 IHS or tribally operated hosp in Alaska, Arizona, and South Dakota and over the telephone with an  additional nonprobability sample of 7 IHS or tribally operated hospitals in  Arizona, Minnesota, Montana, New Mexico, North Dakota, and Oklahoma and (2) from victim advocacy groups; federal and state prosecutors; and federal, state, local, and tribal law enforcement agencies that play a role in responding to and prosecuting sexual assault and domestic violen ce  cases in most of the locations these 15 hospitals serve. For these  semistructured interviews, we spoke with officials about hospitals that lity  (a) are performing medical forensic exams, (b) are developing the abi to perform such exams, and (c) are not performing such exams. In  addition, to identify the ability of IHS and tribally operated hospita collect and preserve medical forensic evidence, we used a self- administered questionnaire to survey all 45 IHS or tribally operated  hospitals. We received a 100 percent response rate. To determine w of these hospitals are located in remote areas, we used rural-urban  commuting area codes for isolated and small rural communities  hich  developed on the basis of U.S. Census tracts by the Department of  Agriculture’s Economic Research Service. We obtained data from IHS on the location and names of its hospitals, as well as data on hospital visits  by IHS beneficiaries from fiscal year 2006 through fiscal year 2010. To  assess the reliability of the data, we interviewed knowledgeable IHS  officials and performed electronic testing. We determined that the data  were sufficiently reliable to meet the objectives of this engagement.  Appendix I presents a more detailed description of our scope and  methodology.
We conducted this performance audit from October 2010 through  October 2011, in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform th audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. W believe that the evidence obtained provides a reasonable  basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Of the 45 IHS hospitals, 28 are directly operated by IHS, and 17 are  operated by tribes through funds provided by IHS (see fig. 3). Specifica under the Indian Self-Determination and Education Assistance Act, as  amended, IHS provides funds to tribes to run their own hospitals through  self-determination contracts or self-governance compacts. For exampl the tribes in Alaska operate 7 regional hospitals and 165 village clinic s,  mainly through a variety of regional health consortiums that provide  services to groups of tribes. These self-determination contracts and  self-governance compacts implement the act’s commitment to effective  and meaningful participation by the Indian people in the planning,  conduct, and administration of health programs and services. IHS  manages its facilities and staff, including the hospitals it directly operates  and its direct staff, through the Indian Health Manual, among other thin This document serves as the primary reference for IHS employees  on  IHS-specific policy and procedures. In accordance with the Indian  Self-Determination and Education Assistance Act as amended, howeve the self-determination contracts and self-governance compacts under  which tribes operate hospitals do not generally require compliance with  IHS policy. Therefore, IHS policies and procedures—including those laid  gs.  r,  out in the Indian Health Manual—do not generally apply to tribally  operated facilities, although they can be used as models on which to base  local tribal protocols.
With regard to sexual assault, IHS’s Indian Health Manual states tha person cannot give consent to sexual contact if she or he is forced,  threatened, coerced, drugged, inebriated, or unconscious; has certain  disabilities; or is a minor. We use the term sexual assault to refer to the  federal sex abuse felonies and attempts to commit them—that is, sexual abuse and aggravated sexual abuse, abusive sexual contact, or sexualabuse of children. This category includes what is commonly known as  molestation and rape, including (1) cases where the alleged perpetrator  uses force or threats, renders the victim unconscious, or administ ers  drugs or other intoxicants that substantially impair the victim and  (2) cases where the victim is incapable of appraising the nature of conduct or is physically incapable of declining to participate or of  communicating unwillingness to engage in the sexual act. With regar domestic violence, IHS’s Indian Health Manual states that dome violence can involve physical, sexual, emotional, economic, or  psychological actions or threats of actions that influence another person.  stic  Domestic violence includes any behaviors that intimidate, manipulate,  humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, inju or wound someone. We use the term domestic violence to refer to all  major crimes as defined in the Major Crimes Act between intimate  partners or family members, including elders and spouses. Domestic  violence also includes major crimes against children that are not sexual in  nature.
A medical provider specially trained in medical forensic examination may perform such an exam in cases of sexual assault or domestic violence,  and law enforcement officers may interview the victim for his or her  account of what happened. Medical providers typically perform such  exams only for acute cases of sexual assault, where the assault occurre within the previous 72 to 96 hours—when such evidence is considered rson’s  most viable—because physical and biological evidence on a pe body or clothes degrades over time, becoming unviable or too  contaminated to be used. The standard of practice for how long such  evidence is viable changes as scientific advancements are made, with  some jurisdictions now performing medical forensic exams up to 7 days  after an assault. In terms of sexual assaults, Justice’s protocols descr two types of specially trained medical providers who conduct sexual  assault medical forensic exams:    Sexual assault nurse examiner (SANE): a registered nurse who has  received specialized education and has fulfilled clin to perform sexual assault medical forensic exams.    Sexual assault forensic examiner: a health care provider, including a physician or physician assistant, who has been specially educated  ult  and has completed clinical requirements to perform sexual assa medical forensic exams (in the same way a nurse is trained to  become a SANE).
The term SANE refers to registered nurses, a category including nurse  midwives and other advanced practice nurses, among other providers;  the term sexual assault forensic examiner refers more broadly to  medical  providers including registered nurses plus physicians, physician  assistants, and nurse practitioners. Justice’s protocol encourages  certification of SANEs, but certification as a SANE is available only to  registered nurses. No such national or international certification ex sexual assault forensic examiners who are not registered nurses.  Registered nurses can be certified as SANEs through the Intern Association of Forensic Nurses to perform exams for adult and ational  adolescent sexual assault victims or to perform exams in cases of sexual  assault of children who have not reached puberty.  Nurses can become  certified by meeting the association’s eligibility requirements; completing  tion  a didactic training curriculum; and successfully completing a certifica examination covering several topics, such as how to assess sexual  assault patients, how to collect and document evidence in a way that  protects the evidence’s integrity, and how to testify about findings or chain o are  of custody. Beyond cases of sexual assault, medical providers wh specially educated as forensic nurse examiners are able to collect  forensic evidence for a variety of crimes other than or in addition to t exual assault, such as in injury associated with domestic  involving s violence.
Additionally, for child victims, medical providers may perform medical  forensic exams and gather medical history in the hospital, or the child  may be interviewed elsewhere at a child-specific facility such as a child  advocacy center. Such facilities typically use a multidisciplinary, team  approach to minimize the number of times a child is interviewed and to  ensure that those individuals involved in the child’s life, such as parents  or guardians and social services providers, are working together.
The  jurisdiction in Indian country in almost all states where IHS or tribes  operate hospitals. When the alleged perpetrator of a crime in Indian  country is an Indian, tribal governments also have criminal jurisdiction.As a result, the FBI, the Bureau of Indian Affairs, or tribal investigators  conduct criminal investigations of sexual assault and domestic violence.  Once the investigation or preliminary facts are reviewed, the decision  is  made as to whether the investigation should be referred to the U.S.  Attorneys’ Offices, the tribe, or both for possible prosecution. Prosecut in the U.S. Attorneys’ Offices decide whether to accept the matter for  criminal prosecution in federal court. We previously reported that receip of a law enforcement referral does not mean that a prosecutable case t  exists at the time the referral is made and that, upon further investigation,  prosecutors may file the matter for prosecution as a case in court, declineto prosecute the matter, or refer the matter to tribal prosecutors. we  As  reported in February 2011, because of tribes’ limited jurisdiction and  sentencing authority, tribes often rely on the federal government to  investigate and prosecute serious offenses, since a successful federa an tribal courts might  prosecution could result in a longer sentence th impose, even where tribal jurisdiction exists.
In July 2011, Justice sent a letter to the President of the Senate and the Speaker of the  House of Representatives to consider a proposal to, among other things, extend tribal  criminal jurisdiction to non-Indians who commit domestic violence or dating violence in  Indian country.
section_title: IHS’s Ability to Collect and Preserve Medical Forensic Evidence Varies by Hospital
paragraphs: IHS has limited information on the ability of IHS and tribally operated  hospitals to collect and preserve medical forensic evidence in cases of  sexual assault and domestic violence, as needed for criminal  prosecution—that is, on the hospitals’ ability to offer medical forensic  services. To collect this information, we surveyed the 45 IHS and tribally  operated hospitals and found that the ability to provide these services  varies from hospital to hospital, ranging from providing a broad array of  on-site services, including performing medical forensic exams to collect  physical and biological evidence, to choosing to refer patients to other  facilities for such exams. We also found that the services available at a  hospital generally developed without direction from IHS headquarters and  have fluctuated over time. In addition, the utility of such evidence in any  subsequent criminal prosecution depends on hospital staff’s properly  securing and storing physical evidence, which may in turn depend largely  on coordinating with law enforcement agencies.
subsections: section_title: IHS Had Limited Information on the Ability of Its Facilities to Offer Medical Forensic Services
paragraphs: IHS headquarters had limited information on the ability of its facilities to  provide medical forensic services. We found that IHS could not give us  comprehensive information about which of its facilities—including  hospitals and clinics—provided medical forensic services for victims of  sexual assault and domestic violence, although IHS officials identified  hospitals as the facilities most likely to provide such services. IHS  headquarters also could not identify how many providers at IHS hospitals  have had SANE training or certification. In addition, we found that IHS  headquarters does not centrally track the number of medical forensic  exams performed at its facilities. In analyzing electronic data obtained  from IHS headquarters on procedures done at the hospitals, we found  that because of the way hospitals record these data, it is not possible to  accurately isolate medical forensic exams from other medical activities  related to incidents of sexual assault or domestic violence. IHS does,  however, keep centralized data on where victims of sexual assault and  domestic violence were seen and on the primary purpose of these  patients’ visits.
section_title: Hospitals May Perform Medical Forensic Services on Site or Refer Victims to Other Facilities
paragraphs: The results of our survey of all 45 IHS and tribally operated hospitals  showed that some hospitals typically provide medical forensic exams on  site for both adult and child victims of sexual assault, others typically  perform these exams for either adults or children but not both, and still  others refer most or all sexual assault victims to other facilities   (see table 2).
Specifically, 26 of the 45 hospitals reported that they typically perform  sexual assault medical forensic exams for adults, children, or both. Those  hospitals reporting that they perform these exams only for adults refer all  children to other facilities, and hospitals performing exams only for  children refer all adults to other facilities. Additionally, all IHS and tribally  operated hospitals reporting that they typically provide exams on site also  aim to have staff present or on call so they can offer these services  24 hours a day, 7 days a week. Two hospitals also explained that they  use traditional healing practices and objects when treating sexual assault  victims (see fig. 4). The remaining 19 hospitals reported that they  generally refer all adults and children to other facilities for these exams.
Among the seven hospitals that typically perform medical forensic exams  for both adults and children, one tribally operated hospital in Alaska has a  dedicated coordinator who has received SANE training and is available to  perform exams for both adults and children 24 hours a day, 7 days a  week. A victim of sexual assault who arrives at this hospital can typically  be examined within a short time and in a room dedicated to sexual  assault exams. Similarly, an IHS hospital in Arizona has a group of  approximately 14 nurses and doctors who have received specialized  training in sexual assault medical forensic exams, as well as a room  largely dedicated to these exams. When a sexual assault victim arrives at  this hospital, hospital staff contact 1 of the 14 nurses or doctors to  perform the exam or, if none of these medical providers is present, a  predesignated backup provider is called on. Children requiring an exam  generally see a provider, when available, who has undergone specialized  training in pediatric medical forensic exams.
A total of 19 of 45 hospitals reported typically performing medical forensic  exams for either adult or child victims of sexual assault but not for both.  For example, a South Dakota IHS hospital—which offers medical forensic  services 24 hours a day, 7 days a week, with providers on 24-hour call— typically performs medical forensic exams for adults but not children.  When an adult victim arrives, the emergency room does an initial medical  screening and then calls one of three SANE-trained nurses to perform the  medical forensic exam. But because this hospital does not have a  provider trained to do these exams for children, it refers all child victims to  a hospital in Pierre, which is 2 hours away by car, or to a hospital in Sioux  Falls, which is 4 hours away. In contrast, an IHS hospital in New Mexico  performs exams only for children. The providers at this hospital are  available from 8 a.m. to 4:30 p.m. on weekdays and on call during nights  and weekends; overall coverage is 24 hours a day, 7 days a week.
Hospitals that we categorized as being in remote areas are more likely  to perform medical forensic exams and less likely to refer victims  elsewhere for service than IHS and tribally operated hospitals taken as a  whole. Of the 34 hospitals categorized as remote, 22 hospitals reported  that they are able to perform medical forensic exams for adults, children,  or both; 12 of the 34 hospitals reported referring victims to other facilities.  In contrast, the proportions are reversed among the 11 hospitals we  categorized as urban, with 7 of them reporting that they refer all sexual  assault victims to other facilities for exams (see fig. 5 for map of  hospitals). For example, officials from an IHS hospital in the Phoenix,  Arizona, area explained during a site visit that the hospital sees too few  sexual assault cases to warrant having its own staff trained in performing  medical forensic exams; in the officials’ view, it makes more sense for the  hospital to leverage existing resources by referring victims to a nearby  facility offering medical forensic services.
IHS and tribally operated hospitals vary not only in whether and for whom  they can provide medical forensic services but also in the training their  providers have received (see table 3). Of the 26 hospitals that typically  perform medical forensic exams, 20 reported having providers who  received specialized training or certification in sexual assault medical  forensic exams. The remaining 6 hospitals reported offering medical  forensic exams even if the providers performing the exams have not  received this specialized training. In fact, several medical providers told  us that traveling doctors and nurses, who temporarily work at an IHS  hospital for a few weeks or months, may perform these medical forensic  exams on site even if they have not received this specialized training. In  discussions with hospital officials, we also found that hospitals referring  sexual assault victims—whether adults or children—to other facilities for  medical forensic exams may do so because they do not have medical  providers on staff with this specialized training.
Many of the hospitals we surveyed reported that they typically perform  medical forensic exams in cases of domestic violence. They may do so  only in cases of domestic violence that also include a sexual component  or, occasionally, when the injuries sustained from a discrete domestic  violence incident without a sexual component are severe. Officials at  several hospitals explained that for discrete domestic violence incidents  (those that do not include a sexual component), law enforcement officers  usually collect evidence, such as photographs of bruises or other injuries,  for use in court. For example, officials at two separate hospitals explained  that in cases of domestic violence, law enforcement officers take  photographs of physical injuries, and medical providers treat any injuries  requiring medical attention.
section_title: Medical Forensic Services Have Developed Largely without Central Direction
paragraphs: In general, efforts to provide medical forensic services at the local level  have fluctuated over time and have received limited funding from IHS. In  discussions with hospital officials, we found that the provision of medical  forensic services generally developed at a grassroots level, rather than in  response to an explicit requirement from IHS headquarters. Local medical  providers chose to provide such exams in response to an unmet need for  such services in their area, not because IHS headquarters directed them  to do so. For example, a nurse at one hospital explained that she and  five other nurses attended SANE training after recognizing that medical  providers at the hospital were uncomfortable doing sexual assault  medical forensic exams. Additionally, an IHS official at another hospital  explained that his staff began providing medical forensic services after  the area office requested volunteers to pilot providing such services to  better meet the area’s needs.
We also found that the ability of an IHS or tribally operated hospital to  offer medical forensic services has fluctuated over time. Some hospitals,  for example, have been able to sustain or even expand their medical  forensic services. In contrast, other hospitals have lost staff who were  willing or trained to perform medical forensic exams and ceased offering  these exams entirely or waited until new staff could be hired or trained.  For example, officials from one hospital explained during a follow-up  discussion with us that they recently ceased performing sexual assault  medical forensic exams for adults when a shift in staffing resources left  the hospital’s emergency room without providers specially trained in  performing such exams. Consequently, the hospital now performs  medical forensic exams only for children and refers adult victims to a  private hospital in a nearby city, which helps facilitate more consistent  and timely evidence collection, according to a law enforcement official.  Similarly, medical providers explained during a site visit that after the sole  provider of medical forensic exams in a remote Alaskan community left,  the hospital ceased offering medical forensic exams because none of its  remaining staff had specialized training. As a result, all adults and  children have since been flown several hours away to Anchorage to  receive medical forensic exams. Given the importance of providing  medical forensic services locally, however, the hospital staff said that they  recently sent several staff for training in sexual assault medical forensic  exams and hired someone to serve as a coordinator for this effort.
Furthermore, efforts by IHS headquarters to fund medical forensic  services have been limited. The agency has provided some funding for  training and equipment to hospitals or staff, but this funding has been  infrequent or limited, according to IHS officials. Specifically,    Pilot program. In 2002 and 2003, IHS used a grant from Justice to  fund two of its hospitals—one in Shiprock, New Mexico, and the other  in Pine Ridge, South Dakota—to pilot offering medical forensic exams  for adult victims of sexual assault. As part of this pilot program, the  hospitals received funding to send their providers to SANE training  and to purchase equipment needed for medical forensic exams, such  as digital cameras. A hospital official at one of these hospitals  explained that it still offers medical forensic exams and, to better meet  patients’ needs, is expanding its services to also include a clinic more  centrally located on the vast reservation, to provide services closer to  patients’ homes. An IHS official at the other pilot-program hospital  explained that it ceased offering medical forensic exams in 2007 after  too many of its specially trained medical forensic examiners left. This  hospital now sends its patients across state lines to a private provider.    Limited funds for training or equipment. IHS has at times paid for staff  at some of its hospitals to receive SANE training, but such funding  was not part of a comprehensive effort to develop medical forensic  capacity at IHS facilities. From fiscal year 2003 through fiscal year  2011, IHS provided $45,000 for three training sessions for  60 providers. But agency officials also explained that IHS has  provided no additional funding for hospitals to purchase equipment to  conduct these exams. According to staff from one IHS hospital, they  have had to use a digital camera belonging to the local Bureau of  Indian Affairs law enforcement office to photographically document  physical injuries as evidence because they did not have funding to  purchase their own camera.
IHS Domestic Violence Prevention Initiative. IHS received a $7.5 million  appropriation for its domestic violence prevention initiative in fiscal year  2009 and another $10 million appropriation in fiscal year 2010. The  Domestic Violence Prevention Initiative expands prevention, advocacy,  outreach, and medical forensic services in cases of domestic violence  and sexual assault. Of this total funding, $3.5 million funded medical  forensic services such as exams, and the remaining funded prevention,  advocacy, outreach, and coordination. In fact, of the 65 projects IHS  funded through this initiative, 8 projects aimed to use this money for  improving medical forensic services at IHS or tribally operated  hospitals. Further, seven of these eight projects funded hospitals that  already had some staff on board who were specially trained in  providing sexual assault medical forensic exams.
section_title: The Preservation of Medical Forensic Evidence Depends in Large Part on Hospital Coordination with Law Enforcement
paragraphs: The specific policies or procedures that IHS has developed to preserve  medical forensic evidence vary from hospital to hospital and may depend  greatly on coordination with the law enforcement officers who take  possession of the evidence for use in the criminal justice system.  Improperly securing medical forensic evidence or improperly maintaining  its chain of custody—that is, the process that demonstrates the  chronological documentation of the collection, custody, control, transfer,  analysis, and disposition of the evidence—can undermine the evidence’s  usefulness in a criminal investigation or prosecution. Consequently,  according to Justice protocols, it is imperative to properly preserve the  evidence collected during a medical forensic exam. Proper preservation  includes, among other things, securing the physical evidence from  contamination or adulteration, as well as properly following and  documenting the chain of custody. We found that some hospitals had  specific procedures in place for storing and securing physical evidence,  and others did not.
In discussions with law enforcement officers and hospital staff, we found  that the way a hospital does or does not preserve the medical forensic  evidence it collects, such as biological materials or statements from  victims, largely depends on the extent or type of coordination with law  enforcement. For example, at one hospital, providers and law  enforcement officers told us they jointly developed a protocol to store  evidence from completed exams in a locked cabinet to which only law  enforcement officers have the key. This protocol ensures that if a law  enforcement officer cannot immediately take possession of the evidence,  it is nevertheless stored in a fashion that properly maintains the chain of  custody. Similarly, an official at another hospital explained that medical  forensic evidence is stored in a locked filing cabinet in the SANE  coordinator’s office until a law enforcement officer signs a release form to  take possession of it—an arrangement developed between the hospital  and law enforcement to better maintain the chain of custody. In other  communities, multidisciplinary groups—such as sexual assault response  teams, which coordinate community efforts related to cases of adult  sexual assault, or multidisciplinary teams established by prosecutors for  cases involving children—provide opportunities for hospital staff to  develop evidence preservation procedures. For example, officials from  an IHS hospital in a mandatory Public Law 280 state told us that its new  sexual assault response team was instrumental in determining the most  appropriate law enforcement agency—tribal, local, or county—to call to  take possession of medical forensic evidence. Additionally, some hospital  officials told us that they do not specifically coordinate with law  enforcement or had no specific evidence preservation procedures  because they assume that an officer will immediately take possession of  any medical forensic evidence collected. Such assumptions do not  always hold, however, such as if the law enforcement officer is called  away to investigate another crime or cannot wait in the hospital for  completion of the multihour medical forensic exam. Differences in how  hospitals preserve medical forensic evidence may also stem in part from  the type of training received by those who perform medical forensic  exams. For example, SANE training covers securing evidence and  maintaining its chain of custody. Providers who do not receive such  specialized training may be relying on following the instructions contained  in an evidence collection kit—a process that some stakeholders told us  may miss important steps.
section_title: IHS and Tribal Hospitals Face Several Challenges in Standardizing and Sustaining the Provision of Medical Forensic Services
paragraphs: Since enactment of the Indian Health Care Improvement Reauthorization  and Extension Act of 2009 (on March 23, 2010) and the Tribal Law and  Order Act of 2010 (on July 29, 2010), IHS has made significant progress  in developing policies and procedures regarding medical forensic services  for victims of sexual abuse, as the acts required. IHS worked  expeditiously to establish its first agencywide sexual assault policy within  the 1-year deadline established by the Indian Health Care Improvement  Act. The new policy, issued in March 2011, is an important and sound first  step in what is planned to be a continuing effort to provide a standardized  level of medical forensic services. As part of this effort, IHS has a number  of important initiatives under way or under consideration, and events are  unfolding rapidly. For example, in partnership with Justice, a new position  was created in IHS headquarters for a sexual assault exam and response  coordinator, and the position was filled in August 2011.
Still, IHS faces a number of important challenges as it attempts to  implement its new policy and continues to respond to incidents of sexual  assault and domestic violence. These challenges include systemic  issues—such as overcoming long travel distances and developing staffing  models that overcome problems with staff burnout, high turnover, and  compensation—so that standardized medical forensic services can be  provided over the long term. Specifically, we found that hospitals face the  following four challenges in standardizing and sustaining the provision of  medical forensic services:    overcoming long travel distances;    establishing plans to help ensure that hospitals consistently  implement and follow the March 2011 policy;    developing similar policies for domestic violence and child sexual    developing sustainable staffing models that overcome problems with  staff burnout, high turnover, and compensation.
In general, our work confirmed that IHS is aware of the challenges that it  faces and either has initiatives under way to address them or is trying to  formulate such initiatives.
subsections: section_title: Overcoming Travel Distances
paragraphs: We found that long travel distances between IHS patient populations and  hospitals—often across remote terrain with few, if any, roads—pose a  barrier to access to a full range of medical services that an IHS  beneficiary might need, including medical forensic services. Distances are  of particular concern in Alaska, where sexual assault or domestic violence  victims from remote Alaska Native villages must travel hundreds of miles  to hospitals offering on-site medical forensic exams. Travel is typically  possible only by airplane or snow machine; most villages are not  accessible by road. (See fig. 6 for a picture of the ambulance used in one  of the villages.)
Further, victims must typically rely on law enforcement to arrange air  transportation, and bad weather may delay flights for hours or days,  according to stakeholders. Victims living in regions where the nearest  hospital does not provide on-site medical forensic services must often  undertake multistage trips to find access to these services. For example,  medical providers told us that victims from remote villages near Kotzebue,  where the hospital does not provide on-site medical forensic services,  must take at least two flights to reach a hospital that does: a first flight  from their village to Kotzebue and a second one from Kotzebue to  Anchorage (see fig. 7).
Great distances may also separate beneficiaries needing medical forensic  services from hospitals providing these services in states other than  Alaska. For instance, IHS hospitals in Arizona have contracted with an air  ambulance provider to transport patients via helicopter or airplane to  Phoenix for medical services, including medical forensic exams. Such  trips can each cost IHS several thousand dollars, according to IHS  officials.
Medical providers, law enforcement, and prosecutors expressed concerns  that long travel distances may deter victims from reporting sexual assault  and domestic violence and delay collection of the medical forensic  evidence needed for prosecution. They said that great distances may also  discourage victims from reporting assaults to law enforcement and  seeking medical forensic exams, particularly for victims from remote  villages who may need to take two or more flights to obtain an exam.  Also, victims in remote Alaska Native villages who wish to remain  anonymous cannot do so because they generally rely on law enforcement  for air transportation. Moreover, at least one stakeholder told us that  travel delays due to bad weather may make it difficult to collect medical  forensic evidence within the 72- to 96-hour time frame in which such  evidence is considered most viable. According to stakeholders we spoke  with, such long delays are rare, but any delay increases the chance that  physical evidence will become contaminated or lost and that victims may  forget details of the assault.
To help address long travel distances, some hospitals and other  stakeholders, such as law enforcement agencies, told us they are  considering or have suggested expanding medical forensic services to  clinics, either through telemedicine or by training additional medical  providers, and expanding the role of community health aides, the primary  medical providers in remote Alaska Native villages. Telemedicine  technology uses video conference, remote monitoring equipment, and  electronic health records to link patients in remote areas to medical  providers located elsewhere. Telemedicine connects patients in remote  clinics in Alaska to dental, skin, and other health care services and could  be expanded to support treating victims of sexual assault, according to  some stakeholders. One IHS hospital in Montana, for example, is  considering using telemedicine to enable the hospital’s specially trained  medical forensic examiners to consult on child sexual abuse cases—to  determine if a specific injury is consistent with abuse, for example—with  medical providers in remote clinics who do not have this specialized  training. Before such a plan could be put in place, however, officials from  the organization that develops telemedicine technology in Alaska told us,  concerns would need to be addressed about how to securely store and  transmit medical files to protect victim confidentiality and maintain the  evidentiary chain of custody. Rather than use telemedicine, the IHS  hospital located on the edge of a vast reservation is seeking to bring  medical forensic services closer to its beneficiary populations by  developing the capacity to perform medical forensic exams at a centrally  located clinic, according to an IHS official. The hospital has identified  clinic nurses who are interested in receiving specialized training in  conducting the exams.
A few stakeholders also suggested to us that community health aides  could play a larger role in collecting and preserving medical forensic  evidence. Medical providers and community health aides themselves,  however, voiced concerns to us about such a proposal. In cases of sexual  assault, health aides’ scope of practice and training are currently limited  to tasks such as treating victims’ injuries and protecting evidence, such as  clothing, until law enforcement officers arrive; health aides are not  authorized to perform medical forensic exams or to collect evidence  themselves. Among the concerns community health aide officials  mentioned to us is that expecting health aides to perform such exams, on  top of the many tasks already required of them, may increase burnout  rates; they said that such an expectation may also put the health aides at  risk of retaliation from alleged perpetrators or others in a village. Other  suggestions made by stakeholders have included that health aides should  receive additional training on the sexual assault response tasks that are  already within their scope of practice. For example, medical providers told  us that health aides in Alaska’s Yukon-Kuskokwim delta area attended  training in 2010 designed to help health aides and law enforcement  officers understand what health aides should and should not be expected  to do when responding to sexual assault cases. The training focused on  the actions health aides can already take to assist the response of law  enforcement officers and hospitals in such cases, such as asking victims  not to wash or change clothes before undergoing a medical forensic  exam.
section_title: Establishing Plans to Help Ensure That Hospitals Consistently Implement and Follow the March 2011 Sexual Assault Policy
paragraphs: Now that its initial sexual assault policy is in place, IHS faces the  challenge of ensuring that its hospitals consistently implement the policy  and follow its guidelines. IHS is taking initial steps to help hospitals  implement the policy but has not yet developed written, comprehensive  plans for implementation and monitoring. For example, IHS officials told  us the agency is planning to use funding from the existing Domestic  Violence Prevention Initiative to provide policy training to IHS hospitals  and to expand specialized medical forensic training opportunities. IHS  has also partnered with Justice’s Office for Victims of Crime to fund a  national sexual assault exam and response coordinator position within  IHS; the position—which was filled in August 2011—may play a role in  helping implement and monitor the March 2011 policy. Nevertheless, IHS  has not yet developed plans for implementing and monitoring the policy  as a whole. Justice officials echoed these concerns, given most hospitals’  limited technical expertise in medical forensic exams and general lack of  resources for responding to sexual assault.
The Indian Health Care Improvement Act also requires IHS to report to  Congress by September 23, 2011, on “the means and extent to which the  Secretary has carried out” the act’s requirement to establish appropriate  policies, among other things, for responding to victims of sexual abuse  and domestic violence. Agency officials told us that at the time of this  report, IHS had not yet identified sufficient resources for implementing the  policy as a whole, nor had it developed time frames for implementing  major objectives in the policy. Specifically, the agency had not identified  resources for purchasing equipment and supplies, such as digital  cameras and special forensic evidence-drying cabinets, required under  the policy for hospitals providing on-site medical forensic exams.  Furthermore, the agency has set December 31, 2012, as the deadline for  medical providers to be “credentialed and privileged” as specially trained  medical forensic examiners, but it has not identified deadlines IHS  hospitals should meet in implementing other parts of the policy, such as  providing access to medical forensic exams on site or by referral, or  collaborating with the objective of creating sexual assault response  teams. The agency has also not made plans to monitor whether IHS  hospitals are following the policy, such as whether hospitals located more  than 2 hours away from other facilities are developing the capability to  provide on-site medical forensic exams or how well hospitals coordinate  their activities with law enforcement and prosecutors.
Coordination is important because it helps ensure that medical providers  collect and preserve evidence in a way that is useful for prosecution.  Our review found that hospitals’ coordination with law enforcement  agencies and prosecutors varied greatly. Hospitals that do not coordinate  regularly with law enforcement and prosecutors may unintentionally  collect and preserve evidence in a way that hampers the investigation or  prosecution of cases. For example, law enforcement officers in one  location told us that before a candid meeting between medical providers  and the prosecutor took place, providers were unknowingly violating the  chain of custody to such a degree that the prosecutor could not reliably  use their evidence for prosecution. The officers said that the meeting  served as a catalyst for the medical providers to attend SANE training  and for law enforcement officers, the prosecutor, and medical providers to  develop a collaborative response to collecting and preserving evidence in  sexual assault cases. Increased coordination between the hospital and  law enforcement also led one hospital to install a locking cabinet (see  fig. 8) to securely store collected medical forensic evidence before  transferring it to law enforcement. Other medical providers told us they  had not received feedback on medical forensic evidence collection and  preservation from law enforcement officers or prosecutors. In one  location, providers told us they kept completed exam kits with them at all  times—even taking the kits home overnight—until law enforcement took  possession of the kits, even though Justice officials told us that such  practices could undermine the chain of custody. IHS’s March 2011 sexual  assault policy calls on hospitals to coordinate with law enforcement and  prosecutors, but Justice officials expressed concerns that many hospitals  do not have working relationships with law enforcement and prosecutors  that would enable such coordination. Furthermore, the policy does not  specify how IHS headquarters will support its hospitals in building such  relationships or initiating a coordinated response to sexual assault.
According to an agency official, IHS did not have time to develop  implementation and monitoring plans before the March 2011 deadline  established for issuing a policy under the Indian Health Care  Improvement Act. Furthermore, the agency did not seek comments from  tribes before issuing the policy and therefore asked the tribes for  feedback after releasing the policy. According to IHS officials, comments  from tribes were due on May 30, 2011, and the agency was analyzing  these comments and intending to issue a revised policy.
One area of IHS’s March 2011 policy we found to have caused some  confusion deals with guidelines for specialized training and certification  for medical providers. The policy stipulates that nurses, physicians, and  physician assistants must all complete specialized training in performing  sexual assault medical forensic exams. The policy is unclear, however,  about whether, to perform these exams, medical providers need to obtain  documentation of competency beyond this training, especially for  physicians and physician assistants. Sections 3.29.1 and 3.29.5 of the  policy use the terms “credentialed” and “certified” interchangeably—in  defining sexual assault nurse and forensic examiners, in delineating  requirements for training and determining competency to perform these  exams, and in describing how staff obtain privileges to perform these  exams at IHS hospitals. These sections do so even though  “credentialing” generally refers to an internal process for allowing medical  providers to perform specific services in IHS hospitals, and “certification”  is the term used by Justice in its sexual assault protocols and is also  typically used by the organization that developed the SANE specialty to  denote someone who has demonstrated competency in medical forensic  exams and passed a required test. By using these terms interchangeably,  the policy leaves unclear whether medical providers such as physicians  and physician assistants must obtain specialized training and  certification—or just training—before performing sexual assault medical  forensic exams. IHS officials we spoke with provided conflicting  interpretations of the policy, from interpreting it as calling for certification  for sexual assault forensic examiners to calling only for training for these  medical providers. IHS officials acknowledged, however, that no  third-party certification exists for sexual assault forensic examiners in the  same way it exists for nurses, which may imply that IHS would need to  develop its own certification of sexual assault forensic examiners more  broadly. IHS officials acknowledged to us that the agency has no plans to  develop such a certification.
Law enforcement officers and prosecutors told us that variable levels of  specialized training among medical providers have sometimes led to  inconsistencies in the quality and type of medical forensic evidence  collected. Specifically, they said that compared with medical forensic  exams performed by medical providers with specialized training, exams  performed by medical providers without such training have been of lower  quality or did not include certain pieces of evidence. A law enforcement  officer and prosecutors told us that medical providers with SANE training  were more familiar with procedures for collecting evidence and better able  to document the intricacies of injuries and identify subtle signs of assault,  such as small scratches and bruises, than medical providers who did not  have specialized training. A law enforcement officer in one location told  us about a child sexual abuse case in which a physician without  specialized training found no evidence of abuse after performing a  medical forensic exam; in contrast, a SANE-trained medical provider who  performed a subsequent exam found internal injuries and other evidence  of sexual abuse—evidence the physician without specialized training  missed. Stakeholders also told us that because of their specialized  training, SANE-trained medical providers understand the importance of  identifying and collecting evidence consistent with a victim’s account of an  assault, rather than simply following the generic step-by-step instructions  in an evidence collection kit. For example, one victims’ advocacy group  told us about a case in which a medical provider without specialized  training collected only vaginal swabs from a victim when the assault  actually involved anal rape—all because the medical provider did not ask  the victim to describe the assault. No consensus exists on the specific  threshold of specialized training needed to perform adequate exams; law  enforcement officers and prosecutors we spoke with, however, generally  agreed that some level of specialized training helps improve the quality of  evidence collection.
Without clear training and certification guidelines for physicians and  physician assistants, medical forensic exams may continue to be  performed by medical providers with inconsistent levels of knowledge and  expertise. As a result, IHS beneficiaries cannot be assured of uniform  quality in medical forensic services received, and law enforcement  entities cannot count on uniform quality in the medical forensic evidence  collected and preserved, even with IHS’s new sexual assault policy.  Furthermore, calling for nurses to be SANE certified or physicians and  physician assistants to be certified as sexual assault forensic  examiners—if such a certification is developed—may be a difficult  standard for hospitals to meet. Very few hospitals currently have nurses  certified as SANEs, no comparable certification exists for physicians and  physician assistants, and some medical providers we spoke with told us it  can be challenging to complete the clinical training needed to be eligible  for SANE certification. Some medical providers told us they are planning  to complete their clinical training at another facility because their home  hospital does not have a certified SANE provider who can validate their  competency or does not see enough sexual assault cases to provide  sufficient practical experience in performing medical forensic exams to  demonstrate competency. Moreover, hospitals already face considerable  challenges in attracting and retaining medical providers who are willing or  able to perform the exams; calling for certification may unintentionally  exacerbate this challenge, even though several stakeholders told us that  it is the SANE training rather than the certification that is most important  for performing high-quality medical forensic exams.
In addition to the lack of clarity around training and certification guidelines  for physicians and physician assistants under IHS’s new sexual assault  policy, we have concerns that implementing and monitoring the policy’s  overall training and certification guidelines may be challenging given IHS  headquarters’ limited knowledge about how many of its medical providers  have such training or certification. Without this baseline information, the  agency may be unable to accurately allocate resources for training or  identify IHS hospitals with certified SANE providers who can train or  validate the competency of providers from other IHS hospitals. The  agency also does not have a system in place to track providers’ progress  toward meeting its training and certification guidelines. As a result, it may  be unable to hold hospitals accountable for following this section of the  policy.
section_title: Developing Policies on Domestic Violence and Child Sexual Abuse
paragraphs: IHS’s March 2011 sexual assault policy instructs IHS hospitals to provide  a standardized response to adult and adolescent victims of sexual  assault. Specifically, the new policy calls for all IHS-operated hospitals  to provide adult and adolescent patients who arrive in need of a medical  forensic exam with access to an exam by a medical forensic examiner,  either on site or by referral to a nearby facility. The new policy covers  adult and adolescent victims of sexual assault, but it does not cover  whether or how hospitals should respond to discrete incidents of domestic  violence that do not include a sexual component or cover cases of child  sexual abuse. Consequently, IHS hospitals do not have specific or  recently updated guidance on whether to provide medical forensic  services for victims of domestic violence and child sexual abuse; as a  result, these victims may not have access to the full range of services  they need.
Agency officials told us that IHS is deciding how to provide direction on  responding to incidents of domestic violence and child sexual abuse— whether through new policies or by updating existing sections of the  Indian Health Manual—but that the agency does not have concrete plans  to develop policies similar in scope and specificity to the March 2011  sexual assault policy. The Indian Health Care Improvement Act requires  IHS to establish “appropriate protocols, policies, procedures,   standards of practice . . . for victims of domestic violence and sexual  abuse” and to develop appropriate victim services, including  improvements to forensic examinations and evidence collection.  According to an IHS official, the agency did not have time to develop a  separate domestic violence policy before the Indian Health Care  Improvement Act’s March 2011 deadline for establishing such a policy.  In addition, the agency decided to limit the policy’s scope to adults and  adolescents because Justice has not yet developed child sexual abuse  protocols and recommended against including child sexual assault and  adult sexual assault in the same protocol. Moreover, the Tribal Law and  Order Act of 2010 directs IHS to base its sexual assault policies and  protocols on those established by Justice. Therefore, the March 2011  policy does not address child sexual abuse.
IHS officials also acknowledged that the sexual assault policy applies only  to IHS-operated hospitals, not tribally operated hospitals. In accordance  with the Indian Self-Determination and Education Assistance Act, the self- determination contracts and self-governance compacts under which tribes  operate hospitals generally do not require compliance with IHS policy. An  objective of the Indian Self-Determination and Education Assistance Act  is to assure the maximum Indian participation in the direction of federal  services to “Indian communities so as to render such services more  responsive to the needs and desires of those communities.”  Accordingly, tribes are accountable for managing day-to-day operations  of IHS-funded programs, services, and activities included in their self- determination contract or self-governance compact. Tribes thereby accept  the responsibility and accountability to beneficiaries under the contract  with respect to use of the funds and the satisfactory performance of IHS  programs, functions, services, and activities funded under their contract.  At the same time, it is the policy of the Secretary of Health and Human  Services to facilitate tribal efforts to plan, conduct, and administer  programs, functions, services, and activities under the act. To that end, as  requested, IHS may provide technical assistance to tribes in developing  their capability to administer quality programs. According to IHS officials,  tribally operated hospitals may choose to use IHS’s March 2011 policy as  a model for developing their own sexual assault policies.
IHS could negotiate contract or compact provisions requiring tribes to  abide by IHS’s sexual assault policy, but the tribes would have to agree to  such a provision. IHS officials told us the agency is hesitant to pursue this  approach, and has not generally used it, because a multitude of other  issues are also up for negotiation. Furthermore, IHS officials indicated  that they do not plan to include such a provision in compacts or contracts  the agency negotiates.
section_title: Developing Sustainable Staffing Models
paragraphs: Hospital officials told us they face challenges in designing staffing models  for collecting and preserving medical forensic evidence that can  overcome problems with staff burnout, high turnover, and compensation  over time. In some hospitals where we conducted interviews, medical  forensic services were not organized into a formal program or housed  within a specific hospital department. Instead, several officials told us,  medical forensic exams are performed by individual medical providers,  sometimes from different departments, and often outside the medical  providers’ official job duties and beyond their normal working hours. For  example, at one hospital, officials told us that nurses from different units  received specialized training in performing medical forensic exams and  agreed to be on call to perform the exams day or night. Performing these  exams was not written into the nurses’ formal job descriptions, however,  and the nurses were expected to complete their official job duties, as well  as medical forensic activities. Medical providers told us that burnout may  occur for several reasons—including stress, lack of supervisor support,  and inadequate compensation—stemming from staffing arrangements in  which medical providers perform exams in addition to their official job  duties.
Potential burnout is a serious concern because it can undermine a  hospital’s ability to sustain access to medical forensic services. IHS  officials acknowledged that turnover rates for medical providers specially  trained in performing medical forensic exams are generally very high, with  such providers often leaving IHS facilities after only 2 years. Some  medical providers told us they find it stressful to balance their normal job  duties with providing medical forensic services. For example, in one  hospital, several medical providers described the staffing arrangement for  medical forensic exams as relying on nurses performing the work of  two full-time jobs—their official jobs and their medical forensic exam  duties—while receiving compensation only for their official jobs.
In some hospitals, moreover, medical providers told us that their  supervisors do not consistently allow them to participate in tasks outside  of their normal duties. For example, medical providers told us about  instances in which supervisors did not permit them to take time away from  their normal duties to attend sexual assault response team meetings; as a  result, the medical providers missed the meetings or worked beyond their  normal hours to attend. In other cases, because of general hospital  understaffing, some medical providers were unable to find backup  coverage for their normal duties when called away for several hours to  perform medical forensic exams. Consequently, some medical providers  had to leave their normal duties unattended or have victims wait to  receive exams until the medical providers’ normal shifts were over, which  is stressful, according to at least one medical provider.
In addition to issues related to understaffing, medical providers  performing medical forensic exams over and above their normal duties  said that they may not receive enough compensation to prevent attrition.  The type and amount of compensation provided for performing medical  forensic exams vary across hospitals, with some medical providers  receiving overtime pay or compensatory time off and others receiving  nothing beyond their normal salaries. Some medical providers told us  they had trouble obtaining sufficient compensation. For example, medical  providers in one hospital told us they receive compensatory time off for  performing medical forensic exams, but they can rarely use the additional  leave hours because the hospital is too short-staffed to approve time off.  In another hospital, nurses who provided medical forensic exams in  addition to their normal job duties found it difficult to obtain approval from  their supervisors for overtime pay when performing the exams made them  exceed their normal hours. The overtime rate the nurses said they were  paid was commensurate to the nurses’ regular hourly rate, not the time  and a half usually accorded for overtime. The former SANE coordinator at  this hospital told us that such compensation challenges contributed to  nurses’ burning out over time and ceasing their medical forensic exam  duties. When the nurses stopped offering the exams, the hospital was  unable to provide exams for victims who needed them and began  referring victims to another facility, according to the coordinator.
Concerning staffing, we have issued a guide federal agencies can use in  maintaining or implementing effective internal control. One of the factors  this guide states that agencies should consider in determining whether a  positive control environment has been achieved concerns  organizational structure and whether the agency has the appropria number of employees—specifically, so that employees do not have to  work outside the ordinary workweek to complete their assigned tasks.  Additionally, in its 2006-2011 Strategic Plan, IHS acknowledges the  difficulty the agency has long faced in attracting and retaining medical  providers across IHS. Attraction and retention is particularly challenging  for remote facilities in isolated areas, where medical providers may be  offered incentive pay for accepting positions. The agency’s strategic pla outlines strategies for recruiting, retaining, and developing employees, n  stating that the agency will “ensure an ongoing process to identify a nd  te  implement the best practices related to staff retention” and “continue to explore options to provide adequate staffing for all facilities.”
Some hospitals have already identified and implemented staffing options  for medical forensic services, which aim to address concerns about  provider burnout and sustainability. Several hospitals have incorporated  medical forensic services into normal job duties for medical providers in a  specific hospital department. For example, at one hospital in South  Dakota, medical providers told us that most nurse midwives within the  hospital’s midwife clinic receive SANE training and perform medical  forensic exams as part of their normal clinic duties. In addition, several  hospitals in Alaska have hired sexual assault response team  coordinators, whose part- or full-time responsibilities are to manage the  hospitals’ medical forensic services and perform medical forensic exams,  according to hospital officials. An official at one hospital told us the  hospital provided retention pay in an effort to adequately compensate  medical providers for performing these exams.
Such options may help reduce medical provider stress and burnout, but  no single staffing arrangement works for all hospitals or medical  providers. For example, medical providers from one hospital told us their  hospital considered incorporating the exams into providers’ job  descriptions but decided not to because doing so would make it even  more difficult to attract candidates for already hard-to-fill positions. In  addition, one stakeholder told us many hospitals do not see enough  sexual assault cases to warrant a part- or full-time position for a sexual  assault response team coordinator. Moreover, according to IHS officials,  annual pay caps may limit the amount of bonus or retention pay that  medical providers are eligible to receive for performing medical forensic  exams. IHS is developing a proposal to separate the salary series of  advanced practice nurses—the type of nurse likely to perform medical  forensic exams within IHS—from other registered nurses so that  advanced practice nurses can receive higher maximum pay. IHS officials  told us this proposal may help address the constraints imposed by salary  caps, which currently make it impractical for many nurses to be  compensated for performing medical forensic exams.
section_title: Factors besides Medical Forensic Evidence also Contribute to Decisions to Prosecute Cases of Sexual Assault and Domestic Violence
paragraphs: Decisions to prosecute sexual assault or domestic violence cases are  based on the totality of evidence collected, one piece of which is medical  forensic evidence collected by IHS and tribally operated hospitals. Many  of the factors contributing to a decision to prosecute are not unique to  incidents of sexual assault or domestic violence involving Indians in  remote reservations or villages; nevertheless, prosecutors acknowledged,  they affect the totality of the available evidence and thus contribute to  decisions to prosecute such cases. Specifically, officials from the  responsible law enforcement and prosecuting agencies told us they  generally base their decisions to refer sexual assault or domestic violence  investigations for possible prosecution and to accept these matters for  prosecution on the total picture presented by the quality and quantity of  available evidence. Prosecutors and law enforcement officials said they  consider several factors—including medical forensic evidence collected  by hospitals. They also said that the relative importance of these factors  can differ from case to case. In some cases, medical forensic evidence  may be a crucial factor; in others, however, it may not be relevant or  available. For example, photographic evidence or DNA collected during a  genital exam may be critical in showing that an alleged perpetrator had  sex with the victim, but such medical forensic evidence may not be  relevant when the victim and alleged perpetrator admit to having had sex  but disagree as to whether the sex was consensual. In many of those  cases where consent is the main issue, according to prosecutors and  Justice’s sexual assault protocols, medical forensic evidence does not  reveal physical injuries that readily demonstrate a lack of consent. Also,  law enforcement officials and prosecutors told us that medical forensic  evidence may be unavailable if a victim reports an assault weeks or  months later, as often happens in cases of child sexual abuse, because,  for example, DNA evidence or relevant fibers would likely have washed  away or become contaminated in the meantime.
In addition to this medical forensic evidence, law enforcement officials  told us that when deciding whether to refer an investigation for possible  prosecution, they consider several other factors, including quality of the  criminal investigation conducted, credibility of witnesses who may have  been intoxicated at the time of the assault, and coordination with relevant  agencies to obtain supporting evidence. For example, federal prosecutors  acknowledged that quality of the criminal investigation is important  because evidence in a criminal matter must meet a relatively high  threshold to be accepted for prosecution—that is, prosecutors must  believe that existing evidence is compelling enough to demonstrate to a  jury guilt beyond a reasonable doubt. As a result, prosecutors  acknowledged that a law enforcement agency that refers all criminal  investigations involving sexual assault for possible prosecution— regardless of whether the extent or quality of evidence collected during its  investigation would warrant such a referral—may find that prosecutors  decline to prosecute some of these matters. Law enforcement officials  and prosecutors also told us that intoxication of witnesses at the time of  an assault can mean these witnesses may be less credible in court  because, for example, intoxication adversely affects ability to clearly recall  circumstances around the assault or specific statements made by the  victim or alleged perpetrator. Additionally, law enforcement officials and  prosecutors stated that decisions to refer investigations for possible  prosecution are also based on obtaining additional evidence that supports  the victim’s account. Availability of coordinated efforts, such as sexual  assault response teams, can greatly enhance the quality of a forensic  interview with a victim about an assault and facilitate gathering such  supporting evidence.
Similarly, prosecutors consider additional factors besides medical forensic  evidence when deciding whether to accept a matter for prosecution,  including juries’ increased expectation of seeing DNA evidence;  perceived credibility of the victim, alleged perpetrator, or other involved  party; and availability of involved parties, such as witnesses or hospital  providers, to testify. Specifically, several law enforcement officials and  prosecutors stated that, in light of popular television series featuring  forensic evidence, juries have come to expect prosecutors to regularly  present DNA and other forensic evidence before they are willing to  convict. As a result, several prosecutors told us they need to factor in  such juror expectations when deciding whether they believe they have  strong enough evidence to obtain a conviction or plea deal. Additionally,  prosecutors told us that decisions to accept matters for prosecution are  also based on how believable a witness, victim, or alleged perpetrator  seems to be. The credibility of witnesses, including the victim, can be  based on a variety of factors, including how well he or she can recall  details of the assault. For example, one prosecutor told us her office  concluded that the testimony of a particular victim could be persuasive  because the woman accurately described the layout of the room where  she alleged she was raped, even though the alleged perpetrator told  police she had never been inside his house. Prosecutors across the  country told us that intoxication of victims at the time of assault is not  alone an acceptable reason to decline a matter for prosecution.
With regard to witness testimony, federal and state prosecutors told us  that availability of potential witnesses to testify is also an important factor.  Some victims in small reservations or isolated villages may refuse to  cooperate or may retract their initial statement, for example, because of  pressure exerted on them by family or community members who may  depend on the alleged perpetrator for necessities such as food or fuel. As  a result, the victim may be unavailable to testify. Additionally, according to  several prosecutors with whom we spoke, the availability to testify of  medical providers who performed the associated medical forensic exams  at IHS or tribally operated hospitals is an important factor because such  testimony can help demonstrate that an assault occurred or help  otherwise support a victim’s account of an assault. Specifically, some  prosecutors told us that it may be difficult to locate traveling medical  providers who work at these hospitals temporarily; in addition, hospital  staffing shortages may keep supervisors from releasing staff from hospital  duties to testify. Consequently, some medical forensic examiners at IHS  and tribally operated hospitals may not be able to testify in court that  evidence obtained from a medical forensic exam belongs to a given victim  or attest to a victim’s statements made during the exam about the  assault—testimony that prosecutors repeatedly stated is critical to using  the medical forensic evidence in court. IHS officials noted, however, that  the Tribal Law and Order Act of 2010’s requirement that state and tribal  courts provide employees with 30-day notice of the request for testimony  would make it much more likely that a traveling provider could be located  and appear or a provider’s schedule changed to accommodate a court  appearance.
In this context, section 263 of the Tribal Law and Order Act of 2010  contains requirements for IHS regarding approval or disapproval of  requests or subpoenas from tribal or state courts for employee testimony.  IHS’s March 2011 sexual assault policy, however, is not entirely  consistent with section 263, and, in some cases, the policy is not clear.    First, the policy does not state that subpoenas and requests for IHS  employee testimony in tribal or state courts not approved or  disapproved within 30 days are considered approved. In this regard,  the policy appears to contradict section 263 of the act, which states  that subpoenas or requests will be considered approved if IHS fails to  approve or disapprove a subpoena or request 30 days after receiving  notice of it.    Second, it is unclear whether the prior approval discussed in the  policy refers to the agency’s approval of the subpoena, as required by  the act, or supervisory approval of the employee’s release from  hospital duties. To the extent that the policy’s discussion refers to  release from hospital duties, the policy is silent about whether and  under what circumstances supervisors can refuse to release a  subpoenaed employee to testify if the subpoena or request is  approved or considered approved.    Third, the policy does not specify criteria to be used to approve a  subpoena. Specifically, the policy does not specify that, in accordance  with section 263, the IHS Director must approve requests or  subpoenas from tribal and state courts if they do not violate the  Department of Health and Human Services’ policy to maintain  impartiality. Explicitly articulating these criteria is important because  departmental officials told us requests for IHS employee testimony in  these criminal prosecutions would likely always satisfy the criteria and  because responding to such requests are in the agency’s best  interest. In addition, the policy does not discuss legal limitations  placed by privacy laws on the production of medical records in  response to state or tribal court subpoenas.    Fourth, the policy does not specify whether it also applies to  subpoenas and requests from federal courts—a process currently  governed by an unwritten policy—even though IHS officials told us  they intended for the policy to cover federal subpoenas and requests  as well as those from tribal and state courts.
According to Health and Human Services officials, the department is  drafting a more specific and comprehensive description of the subpoena  approval process. As of September 2, 2011, however, this document,  whose audience is officials involved in the subpoena approval process,  had not been completed or disseminated; we have therefore not reviewed  it. Moreover, it is unclear how widely it will be disseminated. We received  inconsistent accounts from departmental and IHS officials about the  extent to which the document will be made available to line staff—the  very staff who would be subpoenaed to testify. According to federal  standards for internal control, information should be recorded and  communicated to management and others within an agency in a form and  within a time frame that enables them to carry out their responsibilities.  Moreover, the federal standards call for effective communication to flow  down, across, and up the organization. Therefore, it is still uncertain  when and by what processes IHS staff will be able to respond to  subpoenas or testify in court about the medical forensic exams they  conduct—an ambiguity in the policy that is of great concern, according to  several Justice officials with whom we spoke.
section_title: Conclusions
paragraphs: Medical providers in IHS and tribally operated hospitals are called upon to  fulfill twin purposes when seeing patients who are victims of sexual  assault and domestic violence—to treat the victim’s injuries and trauma  and to collect medical forensic evidence of high enough quality that it can  be used to prosecute crimes. The provision of medical forensic services  and collection and preservation of high-quality evidence, however, are  highly variable across IHS and tribally operated hospitals, hampered in  part by distances victims must travel and the absence, until recently, of  central direction from IHS on what, how, and by whom these services are  to be provided. IHS has made significant progress in the last 2 years, and  its March 2011 sexual assault policy takes a sound first step toward  addressing problems like these, but the agency, its hospitals, and medical  providers have a long way to go to fulfill the policy’s provisions. Without  articulating how it plans to implement the policy and monitor progress  toward meeting policy requirements, IHS may not be able to hold  individual hospitals accountable to the agency, and the agency may not  be able to hold itself accountable to its beneficiaries. The road ahead is  likely to be particularly arduous for the more remote hospitals, which have  long faced obstacles in attracting and retaining medical providers and are  now faced with numerous new demands, such as offering medical  forensic exams on site or by referral within 2 hours and making readily  available digital cameras and other equipment and supplies needed to  collect medical forensic evidence. In addition, responding to incidents of  sexual assault and domestic violence requires a multifaceted approach  involving not only medical providers but also law enforcement and  prosecuting agencies and other stakeholders identified in the policy. The  medical forensic evidence needs to be collected and preserved in a way  that facilitates its use by law enforcement and prosecuting agencies. Not  all IHS hospitals and staff regularly collaborate with these stakeholders or  obtain regular feedback from them on evidence collection and  preservation. Without considerable and concerted investment in the staff  and hospitals responsible for providing medical forensic services—and  without a detailed implementation plan to clarify how the agency will  support its hospitals and staff in meeting the policy’s requirements and by  when—the agency is unlikely to meet those requirements.
In addition, IHS’s March 2011 sexual assault policy does not address how  its hospitals should respond in cases of discrete domestic violence  without a sexual component or in cases of child sexual abuse. IHS is  currently considering how its hospitals should respond to such cases, but  it has not developed policies that are similar in scope and specificity to its  March 2011 sexual assault policy for adolescents and adults. This gap is  significant, but IHS is only one of the agencies involved in the  multifaceted response to incidents of sexual assault and domestic  violence. All the responding federal agencies should present a consistent  and coordinated response to these issues. Justice also has not yet  developed a policy for responding to child sexual abuse incidents, which  is critical, since the Tribal Law and Order Act of 2010 mandates that IHS  develop standardized sexual assault policies and protocols based on a  similar protocol established by Justice.
IHS’s recent effort to solicit and analyze comments from the tribes and  Justice on the March 2011 policy presents an opportunity for the agency  to revise areas that, as originally written, are unclear or inconsistent.  Specifically, it is unclear whether sections 3.29.1 and 3.29.5 of the policy  require both training and certification, or only training, of IHS physicians  and physician assistants performing sexual assault medical forensic  exams. Also, the policy does not specify how physicians and physician  assistants are to attain certification when no such certification by IHS or a  third party exists for medical providers other than nurses. IHS’s sexual  assault policy is also not consistent with provisions in section 263 of the  Tribal Law and Order Act of 2010, which states, among other provisions,  that subpoenas and requests for employee testimony or documents from  state and tribal courts not approved or disapproved within 30 days are  considered approved. To the extent that the policy’s discussion of  subpoena and request approvals refers to release from hospital duties,  the policy is silent about whether and how IHS plans to approve the  release of staff providing medical forensic exams to testify or otherwise  comply with subpoena requests. Without greater clarity in the policy’s  language—and without giving relevant staff explicit guidance on how to  respond when subpoenaed or requested to testify—providers who  perform sexual assault medical forensic exams may not understand the  circumstances under which they are allowed or required to testify in court,  a serious concern that Justice has echoed.
Some of the prior efforts to provide medical forensic services at individual  hospitals failed for various reasons, including staffing problems related to  burnout, high turnover, and compensation. The March 2011 sexual assault  policy provides the high-level management endorsement that had been  missing in the past, but devising appropriate staffing models—so that the  provision of standardized medical forensic services being developed under  the new policy will continue well into the future—remains a challenge.  At some locations, current staffing models present disincentives to the  provision of these services, such as supervisory refusal to give medical  providers permission to attend sexual assault team meetings or to approve  adequate compensation for providing medical forensic services in addition  to normal job duties or beyond a unit’s official area of responsibility. Given  the agency’s reliance on temporary medical providers, as well as high  burnout and turnover rates among medical providers, unless corrected,  such disincentives are likely to undermine IHS’s efforts to fulfill the  March 2011 policy’s goals over the long term.
Finally, IHS also has an opportunity to incorporate comments from tribes  that may choose to use the March 2011 policy as a model on which to base  their own sexual assault response policies in tribally operated hospitals or  clinics. As we discussed earlier, IHS policies and procedures can be used  as models on which to base local tribal protocols even though they do not  generally apply to its 17 tribally operated facilities. In addition, IHS  recognizes that hospital protocols, particularly for complex and sensitive  matters like sexual assault, need to reflect each community’s individual  circumstances. Coordinating with tribes may therefore be especially  important to those tribally operated hospitals in Alaska, where the state,  rather than the federal government, generally has criminal jurisdiction and  where the state has made combating sexual assault and domestic violence  a high priority.
section_title: Recommendations for Executive Action
paragraphs: To improve or expand medical forensic exams and related activities for  the 28 IHS operated hospitals, we recommend that the Secretary of  Health and Human Services direct the Director of the Indian Health  Service to take the following five actions:    Develop an implementation plan for the March 2011 IHS sexual  assault policy (Indian Health Manual, chapter 3.29)—and monitor its  progress—to clarify how the agency will support its hospitals and staff  in fulfilling the policy, in particular, that the hospitals or staff:    obtain training and certification in providing forensic medical    obtain equipment like cameras needed to collect evidence;    provide medical forensic exams on site or at a referral facility  within 2 hours of a patient’s arrival; and  collaborate with law enforcement agencies, prosecution, and other  stakeholders identified in the policy with the objective of creating  sexual assault response teams and obtaining regular feedback  from such stakeholders on evidence collection and preservation.    Develop a policy that details how IHS should respond to discrete  incidents of domestic violence without a sexual component and,  working with Justice, develop a policy for responding to incidents of  child sexual abuse consistent with protocols Justice develops for  these incidents; such policies should be similar in scope and  specificity to the March 2011 IHS policy on responding to adult and  adolescent sexual assaults.    Clarify whether sections 3.29.1 and 3.29.5 of the March 2011 IHS  sexual assault policy call for training and certification, or only training,  of IHS physicians and physician assistants performing sexual assault  medical forensic exams.    Modify the March 2011 IHS sexual assault policy so that it  comprehensively and clearly outlines (1) the process for approving  subpoenas and requests for IHS employees to provide testimony in  federal, state, and tribal courts and (2) reflects the provisions in  section 263 of the Tribal Law and Order Act of 2010, including that  subpoenas and requests not approved or disapproved within 30 days  are considered approved.    Explore ways to structure medical forensic activities within IHS  facilities so that these activities come under an individual’s normal  duties or unit’s official area of responsibility, in part to ensure that  providers are compensated for performing medical forensic services.
section_title: Agency Comments
paragraphs: We provided a copy of our draft report to the Departments of Health and  Human Services, the Interior, and Justice and to the state of Alaska. In its  written response, reprinted in appendix IV, the Department of Health and  Human Services agreed with our five recommendations and stated that  work is now under way to implement each of them. The state of Alaska  generally agreed with our conclusions and recommendations, especially  the recommendation to develop additional policies specific to child sexual  abuse, and expressed its willingness to collaborate with the Indian Health  Service in developing sexual assault policies applicable to Alaska (see  app. V). The Department of Health and Human Services and the state of  Alaska, as well as the Departments of the Interior and Justice, provided  technical comments, which we incorporated into the report as  appropriate.
We are sending copies of this report to the appropriate congressional  committees, the Secretary of Health and Human Services, the Secretary  of the Interior, the Attorney General of the United States, the Governor of  Alaska, and other interested parties. In addition, the report is available at  no charge on the GAO website at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix VI.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: Our objectives were to determine (1) the ability of Indian Health Service  (IHS) and tribally operated hospitals to collect and preserve medical  forensic evidence for use in criminal prosecution in sexual assault and  domestic violence cases; (2) what challenges, if any, these hospitals face  in collecting and preserving such evidence, particularly in remote Indian  reservations and Alaska Native villages; and (3) what factors besides  medical forensic evidence collected by these hospitals contribute to a  decision to prosecute such cases.
For all three objectives, we collected and analyzed laws, regulations, and  agency policies relevant to the collection and preservation of medical  forensic evidence by IHS and tribally operated hospitals in cases of  sexual assault and domestic violence, and we interviewed and gathered  relevant documentation from headquarters officials at IHS, the Bureau of  Indian Affairs, the Department of Justice, and the state of Alaska. In  addition, we conducted over 60 semistructured interviews with several  groups of stakeholders (1) from hospital staff during site visits to a  nonprobability sample of 8 IHS or tribally operated hospitals in Alaska,  Arizona, and South Dakota and over the telephone with an additional  nonprobability sample of 7 IHS or tribally operated hospitals in Arizona,  Minnesota, Montana, New Mexico, North Dakota, and Oklahoma and  (2) from victim advocacy groups; federal and state prosecutors; and  federal, state, local, and tribal law enforcement agencies that play a role  in responding to and prosecuting sexual assault and domestic violence  cases in most of the locations these 15 hospitals serve. We spoke with  officials about hospitals that are performing medical forensic exams, that  are developing the ability to perform such exams, and that do not perform  these exams.
To determine the ability of IHS and tribally operated hospitals to collect  and preserve medical forensic evidence, we surveyed all 45 IHS and  tribally operated hospitals on available services, obtained electronic data  from IHS on procedures and purpose of visits related to sexual assaults  and domestic violence, and determined which hospitals were located in  remote areas.    First, we determined the type of facility within the IHS system that is  most likely to provide medical forensic services. From discussions  with IHS officials and others, we found that hospitals were the most  appropriate type of facility to include in our analysis because of the  level of medical expertise and infrastructure available in these  facilities relative to other types of health centers or specialized clinics.  We then obtained an electronic list of all IHS and tribally operated  hospitals in the United States, including location and contact  information for each. We assessed the reliability of this list by  validating and cross-checking the data with the IHS official who  oversees the information. After eliminating two private hospitals that  were erroneously included in the list, we determined that the data  were sufficiently reliable for the purpose of this report. Using this list of  45 IHS and tribally operated hospitals, we e-mailed a self- administered questionnaire to survey each of the 45 hospitals. (See  app. II for a blank copy of the questionnaire.) The questions were  designed to identify the ability of each hospital to collect and preserve  medical forensic evidence at the time the questions were answered.  To develop the survey questions, we reviewed existing interviews,  interviewed IHS officials and providers at several IHS and tribally  operated hospitals, and reviewed relevant Justice protocols. We took  steps to minimize errors in the survey effort’s development and data  collection process. For example, the team designed specific questions  in consultation with a social science survey specialist and design  methodologist. We conducted several pretests with medical providers  at three separate hospitals—two IHS-operated hospitals and one  tribally operated hospital—to help ensure that the questions were  clear, relevant, and unbiased and to ensure that they could be  completed quickly. Another survey specialist also reviewed the  questionnaire, and suggestions were included where appropriate. We  sent the questionnaire to the most knowledgeable hospital official at  each location—typically the clinical director and chief executive  officer—to be the lead respondent and, if necessary, to confer with  other representatives within the hospital to answer questions requiring  more detailed knowledge. To maximize our response rate, we sent  follow-up e-mails and left reminder telephone messages over a period  of approximately 11 weeks—from March 31, 2011, when we started  the survey effort, through June 14, 2011, when we closed it. We  received responses from 100 percent of the hospitals, and we  followed up to clarify specific responses as needed. Accordingly, the  responses represent a snapshot in time of each hospital’s medical  forensic services. We entered the responses into a spreadsheet and  analyzed the results. A separate analyst verified the accuracy of data  entry and analyses. (See app. III for a summary of key survey results.)    Second, we obtained electronic data on the reasons for hospital visits  by IHS beneficiaries from fiscal year 2006 through fiscal year 2010 for  each of the 45 hospitals that report such data to IHS.
Two hospitals—Sage Memorial Hospital in Ganado, Arizona, and Norton Sound Regional  Hospital in Nome, Alaska—do not use IHS’s comprehensive health information system,  called the Resource Patient Management Information System, but a different electronic  health records system. We were therefore unable to assess the reliability of their data or  to use their data in any analysis. commuting area codes—developed on the basis of U.S. Census  tracts by the Department of Agriculture’s Economic Research  Service—because IHS has no technical definitions for remote. The  rural-urban commuting area system defines remote areas as those  with dispersed and small populations and where travel times are  longer because of limitations in transportation infrastructure, and it  defines urban areas as those with large populations and short travel  times between cities. We linked a hospital’s zip code to rural-urban  commuting area data—also broken out by zip code—to determine if a  hospital is located in an isolated, small rural, large rural, or urban  area, as classified by the rural-urban commuting area system. We  refined these four categories into a two-category classification  scheme—collapsing the “isolated” and “small rural” categories into  one remote category and collapsing the “urban” and “large rural”  categories into one urban category—to aid in analysis and better  respond to our objectives.
To determine the challenges faced by these hospitals in collecting and  preserving medical forensic evidence, particularly in remote Indian  reservations and Alaska Native villages, we also collected and analyzed  pertinent laws, regulations, policies, protocols, and reports from IHS,  Justice, and other entities. On the basis of initial interviews and  responses from our survey of hospitals, we selected a nonprobability  sample of IHS and tribally operated hospitals with which to conduct  semistructured interviews on challenges they face in collecting and  preserving medical forensic evidence. We chose 15 hospitals according  to a series of selection criteria that included geographic location,  remoteness, whether the state or federal government had criminal  jurisdiction in Indian country served by the hospital, and whether the  hospital was IHS or tribally operated. Additionally, because we used a  nonprobability sample to select these IHS and tribally operated hospitals  to interview, the information we gathered in our semistructured interviews  cannot be generalized to all hospitals and instead represents the  perspectives only of these hospitals’ providers and stakeholders. We also  interviewed many victim advocacy groups, federal and state prosecutors,  and federal and state and local law enforcement agencies that play a role  in responding to and prosecuting sexual assault and domestic violence  cases in most of the locations these 15 hospitals serve. We reviewed and  analyzed our interviews and supporting documentation to identify  systemic and regionally specific challenges.
Finally, to identify additional factors that federal prosecutors may consider  when determining whether to prosecute cases of sexual assault and  domestic violence, we reviewed relevant studies about these crimes and  reviewed standards related to decisions by law enforcement to refer, or  decisions by prosecutors to accept, a matter for criminal prosecution.
We conducted this performance audit from October 2010 through  October 2011, in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
section_title: Appendix II: GAO Survey of 45 IHS and Tribally Operated Hospitals
paragraphs: This questionnaire asks for information about medical forensic examinations done in cases of sexual  assault or domestic violence for adults and/or children; and information on whether or not your facility  has, or ever had, a program offering such medical forensic examination services.
The U.S. Government Accountability Office (GAO) is an agency that assists the U.S. Congress in  evaluating federal programs.  We have been asked to provide Congress with information about the  capability of Indian Health Service (IHS) to collect and preserve evidence in cases of sexual assault/abuse  and domestic violence (involving adults or children) for criminal prosecution.  The intent of this  questionnaire is to determine which IHS and tribal hospitals have medical forensic examiner programs or  provide the services of a medical forensic examiner in cases of sexual assault and domestic violence  (involving adults and/or children). For the purposes of this questionnaire, the medical forensic  examination is the medical treatment of a patient as well as the collection of forensic evidence.   Specifically, the forensic component could include performing a forensic evidence collection kit  sometimes referred to as a “rape kit”, gathering a medical forensic history, conducting an exam,  documenting biological and physical findings, and collecting evidence from the patient. We recognize  that there is a continuum of forensic evidence collection services that can occur depending on the  availability of staff and the medical condition of the victim.
Your facility was selected because it is one of the 47 hospitals operated by IHS, a tribe, consortium, or  has a contract to provide services. It should take you about 5 to 10 minutes to complete this questionnaire.  The person with the most knowledge of the forensic examination program should complete this  questionnaire for the entire facility. If you feel you are not the most knowledgeable person in your facility  about these exams, please contact Kyle Stetler (contact information below) and let him know who you  feel would be the best person to complete it and we will arrange to send it to that person.
Your cooperation is critical to providing the Congress complete and balanced information about the  capability of IHS to collect and preserve evidence in cases of sexual assault/abuse and domestic violence.
Completing and Returning the Questionnaire  Please complete and return this questionnaire as soon as possible, but no later than Thursday, April 7,  2011.  After receiving your responses, we may also want to follow up with some of you by telephone to  better understand your program or how you operate in lieu of a program.
To answer the questions, first open the attached MS Word file and save the file to your computer.  Then  enter your responses directly to the saved document following the instructions below.  Once the questions  are completed, please return them by attaching the saved document to an e-mail message to  Stetlerk@gao.gov. Or mail to 701 5th Ave., Suite 2700, Seattle WA. 98104.
Instructions for Completing the Questions Onscreen    Please use your mouse to navigate, clicking on the field or check box    To select a check box or a button, click on the center of the box.    To change or deselect a check box response, click on the check box and the ‘X’ will disappear.    To answer a question that requires that you write a comment, click on the answer box _____ and   you wish to answer.  begin typing.  The box will expand to accommodate your answer.  You are not limited to the  amount of space you see on the screen.  If you have additional clarifications or comments on any of the questions, please include those in  the comment box at the end of this document or in a separate document.
Title:  Facility/Program Name:   SECTION A.  ADULT VICTIMS OF SEXUAL ASSAULT  1.  Currently, if an adult victim of sexual assault comes into your facility, with what  frequency does your facility conduct a medical forensic examination, that is, the  medical treatment of a patient as well as the collection of forensic evidence?   (Specifically, the forensic component could include such things as performing a forensic  evidence collection kit sometime referred to as a “rape kit”, gathering a medical forensic  history, conducting an exam, documenting biological and physical findings, and collecting  evidence from the patient.)
Typically or always conducts ………..
Sometimes conducts …………………   Rarely conducts …………………...…   Never conducts ………………………     2.  If the frequency with which your facility conducts these medical forensic examinations  has substantially changed in the last five years, please describe below. The box will  expand to fit your answer.
NOTE:  If you answered “Never conducts” to Question 1, please skip to Question 7  3.  If your facility conducts medical forensic examinations in cases of adult sexual assault,  which types of providers typically conduct medical forensic examinations? For each  row, please check all that apply.
Do not have  this type of  b.  Physician’s Assistant  e.  Other (Specify below)  4.  If your facility conducts medical forensic examinations in cases of adult sexual assault,  what is the level of training of the providers who typically conduct these examinations?  For each row, please check all that apply.
No providers of this type have  specific forensic training or do  not have this type of provider  b.  Physician’s Assistant  c.  Nurse Practitioner / Advanced  e.  Other (Specify below)
5.  Has there ever been an extended period of time, during the last 5 years, when there was  no one available to conduct the medical forensic examinations for adult victims of  sexual assault?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #7  6.  If yes, please describe the circumstances. The boxes will expand to fit your answer.  7.  Does your facility (ever) refer adult sexual assault patients someplace else for medical  forensic examinations?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #9  8.  If checked “Yes,” please specify where and under what circumstances.
SECTION B.  ADULT VICTIMS OF DOMESTIC VIOLENCE  9.  If an adult victim of domestic violence comes into your facility, with what frequency  does your facility conduct a medical forensic examination, that is, the medical treatment  of a patient as well as the collection of forensic evidence?
Typically or always conducts ………..
Sometimes conducts …………………   Rarely conducts …………………...…   Never conducts ………………………   10. If the frequency with which your facility conducts these medical forensic examinations  has substantially changed in the last five years, please describe below. The box will  expand to fit your answer.
NOTE:  If you answered “Never conducts” to Question 9, please skip to Question 15  11. If your facility conducts medical forensic examinations in cases of adult domestic  violence, which types of providers typically conduct medical forensic examinations? For  each row, please check all that apply.
Do not have  this type of  below)
12. If your facility conducts medical forensic examinations in cases of adult domestic  violence, what is the level of training of the providers who typically conduct these  examinations? For each row, please check all that apply.
No providers of this type have  specific forensic training or do  not have this type of provider  b.  Physician’s Assistant  e.  Other (Specify below)
13. Has there ever been an extended period of time, during the last 5 years, when there was  no   one available to conduct the medical forensic examinations for adult victims of  domestic violence?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #15  14. If yes, please describe the circumstances.  15. Does your facility (ever) refer adult domestic violence patients someplace else for  medical forensic examinations?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #17  16. If you checked “Yes,” please specify where and under what circumstances.
SECTION C.  CHILD VICTIMS OF SEXUAL ABUSE    17. If a child victim of sexual abuse comes into your facility, with what frequency does your  facility conduct a medical forensic examination, that is, the medical treatment of a  patient as well as the collection of forensic evidence?
Typically or always conducts ………..
Sometimes conducts …………………   Rarely conducts …………………...…   Never conducts ………………………     18. If the frequency with which your facility conducts these medical forensic examinations  has substantially changed in the last five years, please describe below. The box will  expand to fit your answer.
NOTE:  If you answered “Never conducts” to Question 17, please skip to Question 23  19. If your facility conducts medical forensic examinations in cases of child sexual abuse,  which types of providers typically conduct medical forensic examinations? For each  row, please check all that apply.
Do not have  this type of  b.  Physician’s Assistant  f.  Other (Specify below)  20. If your facility conducts medical forensic examinations in cases of child sexual abuse,  what is the level of training of the providers who typically conduct these examinations?  For each row, please check all that apply.
No providers of this type have  specific forensic training or do  not have this type of provider  b.  Physician’s Assistant  c.  Pediatric Nurse Practitioner /  f.  Other (Specify below)
21. Has there ever been an extended period of time, during the last 5 years, when there was  no one available to conduct the medical forensic examinations for child victims of  sexual abuse?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #23  22. If yes, please describe the circumstances.  23. Does your facility (ever) refer child sexual abuse patients someplace else for medical  forensic examinations?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #25  24. If you checked “Yes,” please specify where and under what circumstances.
SECTION D.  CHILD VICTIMS OF PHYSICAL ABUSE  25. If a child victim of physical abuse comes into your facility, with what frequency does  your facility conduct a medical forensic examination, that is, the medical treatment of a  patient as well as the collection of forensic evidence?
Typically or always conducts ………..
Sometimes conducts …………………   Rarely conducts …………………...…   Never conducts ………………………   26. If the frequency with which your facility conducts these medical forensic examinations  has substantially changed in the last five years, please describe below. The boxes will  expand to fit your answer.
NOTE:  If you answered “Never conducts” to Question 25, please skip to Question 31  27. If your facility conducts medical forensic examinations in cases of child physical abuse,  which types of providers typically conduct medical forensic examinations? For each  row, please check all that apply.
Do not have  this type of  b.  Physician’s Assistant  Practitioner / Advanced  Practice Nurse  f.  Other (Specify below)  28. If your facility conducts medical forensic examinations in cases of child physical abuse,  what is the level of training of the providers who typically conduct these examinations?  For each row, please check all that apply.
No providers of this type have  specific forensic training or do not  have this type of provider  b.  Physician’s Assistant  c.  Pediatric Nurse Practitioner /  f.  Other (Specify below)
29. Has there ever been an extended period of time, during the last 5 years, when there was  no one available to conduct the medical forensic examinations for child victims of  physical abuse?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #31  30. If yes, please describe the circumstances.  31. Does your facility (ever) refer child physical abuse patients someplace else for medical  forensic examinations?
Yes………….……………  No….…………………….
Î  SKIP TO QUESTION #33  32. If you checked “Yes,” please specify where and under what circumstances.  33. Does your facility have the capacity to perform medical forensic examinations for adult  or child victims of sexual assault and/or domestic violence 24 hours a day, 7 days a  week?
Yes………….……………  No….…………………….  No program……………...
Î Please skip to Question 36  34. What are the current days and hours of operation for your medical forensic examiner  staff or program that treats adult or child victims of sexual assault and/or domestic  violence? Please describe in the box below if the hours are different for children or adults.
Please indicate time in 24-hour clock format.  If you are not open/available during one or  more time slots, please type N/A in that time slot.
To  To  To  To  To  To  To  35. Please describe, if applicable, other provider/staff availability for children or adults.    36. Are there any (other) IHS or tribal clinics in your service area offering medical forensic  examinations to child or adult victims of sexual assault or domestic violence?
Yes………….……………  No….…………………….  Don’t know...…………….
Î Please skip to Question 38    Î Please skip to Question 38  37. If there are other IHS or tribal clinics in your service area to whom you may refer  medical forensic examinations for child or adult victims of sexual assault or domestic  violence, what are the names of the clinics and their contact information, to the extent it  is available (please provide for up to 3 clinics):  38. Is there any additional information that you would like to provide in regards to medical  forensic examinations?
Thank you very much for your participation!
Please save your responses before exiting and return the questionnaire by attaching the document to an e- mail message to StetlerK@gao.gov.
section_title: Appendix III: Summary of Key Survey Results on Provision of Medical Forensic Services for Sexual Assault Victims
subsections: section_title: Urban or remote
paragraphs: Legend: ■ = Typically performs; ○ = Does not typically perform (i.e., never, rarely, or sometimes  performs medical forensic exams)
On follow-up with San Carlos Hospital, we found that it does not typically perform medical forensic  exams for adults, although its survey response said it did perform such exams. Therefore, the number  of hospitals typically performing exams changed from a reported value of 27 to an actual value of  26 in our report.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: Comments from the State of Alaska
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the individual contact named above, Jeffery D. Malcolm  (Assistant Director), Ellen W. Chu, Katherine Killebrew, Ruben Montes de  Oca, Kim Raheb, Kelly Rubin, Jeanette M. Soares, Kyle Stetler, Shana B.  Wallace, and Tama R. Weinberg made key contributions to this report.