Indian Health Service: Actions Needed to Improve Oversight of Quality of Care
Published: 2017-01-09T00:00:00

Fast Facts:
American Indians and Alaska Natives die at higher rates than other Americans from preventable causes—such as diabetes and influenza.
The Indian Health Service is charged with providing health care to these populations, but we found it had limited, inconsistent oversight over the quality of care at its facilities. Among other things, a lack of agency-wide performance standards and significant leadership turnover affected its oversight of quality.
We recommended that IHS develop agency-wide standards for quality care, monitor facility performance in meeting these standards, and develop succession plans for the replacement of key personnel.

Highlights:
section_title: Why GAO Did This Study
paragraphs: IHS is charged with providing health care to American Indian/Alaska Native (AI/AN) people who are members or descendants of 567 tribes. AI/AN people born today have a life expectancy that is 4.4 years lower than all races in the United States, and they continue to die at higher rates than other Americans from preventable causes. Concerns about the quality of care provided to AI/ANs in IHS facilities have been identified recently by federal officials and tribal members. GAO was asked to review how IHS oversees the quality of care provided in its facilities.
This report examines IHS's oversight of the quality of care provided in its federally operated facilities. GAO reviewed policies and guidance related to quality of care in federally operated facilities and interviewed IHS officials at the headquarters level and all nine area offices with federally operated facilities. GAO also examined documents from governance meetings between area office and facility staff.
section_title: What GAO Found
paragraphs: The Indian Health Service's (IHS) oversight of the quality of care provided in its federally operated facilities has been limited and inconsistent. While some oversight functions are performed at the headquarters level, the agency has delegated primary responsibility for the oversight of care to nine area offices. Area officials stated that the oversight they provide has included, for example, holding periodic meetings with facility staff, reviewing available quality performance data and reviewing adverse events. However, GAO found that this oversight was limited and inconsistent across IHS facilities, due in part to a lack of agency-wide quality of care standards. Specifically, GAO found:
variation in the frequency of governing board meetings and the extent to which quality was a standing agenda item at these meetings;
limited and inconsistent reporting of quality data across IHS areas and facilities; and
inconsistent reporting of adverse events at federally operated facilities.
These inconsistencies are also exacerbated by significant turnover in area leadership. Officials from four of the nine area offices in our review reported that they each had at least three area directors in the past five years. According to IHS officials, the agency has not defined contingency or succession plans for the replacement of key personnel, including area directors. IHS's lack of agency-wide quality of care standards and lack of contingency and succession plans for key personnel are inconsistent with federal internal control standards. These standards suggest that agencies should establish and review performance standards and then monitor data to assess the quality of performance over time, and define contingency and succession plans for the replacement of key personnel to help IHS continue achieving its objectives. As a result, IHS officials cannot ensure that facilities are providing quality health care.
Recognizing the challenges it faces with overseeing and providing quality health care in its facilities, IHS finalized the development of a quality framework in November 2016 that outlines, at a high level, IHS's plan to develop, implement, and sustain a quality program intended to improve patient experience and ensure the delivery of reliably high quality health care. For example, the framework directs IHS to develop a quality office that will be responsible for identifying resource needs, structures, processes, and supports for an effective and sustainable quality assessment and performance improvement system. More specifically, the framework directs IHS to develop a process for monitoring select performance measures, such as measures of clinical care, patient access, and financial performance, for periodic review by leadership. The framework also explains that IHS will enhance its current patient safety reporting systems to encourage consistent use by staff. If effectively implemented, the quality framework could address the limited and inconsistent oversight of the quality of care provided in federally operated IHS facilities. As of November 2016, IHS officials stated that the agency has not yet selected quality performance measures but has plans to do so.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Secretary of the Department of Health and Human Services direct the Director of IHS to (1) as it implements its quality framework, ensure that agency-wide standards for the quality of care provided in its federally operated facilities are developed, that facility performance in meeting these standards is monitored over time, and that enhancements are made to its adverse event reporting system, and (2) develop contingency and succession plans for the replacement of key personnel.
HHS concurred with GAO's recommendations.

section_title: Letter
paragraphs: The Indian Health Service (IHS), an agency within the Department of  Health and Human Services (HHS), is charged with providing health care  services to the approximately 2.2 million American Indian and Alaska  Native (AI/AN) people who are members or descendants of 567 federally  recognized tribes. IHS’s mission is to raise the physical, mental, social,  and spiritual health of American Indians and Alaska Natives to the highest  level. IHS provides health care services directly through a system of  federally operated IHS facilities—hospitals, health clinics, and health  stations operated by IHS—and also funds services provided in facilities  operated by tribes or others. In fiscal year 2016, IHS allocated about  $1.9 billion for health services provided by federally and tribally operated  hospitals, health centers, and health stations. Federally operated IHS  facilities, which received over 5 million outpatient visits and nearly 19  thousand inpatient admissions in 2014, provide mostly primary and  emergency care, as well as some ancillary and specialty services. These  facilities are located in nine federally designated geographic areas  overseen by IHS area offices.
AI/AN people born today have a life expectancy that is 4.4 years less than  all races in the United States and die at higher rates than other  Americans from many preventable causes, including diabetes mellitus,  suicide, chronic liver disease and cirrhosis, and chronic lower respiratory  diseases. Such health concerns underscore the importance of quality  health care for AI/AN people. However, the quality of care provided to  AI/ANs in IHS facilities has been questioned recently by the Centers for  Medicare & Medicaid Services (CMS), the HHS Office of Inspector  General (OIG), Congress, and tribal members. In 2015 and 2016, CMS  cited four facilities in the Great Plains area that were out of compliance  with the minimum standards required to participate in the Medicare and  Medicaid programs. During surveys of these facilities, CMS officials found  serious deficiencies in the quality of care provided—including the hand- washing of surgical instruments, the failure to provide patients with  appropriate medical screening examinations, and the failure to take  infection control measures with a patient with a history of untreated  tuberculosis. In addition, during a 2016 Senate hearing about  substandard quality of care at IHS facilities, tribal members testified about  patients being sent home from facilities without being seen, misdiagnoses  resulting in patient deaths, and incorrectly prescribed medications.
You asked us to examine how IHS ensures quality of care at its facilities.  This report examines IHS’s oversight of the quality of care provided in its  federally operated facilities.
To examine IHS’s oversight of the quality of care provided in its federally  operated facilities, we reviewed the Indian Health Manual, IHS guidance,  prior GAO reports, and HHS management and employee performance  documents, including executive performance agreements and HHS  Performance Management Appraisal Program (PMAP) documents. We  also collected information about IHS succession planning and turnover in  leadership positions. We assessed the reliability of the leadership  turnover data, which we obtained from the nine area offices, by  conducting follow-up interviews with area officials and checking for  completeness. We determined that these data were sufficiently reliable  for the purposes of our reporting objective. We also reviewed  documentation of area governing board meetings and facility reviews,  including meeting agendas and minutes. We interviewed officials from  IHS Headquarters and senior officials at all nine area offices that have  oversight responsibilities for federally operated IHS facilities about how  the agency has designed processes that enable it to ensure oversight of  high quality health care to AI/AN people on a consistent basis. In addition,  we visited two federally operated facilities in one IHS area and asked staff  about how they monitor the quality of care in their facility and any specific  measures or information that IHS uses to monitor the quality of care. We  compared IHS oversight practices against relevant standards for internal  control in the federal government.
We conducted this performance audit from March 2016 through January  2017 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 finding  and conclusions based on our audit objective.
subsections: section_title: Background
paragraphs: IHS was established within the Public Health Service in 1955 to provide  health services to members of AI/AN tribes primarily in rural areas on or  near reservations. IHS provides these services directly through a network  of hospitals, clinics, and health stations operated by IHS, and it also funds  services provided at tribally operated IHS facilities. The federally  operated system comprises 26 hospitals, 56 health centers, and 32 health  stations in 33 states and received over 5 million outpatient visits and  approximately 19,000 admissions in 2014. (See table 1.)
Federally operated IHS hospitals range in size from 4 to 133 beds and  are open 24 hours a day for emergency care needs. Health centers offer  a range of care, including primary care services and at least some  ancillary services, such as pharmacy, laboratory, and X-ray services, and  they are open for at least 40 hours a week. Health stations offer only  primary care services on a regularly scheduled basis and are open fewer  than 40 hours a week.
IHS oversees its health care facilities through a decentralized system of  area offices, which are led by area directors and located in 12 geographic  areas. (See fig. 1 for a U.S. map showing the IHS patient population by  area). Nine of these 12 IHS areas have federally operated IHS facilities— Albuquerque, Bemidji, Billings, Great Plains, Nashville, Navajo, Oklahoma  City, Phoenix, and Portland.
According to IHS, the headquarters office is responsible for setting health  care policy, ensuring the delivery of quality comprehensive health  services, and advocating for the health needs and concerns of AI/AN  people. The IHS area offices are responsible for distributing funds to the  facilities in their areas, monitoring their operation, and providing guidance  and technical assistance. (See fig. 2).
According to IHS, its mission to raise the physical, mental, social, and  spiritual health of AI/AN people to the highest level cascades through  every organizational level and individual in the agency. This cascading  method of accountability is often used by health care organizations with a  decentralized management structure and is recommended by the Office  of Personnel Management (OPM) for agencies with clear organizational  goals and objectives. In addition, in 2009 IHS developed four agency- wide priorities that serve as a strategic framework for improvement within  the agency. One of these four priorities is to improve the quality of and  access to care. In 2016, IHS established the following revised agency-wide priorities: assess care, improve delivery of services, address  behavioral health issues, strengthen management, bring health care  quality expertise to IHS, and engage local resources.
section_title: IHS’s Oversight of the Quality of Care Provided in Its Facilities Has Been Limited and Inconsistent, but IHS Has Drafted New Oversight Initiatives
subsections: section_title: IHS’s Oversight of the Quality of Care Provided in Its Facilities Has Been Limited and Inconsistent
paragraphs: IHS’s oversight of the quality of care provided in its federally operated  facilities has been limited and inconsistent. While some oversight  functions are performed at the headquarters level, the agency has  delegated primary responsibility for the oversight of the quality of care to  the area offices. Area officials told us that the oversight they provide has  generally included (1) holding periodic meetings with facility staff, such as  governing board and other meetings; (2) reviewing available quality  performance data; (3) reviewing data on adverse events occurring in their  facilities; (4) monitoring compliance with facility certification and  accreditation requirements; and (5) appraising employee performance.  However, our review found that this oversight was limited and  inconsistent across IHS areas and facilities, in part due to a lack of  agency-wide quality performance standards and significant leadership  turnover in some offices.
Meeting with facility staff. Officials from all nine of the area offices  that oversee federally operated IHS facilities told us that they monitor  the quality of care provided by facilities through periodic meetings with  facility staff—including governing board meetings and other meetings.  However, according to area office officials, the frequency of these  meetings varies widely by area. In general, these meetings are used  to discuss a range of issues, such as quality of care, equipment  problems, staff vacancies, and provider credentialing. For example,  documentation of a governing board meeting with facility staff in the  Phoenix area shows that board members and staff discussed a  problem with the facility’s wireless internet connection, which was  negatively affecting their bar code medication administration (BCMA)  system. A board member noted that these connectivity issues  caused a patient safety risk, but another board member noted that  they had a short-term resolution in place and area office officials were  working with the wireless carrier to resolve the problem over the long- term. Area offices vary, however, as to whether, or to what extent,  these meetings focus on the quality of care. For example, officials  from one area office stated that their governing board meetings  include a standardized agenda that includes quality of care items, and  that facilities are required to submit data reports that include  information on quality issues such as rates of hospital acquired  infections, patient complaints, and provider productivity. In contrast,  officials from another area office told us that there are no standing  agenda items for the discussion of quality of care, and that facility staff  set the meeting agendas based on issues they want to discuss.  Furthermore, the frequency of governing board meetings with facility  staff varied widely among the area offices, ranging from quarterly to  annually.
Reviewing available quality performance data. According to IHS  officials, clinical quality performance data are generally collected and  reported consistently to IHS’s area and headquarters offices in  response to requirements in the Government Performance and  Results Act of 1993 (GPRA), but other data used to oversee the  quality of care provided in facilities are not reported or reviewed  consistently across IHS. Officials from all nine area offices in our  review stated that they periodically review reports showing facility  progress in meeting 24 annual GPRA clinical performance measure  targets. These performance measures focus on health screening and  prevention activities, such as cancer screening, immunization rates,  and tobacco cessation activities, and do not include broader  measures of quality, such as whether patients are receiving proper  diagnoses and medications, and the extent to which facility staff  properly perform infection control activities. Area officials reported that  they review other quality performance data, such as the percentage of  medication orders reviewed for therapeutic duplication, the number of  mislabeled laboratory specimens, and patient satisfaction, but these  data are not consistently obtained or reviewed by all area offices  because IHS has not required that they be reviewed or reported. In  addition, staff from the two facilities in our review told us that  limitations of IHS’s electronic health record system—the Resource  and Patient Management System (RPMS)—also contribute to  variation in the quality performance data that are collected and  reported to area offices. For example, staff told us that certain data  elements, such as patient diagnoses, are difficult to extract from  RPMS. Officials from facilities and area offices said that pulling these  data may require special modifications to RPMS. Officials said that  modifying RPMS requires knowledge of computer programming and  can be costly, so some facility staff may manually enter and extract  certain data. Officials from several areas also told us that some  facilities have hired contractors or purchased software to assist them  in monitoring their data. One such software package—QlikView— provides facility staff with multiple data reporting options. Staff from  one facility said that, from an information technology standpoint, they  face “massively complicated issues” when the lack of a standardized  user interface leads to individual facilities across IHS customizing  RPMS for their own needs. IHS officials told us that they are working  on improving RPMS, in part, by developing software to stabilize the  system; however, we have not assessed these efforts.
Monitoring adverse events. Officials from all nine area offices told  us that their oversight of the quality of care includes monitoring  adverse events that occur at IHS facilities, such as medication errors  or patient falls, and taking steps to prevent future adverse events.  While all IHS facilities have the means to report and monitor adverse  events through an IHS-wide web-based reporting tool—WebCident— officials told us reporting adverse events through WebCident has  been inconsistent. Officials from one area office stated that adverse  events are not always reported through WebCident, and therefore the  appropriate staff are often not notified when adverse events occur,  including those resulting in patient harm. These officials stated that  this creates a lost opportunity to address the deficiency and improve,  as well as to hold individuals accountable. Officials from IHS  headquarters reported that they plan to enhance this reporting system  to encourage consistent use by facility staff, or replace it with a new  system after January 2017.
Monitoring compliance with facility certification and  accreditation requirements. Officials from all nine area offices in our  review told us that they monitor the ongoing compliance with  certification and accreditation requirements of the facilities in their  area—such as through mock surveys and other interim monitoring—to  help ensure that they maintain their certification by CMS to participate  in the Medicare and Medicaid programs, as well as their accreditation  by accrediting bodies such as The Joint Commission and the  Accreditation Association for Ambulatory Health Care (AAAHC). For  example, documentation of a mock survey of a facility in the Phoenix  area states that the facility emergency department was improperly  storing contaminated medical instruments. In addition, documentation  of a mock survey of a facility in the Albuquerque area states that the  surveyors found defective lead aprons, as well as a high-voltage  power line sitting on the floor instead of behind a wall, and exposed  electrical wiring blocking the door and wrapped around a door  handle—which the surveyors concluded could be a serious hazard.  These findings underscore the need for such surveys, but the  frequency with which these mock surveys have been conducted  varies by area. Officials from one area office told us that they have  conducted mock accreditation surveys of facilities in their area  annually for the past 15 years. Officials from other area offices stated  that they have recently begun performing such mock surveys. IHS  officials told us that in May 2016, IHS began a system-wide mock  survey initiative at all 26 federally operated hospitals to assess  compliance with the CMS Conditions of Participation and readiness  for reaccreditation. Surveys conducted by CMS and accrediting  bodies are relatively infrequent, however, and this infrequency  highlights the importance of interim monitoring. For instance, area  office staff told us that The Joint Commission conducts site visits  every 3 years, and, while CMS attempts to conduct site visits every 3  to 4 years, staff of one facility we visited stated that CMS had not  surveyed the facility in 10 years.
Appraising employee performance. According to IHS, area  directors are held accountable for achieving agency-wide goals and  specific performance objectives through an appraisal process that  also enables these goals and objectives to cascade down to chief  executive officers (CEO) at individual facilities and to all agency  employees. Area directors sign performance agreements  documenting their accountability. The fiscal year 2016 performance  requirements included a provision on ensuring that all IHS operated  health care facilities achieve and maintain accreditation or certification  by a national health care organization in fiscal year 2016. The  performance requirements also included a provision on quality care  that requires documentation of the implementation of “at least two  activities to improve wait times and access to quality health care for  patients that are based on enhanced implementation of current quality  initiatives or new quality initiatives and that have measurable goals,  measures and outcomes,” as well as improvements resulting from  these efforts. However, area officials can choose activities to satisfy  this requirement from a list of suggestions—such as improving  customer service and expanding clinic hours—without directly  addressing the quality of care in their facilities.
These inconsistencies are exacerbated by significant turnover in area  leadership. Officials from four of the nine area offices in our review  reported that they had at least three area directors in the past 5 years,  and officials from three area offices reported that they had at least three  chief medical officers. (See fig. 3 and 4).
Officials stated that inconsistent area office and facility leadership is  detrimental to the oversight of facility operations and the supervision of  personnel. For example, officials from multiple area offices told us that  frequent leadership turnover can lead to instability in oversight initiatives if  these initiatives are started but not completed. In addition, an area office’s  review of a facility in the Navajo area documented that the majority of  facility staff interviewed felt that there were too many people in acting  leadership positions, that acting leaders were afraid to commit to  decisions, and that the leaders needed additional supervisory training. In  addition, the facility staff interviewed stated that those in acting leadership  positions had their own work to contend with and were not always  responsive to the responsibilities of the leadership position. According to  IHS officials, the agency has not defined contingency or succession plans  for the replacement of key personnel, including area directors. See  appendix I for additional information on leadership turnover within IHS.
IHS’s limited and inconsistent agency-wide oversight of the quality of care  in its federally operated facilities, as well as its lack of contingency and  succession plans for key personnel, is inconsistent with federal internal  control standards. These standards suggest that agencies should  establish and review performance standards and then monitor data to  assess the quality of performance over time, and that agencies should  define contingency and succession plans for key roles to help continue  achieving objectives. As a result of IHS’s lack of consistent agency-wide  quality performance standards, as well as the significant turnover in area  leadership, IHS officials cannot ensure that facilities are providing quality  health care to their patients, and therefore that the agency is making  steps toward fulfilling its mission to raise the physical, mental, social, and  spiritual health of AI/AN people to the highest level.
section_title: IHS Developed a Quality Framework, but Has Just Begun to Implement Planned Changes
paragraphs: Recognizing some of the challenges it faces with overseeing and  providing quality health care in its facilities, IHS finalized the development  of a quality framework in November 2016 that outlines, at a high level,  IHS’s vision, goals, and priorities to develop, implement, and sustain an  effective quality program that is intended to improve patient experience  and ensure the delivery of reliably high quality health care for IHS direct  service facilities. According to IHS, the priorities of the framework are to  (1) strengthen organizational capacity to improve quality of care and  systems, (2) meet and maintain accreditation for federally operated  facilities, (3) align service delivery processes to improve patient  experience, (4) ensure patient safety, and (5) improve transparency and  communication regarding patient safety and quality to IHS stakeholders.  While this framework is focused on initiatives related to improving the  quality of care provided in its facilities—such as increasing staff training  and technical assistance on achieving compliance with quality and safety  standards, promoting a culture of patient safety, and developing a patient  perception survey process—elements of the framework also describe IHS  plans to improve oversight. For example, the framework directs IHS to  establish a quality office that will be responsible for assessing area office  and facility functions, staffing, and critical quality assurance activities.  This quality office is to be developed as part of an overall realignment of  offices in IHS, and according to the framework, the office will be  responsible for identifying resource needs, structures, processes, and  supports for an effective and sustainable quality assessment and  performance improvement system. More specifically, the framework  directs IHS to develop a process for monitoring performance measures,  such as measures of clinical care, patient access, and financial  performance, for periodic review by leadership. In addition, IHS’s quality  framework states that the agency will implement annual mock  accreditation surveys for all federally operated facilities and develop a  standardized governing board structure to improve planning and oversight  processes. The framework says that “transparency and accountability  will be fostered through regular and frequent (i.e., monthly or quarterly)  communications” between offices. The framework also explains that IHS  will enhance its adverse event reporting system to encourage consistent  use by facility staff, or replace it with a new system after January 2017.
If effectively implemented, the quality framework could address the limited  and inconsistent oversight of the quality of care provided in federally  operated IHS facilities. However, as of November 2016, the quality office  had not yet been formed, and officials told us the agency’s plan for  realigning offices was out for tribal review and comment. In addition, IHS  officials stated that the agency has not yet selected quality performance  measures but has plans to do so. Furthermore, the quality framework  states that IHS will support enhanced efforts to recruit and retain highly  qualified executives. While IHS officials reported that they are  implementing strategies to recruit and retain staff, the quality framework  does not specifically mention contingency or succession plans for key  personnel.
section_title: Conclusions
paragraphs: American Indians and Alaska Natives die at higher rates than other  Americans from many causes—such as lower respiratory infections and  complications from diabetes—that can be mitigated through access to  quality health care services, and concerns continue to be raised about the  quality of care provided in federally operated IHS facilities, including  misdiagnoses, incorrectly prescribed medications, and unsafe facility  conditions. Despite IHS’s mission to raise the physical, mental, social,  and spiritual health of American Indians and Alaska Natives to the highest  level, IHS’s oversight of the quality of care in its federally operated  facilities has been limited and inconsistent. In addition, several of the area  offices in our review experienced frequent leadership turnover with no  contingency or succession plans.
While IHS has recognized the need for quality improvement and has  drafted a quality framework to improve the oversight of the quality of care  provided, it has not yet developed quality performance standards. Until  IHS develops agency-wide standards for the quality of care provided in its  federally operated facilities, systematically monitors facility performance  in meeting these standards at all facilities, and develops contingency and  succession plans for key personnel to address its significant leadership  turnover, it cannot ensure that it is consistently providing quality medical  care to the AI/AN population served in its facilities.
section_title: Recommendations
paragraphs: To help ensure that quality care is provided to AI/AN people, the  Secretary of HHS should direct the Director of IHS to take the following  two actions:  1.  As part of the implementation of its quality framework, ensure that  agency-wide standards for the quality of care provided in its federally  operated facilities are developed, that facility performance in meeting  these standards is systematically monitored over time, and that  enhancements are made to its adverse event reporting system.  2.  Develop contingency and succession plans for the replacement of key  personnel, including area directors.
section_title: Agency Comments and our Evaluation
paragraphs: We provided a draft of this report to HHS for its review and comment.  HHS provided written comments, which are reproduced in appendix II.  HHS concurred with both of our recommendations.
In its comments, HHS elaborated on steps that IHS has started taking to  improve its oversight of the quality of care provided in its federally  operated facilities, which we describe in our report. Specifically, HHS  described the development of IHS’s quality framework and quality office,  plans to develop agency-wide quality measures, the standardization of  governing board by-laws, plans to enhance or replace its adverse event  reporting system, and its annual mock survey initiative. In its comments,  HHS also described IHS’s corrective action plan process related to the  mock survey initiative, and we added this information to our report. HHS  also provided information on steps that IHS is taking to improve the  quality of care in its federally operated facilities, including steps taken  toward the automation and systemization of provider credentialing.
Regarding our second recommendation to develop contingency and  succession plans for the replacement of key personnel, including area  directors, HHS stated that IHS has already begun to address this  recommendation. For instance, HHS reported that on December 2, 2016,  IHS distributed succession planning instructions and descriptions of the  competencies associated with each position in IHS headquarters, area  offices, and facilities to all headquarters office directors and area  directors. In addition, HHS reported that IHS has contingency plans in  place to ensure continuity of operations in emergency situations.  However, as explained in our report, standards for internal control in the  federal government state that the agency should have contingency plans  in place to respond to sudden personnel changes, which would include  non-emergency situations as well.
HHS also provided technical comments, which we incorporated where  appropriate.
We are sending a copy of this report to the Secretary of the Department  of Health and Human Services. The report will be available at no charge  on GAO’s website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or kingk@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 key contributions to this report are  listed in appendix III.
section_title: Appendix I: Information on Leadership Turnover at IHS Area Offices and Facilities
paragraphs: Officials from some area offices in our review reported significant turnover  of staff in area office leadership positions. Officials from four of the nine  area offices in our review reported that they had at least three area  directors in the past 5 years, and three area offices reported that they had  at least three chief medical officers. See table 2.
In addition, area offices reported 19 federally operated facilities that had 4  or more chief executive officers (CEO) in the past 5 years. One area  reported that one of its hospitals had 10 CEOs and 6 clinical directors in  the past 5 years. See table 3.
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Kristi Peterson, Assistant  Director; Kelly DeMots; Krister Friday; Keith Haddock; Lisa Rogers;  Patricia Roy; Jennifer Whitworth; and Emily Wilson made key  contributions to this report.