GAO: Quality of Care Oversight Is Lacking at IHS

by U.S. Medicine

March 10, 2017

By Sandra Basu

IHS has come under fire for lack of oversight of quality of healthcare for American Indians and Alaska Natives. Photo Courtesy of the Indian Health Service/U.S. Department of Health and Human Services.

WASHINGTON — The Indian Health Service’s “oversight of the quality of care in its federally-operated facilities has been limited and inconsistent,” according to a new report pointing out the agency’s mission is to “raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.”

The Government Accountability Office (GAO) document added,

“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.”

Those findings were part of the report, Indian Health Service Actions Needed to Improve Oversight of Quality of Care, which examined IHS’s oversight of the quality of care provided in its federally-operated facilities. The performance audit was conducted from March 2016 through January 2017 in response to a congressional query.

“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,” report authors stated.

Oversight Challenges

The report explained that, while some oversight functions in IHS are performed at the headquarters level, primary responsibility for the oversight of the quality of care has been delegated to the area offices. Inconsistencies in carrying out that oversight by the area offices were documented, however.

For example, while area officials said they hold periodic meetings with facility staff in order to monitor the quality of care provided by the facilities, the meetings varied on whether or to what extent they focused on the quality of care, according to the analysis. “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,” the report said. “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.”

GAO also noted that, while all nine area offices monitor adverse events that occur at IHS facilities, officials from one area office told investigators that reporting of adverse events by the facilities through WebCident system has been inconsistent.

“These officials stated that this creates a lost opportunity to address the deficiency and improve, as well as to hold individuals accountable,” the document emphasized. “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.”

Furthermore, according to IHS officials, clinical quality performance data are generally collected and reported consistently to IHS’s area and headquarters offices, “but other data used to oversee the quality of care provided in facilities are not reported or reviewed consistently across IHS.”

According to GAO, area directors are held responsible for 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.” As part of that duty, area directors must sign performance agreements that includes a requirement for documentation for the implementation of at least two activities to improve wait times and access to quality health care.

The problem, according to GAO, is that “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.”

The report noted that the inconsistencies it found are “exacerbated by significant turnover in area leadership” and that “the agency has not defined contingency or succession plans for the replacement of key personnel, including area directors.”


GAO pointed to a quality framework IHS finalized in November 2016 that, if implemented, could address the “limited and inconsistent oversight of the quality of care provided in federally operated IHS facilities.”

Still, the oversight group reported that as of November 2016, the formation of the quality office that was part of that framework had not occurred nor had the agency selected quality performance measures, although it has plans to do so. In addition, the report explained that “the quality framework does not specifically mention contingency or succession plans for key personnel.”

The GAO recommended that, as part of the implementation of its quality framework, IHS needed to “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.”

It also suggested that IHS develop contingency and succession plans for the replacement of key personnel, including area directors.

HHS concurred with GAO’s recommendations.

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