Indian Health Service:
Actions Needed to Improve Oversight of Patient Wait Times
GAO-16-333: Published: Mar 29, 2016. Publicly Released: Apr 28, 2016.
What GAO Found
The Indian Health Service (IHS) has not conducted any systematic, agency-wide oversight of the timeliness of primary care provided in its federally operated facilities. IHS has delegated primary responsibility for the oversight of care provided in its facilities to its area offices and has not set any agency-wide standards for patient wait times—including both how long it should take to schedule an appointment and to complete the actual office visit. The oversight provided by area offices has generally only occurred during periodic meetings with facility staff and only when relevant issues, such as patient complaints, have arisen. While staff at some facilities have measured patient wait times, their efforts have been hampered by an electronic health record system that does not provide complete information on patient wait times. In 2009, IHS set four agency-wide improvement priorities of which one was to improve the quality of and access to health care, and the Department of Health and Human Services has identified timeliness as a key component of access. However, the lack of systematic, agency-wide oversight of the timeliness of primary care appointments prevents IHS from knowing the extent to which it is meeting the goal of providing accessible primary care services to American Indian and Alaska Native (AI/AN) people and is also inconsistent with federal internal control standards. Setting agency-wide standards for patient wait times and monitoring compliance with these standards would allow IHS to assess whether it is meeting this program objective and monitoring compliance with these standards would allow IHS to determine what corrective actions are needed when standards are not being met. IHS officials told GAO that they hope to eventually track patient wait times, but they have been focused on other agency-wide efforts, such as ensuring that facilities are accredited.
To help improve patient access to timely primary care, staff at the seven IHS facilities GAO visited reported that they have taken various steps to help ensure that their patients have access to timely primary care, but obstacles remain. Steps taken by facilities include modifying appointment scheduling procedures and improving communication with patients. For example, staff from multiple facilities stated that they have implemented a modified open access scheduling system, whereby staff schedule a certain portion of appointments in advance and keep the remainder of the appointments open for same-day scheduling. Facility staff also reported taking steps to improve communication with tribal members in their service areas in order to reduce missed appointments and educate patients about the importance of primary care. However, facility staff stated that a lack of sufficient primary care providers, as well as aging infrastructure and equipment, are significant obstacles to ensuring that patients receive timely care. IHS officials and facility staff stated that ongoing staff vacancies significantly reduce their ability to ensure that patients receive timely care. For example, staff at one facility stated that, depending on provider availability, new patients may wait 3 or 4 months for an initial appointment. Facility staff also reported working in outdated facilities with insufficient space to accommodate additional providers and with outdated medical and telecommunications equipment, such as analog mammography machines and telephones with an insufficient number of lines for scheduling patient appointments.
Why GAO Did This Study
IHS is charged with providing health care to AI/AN people—members or descendants of 566 federally recognized tribes. AI/AN people die at higher rates than other Americans from conditions that could be mitigated through access to preventive primary care services and have experienced long-standing problems accessing health care services. GAO was asked to review how IHS ensures access to care at its facilities and steps taken to address reports of lengthy wait times for appointments.
This report examines (1) the extent to which IHS oversees access to timely primary care, and (2) any steps that selected facilities have taken to help ensure patient access to timely primary care. GAO reviewed policies and guidance related to access to IHS primary care; interviewed IHS officials; and visited a nongeneralizable sample of seven facilities that varied in their size and services provided. GAO also examined documents from governance meetings between IHS area office and facility staff that took place between January 1, 2014, and September 1, 2015.
What GAO Recommends
GAO recommends that IHS (1) communicate specific agency-wide standards for patient wait times, and (2) monitor patient wait times in its federally operated facilities, and ensure corrective actions are taken when standards are not met.
In commenting on a draft of this report, IHS agreed that setting quality standards and monitoring against those standards is a key strategy for improving patient care.
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Recommendations for Executive Action
Status: Closed - Implemented
Comments: IHS developed specific standards for patient wait times and published them to the Indian Health Manual website in August 2017.
Recommendation: To help ensure that timely primary care is available and accessible to AI/AN people, the Secretary of HHS should direct the Director of IHS to develop and communicate specific agency-wide standards for patient wait times in its federally operated facilities. As part of its process, IHS should review its experience with the timeliness goals it set as part of its Improving Patient Care program.
Agency Affected: Department of Health and Human Services
Comments: As of June 2017, according to IHS, the implementation of an agency-wide standard for patient wait times will be accomplished as follows: A decision will be made on the standard to be used, by the IHS Director no later than July 2017. Using a pilot sample of facilities (two to four facilities), the standard will be assigned to the Area Directors over the selected pilot facilities in October 2017. Systems of measurement will be decided and communicated to the Area Directors for the pilot facilities. By December 31, 2017, three months of activity will be analyzed and evaluated against the standard. Between January and March, 2018, adjustments to the necessary systems of measure, or adjustments to the reasonably expected performance standard will be made. A final evaluation will be performed not later than September 2018, and final adjustments will be made to either the measurement system or the standard to allow for full implementation of the standard across all IHS Areas by October, 2018.
Recommendation: To help ensure that timely primary care is available and accessible to AI/AN people, the Secretary of HHS should direct the Director of IHS to monitor patient wait times in its federally operated facilities and ensure corrective actions are taken when standards are not met.
Agency Affected: Department of Health and Human Services