Indian Health Service: Actions Needed to Improve Oversight of Provider Misconduct and Substandard Performance

GAO-21-97 Published: Dec 10, 2020. Publicly Released: Dec 10, 2020.
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Fast Facts

The Indian Health Service delivers health care to American Indians and Alaska Natives. Recent cases of provider misconduct, including sexual abuse and physical assault, have raised questions about protecting patients from harm.

IHS has taken steps to address these concerns but inconsistencies remain in its oversight. IHS lacks

A consistent process to review its regional offices' trainings and policies

A standard format to document reviews of information (such as patient complaints) to ensure consistent oversight at facilities

We made 3 recommendations to improve oversight, which could better protect patients from harm.

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Highlights

What GAO Found

The Indian Health Service's (IHS) policies related to provider misconduct and substandard performance outline several key aspects of oversight, such as protecting children against sexual abuse by providers, ethical and professional conduct, and processes for managing an alleged case of misconduct. Although the Department of Health and Human Services (HHS) or IHS headquarters have established most of these policies, area offices that are responsible for overseeing facility operations and facilities, such as hospitals, may develop and issue their own policies as long as they are consistent with headquarters' policies, according to officials.

Although some oversight activities are performed at IHS headquarters, IHS has delegated primary responsibility for oversight of provider misconduct and substandard performance to the area offices. However, GAO found some inconsistencies in oversight activities across IHS areas and facilities. For example,

Although all nine area offices require that new supervisors attend mandatory supervisory training, most area offices provided additional trainings related to provider misconduct and substandard performance. The content of these additional trainings varied across area offices. For example, three area offices offered training on conducting investigations of alleged misconduct, while other area offices did not. Officials from IHS headquarters told GAO they do not systematically review trainings developed by the areas to ensure they are consistent with policy or IHS-wide training.

  • Facility governing boards—made up of IHS area office officials, including the Area Director, and facility officials, such as the Chief Executive Officer—are responsible for overseeing each facility's quality of and access to care. They generally review information related to provider misconduct and substandard performance. However, there is no standard format used by governing boards to document their review, making it difficult to determine the extent this oversight is consistently conducted. In some cases, there was no documentation by governing boards of a discussion about provider misconduct or substandard performance. For example, none of the seven governing board meeting minutes provided from one area office documented their discussion of patient complaints. In other cases, there was detailed documentation of the governing board's review. Additionally, governing boards did not always clearly document how or why an oversight decision, such as whether to grant privileges to a provider, had been made based on their review of available information.

These inconsistencies in IHS's oversight activities could limit the agency's efforts to oversee provider misconduct and substandard performance. For example, by not reviewing trainings developed by area offices, IHS headquarters may also be unable to identify gaps in staff knowledge or best practices that could be applied across area offices. Addressing these inconsistencies would better position the agency to effectively protect patients from abuse and harm resulting from provider misconduct or substandard performance.

Why GAO Did This Study

IHS provides care to American Indians and Alaska Natives (AI/AN) through a system of federally and tribally operated facilities. Recent cases of alleged and confirmed misconduct and substandard performance by IHS employees have raised questions about protecting the AI/AN population from abuse and harm. For example, in February 2020, a former IHS pediatrician was sentenced to five consecutive lifetime terms for multiple sex offenses against children. Several studies have been initiated or completed in response, and IHS has reported efforts to enhance safe and quality care for its patients.

GAO was asked to review IHS oversight of misconduct and substandard performance. This report (1) describes IHS policies related to provider misconduct and substandard performance and (2) assesses IHS oversight of provider misconduct and substandard performance. GAO reviewed policies and documents, including minutes from 80 governing board meetings from January 2018 to December 2019. GAO also interviewed IHS officials from headquarters, all nine area offices with two or more federally operated facilities, and two federally operated facilities.

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Recommendations

GAO is making three recommendations, including that IHS should establish a process to review area office trainings as well as establish a standard approach for documenting governing board review of information. HHS concurred with these recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Indian Health Service The Director of IHS should establish a process at headquarters to review area office policies related to misconduct and substandard performance to ensure that area office policies are consistent with headquarters' policies. (Recommendation 1)
Closed – Implemented
IHS established a process at headquarters to review area office policies related to misconduct and substandard performance. Specifically, IHS established policy in April 2022 that requires all IHS areas to obtain headquarters' review and clearance of their policies, including current, new, or revised policies. When submitting the policy for review, the area office is required to submit information about how the area-specific policy aligns with Department of Health and Human Services and IHS policy on misconduct or substandard performance and the purposes, goals, and objectives for the area-specific policy. In June 2022, IHS reported to us that its Office of Human Resources will hold quarterly meetings with employee and labor relations specialists from the area offices to reinforce this policy. IHS also reported that headquarters staff will conduct continued monitoring of this policy. Establishing this process will help IHS to ensure that area office policies are consistent with headquarters' policies.
Indian Health Service The Director of IHS should establish a process at headquarters to review area office trainings related to misconduct and substandard performance to ensure that staff receive consistent information about how to address misconduct or substandard performance. (Recommendation 2)
Closed – Implemented
IHS established a process at headquarters to review area office trainings related to misconduct and substandard performance. Specifically, IHS established policy in February 2022 that requires all IHS areas to obtain headquarters' review and clearance of their trainings, including current, new, or revised trainings. When submitting the trainings for review, the area office is required to submit information about how the area-specific training aligns with Department of Health and Human Services and IHS policy on misconduct or substandard performance and the purposes, goals, and objectives for the area-specific training. In June 2022, IHS reported to us that its Office of Human Resources will hold quarterly meetings with employee and labor relations specialists from the area offices to reinforce this policy. IHS also reported that headquarters will conduct continued monitoring of this policy. Establishing this process will help IHS to ensure that staff receive consistent information about how to address misconduct or substandard performance.
Indian Health Service The Director of IHS headquarters should establish a standard approach or tool to ensure that governing boards consistently document their review of information related to provider misconduct and substandard performance. (Recommendation 3)
Open
IHS is working to establish a standard approach or tool to ensure that governing boards consistently document their review of information related to provider misconduct and substandard performance, as we recommended in December 2020. In May 2021, IHS told us that the IHS Director will issue a policy directive to all area offices that will include guidance on including provider misconduct reports in each Governing Board meeting. The policy directive will also require governing boards to notify the IHS Quality Assurance Risk Management Committee of major high-risk incidents. In June 2022, IHS reported that this policy is in the final review process. Additionally, IHS reported four area offices are working to standardize governing board efforts and IHS is working on including more area offices in these efforts. IHS also included governance and credentialing and privileging as part of its 2020 and 2021 oversight reviews. The information from these reviews will inform the development of standard tools for the governing boards, according to IHS.

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