IHS’s Oversight of the Quality of Care Provided in Its Facilities Has Been Limited and Inconsistent, but IHS Has Drafted New Oversight Initiatives

		IHS’s Oversight of the Quality of Care Provided in Its Facilities Has Been Limited and Inconsistent

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. 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. 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. Reviewing available quality performance data. Monitoring adverse events. 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. According to  IHS officials, the agency has not defined contingency or succession plans  for the replacement of key personnel, including area directors. 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. IHS Developed a Quality Framework, but Has Just Begun to Implement Planned Changes

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. 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. 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. In addition, IHS  officials stated that the agency has not yet selected quality performance  measures but has plans to do so. Conclusions

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. 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. 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. HHS concurred with both of our recommendations. We are sending a copy of this report to the Secretary of the Department  of Health and Human Services.
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

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.