Improving Indian Health Service hospitals

Agency strives to ensure safety, coordinate quality initiatives.

The Indian Health Service (IHS) is tasked with delivering comprehensive health care to about 2.2 million Native Americans, but recent evidence has suggested that some of its hospitals have fallen dangerously short of this goal.

In Rapid City, S.D., for example, the emergency department of Sioux San Hospital was closed in 2016 for deficiencies so severe that they constituted “an immediate and serious threat to the health and safety of any individual who comes to your hospital to receive emergency services,” CMS wrote in a letter to the hospital.

Photo by Thinkstock
Photo by Thinkstock

Also in 2016, CMS warned the Pine Ridge IHS hospital that it was in “immediate jeopardy” of closing after CMS inspectors found that staff had failed to appropriately assess patients, had not adequately factored patient history into diagnoses, had made patients wait for care they needed immediately, and had been inadequately trained in intubation and respirator use. The emergency department of a third IHS Great Plains hospital, Rosebud, was shuttered for seven months after CMS found similar deficiencies.

These cases reveal systemic problems with safety, access, and quality of care at IHS that extend beyond the Great Plains Area. In Window Rock, Ariz., for example, Crownpoint Medical Center closed its emergency department, inpatient services, and obstetrics care units in 2015 due to staffing shortages, according to a press release from the Navajo Nation.

Today, however, some dedicated clinicians and government initiatives are working to correct these deficiencies and provide Native Americans with high-quality inpatient care.


IHS hospitals and their clinicians face multiple hurdles, said Lee Lawrence, MD, chief medical officer of the IHS Great Plains Area. “The remote, rural, and distant locations, limited funding, outdated or missing equipment, and chronic staffing vacancies make medical care in the IHS system particularly challenging,” he said.

For example, some facilities lack CT scanners, so patients must be flown long distances to better-equipped IHS medical centers, Dr. Lawrence said. Pregnant patients also must endure long-distance transfers if their local IHS hospital cannot retain appropriate obstetric staff. “Particularly challenging to the hospitalists is the lack of ICUs in many of our facilities, requiring them to make the difficult decision of admitting or transferring the more critical patients,” Dr. Lawrence added.

Dorothy Sanderson, MD, FACP, agreed. The aging of IHS facilities, infrastructure, and equipment, combined with geographic isolation and budget shortages, force hospitalists and their clinical colleagues “to be as creative as possible in finding ways to provide the culturally sensitive and excellent medical care our patients deserve,” she said.

IHS hospitals also are uniquely complex, explained Dr. Sanderson, who is a hospitalist and chief of internal medicine at Phoenix Indian Medical Center in Phoenix. Some are federal facilities, while others fall under tribal authority. Some have a very limited scope of practice, while others offer certain specialty and diagnostic services.

But despite—or perhaps because of—these tiered intricacies, IHS headquarters has for years delegated the oversight of care to its nine geographic areas, according to a January 2017 report by the U.S. Government Accountability Office (GAO). As a result, IHS lacked agency-wide standards for quality of care, and oversight of quality issues was “limited and inconsistent,” the report asserted. For example, authorities in some IHS areas did not meet regularly and failed to make quality a standing agenda item at their meetings. Reporting of data on quality and adverse events also was sporadic and incomplete, the GAO found.

Systemic change

Such revelations spurred IHS in 2016 to craft a quality framework that aspires to ensure patient safety, boost organizational capacity, and meet and maintain accreditation standards, the agency stated in a recent press release. IHS also has pledged to expand existing safety reporting systems and promote a culture of transparency and patient safety in which hospital staff feel comfortable reporting medical errors.

As part of these efforts, CMS has added IHS to its national Hospital Improvement Innovation Networks program, which aims to cut overall patient harm by 20% and to reduce 30-day readmissions by 12% between 2014 and 2019. Premier, Inc., a private health care improvement company, will serve as the Hospital Improvement Innovation Network organization for IHS. CMS also has tapped HealthInsight, a nonprofit, community-based organization, to help coordinate quality improvement efforts at the 25 IHS hospitals that are Medicare-certified.

In the Great Plains Area, a newly hired manager is implementing quality assurance and performance improvement programs at each of the IHS hospitals, Dr. Lawrence said. The Great Plains Area also has set new minimum standards for medical equipment and has contracted with The Joint Commission to provide accreditation, training, and education on quality assurance and patient safety.

In order to continue receiving CMS reimbursements, the Pine Ridge and Rosebud hospitals also have agreed to shift executive hospital leadership to expert contractors who will thoroughly train local administrators and then shift to mentoring and coaching roles.

The Great Plains Area also has allocated $8.6 million to provide telemedicine services at all 19 of its service units, which together serve about 130,000 patients. “The telemedicine initiative is an important step in expanding access to care for patients, who will receive specialized care nearer to home instead of traveling long distances to see a specialist,” Dr. Sanderson said.

Local progress

Clinicians at Phoenix Indian Medical Center in Arizona did not await external or top-down pressure to make positive changes. To support complex patients in the face of limited resources, surgeons and their colleagues designed a Perioperative Surgical Home (POSH), a model which the American Society of Anesthesiologists (ASA) promotes as an innovation for providing safe, patient-centered care.

Perioperative care has become highly fragmented, according to the ASA. The perioperative surgical home model overcomes this tendency by teaming up hospitalists, surgeons, anesthesiologists, nurses, pharmacists, respiratory therapists, and nutritionists so they can comprehensively evaluate medical and psychosocial needs before and after surgery and create detailed pre- and postoperative needs assessments and treatment plans, Dr. Sanderson said.

Implementing a POSH enabled Phoenix Indian Medical Center to expand its scope of surgical services—a vital step for a hospital that serves more than 140,000 patients from 40 tribes. In addition, evaluations during the early stages of the project revealed opportunities for improvement, such as a perioperative antibiotic prophylaxis program, a recovery pathway for colorectal surgery patients, and a ventral hernia program, which clinicians can tailor based on patient needs, Dr. Sanderson said.

To encourage early mobility after surgery, staff also designed a WeMove! program that provided detailed instructions for patients, a walking circuit in the medical-surgery ward, and 55 new chairs. Early results showed patients were out of bed 40% more often after the program started, Dr. Sanderson said.

Recognizing the need for ongoing staff education, clinicians also designed a web-based curriculum on the essentials of surgery and began organizing regular lectures at the hospital for CME credit. To help reinforce the program, they also updated their electronic health record system to include POSH notes and nursing documentation.

The model is generalizable, Dr. Sanderson emphasized. “Any facility [with] complex patients requiring multiple encounters in the perioperative setting can benefit from evaluating the process through which patients prepare for surgical procedures.”