- The Department of Health and Human Services (HHS) Office of the Inspector General (OIG) recently identified several quality improvement challenges at Indian Health Services (IHS) hospitals, including access to care limitations, clinical incompetency, healthcare employment instability, and antiquated physical structures.
The HHS watchdog found longstanding issues at the 28 IHS hospitals that have led to below-standard quality of care and compliancy violations with Medicare Conditions for Participation.
IHS is responsible for providing healthcare services to 567 federally-recognized American Indian and Alaska Natives tribes, which includes performing free primary and preventative services for nearly 2.2 million individuals. However, OIG found that IHS hospitals are still facing similar care quality challenges, such as lack of funding, personnel, and equipment, from almost a century ago.
Access to care limitations hinder quality improvement
The OIG report stated that access to care at IHS hospitals was limited because of high outpatient volume, restricted scope of services, and geographic isolation.
IHS hospitals were burdened by the increasing number of outpatient users, which grew by 70 percent between 1986 and 2013. The increasing number of outpatients, however, led to longer waiting times and difficulties with scheduling appointments.
Despite the increasing user population, OIG found that IHS hospitals lacked a broad scope of services, which further restricted the ability to care for some patients. IHS administrators from one hospital told OIG that most of their providers were mid-level and family practice providers who were not able to provide specialty care. As a result, many IHS patients were referred to other non-IHS providers.
Referrals were typically paid for through the Purchased and Referred Care program, but longstanding funding constraints caused many referrals to be denied. In 2013, OIG reported that the program denied over $760 million in referral request for about 146,928 services. Most of the denied requests were for preventative, primary, secondary, chronic tertiary, and extended care services because these were lower on the medial priority list.
Geographic isolation also led to limited access to care, OIG noted. Staff from half of the hospitals reported significant quality improvement issues resulting from limited specialist access. Administrators from 11 hospitals stated that they had difficulties securing post-acute care because of limited placement options and one administrator told OIG that patients needed to travel between 100 and 200 miles to get post-acute care.
Another IHS administrator mentioned that the lack of resources, such as nursing homes and rehabilitation clinics, as well as the “third world” living conditions (e.g. no running water or electricity) sometimes prevented the hospital from discharging patients.
Low inpatient volume led to clinical incompetency
IHS hospitals could not maintain clinical competencies because of low inpatient populations, OIG stated. The average number of inpatients at individual IHS hospitals was 8, whereas the national average was 104 inpatients.
Low inpatient volume impacted quality of care because providers were not experienced with treating high-risk conditions, OIG added. For example, CMS found three patient deaths at a IHS hospital in 2014 were caused by a “lack of staff proficiency and inability to identify problems.” The federal agency stated that hospital staff did not know how to perform emergency resuscitations and crash carts did not contain necessary equipment. Staff also did not know how to call emergency codes to acquire assistance, recognize symptoms of life-threatening conditions, and provide stabilizing treatment.
Healthcare employment instability challenges quality improvement
One of the top quality improvement concerns for most IHS hospitals was healthcare employment issues, including the inability to recruit and retain staff. Vacancy rates across IHS facilities for physicians was 23 in 2014, while national vacancy rate for hospital physicians was less than 18 percent in 2013.
According to IHS staff, high vacancy rates affected care quality because hospitals were forced to turn away patients. Insufficient staffing also caused Emergency Medical Treatment & Labor Act violations because the hospital did not have enough staff in the emergency room.
The HHS watchdog attributed provider shortages to geographic isolation, limited incentives, non-competitive compensation, and long hiring processes. Administrators from 13 IHS hospitals reported that the remote location impacted their ability to recruit and retain staff, especially since housing, amenities, and job opportunities for other family members were limited in the area.
IHS hospitals also did not offer sufficient incentives or competitive compensation for all providers, OIG stated. Physicians were offered loan repayment and relocation bonuses, but these are not given to other essential staff, such as nurses. IHS hospitals could not compete for staff because of “the lack of recruitment incentives (particularly, the lack of signing bonuses), the hospital’s remote location, and the fact that its locality pay is the same as that for IHS hospitals in less rural areas.”
Many potential employees also do not complete the lengthy IHS hiring process, which took 77 days on average. Although, some IHS administrators noted that it can take as long as six months to hire new staff.
In addition to providers, IHS hospitals faced healthcare employment challenges with leadership positions. Most of the hospitals (24 out of 28) reported having someone in an “acting” leadership position with CEO being the most common acting position, followed by clinical director and director of nursing. Hospitals also had multiple acting leaders in these positions over a short period of time, including one hospital that had three different acting CEOs in a six-week timeframe.
The high number of acting hospital executives led to “inconsistent facility leadership,” OIG noted.
Contracted providers that were hired to supplement permanent staff also troubled IHS hospitals. OIG stated that hospital employees had to refer patients to other providers for follow-up care because contracted employees did not stay long enough for subsequent appointments.
Using contracted providers also drained IHS budgets and prevented the facilities from focusing on more sustainable quality improvement initiatives, such as updating buildings and equipment.
Outdated physical structures contributed to low-quality care
Administrators at 15 hospitals said that old physical environments made it harder to provide high-quality care and comply with Medicare Conditions for Participation. The average length of time since a major renovation was 37 years at IHS hospitals versus only ten years for hospitals nationwide.
As a result, 35 percent of deficiencies cited in the healthcare system’s most recent survey were related to the physical environment. Some of the hospitals reported inappropriate air flow and pressure, which could potentially lead to more infections, as well as infrastructure issues that prevented quality improvement projects, such as installing IT lines to support EHR technology.
The HHS watchdog also found that hospitals did not have enough space to appropriately care for patients. More than two-thirds of the hospitals reported insufficient space and seven of these hospitals stated that they have less than half the estimated space necessary to meet community needs.
“Although most IHS hospitals have outgrown their facilities, funding constraints prevent them from engaging in major renovation and construction,” OIG stated.
To resolve quality improvement challenges, OIG advised the newly formed HHS Executive Council to work with IHS on improving longstanding quality of care issues. The council should “collaborate with IHS and leverage the council’s organizational expertise in areas such as rural health, providing care to vulnerable populations, hospital management, performance metrics, and payment methodologies.”
The HHS watchdog also suggested that IHS perform a needs assessment and develop a strategic plan to improve care quality. The healthcare system should update its strategic plan from 2011 to fix quality improvement challenges, such as maintaining clinical competence, decreasing referral denials, increasing referral networks, ensuring building and equipment maintenance, providing appropriate IT support, improving clinical support, and assessing physical security.
In an accompanying report, OIG found that many of the quality improvement challenges at IHS were caused by a lack of monitoring practices.
“IHS may be missing opportunities to identify and remediate quality problems in its hospitals because it performed limited oversight regarding quality care and compliance with the CoPs [Conditions of Participation],” OIG wrote. “IHS relies on its Area Offices to monitor hospitals.”
OIG recommended that IHS develop a quality-focused compliance program, create standards for Governing Board and leadership oversight activities, identify more appropriate hospital performance metrics, and invest in hospital administration and staff training.
The HHS watchdog also advised CMS to conduct more frequent surveys to help IHS identify sub-standard care and provide the healthcare system with technical assistance and training.