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

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.

What GAO Recommends

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.

For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.

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    What GAO Found Passengers with disabilities face infrastructure, information, and customer service barriers at U.S. airports, according to representatives of selected airports, disability advocacy organizations, as well as a review of relevant literature. Infrastructure barriers can include complex terminal layouts and long distances between gates and can be difficult for some to navigate. Essential travel information is not always available in a format accessible to all. For example, a person with hearing loss could miss crucial gate information that is solely provided over a loudspeaker. A passenger might not receive appropriately sensitive service, such as wheelchair assistance, at the airport, although the service provided is required by the Air Carrier Access Act of 1986 (ACAA) regulations. According to stakeholders, while no solution meets all needs, a number of practices can help reduce or eliminate some of these barriers to equal access at airports. For example, some selected airports use external disability community and passenger groups to proactively engage in identifying barriers and develop solutions. Other airports have implemented technology-based solutions, such as mobile phone applications to make airport navigation easier. Examples of Stakeholder-Identified Features to Assist Airport Passengers with Disabilities The Office of Aviation Consumer Protection within the Department of Transportation (DOT) is responsible for oversight of airlines' compliance with the ACAA. In 2008, DOT updated its entire ACAA regulation, including adding new training requirements for airline personnel, such as requiring training to be recurrent. Following this update, DOT conducted outreach to domestic and foreign airlines on the changes and reviewed airlines' disability training sessions and materials. Agency officials said that in recent years, DOT has conducted reviews of airlines' training only when passengers' complaints indicate a possible problem, as officials' analyses have not shown training generally to be a significant cause of service violations. DOT officials and stakeholders said other factors, such as limited availability of staff to assist passengers with disabilities, at times may affect the service passengers with disabilities receive. DOT is assessing some of these factors through the statutorily mandated ACAA Advisory Committee, formed in late 2019 to make recommendations to improve accessibility to air travel. The committee met in 2020, established three subcommittees, and plans to reconvene by summer 2021. Why GAO Did This Study Approximately 43 million people in the United States have some type of disability, which may affect mobility, vision, hearing, and cognition. Without accessible airport facilities and accommodations—such as appropriate assistance from the check-in counter to the gate, or effective communication of flight information—air travel for people with disabilities can be extremely challenging. The FAA Reauthorization Act of 2018 includes provisions for GAO to review leading airport accessibility practices for passengers with disabilities, as well as required training for airline and contract service personnel who assist these passengers within the airport. This report examines, among other objectives: stakeholder-identified barriers that passengers with disabilities face when accessing airport facilities, accessibility practices to assist passengers with disabilities, as well as how DOT has overseen airlines' disability-related training. GAO reviewed relevant federal laws, regulations, DOT documents, literature, as well as information describing disability training provided by selected airlines and contractors. GAO interviewed a non-generalizable sample of stakeholders, including those at 16 U.S. airports selected based on size and geography, eight large and low-cost domestic airlines selected based on the greatest number of disability-related passenger complaints and enplanements, and six aviation service contractors working for those airlines. GAO also conducted interviews with DOT officials and 10 disability advocacy organizations, among others. For more information, contact Heather Krause at (202) 512-2834 or krauseh@gao.gov.
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