Testimony from RADM Chris Buchanan, R.E.H.S., M.P.H. on High Risk, No Reward: GAO’s High Risk List for Indian Programs before Committee on Indian Affairs

Chairman and Members of the Committee:

Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members of the Committee. I am Chris Buchanan, an enrolled member of the Seminole Nation of Oklahoma and Acting Director of the Indian Health Service (IHS). I am pleased to have the opportunity to testify before the Senate Committee on Indian Affairs on the Government Accountability Office (GAO) 2017 High Risk Report. I would like to thank you, Chairman Hoeven, Vice-Chairman Udall, and members of the Committee for elevating the importance of delivering quality care through the IHS.

The IHS plays a unique role in the Department of Health and Human Services (HHS) because it was established to carry out the responsibilities, authorities, and functions of the United States to provide health care services to American Indians and Alaska Natives. The mission of the IHS, in partnership with American Indian and Alaska Native people, is to raise the physical, mental, social, and spiritual health of American Indian and Alaska Natives to the highest level. The IHS provides comprehensive health care delivery to approximately 2.2 million American Indian and Alaska Natives through 26 hospitals, 59 health centers, 32 health stations, and nine school health centers. Tribes also provide healthcare access through an additional 19 hospitals, 284 health centers, 163 Alaska Village Clinics, 79 health stations, and eight school health centers.

Providing quality healthcare is our highest priority. We share the urgency of addressing longstanding systemic problems highlighted in the February 2017 GAO High Risk Report. I would like to describe for you how we are addressing these challenges and highlight examples of recent progress.

Enterprise Risk Management Program

IHS has strengthened its Enterprise Risk Management (ERM) Program, which closely aligns our Risk Profile to our activities under the Federal Manager’s Financial Integrity Act (FMFIA). A key element of the FMFIA, in addition to maintaining financial integrity, is providing annual assurance to the Secretary and the Congress that programs are effective and meet their objectives. The GAO High Risk Report recommendations have been directly incorporated into our ERM work for 2017. All senior executives in IHS have been directly involved in national risk assessment discussions with a focus on effective risk mitigation planned for all executives and managers in 2017.

IHS has dedicated sufficient resources to ensure that we have the needed expertise in IHS Headquarters to lead and oversee a successful risk management approach to improvement in all program areas on the GAO High Risk Report. In concert with closer attention to unimplemented recommendations from GAO, we are also intensifying our efforts to close out open Office of Inspector General (OIG) recommendations. In April 2017, IHS successfully closed three long-standing OIG open recommendations, related to improvements needed in the IHS Behavioral Health Program. IHS has made progress in establishing and increasing partnerships within the agency, improved collaborations with other federal agencies and tribal organizations, and extensive training for program staff to ensure sustainability.

IHS has increased senior management attention and priority on prior GAO recommendations related to management oversight of Indian health care and is implementing many positive changes. We are using the GAO findings and recommendations to inform our strategic and tactical planning efforts.

Third Party Revenue

IHS has diligently worked to improve access to care for our beneficiaries through outreach, education and enrollment activities that has resulted in higher total third party collections. We saw a 21 percent increase in total Medicaid reimbursements and a 28 percent increase in total collections from private insurers from FY 2012 to FY 2016. Another result of enrollment activities is to increase patient access to care by having third party payers cover care provided outside of the Indian health system for eligible beneficiaries. Also, in all IHS areas, we have programs that are able to purchase health care beyond the medical priority I.

Realignment and Reorganization

IHS is exploring ways to realign performance accountability to strengthen both field operations and headquarters oversight responsibilities by setting clear senior executive expectations, and establishing clearer lines of accountability. We also want to strengthen executive leadership accountability for accomplishing the objectives of the priorities of IHS that will result in improvement of the quality of health care provided.

Quality Framework

IHS is strongly committed to assuring that all its hospitals and clinics have quality-focused compliance programs. In partnership with the HHS Executive Council on Quality Health Care, IHS developed a strong Quality Framework (QF) that is now being implemented. We developed the QF by assessing current IHS quality policies, practices, and programs, incorporating standards from national experts, consulting with tribal leaders, and including best practices and expertise from across the IHS system of care, as well as leveraging quality specialists across HHS. The core elements are:

• Strengthening Organizational Capacity to Improve Quality of Care and Systems,
• Meeting and Maintaining Accreditation for IHS Direct Service Facilities,
• Aligning Service Delivery Processes to Improve Patient Experience,
• Ensuring Patient Safety, and
• Improving Transparency and Communication Regarding Patient Safety and Quality to IHS Stakeholders.

We established the position of Deputy Director for Quality Health Care as part of the agency’s senior leadership team to provide a national focus for advising the IHS director and providing leadership and guidance to the field on all aspects of assuring quality health care. Continuing the implementation of the strategic QF at all levels of IHS and in partnership with Tribal/Urban Indian organization partners is a key priority of this position. This includes oversight of critical quality improvement strategies related to accreditation/certification, patient safety, and quality care.

Quality Improvement Initiatives

We have made great progress in the past few months. On April 28th, IHS finalized a contract to purchase software for a National Provider Credentialing System, with a plan to roll out the system in four pilot IHS areas in July 2017 and a plan to implement across the other IHS areas by the end of 2017. The credentialing policy has been updated, and is the final stages of clearance. IHS plans to release a request for proposals for a single accrediting organization for IHS hospitals by July 2017. To help hospitals maintain accreditation, IHS established a formal partnership with our sister agency, the Centers for Medicare & Medicaid Services (CMS), through a contract to support best health care practices and other organizational improvements for IHS federally-operated hospitals that participate in the Medicare program.

IHS hospitals can partner with CMS, which is supporting a Quality Innovation Network – Quality Improvement Organization to support, build, and redesign, if needed, their hospital operating infrastructure in order to provide high quality health care services. Under this partnership, IHS hospitals are able to focus on improving leadership and staff development, data acquisition and analytics, clinical standards of care, and quality of care related to the Medicare program.

In addition, IHS is developing a performance accountability dashboard and related metrics to support Headquarters’ oversight and monitoring functions. Earlier this month, pilot testing began for a system to collect standardized information on patient experience with care, using tablet devices. Workgroups are also finalizing standard setting for patient wait times and their measurement, and minimum standards for hospital Governing Board meetings. Beginning with the Great Plains Area, IHS is pilot testing a leadership coaching and mentoring program to strengthen organizational capacity to improve quality and governance.

Effective medical equipment is vital to patient safety and quality care. In June 2016, IHS established a new policy to ensure critical medical equipment used at IHS facilities is properly maintained and reliable. Additionally, we mandated the use of a computerized system in all Federal health facilities to inventory medical equipment and provide other information about longevity and reliability. As implementation continues, we expect to see improved management of our medical equipment inventory to ensure outdated and non-functioning equipment is replaced in a timely manner.

Workforce Development

One of the most difficult challenges for IHS remains recruiting and retaining highly skilled administrators and physicians in rural and remote areas. To make a career in IHS more attractive to modern health care practitioners and health care administrators, IHS is implementing various strategies to increase recruitment and retention. To share a few examples, IHS has implemented a senior executive search committee process for recruiting highly qualified executives. Search committees are made up of IHS leadership and tribal partners who are charged with candidate outreach, assessment, and vetting. Through this new process, the IHS is more widely advertising vacancies through Federal, State, and non-profit partners, and is actively seeking additional venues to attract a diverse applicant pool of qualified candidates.

IHS also has partnered closely with the Office of the Surgeon General to increase the recruitment of Commissioned Corps officers to provide management and clinical services throughout the IHS. The Commissioned Corps is offering expedited commissioning to applicants who commit to service in an IHS facility with critical staffing needs. In addition, the IHS and the Health Resources and Services Administration continue to work together to make the National Health Service Corps (NHSC) more accessible to fill health professional vacancies. This allows IHS facilities to recruit and retain primary care providers by using NHSC scholarship and loan repayment incentives. As of April 2017, 472 NHSC loan repayment and 21 NHSC scholars have entered our workforce in IHS and tribal facilities.

These examples demonstrate that IHS is taking its challenges seriously, and is continuing to take assertive and proactive steps to address them. Thank you for your commitment to improving quality, safety, and access to health care for American Indians and Alaska Natives. I will be happy to answer any questions the Committee may have.