Testimony from RADM Chris Buchanan, R.E.H.S., M.P.H. on Restoring Accountability in the Indian Health Service Act of 2017 before Subcommittee on Indian, Insular and Alaska Native Affairs

Mr. Chairman and Members of the Subcommittee:

Good afternoon, Chairman LaMalfa, Ranking Member Torres, and Members of the Subcommittee. I am Chris Buchanan, an enrolled member of the Seminole Nation of Oklahoma and Deputy Director of the Indian Health Service (IHS). I am pleased to have the opportunity to testify before the House Natural Resources Committee’s Subcommittee on Insular, Indian and Alaska Native Affairs on H.R. 2662, the “Restoring Accountability in the Indian Health Service Act of 2017”. I would like to thank you, Chairman LaMalfa and Members of the Subcommittee for elevating the importance of delivering quality care through the IHS.

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 healthcare services to American Indians and Alaska Natives. The mission of IHS, in partnership with American Indian and Alaska Native people, is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. IHS provides comprehensive healthcare delivery to approximately 2.2 million American Indians 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 that hamper our ability to fully carry out the IHS mission. In November 2016, we launched our 2016-2017 Quality Framework and Implementation Plan to strengthen the quality of care that IHS delivers to the patients we serve. Implementation of the Quality Framework is intended to strengthen organizational capacity to improve quality of care, improve our ability to meet and maintain accreditation for IHS direct service facilities, align service delivery processes to improve the patient experience, ensure patient safety, and improve processes and strengthen communications for early identification of risks. The Quality Framework will be reviewed and updated at least annually in partnership with Tribes.

The HHS Executive Council on Quality Care (the Council), which was stood up in November 2016, provides support to IHS by identifying and facilitating collaborative, action-oriented approaches from across the Department to address issues that affect the quality of healthcare provided to American Indians and Alaska Natives we serve. The Council includes leadership from 12 HHS Staff and Operating Divisions. The Council’s mission is to support IHS’ efforts to develop, enact, and sustain an effective quality program – to improve quality and patient safety in the hospitals and clinics that IHS administers. This may include providing technical assistance to bolster quality and safety, identifying solutions to address workforce recruitment and retention challenges, seeking creative solutions to infrastructure needs, and enhancing stakeholder engagement. The Council partners with HHS leadership and staff in policy implementation.

Since November, 2016, IHS has made substantial progress in implementing the Quality Framework and in addressing many of the challenges you have identified in your proposed legislation.

Strengthening Organizational Capacity

The Quality Framework guides how we develop, implement, and sustain an effective quality program that improves patient experience and outcomes. We are doing this by strengthening our organizational capacity, and ensuring the delivery of reliable, high quality healthcare at IHS direct service facilities.

We recently awarded a contract for credentialing software that will provide enhanced capabilities and standardize the credentialing process across IHS. The new system will streamline credentialing and facilitate the hiring of qualified practitioners as well as, privileging and performance evaluations of IHS practitioners. This will help ensure the quality and safety of care delivered in IHS Federal Government hospitals and health centers. We are on course with the implementation of this medical credentialing system. We expect to test it in four IHS Areas in July 2017, and plan to implement it across the remaining IHS Areas by the end of 2017. Our agency credentialing policy is in the process of being updated.

Ensuring timely access to care requires that we develop standards for waiting times for appointments, as well as for the time spent in the provider’s office, and that we benchmark against clear standards. IHS Service Units currently collect patient wait time data to track the patient care experience as part of the Improving Patient Care program. Agency-wide standards for wait times are also in development. To ensure accountability at the highest level, and to improve transparency about access to and quality of care, IHS is implementing a performance accountability dashboard. This includes reporting on patient wait times. Pilot testing of the dashboard and associated data collection is targeted for this summer.

Strengthening governance and leadership at all levels of the IHS system is essential to assuring quality healthcare. IHS now requires a standardized governance process and use of a standard governing board agenda across all IHS Areas with federally-operated facilities. The first leadership training class to prepare selected individuals to serve in leadership positions at the Service unit, Area, and Headquarters levels was launched June 6^th with 34 participants. In addition, IHS has begun implementing a leadership coaching and mentoring program in the Great Plains Area as new leaders are recruited.

Workforce Strategies

IHS faces significant recruitment challenges due to the remote, rural location of our healthcare facilities and Area offices. To make a career in IHS more attractive to modern healthcare practitioners, IHS is implementing various strategies to increase recruitment and retention. Global recruitment is one strategy we have implemented that allows for a streamlined approach to filling critical provider vacancies at multiple locations. Applicants only need to apply to a single vacancy announcement and can be considered for multiple positions throughout the country. Recruiting for critical positions by using a single announcement to recruit for multiple positions is showing promise.

IHS continues the successful partnership with the Office of the Surgeon General to increase the recruitment and retention of Commissioned Corps officers, and most recently the IHS has been given priority access to new Commissioned Corps applicants. This allows IHS to make the first contact with these applicants in an effort to recruit them to fill health professional vacancies throughout IHS. This new effort began in May, and we can provide periodic updates on this effort. IHS also continues to partner with the National Health Service Corps (NHSC). Use of NHSC allows IHS facilities to recruit and retain primary care providers by using NHSC scholarship and loan repayment incentives. As of April 2017, 472 NHSC recipients are currently part of our workforce serving in IHS, tribal and urban facilities.

These actions demonstrate that IHS is taking its challenges seriously, and is continuing to take assertive and proactive steps to address them.

H.R. 2662

H.R. 2662 proposes specific authorities to aid us in elevating the health of American Indians and Alaska Natives to the highest level. IHS is prepared to provide the Subcommittee technical assistance on the legislation and I would like to provide additional technical comments on various sections of the bill.

Section 101 would address the need for IHS to offer more flexible and competitive benefits to recruit employees by establishing a comparable pay system as allowed under Chapter 74 of

Title 38. IHS appreciates the authority we already have to use the pay flexibilities under

Chapter 74 of Title 38. We are working with OPM, OMB, and other affected agencies to explore ways to enhance utilization of our current pay authorities to enhance our ability to recruit and retain high quality staff.

Section 102 requires a Service-wide centralized credentialing system to credential licensed health professionals who seek to provide healthcare services at any Service facility. IHS supports the use of a standard system for credentialing. We are implementing a national system for credentialing as well as privileging and evaluating performance of IHS practitioners. Our new system will allow the local and/or Area offices to perform these functions in alignment with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and external accreditation standards for governance of hospitals and ambulatory care facilities.

Section 104 would make certain healthcare management or healthcare executive positions eligible professions for loan repayment awards, in exchange for non-clinical service obligations. Management expertise is very important in a health system as large as IHS.

Section 106 addresses IHS authority to remove or demote employees. IHS has existing authorities to implement adverse employment actions.

Section 107 requires IHS to develop and implement standards to measure the timeliness of care at direct-service IHS facilities. As described above, IHS is in the process of establishing agency-wide standards for wait times to each federally-operated service unit. A process for uniform data collection and reporting is also being established.

Section 108 adds specific requirements for implementation of annual mandatory cultural competency training programs for IHS employees, and other contracted employees engaged in direct patient care. Cultural competency in the IHS workforce is essential to the provision of quality care and is a requirement under the accreditation standards for hospitals. I have recently issued direction for all IHS employees to complete training, which will become an annual requirement.

Section 110 requires IHS to establish a tribal consultation policy. The specific provision is unnecessary as IHS already has a tribal consultation policy in place. The requirements for consultation are contained in statutes and various Presidential Executive Orders including: the Indian Self-Determination and Education Assistance Act, Indian Health Care Improvement Act, Presidential Memoranda in 1994 and 2004, and Executive Orders in 1998 and 2000. It is the policy of HHS and IHS that consultation with American Indian and Alaska Native Tribes will occur to the extent practicable and permitted by law before any action is taken that will significantly affect Indian Tribes. IHS is committed to regular and meaningful tribal consultation and collaboration as an essential element for a sound and productive relationship with Tribes.

Despite all of the challenges, I am firmly committed to improving quality, safety, and access to healthcare for American Indians and Alaska Natives, in collaboration with HHS, our partners across Indian Country, and Congress. I appreciate all your efforts in helping us provide the best possible healthcare services to the people we serve to ensure a healthier future for all American Indians and Alaska Natives.

We look forward to working with the Subcommittee on this legislation as it moves through the legislative process. Thank you for your commitment to improving quality, safety, and access to healthcare for American Indians and Alaska Natives. I am happy to answer any questions the Subcommittee may have.