Indian Health Service Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic, OEI 06-20-00700
- Issuer
- Office of Inspector General
- Document type
- Brief
Summary
A report from the U.S. Department of Health and Human Services Office of Inspector General, OEI-06-20-00700, dated September 2021, on Indian Health Service use of Critical Care Response Teams during the COVID-19 pandemic. The review examines IHS's first five CCRT deployments, which served six IHS facilities and three Tribal facilities from June through September 2020, and is based on document reviews and interviews with 74 key officials and staff. OIG found that IHS awarded a pilot contract in May 2020, that teams provided hands-on training and some direct patient care, and that IHS awarded two contracts in January 2021 to extend the program. OIG recommends that IHS solicit feedback from CCRTs, share their recommendations across facilities, and assess the model for non-COVID-19-related care; IHS concurred.
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U.S. Department of Health and Human Services
Office of Inspector General
Indian Health Service Use of
Critical Care Response Teams
Has Helped To Meet Facility
Needs During the COVID-19
Pandemic
Suzanne Murrin
Deputy Inspector General for Evaluation and Inspections
September 2021, OEI-06-20-00700
U.S. Department of Health and Human Services
Office of Inspector General
Report in Brief
September 2021, OEI-06-20-00700
Why OIG Did This Review Indian Health Service Use of Critical Care
Coronavirus disease 2019
(COVID-19) is a highly contagious,
Response Teams Has Helped To Meet Facility
sometimes fatal, disease that has Needs During the COVID-19 Pandemic
disproportionately affected
American Indians and Alaska What OIG Found
Natives (AI/ANs). The Indian Health Key Takeaway IHS designed and launched the CCRT program
Service (IHS) and Tribal health care IHS developed the CCRT within a few months of COVID-19’s reaching
facilities are the main health care program as an innovative the United States. IHS awarded a contract in
providers for the AI/AN population. capacity-building tool to May 2020 to pilot the program and began
Prior OIG work found that IHS strengthen IHS and Tribal receiving facility requests for CCRT
facilities often lacked sufficient staff facilities’ response to the deployments shortly thereafter. IHS expedited
and had limited access to clinical COVID-19 pandemic. the credentialing and onboarding process, and
specialists, as well as finding other The program is a positive the first team arrived onsite at a tribally
quality-of-care concerns. One step in IHS’s efforts to operated facility in June 2020. CCRT teams
recent IHS effort to address staffing promptly respond to the consisted of a critical care physician, one or
and quality concerns is its immediate needs of two critical care nurses, and a respiratory
development of Critical Care facilities. The CCRT therapist, all deployed on short notice. At the
Response Teams (CCRTs) to model also holds promise time of our review, IHS had fulfilled all
support IHS and Tribal facilities in for addressing requests for CCRTs in a timely manner.
caring for critically ill COVID-19 longstanding challenges
patients. This study examines IHS’s While onsite, the CCRTs provided hands-on
facing some facilities
first five deployments of the CCRTs, training to strengthen staff skills and capacity
related to quality of care
which provided services to six IHS to handle surges of COVID-19 patients.
and staffing.
facilities and three Tribal facilities Facility administrators found the deployments,
from June through September which typically lasted 2 weeks, valuable. In
2020. interviews, IHS officials and staff credited the CCRT training with saving lives
and stated that the teams’ presence boosted staff’s confidence and skills.
Although the CCRTs focused mostly on training staff, the teams also provided
How OIG Did This Review
direct patient care, particularly during patient surges.
We based our findings on
document reviews and interviews Throughout each CCRT deployment, facilities provided close oversight and
with 74 key officials and staff at IHS communicated frequently with IHS headquarters and Area Offices about
headquarters, IHS Area Offices, IHS- CCRT activities. In January 2021, IHS awarded two contracts to extend the
operated facilities, and tribally program through the pandemic. Although none of the facilities in our
operated facilities, as well as with sample planned to request another CCRT deployment, all facilities reported a
contracted providers who served on need for similar resources to assist with non-COVID-19-related care.
the CCRTs. We conducted data
collection in December 2020 and What OIG Recommends
January 2021. We reviewed To further leverage the successes of the CCRT model in support of IHS’s
contracts and other documents broader care improvement efforts, we recommend that IHS (1) solicit
related to IHS’s deployment of the feedback from CCRTs regarding their observations of potential need for
CCRTs. Topics for the interviews broader IHS-wide improvements beyond COVID-19-related care; (2) share
included processes for deploying the CCRTs’ recommendations across all IHS and Tribal facilities; and (3) assess
the teams; roles and expectations; whether IHS could use the CCRT model to provide support and training for
and strategies used to address any non-COVID-19-related care. IHS concurred with our recommendations.
challenges encountered during the
deployments.
TABLE OF CONTENTS
BACKGROUND 1
Methodology 6
FINDINGS 8
IHS designed and launched the CCRT program as a capacity-building resource to meet IHS 8
and Tribal facility needs during the COVID-19 pandemic
CCRTs assessed facility needs and trained staff on COVID-19-related care, which strengthened 11
facilities’ ability to handle patient surges and reaped benefits beyond the deployment
Facility administrators provided close oversight of the CCRTs during the deployments, and 17
communicated frequently with IHS HQ and Area Offices about CCRT activities and progress
IHS awarded new CCRT contracts in January 2021, extending the program through the 18
pandemic, and facilities expressed the need for a similar program for non-COVID-19-related
care
CONCLUSION AND RECOMMENDATIONS FOR IHS 19
Solicit feedback from CCRTs regarding their observations of potential need for broader IHS- 19
wide improvements
Compile the CCRTs’ recommendations to individual facilities and share them across all IHS 20
and Tribal facilities
Assess whether IHS could use the CCRT model to provide support and training to facilities 20
needing assistance with non-COVID-19-related care
AGENCY COMMENTS AND OIG RESPONSE 21
APPENDIX 22
Agency Comments 22
ACKNOWLEDGMENTS AND CONTACT 24
ABOUT THE OFFICE OF INSPECTOR GENERAL 25
ENDNOTES 26
BACKGROUND
Objective
To assess Indian Health Service (IHS) use of Critical Care Response Teams to
support IHS and Tribal health care facilities during the coronavirus disease 2019
(COVID-19) pandemic.
Indian Health Service
IHS is responsible for providing Federal health services to American Indians and
Alaska Natives (AI/ANs) and has an annual budget of approximately $6 billion. 1 In
partnership with Tribes, IHS provides primary and preventive health care services to
approximately 2.6 million AI/ANs who are members of the 574 federally recognized
Tribes in the United States. 2 IHS provides these services directly to AI/ANs through
IHS-operated facilities or provides funding to Tribes through self-determination
contracts and self-governance contracts to operate their own health care systems. 3
IHS also supports contracts and grants to Urban Indian Organizations (UIOs), which
provide medical, dental, mental health, and other services to AI/ANs living
off-reservation in urban locations. 4, 5
Health care challenges caused and exacerbated by the COVID-19 pandemic, such as
staffing shortages and outdated equipment, have raised concerns about ensuring safe
and accessible health care for AI/ANs. 6 According to the Centers for Disease Control
and Prevention (CDC), the incidence of laboratory-confirmed COVID-19 cases, as well
as hospitalization and death rates, are higher among AI/ANs than among
non-Hispanic white persons. 7 As a response to those concerns, IHS took steps to
bolster the capacity of IHS and Tribal facilities and developed the Critical Care
Response Team (CCRT) program to assist facilities in caring for COVID-19 patients,
among other efforts. 8 The CCRTs are small teams of contracted critical care providers
that can deploy, as needed, to support IHS and Tribal facilities that are experiencing
or need assistance in preparing for surges of COVID-19 patients. 9
Organizational Structure
IHS headquarters (HQ) provides general direction, policy development, and support
for each of the 12 IHS Area Offices and their service units. Area Offices oversee the
delivery of health services and provide administrative and technical support to the
service units’ health care delivery sites, which may include hospitals, health centers,
and health stations, among other facility types. 10, 11, 12, 13 As of August 2020, there
were a total of 170 service units operated by IHS or Tribes, and within these service
units were 24 IHS-operated hospitals, mostly in remote locations, and 22 tribally run
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
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hospitals, among other facility types. a (See Exhibit 1 for a list of the number and type
of facilities operated by IHS and Tribes. 14)
Exhibit 1: IHS and Tribal health care facilities by type
Type of Facility IHS Tribal
Hospital 24 22
Health Center 51 279
Health Station 24 79
Alaska Village Center 0 59
School Health Center 12 6
Youth Regional Treatment Center 6 6
Total 117 451
Source: IHS, IHS Profile. Accessed at https://www.ihs.gov/newsroom/factsheets/ihsprofile/ on September 30, 2020.
Impact of COVID-19 Pandemic on IHS and Tribal Facilities
SARS-CoV2 is a highly contagious coronavirus that causes the disease COVID-19,
which can be fatal in some cases. 15, 16 Common COVID-19 symptoms include fever,
cough, shortness of breath, fatigue, and loss of taste or smell. 17 The first U.S. patient
with COVID-19 was reported on January 20, 2020, and on March 11, 2020, the World
Health Organization declared COVID-19 to be a pandemic. 18, 19 As of September 1,
2021, there had been more than 39 million confirmed cases in the United States, with
over 638,000 deaths. 20
The COVID-19 pandemic has disproportionately affected racial and ethnic minority
groups in the United States, including AI/ANs. 21 As of August 28, 2021, IHS had
reported 226,953 cumulative positive COVID-19 tests and a 7-day rolling average
positivity rate of 10.2 percent across IHS, Tribal, and UIO facilities. b, 22 According to
CDC, the incidence of laboratory-confirmed COVID-19 cases was estimated to be
1.6 to 3.5 times as high among AI/ANs than among non-Hispanic white persons. 23, 24
Similarly, hospitalization rates were 3.5 times as high and death rates were 2.4 times
as high for AI/ANs than for non-Hispanic white persons. 25 Moreover, for individuals
aged 20-49 years, death rates are estimated to be 8 to 12 times as high for AI/ANs
than for non-Hispanic white persons. 26 However, CDC acknowledged limitations to
_____________________________________________________________________________________________________________________________
a A service unit is an administrative subunit of an IHS Area, operated by IHS or a Tribe, with
responsibilities for providing IHS services within a particular geographic area. Each service unit may
contain one or more health care facilities.
b Tribes and UIOs are not required to report COVID-19 testing data to IHS; therefore, the number of
positive tests may not represent the total number of positive COVID-19 cases across IHS, Tribal, and UIO
facilities.
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these findings because of racial and ethnic misclassifications in epidemiologic and
administrative data sets, and it has concluded that the numbers may underestimate
actual AI/AN morbidity and mortality rates.
The COVID-19 pandemic created and exacerbated challenges for the U.S. hospital
system, including IHS and Tribal facilities. 27, 28, 29 As front-line responders, hospitals
have significant responsibilities in identifying and treating patients with COVID-19.
IHS and Tribal facilities often serve as the main health care providers for AI/ANs,
making them an integral part of the COVID-19 response, but many of those facilities
have experienced challenges during the pandemic—from difficulty in accessing
personal protective equipment (PPE) to capacity limitations as a result of outdated
buildings and equipment and staffing shortages. 30, 31
Historically, IHS has had sizable vacancy rates among its health care providers (e.g.,
physicians, nurses, dentists, and other clinical staff), with limited access to clinical
specialists—a challenge that could worsen as providers become sick with COVID-19
or leave their positions for any other reasons. For physicians alone, IHS has had
vacancy rates of 25 percent. 32, 33, 34 The inability to secure sufficient staffing has been
a concern for hospitals nationwide during the pandemic, and staffing shortages are
expected to grow for years to come. 35 It is estimated that by 2033, there will be a
shortage of between 54,100 and 139,000 physicians in the United States, which could
lead to further vacancies for IHS. 36
COVID-19 Funding
As of March 2021, IHS had received approximately $9 billion in total supplemental
funding to support its response to the COVID-19 pandemic, including funding from
the Coronavirus Aid, Relief, and Economic Security (CARES) Act; the Paycheck
Protection Program and Health Care Enhancement Act; the Families First Coronavirus
Response Act; the Coronavirus Preparedness and Response Supplemental
Appropriations Act; the Coronavirus Response and Relief Supplemental
Appropriations Act; and the American Rescue Plan Act of 2021. 37, 38, 39, 40, 41, 42, 43
In deciding how to allocate the funding, IHS engaged in Tribal Consultation and
Urban Confer sessions to ensure that funds would meet the needs of AI/ANs. 44 IHS
has used funding to purchase supplies and to support COVID-19 testing, contact
tracing, and vaccine distribution, as well as to hire and support staff and maintain or
improve facilities, among other efforts. 45, 46, 47, 48 IHS has also used funding to expand
and improve telehealth and has plans to use some of the funding to update its
electronic health record system. 49, 50
IHS Response to COVID-19 Pandemic
IHS has undertaken several efforts to support IHS and Tribal facilities during the
pandemic, sometimes in collaboration with other Federal and State agencies. These
efforts have involved assisting facilities in coordinating emergency response activities;
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supplementing staffing; acquiring and distributing COVID-19 tests and supplies; and
distributing and administering vaccines. IHS established a section on its website
dedicated to the agency’s COVID-19 response, where it has provided frequent
updates on its activities throughout the pandemic. 51
Incident Command and Coordination. In March 2020, IHS activated its Incident
Command Structure to respond to COVID-19 using the agency’s pandemic response
plan and facilities’ disaster plans. 52 The purpose of the Incident Command Structure
is to establish communication protocols to ensure comprehensive situational
awareness and efficient deployment of resources across the agency. 53 The Incident
Command Structure is led by the Deputy Director of IHS and consists of leadership in
IHS HQ and representatives from Area Offices, facilities, and other groups within the
agency. To enhance coordination during the pandemic, IHS trained staff in the Area
Offices to serve as Emergency Management Points of Contact to facilitate the flow of
resources, such as PPE and test kits, from centralized systems to the facilities. 54 Area
Offices also provided technical assistance and support to IHS, Tribal, and UIO facilities.
In addition, IHS HQ held regular conference calls with Tribal leaders and UIOs to
provide updates, answer questions, and hear concerns from Tribal communities to
better coordinate response efforts. 55
Supplemental Staffing. To alleviate staffing shortages during the pandemic, IHS took
several steps to bolster staffing in facilities. Those steps included using direct hire
authority and instituting interim procedures for onboarding personnel. 56 IHS also
acquired temporary deployments from the Department of Veterans Affairs (VA), the
Department of Defense (DoD), and the U.S. Public Health Service (USPHS)
Commissioned Corps. 57 IHS signed interagency agreements with VA and DoD that
arranged for coordinated delivery of health care and other services from those
agencies, including for IHS use of VA and DoD medical personnel and hospital
beds. 58, 59 IHS has a long history of receiving assistance from the USPHS, which
comprises approximately 6,100 public health and safety professionals (e.g., doctors,
nurses), assigned to various Federal agencies, and is available to the President and the
HHS Secretary to rapidly respond to any public health emergency or crisis within or
outside the United States. 60, 61, 62
Tests and Supplies. To assist facilities in obtaining COVID-19 test kits and supplies,
IHS used its National Supply Service Center, which manages the purchase and
distribution of pharmaceuticals, medical, and other health-care-related supply items,
and provides advice, consultation, and assistance to IHS, Tribal, and UIO facilities on
supply management. 63, 64 Tribes could also follow their usual processes for ordering
supplies. 65 As of April 14, 2021, IHS had distributed over 84 million units of PPE and
other COVID-19-related products to IHS, Tribal, and UIO facilities, and as of
August 28, 2021, those entities had performed nearly 2.8 million tests. 66, 67 To
administer the tests and vaccines, some facilities partnered with State National Guard
units. 68, 69, 70, 71
Vaccines. As of August 30, 2021, IHS had distributed more than 1.9 million COVID-19
vaccine doses to IHS, Tribal, and UIO facilities. As of the same date, these entities had
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together administered over 1.5 million of those doses. 72 As of September 1, 2021,
approximately 46 percent of all AI/ANs were fully vaccinated (i.e., had received one
dose of a single-shot COVID-19 vaccine or the second dose in a two-dose COVID-19
vaccine series)—a higher vaccination rate than that of any other racial or ethnic group
in the United States. 73 In an effort to reduce the spread and impact of COVID-19
across the country, many IHS, Tribal, and UIO facilities also provided vaccinations to
nonbeneficiaries (i.e., individuals who are not members of a federally recognized
Tribe), such as first responders, teachers, and other community members. 74, 75, 76
Critical Care Response Teams
In May 2020, IHS awarded a contract to form the CCRT program to assist IHS and
Tribal health care facilities in preparing for and responding to the pandemic. 77, 78 The
CCRT program is designed to provide facilities with short-term assistance focused on
providing urgent medical care for COVID-19 patients through hands-on clinical
training and consultation on facility operations by a small team of contracted staff. 79
IHS designated $5.8 million of its CARES Act funding to pilot the CCRT program and
deployed the first team in June 2020. During June through September 2020, IHS
deployed five CCRTs that provided services to a total of nine facilities. In January
2021, IHS extended the CCRT program by awarding two Indefinite Delivery Indefinite
Quantity contracts to continue assisting IHS and Tribal facilities with COVID-19-
related care throughout the pandemic.
Related OIG Work
OIG has a substantial body of work related to IHS and Tribal programs. Since 2016,
OIG has focused primarily on IHS management of hospitals. Our work has included
issuing reports describing lack of quality oversight and a number of challenges that
affect IHS hospitals’ ability to provide quality care and maintain compliance with
Federal requirements. 80, 81, 82, 83 Recently published reports include a study examining
the sufficiency of IHS policies for preventing, reporting, and addressing patient abuse
and facility implementation of those policies; a medical record review examining
adverse events (patient harm resulting from medical care) in IHS hospitals; and a
companion report focusing on labor and delivery care. 84, 85, 86, 87
OIG has also undertaken extensive oversight work related to COVID-19. See the OIG
COVID-19 Portal for more information. Two reports—one released in April 2020 and
the other in March 2021—outlined the challenges that a sample of U.S. hospitals
reported facing in response to COVID-19 during the early weeks of the pandemic and
1 year into the pandemic, respectively. 88, 89 Other work includes toolkits detailing
lessons learned from OIG reports published from 2002 to 2020 about health care
facility and community emergency response. 90, 91
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Methodology
Scope of Inspection
For this evaluation, we purposively selected a sample of IHS’s CCRT deployments,
which included the first five deployments. During June through September 2020,
these five CCRT deployments provided services to six IHS-operated facilities and
three Tribal facilities. (See Exhibit 2 for details about the facilities that received the
five deployments.) We collected data through interviews with selected key IHS
officials; IHS and Tribal facility leadership and staff; and members of the CCRTs, as well
as through document reviews, in December 2020 and January 2021. We examined
IHS’s use of the CCRTs to meet facility needs; its management and oversight of the
teams; any challenges encountered during the deployments; and lessons learned that
IHS could apply to future CCRT deployments.
Exhibit 2: Facilities that received a CCRT deployment during June through
September 2020
Source: OIG compiled this table using data obtained from IHS during September 2020 through January 2021.
Data Collection and Analysis
Interviews. To assess IHS's use of the CCRTs to support facilities during the
pandemic, we conducted in-depth telephone interviews with 74 respondents,
individually or in small groups in December 2020. The interview respondents included
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
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key officials and staff at IHS HQ and the five Area Offices that received the
deployments (Billings, Great Plains, Nashville, Oklahoma City, and Tucson); leadership
and staff at the selected IHS and Tribal facilities; and members of the CCRTs.
During these interviews, we discussed the development of the CCRT program; the
process for requesting deployments; and onboarding and oversight of the CCRTs at
the facilities. We also asked about the roles and expectations of the deployments;
any challenges encountered and strategies used to address them; and facility needs
for future CCRT deployments. We employed semistructured interview protocols that
allowed us to modify questions, as needed, and to follow up on additional issues as
we learned new information and identified key issues.
Document Reviews. To determine the CCRTs’ responsibilities and obligations, we
reviewed contracts, including statements of objectives; debriefing materials, including
recommendations that CCRTs provided to facilities; and other documents related to
the deployments. To better understand the context surrounding the deployments, we
also reviewed facility staffing data, capacity data, and other data obtained from IHS
HQ and the facilities.
Data Analysis. We conducted a qualitative analysis of interview data and documents
to identify themes and describe the IHS processes for developing, deploying, and
managing the CCRTs; facilities’ perspectives on the effectiveness of the deployments;
and any challenges in or lessons learned from the deployments. We present this data
in both aggregate analysis and individual quotations in this report.
Limitations
We did not independently verify the information reported by interview respondents
or assess the extent to which facilities incorporated the CCRT recommendations
provided to facilities during the deployments. Further, in our review of the CCRT
contract, we did not assess IHS invoices, cost estimates, or compliance with Federal
Acquisition Regulations. Lastly, this study focused only on the five deployments that
occurred during June through September 2020 and did not include facilities that
received deployments outside of that timeframe. IHS has contracted with different
staffing agencies since November 2020, and we recognize that the experiences of
facility staff and CCRTs for those deployments may not reflect those described in this
report.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
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FINDINGS
IHS designed and launched the CCRT program as a capacity-
building resource to meet IHS and Tribal facility needs during
the COVID-19 pandemic
In March 2020, shortly after the World Health Organization declared COVID-19
a pandemic, IHS began to explore ways in which the agency could help prepare IHS
and Tribal health care facilities in responding to the pandemic. IHS officials reported
that at the time, there were few COVID-19 cases in IHS and Tribal facilities, but there
were concerns about facilities’ ability to adequately care for COVID-19 patients and
handle a potential surge of such patients. IHS officials and staff were concerned that
as infections began to spread across the United States, it would become difficult for
facilities to secure sufficient staffing, particularly critical care providers, especially
because staffing was already a challenge in many facilities prior to the pandemic. IHS
officials and staff were also concerned that some facilities would experience difficulty
in transferring critically ill patients to higher-level care because of limited availability
of beds in intensive care units at receiving hospitals.
Strategy for Success: To assist IHS and Tribal facilities in preparing for and responding to the challenges
Expedited posed by COVID-19, IHS assembled a team of experts from within the agency who
Development developed the CCRT program, a capacity-building resource aimed at strengthening
IHS tasked internal facilities. In interviews, IHS officials described how the team designed the CCRT
experts to quickly program to provide facilities with short-term assistance and hands-on training, based
develop the CCRT on previous experience with hospital management and leadership development
program and deploy
teams and the USPHS Rapid Deployment Forces.
the teams.
IHS awarded a contract in May 2020 to pilot the CCRT program
and began receiving facility requests for CCRT deployments
shortly thereafter
In May 2020, IHS contracted with a staffing agency to pilot the CCRT program and
worked with the contractor to finalize the specifics of the program before
deployments could begin. IHS designed the CCRTs to be small, typically consisting of
a critical care physician; one or two critical care nurses; and a respiratory therapist. As
outlined by the contract, the CCRTs were to be deployed on short notice and to be
available 24 hours a day, 7 days a week for no less than 3 to 5 consecutive working
days per deployment. To serve on the CCRTs, the team members had to have
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academic knowledge and professional experience treating patients who were
suspected or confirmed as having COVID-19.
Strategy for Success: In early June 2020, IHS leadership made agencywide announcements about the newly
Accelerated Timeline established CCRT program and informed IHS and Tribal facilities that they could begin
March 2020 requesting deployments as needed. IHS instructed facilities that to request a
World Health deployment, they should go through the Emergency Management Point of Contact in
Organization declared the Area Office, who would then forward the request to IHS HQ. Officials and staff in
COVID-19 a pandemic
IHS HQ would then review the request and consult with the facility to identify specific
May 2020 needs and determine whether a CCRT deployment would meet those needs or
IHS awarded the first whether other resources would be better suited for the facility. (See Exhibit 3 for
CCRT contract details about IHS’s process for requesting a CCRT deployment; reviewing and
June 2020 approving requests; and deploying a CCRT.)
IHS announced that
CCRTs were available IHS officials reported that the agency received a request for a CCRT deployment
and deployed the first almost immediately after making the announcements. In interviews, one facility
team reported requesting a deployment because it was experiencing a surge of COVID-19
patients at the time and needed help with caring for those patients. Other facilities
explained that they wanted CCRT deployments to help prepare for anticipated future
surges.
Exhibit 3: The process for requesting a CCRT deployment, reviewing and
approving requests, and deploying a CCRT
Source: Documents provided by IHS to OIG, 2020.
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Facility administrators generally described the process for requesting and receiving
approvals for deployments as quick and efficient and said that the timing of the CCRT
deployments was helpful, as patient surges often occurred during or shortly after the
deployment. IHS officials reported that the agency had a process for prioritizing
CCRT deployments if needed, but that it had been able to fulfill all requests in a timely
manner without placing facilities on a waiting list.
IHS expedited the credentialing and onboarding process to
quickly deploy the CCRTs, and the first team arrived onsite in
June 2020
Strategy for Success: To quickly get CCRTs onsite to facilities that requested deployments, IHS HQ reported
Streamlined working closely with Area Offices and facility administrators to expedite credentialing,
Credentialing privileging, and onboarding of the CCRT members. c In interviews, IHS officials and
IHS and facilities staff credited IHS’s new centralized credentialing system, implemented in the last few
streamlined and years, for facilitating quick information-sharing (e.g., resumes, licenses) across
expedited credentialing
facilities, which sped up the credentialing process for CCRTs. IHS had previously
and onboarding of
stored provider credential files at facilities or Area Offices, which did not allow for
CCRTs to quickly begin
deployments.
easy agencywide access. IHS HQ also reported that Area Offices held more frequent
governing-board meetings with facilities to review CCRT candidates. d One Area
official noted that the credentialing approach used for CCRTs improved the agency’s
overall credentialing and privileging process because it forced IHS to examine its
processes and make necessary adjustments.
Facilities could also use emergency/disaster credentialing and privileging to get CCRT
providers on board quickly if they were experiencing a surge and had activated their
facility emergency plans. To use emergency/disaster credentialing and privileging for
CCRT providers, IHS required facilities to verify licensure and identification and check
references and hospital affiliation as they would under normal circumstances,
but—unlike in the normal process—IHS allowed facilities to complete those
verifications up to 72 hours after the provider arrived onsite. Two of the facilities in
our sample reported using emergency/disaster credentialing and privileging, and IHS
officials stated that several of the other facilities that received deployments after our
study period used this type of credentialing and privileging process.
To familiarize the CCRTs with the facilities, each facility provided new-employee
orientation to the teams before or shortly after they arrived onsite. The orientation
_____________________________________________________________________________________________________________________________
c During credentialing, IHS verifies the provider’s education, training, licensure, and experience. During
privileging, IHS identifies the scope of the provider’s expertise and determines which medical functions
the individual is permitted to perform at a particular facility. IHS, Indian Health Manual, pt. 3; ch. 1;
sections 3-1.1 (Introduction) and 3-1.4 (Procedures).
d Each IHS-operated facility has a governing board that is chaired by the Area Director and includes
leadership from the Area Office and the facility. The governing board is the only authority that can grant
full medical staff membership and clinical privileges, and it has the ultimate authority and responsibility
for the oversight and delivery of health care rendered by practitioners who are credentialed and
privileged. IHS, Indian Health Manual, pt. 3, ch. 1, sections 3-1.2 (Responsibilities).
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included trainings that covered facility-specific and agency-specific topics. With the
help from IHS HQ, facilities streamlined the trainings, which allowed providers to take
the trainings virtually before they arrived or to complete them within 1 day when they
arrived onsite.
In June 2020, IHS deployed the first CCRT, which was to a Tribal facility that requested
assistance because of to rising numbers of COVID-19 patients. The team arrived at
the facility within days of the request. During June through September 2020, IHS
deployed the CCRTs a total of five times, providing services to nine facilities—six IHS
facilities and three Tribal facilities. (See Exhibit 2 on page 6 for details about the nine
facilities.)
The teams typically arrived onsite within a few weeks after facilities made their
requests. However, two facilities experienced slight delays in getting the full teams
onsite. An administrator at one of those facilities explained that the deployment was
delayed, and had to begin virtually, because of overlap with the previous deployment
and because one of the CCRT members had contracted COVID-19.
CCRTs assessed facility needs and trained staff on COVID-19-
related care, which strengthened facilities’ ability to handle
patient surges and reaped benefits beyond the deployment
The CCRTs served several functions throughout the deployments to bolster facilities’
ability to care for COVID-19 patients and to protect staff and other patients from
infection. CCRT members reported that one of those functions was to assess facility
needs and make recommendations to optimize patient flow and strengthen staff skills
and capacity. The CCRTs used these assessments to develop trainings specific to each
facility’s needs, which they conducted for staff while onsite. During some of the
deployments, the CCRTs also assisted facilities in providing direct patient care,
particularly if the facilities were experiencing a surge in patients. The deployments,
which typically lasted a couple of weeks, were well-received by facilities, a perspective
that the CCRTs also shared.
The CCRT assessments helped guide facilities in making changes
to more effectively respond to the pandemic, such as revising
policies and agreements; acquiring equipment and supplies; and
conducting system updates
Strategy for Success: CCRT members reported that when they arrived onsite, they immediately began to
Tailored Services assess facilities’ capacity to handle COVID-19 cases. During the assessments, the
CCRTs assessed facility CCRTs examined the facility layout and other logistics; reviewed facility policies and
needs, layout, staff, and procedures; and inventoried facility equipment and supplies. In interviews, facility
other logistics to tailor administrators described these assessments as thorough, as they included most
support and training. departments and examined a wide range of policies and procedures, from patient
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OEI-06-20-00700 Findings | 11
care and infection control to emergency codes and equipment use. CCRT members
reported using the assessments to make recommendations to facilities for
improvement and as a baseline to develop training for facility staff on
COVID-19-related care. Some of these recommendations included replacing
outdated equipment; purchasing additional oxygen supply; reconfiguring space and
erecting divider walls between patient beds; and instituting temporary ventilation
systems.
The CCRTs also helped revise facility policies and procedures. For example, one Area
Office reported that CCRT members helped a facility write policies for using
Vapotherm, a noninvasive high-flow respiratory support system used to treat
respiratory failure that the facility had not used before. 92 In another facility that
operated as an urgent care clinic, the CCRT helped establish a transfer agreement
with a nearby IHS-operated hospital. In interviews, the facility and the CCRT members
described how the hospital had previously refused to accept patients from the facility,
incorrectly believing that the facility—which was also operated by IHS—provided the
same level of care and had the same capability as the hospital.
The hospital’s refusal to accept patients forced the facility to keep critically ill patients
longer, without adequate equipment and staff, before the facility could locate another
hospital further away that would accept the patients. According to the CCRT
members, this delay in care led to an adverse event (patient harm resulting from
medical care or lack of medical care) for one patient. To remedy this problem, the
CCRT brought the facility and the hospital together along with the Area Office to
clarify the capabilities and responsibilities of each and to establish a transfer
agreement between them. Under the agreement, the urgent care facility would
transfer its critically ill patients to the hospital, which would care for the patients until
they could be transferred out to higher-level care.
Strategy for Success: The CCRTs also assisted facilities in conducting system updates to better handle
Standardized EHR suspected or confirmed COVID-19 cases. Before IHS began deployments of the
Templates CCRTs, the agency developed a new COVID-19-specific graphical user interface in its
IHS developed electronic health record (EHR) system. This new interface included templates with
standardized EHR instructions for admissions; transfers; discharges; medications; and other
templates for COVID-19 interventions, such as ventilator treatment. One IHS official noted that these
treatment to provide
templates, which have been standardized across the facilities that received
easy access and use for
deployments, could be updated as the best practices for treating COVID-19 patients
CCRTs and facility staff.
continue to evolve. Officials also explained that having a standardized template
allowed easy access and use for the CCRT members as they deployed to different
facilities. When the CCRTs arrived onsite, they worked with the facilities to train staff
on the new EHR templates; facilities indicated that this training was helpful. One
official in IHS HQ reported that the agency’s response to COVID-19 and the CCRT
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
OEI-06-20-00700 Findings | 12
deployments was a catalyst for the agency to pursue EHR standardization across
facilities and that the EHR templates helped drive the success of the CCRT program. e
Throughout the deployments, CCRTs provided feedback to the facilities regarding
their assessments and observations. The CCRTs formalized this feedback into
recommendations that they shared with facilities and IHS HQ both mid-deployment
and later—during a debriefing presentation—at the end of each deployment. The
recommendations covered an array of topics, which the CCRTs grouped into
six categories: facilities and equipment; clinical pathways; education and training;
discharges and followup; staffing; and systems of care. (See Exhibit 4 for a depiction
of the CCRT categorization of the recommendations and related examples.)
Exhibit 4: CCRTs made recommendations to facilities on the basis of their
assessments, which they grouped into six broad categories.
Examples: institute
hospital response
Facilities Examples: purchase
Clinical teams, change
and equipment, modify
Pathways timing of
Equipment facility layout
medication
administration
Examples: draft Examples: improve
Education protocols for Discharges discharge
and COVID-19 and planning, improve
Training treatment, establish Followup followup
“super trainers”* telephone clinics
Examples: develop
Examples:
strategies for
streamline patient
staffing during Systems of
Staffing handoffs, review
surges, streamline Care
patient transfer
human resources
arrangements
processes
Source: CCRT deployment debriefing documents, June–September 2020.
*Super trainers are facility staff who are trained to provide training to other staff.
Facility administrators and IHS officials expressed appreciation for the teams’
assessments and recommendations. An administrator in one facility stated that
having “an extra set of eyes” was beneficial because it provided a new perspective
_____________________________________________________________________________________________________________________________
e In April 2021, IHS’s then-Acting Director testified before the Subcommittee on Interior, Environment,
and Related Agencies of the Senate Appropriations Committee that the pandemic highlighted challenges
and risks posed by IHS’s decentralized EHR structure and that the agency had recently begun the process
to modernize its EHR system. Accessed at
https://www.appropriations.senate.gov/imo/media/doc/IHS%20Senate%20Interior%20Subcommittee%2
0COVID-19%20Hearing%20Testimony%20-%20Final%20042721.pdf on May 21, 2021.
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OEI-06-20-00700 Findings | 13
different from that of the administrators and staff who may have worked at the facility
for many years. Although the CCRT feedback was well-received, one Area official
reported that the CCRT members’ unfamiliarity with IHS made some
recommendations difficult to implement, resulting in one facility’s tweaking the
recommendations to better align with the facility’s needs and IHS processes. In
interviews, an Area Chief Medical Officer credited the CCRTs’ recommendations for
helping facilities make long-term improvements to their processes and procedures,
which had a positive impact on all patients and would likely continue beyond the
pandemic.
The CCRTs provided hands-on COVID-19-related training across
facility departments and designated staff to continue the training
after the team left, which facility administrators reported
enhanced staff confidence in handling COVID-19 patients
Shortly after the CCRTs arrived onsite and conducted their initial assessments of the
facilities, the teams began to train facility staff on how to properly care for COVID-19
patients, using best practices and personal experiences that the CCRT members had
gained from working in COVID-19 units prior to the deployments with IHS. The
CCRTs tailored the training to address the needs of each facility and to enhance staff’s
individual and institutional knowledge. In interviews, CCRT members and facility
administrators described how they typically began the training sessions with a basic
overview of COVID-19 care and then transitioned into advanced training, focusing
specifically on emergency, inpatient, and critical care. The training covered a wide
range of topics, including handwashing; use of PPE; ventilation and airway
management; Vapotherm therapy and other high-flow nasal oxygen therapy use; and
“proning” of patients—the process of turning a patient from lying on the back to lying
face down to reduce respiratory distress—among other topics. 93
Strategy for Success: The training was mostly interactive, with the CCRT members demonstrating and
Hands-on Training instructing staff at the bedside while attending to patients, or by using mannequins.
CCRT members had The CCRTs also covered training material through mock drills and lectures, virtually or
expertise on COVID-19 in-person. IHS officials and facility administrators reported that the hands-on training
care and provided was the best way for staff to learn because it allowed them to observe and work
hands-on training to
side-by-side with providers who had experience caring for COVID-19 patients. IHS
nearly all facility staff on
officials also stated that having the training in a team-based environment at the
how to properly care for
COVID-19 patients.
facility allowed the learning to occur collectively, which was more effective than
having a few staff at a time attend training at an offsite location where the training
modules might be different each time.
Although the CCRTs targeted specific departments, they also trained other clinical and
nonclinical facility staff to increase the staff’s understanding of the disease and
treatment modalities and to strengthen the facility’s ability to respond to a potential
surge of COVID-19 patients. IHS officials and facility administrators explained that
during a surge, facilities may need to pull staff from other departments to assist with
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OEI-06-20-00700 Findings | 14
patient care, and therefore, those staff also had to be trained on skills that were
essential to treating COVID-19 patients.
According to facility administrators, nearly all clinical facility staff received training on
COVID-19-related competencies during the deployments. In interviews, a number of
IHS officials and facility administrators noted that the training and the onsite presence
of the CCRTs were crucial to instill skills and confidence in staff who often felt
unprepared to manage COVID-19 patients. CCRT members reported that they were
sometimes met with resistance from staff who did not want to move away from their
normal responsibilities and assist with COVID-19 patients, and the team had to work
with facility leadership to build understanding and gain buy-in. Several IHS officials
and staff credited the CCRT training for saving lives because without it, the facilities
would not have had the knowledge or skillset needed to adequately care for
COVID-19 patients.
“The training was hugely valuable to staff in preparing for patients. [The] level of
confidence our staff has now in handling this and the level of care they’re able to
provide… is much greater because of [the CCRT’s] presence.” – Facility Administrator
Strategy for Success: To ensure that facility staff retained the new knowledge and kept up with COVID-19
“Super Trainers” competencies after the CCRTs left, the teams and facilities designated some staff as
Facilities and CCRTs “super trainers” to carry on the training post-deployment. These super trainers
designated “super received additional training from the CCRTs and were tasked with training other staff.
trainers” to continue Several facility administrators reported that by assigning super trainers—who were
staff training members of the facilities’ core staff and were unlikely to leave the facility—the
post-deployment and
facilities could better ensure that staff’s skills and comfort level were sustained over
ensure retention of
time. Facilities could also extend this training to neighboring service units as a way to
skills and knowledge
over time.
strengthen the overall response to outbreaks in their geographic areas.
In some cases, the CCRTs also provided direct patient care and
conducted community outreach on COVID-19 transmission and
treatment, which helped relieve frontline staff and prepare Tribal
communities for potential surges
Although the CCRTs focused mostly on training staff, sometimes they also provided
direct patient care while onsite. In interviews, facility administrators and Area officials
explained that in instances in which the CCRT provided direct patient care, the team
would do so simultaneously with the training. Administrators in one facility that was
experiencing a surge when the team arrived described how the CCRT members
quickly joined the frontline staff and worked side-by-side to care for the rising
number of COVID-19 patients presenting at the facility, while also training staff.
Administrators and staff stated that having the team onsite was “a breath of fresh air”
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OEI-06-20-00700 Findings | 15
that provided relief and helped build confidence in staff who were exhausted from
handling the many COVID-19 cases.
”[We] consistently heard how appreciative [staff] were of the team being there to
help, elbow to elbow… You feel more comfortable if you know you have an expert
there next to you.” – Area Chief Medical Officer
The CCRTs also supported patient care through phone consultations with facility staff
during deployment and post-deployment. In interviews, one of the CCRT providers
reported giving her personal contact information to the facility physicians and said
that she had received frequent calls from the physicians, requesting consultations or
wanting to share their success stories, long after the deployment ended.
In addition to consultations with the CCRTs, facilities had access to a hotline if they
needed advice on patient care. The CCRT staffing agency subcontracted with a
telehealth service provider to operate the hotline, which was staffed with critical care
physicians and nurses. All IHS and Tribal facilities had access to the hotline, which was
available 24 hours a day, 7 days a week. However, during the time period we
reviewed—June through September 2020—few facilities had used this resource. In
July 2021, IHS officials reported that the hotline had been discontinued when the
contract for the service ended in May 2021. Only one facility in our sample had used
the hotline.
In addition to providing direct patient care and training, CCRT members reported
extending their services beyond the facility to the Tribal community. Although
community outreach was not part of the core responsibilities of the CCRTs, during
one of the deployments, Tribal leaders invited the team to attend a Tribal council
meeting to educate the community on COVID-19. The meeting was held virtually and
was broadcast on the local radio. The team reported that they believed that similar
meetings would be helpful to inform community members about the disease, and
they said that they would have liked to conduct more outreach as part of their
deployments. Like the CCRT members, an IHS official also said that there was a need
for additional outreach and education in Tribal communities to help prevent further
spread of the virus and to mitigate capacity issues in the facilities.
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OEI-06-20-00700 Findings | 16
Facility administrators provided close oversight of the CCRTs during
the deployments, and communicated frequently with IHS HQ and
Area Offices about CCRT activities and progress
Strategy for Success: To monitor the progress of CCRT activities and to identify needed program
Consistent Oversight improvements, IHS provided oversight of the deployments both at the facility level
IHS HQ held frequent and the agency level. Facility administrators reported providing direct oversight of
meetings with facilities the CCRTs, using the same chain of command as for other clinical staff in the facility.
and CCRTs to monitor At the HQ level, IHS designated a core group of officials and staff responsible for
program challenges and overseeing the CCRT program; these individuals were available to answer questions
successes. and provide support to facilities throughout the deployment. Members of this core
group reported that they held calls with the facilities and the CCRTs pre-deployment,
mid-deployment, and post-deployment to discuss and monitor the deployments.
IHS officials and facility administrators explained that the pre-deployment calls were
used for planning purposes to determine facility-specific needs and CCRT
responsibilities, while the mid-deployment calls focused on the progress of the CCRT
activities and any challenges that facilities and CCRTs encountered and changes they
made as a result. During the post-deployment calls, which were held at the end of
each deployment, facilities and CCRTs gave debriefings on their experiences and the
CCRTs presented their recommendations for facility improvements. Members of the
core group reported using the information from these calls, as well as from other
sources, to modify the CCRT program and to improve future deployments. For
example, IHS officials noted that the CCRT program evolved over time to become
more about building capacity of existing staff than about supplementing those staff.
In interviews, facilities said that they found the frequent and open communication
with the core group to be helpful. The CCRT members also described the calls with
the core group as valuable, but they said that they would have liked more
opportunities to provide IHS with their overall observations and suggestions for
improvements agencywide, beyond the individual facilities. One observation that
CCRT members reported was that facilities used different equipment, and they
suggested that it would be more efficient if the agency used a blanket purchase
agreement to standardize equipment across facilities. The CCRT members noted that
it was cumbersome for the teams and other temporary staff to learn and operate
different equipment in each facility, particularly since the equipment was often old
and outdated. CCRT members also reported observing—to their surprise—that IHS
and Tribal facilities had many staff in administrative roles who were qualified to
provide care but did not, and that facilities were quick to transfer patients to other
facilities even though sometimes they had the capabilities to care for those patients
themselves.
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OEI-06-20-00700 Findings | 17
IHS awarded new CCRT contracts in January 2021, extending the
program through the pandemic, and facilities expressed the
need for a similar program for non-COVID-19-related care
Strategy for Success: Shortly after IHS began piloting the CCRT program, it decided to extend the program
Program Continuity through the pandemic, and in October 2020, IHS began soliciting proposals for an
IHS awarded additional Indefinite Delivery Indefinite Quantity (IDIQ) contract. The IDIQ contract allowed IHS
contracts to continue to provide an indefinite quantity of services to facilities needing assistance with
the CCRT program COVID-19-related care through the duration of the pandemic. To ensure continuity
throughout the of the CCRT program when the deployments of the initial CCRT contract ended in
pandemic. November 2020, IHS officials reported using a transitional contractor to provide CCRT
deployments while the agency was reviewing proposals for the IDIQ contract.
In January 2021, IHS awarded the IDIQ contract to two separate staffing agencies and
extended the CCRT program through at least the end of 2021. The contract includes
provisions that can extend the program through 2025, if needed, using 1-year
increments. In interviews, IHS officials and staff noted that having two contractors
allows IHS to deploy multiple teams at the same time, and therefore, to better meet
facility needs and train more staff on COVID-19 safeguards and treatment. As of
March 8, 2021, IHS had deployed CCRTs a total of 21 times to IHS and Tribal facilities,
using the initial, transitional, and IDIQ contractors. During these deployments, the
CCRTs provided services to 15 IHS hospitals, 3 Tribal hospitals, and several satellite
health centers and other facilities included in those deployments, and the teams
trained a total of 1,255 facility staff. f
None of the facilities in our sample indicated at the time of our review that they had
plans to request another CCRT deployment. However, we found that one of the
facilities received a second deployment after our review period. Further, several
administrators and staff expressed interest in receiving additional consultation and
COVID-19 training from the CCRTs. Administrators in one facility reported that they
wanted CCRT providers to review the facility’s progress in implementing the
recommendations that the CCRT had provided during the deployment.
In addition to reporting a need for more COVID-19 support, all facilities in our sample
reported a need for resources similar to the CCRT program to assist facilities with
training and consultation on non-COVID-19-related care, such as prevention,
detection, and treatment of sepsis and high-risk obstetrics, among other topics.
One facility reported that the CCRT’s assistance in implementing the EHR templates
for COVID-19 had been helpful, but more assistance was needed to standardize other
IT-related templates in the facility. In interviews, IHS officials indicated that they were
open to providing additional non-COVID-19-related support to facilities, but they
acknowledged that recurrent funding was needed to establish such a program and
that it would need to be tailored to accommodate specific needs.
_____________________________________________________________________________________________________________________________
f The 21 deployments that had occurred as of March 8, 2021, included the 5 deployments in our sample.
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OEI-06-20-00700 Findings | 18
CONCLUSION AND RECOMMENDATIONS
The COVID-19 pandemic has been taxing on health care systems, and many U.S.
hospitals have experienced shortages in both staffing and patient beds. Given these
challenges and the disproportionate numbers of AI/ANs affected by the disease, IHS
developed the CCRT program to strengthen IHS and Tribal facilities’ response to the
pandemic. IHS designed the CCRTs as a resource for IHS and Tribal facilities to
maximize their capacity to care for COVID-19 patients and effectively manage patient
surges, even with limited staff. The CCRT deployments provided facilities with
assessments of their operations; hands-on training for staff; and assistance in
implementing necessary changes to improve the care and outcome for critically ill
COVID-19 patients. The CCRTs used a comprehensive approach to involve as many
departments and staff as possible in the assessments and trainings, so that facilities
could more easily pull staff from their regular duties to assist with patient care during
surges.
Officials and staff across the agency and Tribal facilities have found this innovative
resource to be successful, and IHS recently extended the program to continue
deployments through the pandemic. The CCRT program is a positive step in IHS’s
efforts to respond promptly to the immediate needs of facilities, and it also holds
promise as a model for addressing some of the longstanding challenges that facilities
face related to quality of care and staffing.
To build on its successes and further leverage the CCRT model in support of IHS’s
broader care improvements efforts, we make three recommendations to IHS.
We recommend that IHS:
Solicit feedback from CCRTs regarding their observations of
potential need for broader IHS-wide improvements
To supplement the recommendations that CCRTs made to individual IHS and Tribal
facilities, IHS should solicit feedback from the teams regarding their observations of
potential need for broader agencywide improvements, which may extend beyond
COVID-19-related care. The frequent deployments and in-depth facility assessments
provided the CCRTs with insight into common issues shared across facilities. During
the deployments, the CCRTs typically provided recommendations for improvement,
but those recommendations were specific to individual facilities rather than agency-
focused. To help IHS modify future deployments and identify needs and solutions for
agencywide improvements beyond COVID-19-related care, IHS should provide
opportunities for CCRTs to share their broader observations. For example, IHS could
host monthly or quarterly meetings with the CCRTs during which the teams could
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OEI-06-20-00700 Conclusion and Recommendations | 19
present their observations and suggestions for improvements beyond the individual
facilities.
Compile the CCRTs’ recommendations to individual facilities
and share them across all IHS and Tribal facilities
To further strengthen facilities’ COVID-19 response, IHS should compile all CCRT
recommendations into one resource and share it with facilities across the agency and
Tribes. This could be particularly beneficial for facilities that have not requested or
have not yet received a CCRT deployment. Although the recommendations are
facility-specific, they could highlight improvement efforts that other facilities could
replicate or use as guidance to make necessary changes that they might not
otherwise have been aware of or considered.
Assess whether IHS could use the CCRT model to provide
support and training to facilities needing assistance with
non-COVID-19-related care
Given the program’s success at helping meet facility needs during the pandemic and
IHS’s longstanding problems ensuring staffing and clinical expertise, IHS should
consider the feasibility of building agencywide training on non-COVID-19-related
issues using the CCRT model of hands-on training at the facility level. The training
could be tailored to specific facility needs and cover topics identified as high-risk by
facilities and previous OIG reports, such as emergency care and labor and delivery
(e.g., high-risk obstetrics). Any new CCRT program should include components
similar to those of the current CCRT program—such as facility assessments;
recommendations for policy and process improvements; training at the bedside; and
other types of interactive trainings—and could also include direct patient care during
crises. We recognize that there might be budget constraints affecting IHS's ability to
establish a similar program for non-COVID-19-related issues, as funding for the CCRT
program is directly tied to the agency’s COVID-19 response. To launch a similar
program, IHS would have to seek additional funds or shift funds from other areas.
However, it is important to note that deployments of small, highly experienced teams
assigned to train existing staff may be an efficient and effective way for IHS to expand
facility capacity without paying for contracted providers or specialists at each facility
and without having to send staff to offsite locations for trainings.
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OEI-06-20-00700 Conclusion and Recommendations | 20
AGENCY COMMENTS AND OIG RESPONSE
IHS concurred with our recommendations, and it reported its planned actions to
implement the recommendations.
In response to our first recommendation—for it to solicit feedback from CCRTs
regarding their observations of potential need for broader IHS-wide improvements—
IHS stated that it plans to solicit feedback from the current CCRT deployments to
identify issues that may be applicable more broadly and that could be addressed
throughout IHS.
In response to our second recommendation—for it to compile the CCRTs’
recommendations to individual facilities and share them across all IHS and Tribal
facilities—IHS noted that it has compiled a document, which is currently under review,
that summarizes all recommendations from previous CCRT deployments. IHS stated
that it plans to share this document with IHS and Tribal facilities, as appropriate, in
October 2021.
In response to our third recommendation—for it to assess whether IHS could use the
CCRT model to provide support and training to facilities needing assistance with
non-COVID-19-related care, IHS stated that it will assess other ongoing
non-COVID-19 initiatives to determine whether the CCRT model could be used for
such efforts. IHS expects to complete its assessment by October 2021.
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OEI-06-20-00700 Agency Comments and OIG Response | 21
APPENDIX: Agency Comments
DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service
______________________________________________________________________________________________________
Indian Health Service
Rockville, MD 20857
TO: Inspector General
FROM: Acting Director
SUBJECT: IHS Response to Draft OIG Report, (OEI-06-20-00700), “Indian Health Service
Use of Critical Care Response Teams Has Helped to Meet Facility Needs During
the COVID-19 Pandemic,” dated June 2021
We appreciate the opportunity to provide our official comments on the Draft Office of Inspector
General (OIG) Report, (OEI-06-20-00700), “Indian Health Service Use of Critical Care
Response Teams Has Helped to Meet Facility Needs During the COVID-19 Pandemic,” dated
June 2021. The Indian Health Service (IHS) concurs with the three OIG recommendations.
Our responses and planned actions to the three OIG recommendations are discussed below.
Recommendation No. 1: IHS concurs with the recommendation
Solicit feedback from CCRTs regarding their observations of potential need for broader
agencywide improvements.
Planned and completed actions:
Feedback will be solicited from the current Critical Care Response Team (CCRT) contracts to
identify issues that may be implemented on a broader basis throughout the IHS. Feedback from
current CCRT deployments will be shared within 30 days of the IHS receiving the CCRT
contractor’s recommendations.
Recommendation No. 2: IHS concurs with the recommendation
Compile CCRTs’ recommendations to individual facilities and share them across all IHS and
Tribal facilities.
Planned and completed actions:
The IHS compiled a document summarizing all recommendations from previous CCRT
deployments, which could be used by other facilities. These recommended protocols are currently
under Agency review and will be shared in October 2021, with IHS and Tribal facilities, as
appropriate.
Recommendation No. 3: IHS concurs with the recommendation
Assess whether IHS could use the CCRT model to provide support and training to facilities
needing assistance with non-COVID-19 related care.
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OEI-06-20-00700 Appendix | 22
Page 2 – Inspector General
Planned and completed actions:
The IHS will assess other ongoing non-COVID-19 initiatives to determine if using the
CCRT model is appropriate for training and support activities by October 31, 2021.
Thank you for the opportunity to review and comment on this draft OIG report. Please refer any
follow-up questions that you may have regarding our response to Ms. Athena Elliott, Chief
Compliance Officer, IHS, by e-mail at athena.elliott@ihs.gov.
Elizabeth A. Fowler
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OEI-06-20-00700 Appendix | 23
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Petra Nealy served as the team leader for this study, and Charis Burger and
Savanna Thielbar served as the lead analysts. Office of Evaluation and Inspections
staff who provided support include Joe Chiarenzelli, Althea Hosein, and
Christine Moritz.
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector
General for Evaluation and Inspections in the Dallas regional office, and Petra Nealy,
Deputy Regional Inspector General.
Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
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OEI-06-20-00700 Acknowledgments and Contact | 24
ABOUT THE OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law
95-452, as amended, is to protect the integrity of the Department of Health and
Human Services (HHS) programs, as well as the health and welfare of beneficiaries
served by those programs. This statutory mission is carried out through a nationwide
network of audits, investigations, and inspections conducted by the following
operating components:
The Office of Audit Services (OAS) provides auditing services for HHS,
either by conducting audits with its own audit resources or by overseeing audit work
done by others. Audits examine the performance of HHS programs and/or its
grantees and contractors in carrying out their respective responsibilities and are
intended to provide independent assessments of HHS programs and operations.
These audits help reduce waste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable
information on significant issues. These evaluations focus on preventing fraud, waste,
or abuse and promoting economy, efficiency, and effectiveness of departmental
programs. To promote impact, OEI reports also present practical recommendations
for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative
investigations of fraud and misconduct related to HHS programs, operations, and
beneficiaries. With investigators working in all 50 States and the District of Columbia,
OI utilizes its resources by actively coordinating with the Department of Justice and
other Federal, State, and local law enforcement authorities. The investigative efforts
of OI often lead to criminal convictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides
general legal services to OIG, rendering advice and opinions on HHS programs and
operations and providing all legal support for OIG’s internal operations. OCIG
represents OIG in all civil and administrative fraud and abuse cases involving HHS
programs, including False Claims Act, program exclusion, and civil monetary penalty
cases. In connection with these cases, OCIG also negotiates and monitors corporate
integrity agreements. OCIG renders advisory opinions, issues compliance program
guidance, publishes fraud alerts, and provides other guidance to the health care
industry concerning the anti-kickback statute and other OIG enforcement authorities.
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
OEI-06-20-00700 About OIG | 25
ENDNOTES
1 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2021, p. CJ-2, 8.
Accessed at
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf on
April 2, 2020.
2 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2021, pp. CJ-1–2.
Accessed at
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf on
April 2, 2020.
3 Under the Indian Self-Determination and Education Assistance Act, P.L. No. 93-638, IHS contracts and compacts with Tribes or
Tribal Organizations to deliver services.
4 This support is given under the authority of Title V of the Indian Health Care Improvement Act, P.L. No. 94-437.
5 IHS, Office of Urban Indian Health Programs: About Us. Accessed at https://www.ihs.gov/urban/aboutus/ on April 6, 2021.
6 Mark Walker, “Pandemic Highlights Deep-Rooted Problems in Indian Health Service,” The New York Times, updated January 3,
2021. Accessed at https://www.nytimes.com/2020/09/29/us/politics/coronavirus-indian-health-service.html on April 4, 2021.
7 CDC, Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity. Accessed (version updated April 23, 2021) at
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
on May 21, 2021.
8 IHS, COVID-19 Response, 100 Day Review. Accessed at
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on
February 10, 2021.
9 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2,
2020. Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021.
10 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2021, p. CJ-179.
Accessed at
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY_2021_Final_CJ-IHS.pdf on
April 2, 2020.
11 IHS, Locations. Accessed at https://www.ihs.gov/locations/ on September 23, 2020.
12
IHS, IHS Profile. Accessed at https://www.ihs.gov/newsroom/factsheets/ihsprofile/ on September 24, 2020.
13 IHS, Circular No. 88-02. Accessed at https://www.ihs.gov/ihm/circulars/1988/service-unit-boundaries/ on September 30,
2020.
14 IHS, IHS Profile. Accessed at https://www.ihs.gov/newsroom/factsheets/ihsprofile/ on September 24, 2020.
15 Jiaye Liu et al., “Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Shenzhen, China, 2020,”
Emerging Infectious Diseases, June 2020. Accessed at https://wwwnc.cdc.gov/eid/article/26/6/20-0239_article on April 4, 2021.
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
OEI-06-20-00700 Endnotes | 26
16 CDC, Risk for COVID-19 Infection, Hospitalization, and Death by Age Group.
Accessed (version updated February 18, 2021) at
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html on April 4,
2021.
17 CDC, Symptoms of Coronavirus. Accessed at https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
on April 4, 2021. [Page is now titled Symptoms of COVID-19.]
18 Susie Neilson and Aylin Woodward, “A comprehensive timeline of the coronavirus pandemic at 1 year, from China’s first case
to the present,” Business Insider, December 24, 2020. Accessed at https://www.businessinsider.com/coronavirus-pandemic-
timeline-history-major-events-2020-3 on April 4, 2021.
19 WHO, WHO Director-General’s opening remarks at the media briefing on COVID-19—11 March 2020, March 11, 2020.
Accessed at https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-
briefing-on-covid-19---11-march-2020 on April 4, 2021.
20 CDC, COVID Data Tracker, United States COVID-19 Cases, Deaths, and Laboratory Testing (NAATs [Nucleic Acid Amplification
Tests]) by State, Territory, and Jurisdiction, updated September 1, 2021. Accessed at https://covid.cdc.gov/covid-data-
tracker/?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fcases-in-
us.html#cases_casesper100klast7days on September 1, 2021.
21 Miriam E. Van Dyke et al., “Racial and Ethnic Disparities in COVID-19 Incidence by Age, Sex, and Period Among Persons Aged
<25 Years—16 U.S. Jurisdictions, January 1–December 31, 2020,” CDC MMWR [Morbidity and Mortality Weekly Report],
March 19, 2021. Accessed at
https://www.cdc.gov/mmwr/volumes/70/wr/mm7011e1.htm?s_cid=mm7011e1_w#suggestedcitation on April 4, 2021.
22 IHS, Coronavirus (COVID-19), updated August 30, 2021. Accessed at https://www.ihs.gov/coronavirus/ on September 1,
2021.
23 CDC, Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity.
Accessed (version updated April 23, 2021) at
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
on May 21, 2021.
24 Sarah M. Hatcher et al., “COVID-19 Among Indian and Alaska Native Persons—23 States, January 31-July 3, 2020,” CDC
MMWR, August 28, 2020. Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/mm6934e1.htm on April 4, 2021.
25 CDC, Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity.
Accessed (version updated April 23, 2021) at
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html
on May 21, 2021.
26 Jessica Arrazola et al., “COVID-19 Mortality Among American Indian and Alaska Native Persons—14 States, January-June
2020,” CDC MMWR, December 11, 2020. Accessed at https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6949a3-H.pdf on
February 12, 2021.
27 OIG, Hospital Experiences Responding to COVID-19 Pandemic: Results of a National Pulse Survey March 23–27, 2020
(OEI-06-20-00330), April 2020.
28 OIG, Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care Delivery, Results of a National
Pulse Survey February 22-26, 2021 (OEI-09-21-00140), March 2021.
IHS Use of Critical Care Response Teams Has Helped To Meet Facility Needs During the COVID-19 Pandemic
OEI-06-20-00700 Endnotes | 27
29 Mark Walker, “Pandemic Highlights Deep-Rooted Problems in Indian Health Service,” The New York Times, updated
January 3, 2021. Accessed at https://www.nytimes.com/2020/09/29/us/politics/coronavirus-indian-health-service.html on
April 4, 2021.
30 HHS, HHS Announces $500 Million Distribution to Tribal Hospitals, Clinics, and Urban Health Centers, May 22, 2020.
Accessed
at https://www.hhs.gov/about/news/2020/05/22/hhs-announces-500-million-distribution-to-tribal-hospitals-clinics-and-
urban-health-centers.html on September 4, 2020.
31 Mark Walker, “Pandemic Highlights Deep-Rooted Problems in Indian Health Service,” The New York Times, updated
January 3, 2021. Accessed at https://www.nytimes.com/2020/09/29/us/politics/coronavirus-indian-health-service.html on
April 4, 2021.
32 IHS, IHS Recruitment. Accessed at https://www.ihs.gov/dhps/programperformancedata/recruitment/ on September 30, 2020.
33 OIG, Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention To Support Quality Care
(OEI-06-14-00011), October 2016.
34 Government Accountability Office (GAO), Indian Health Service: Agency Faces Ongoing Challenges Filling Provider Vacancies,
GAO-18-580, August 2018. Accessed at https://www.gao.gov/assets/gao-18-580.pdf on May 21, 2021.
35 OIG, Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care Delivery, Results of a National
Pulse Survey February 22-26, 2021 (OEI-09-21-00140), March 2021.
36 Patrick Boyle, “U.S. Physician Shortage Growing,” Association of American Medical Colleges, June 26, 2020. Accessed at
https://www.aamc.org/news-insights/us-physician-shortage-growing on April 4, 2021.
37 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2,
2020. Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021.
38 IHS, Dear Tribal Leader and Urban Indian Organization Leader, May 19, 2020.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2020_Letters/DTLL_DUIOLL_0519202
0.pdf on September 4, 2020.
39 HHS, HHS Announces $500 Million Distribution to Tribal Hospitals, Clinics, and Urban Health Centers, May 22, 2020.
Accessed
at https://www.hhs.gov/about/news/2020/05/22/hhs-announces-500-million-distribution-to-tribal-hospitals-clinics-and-
urban-health-centers.html on September 4, 2020.
40 IHS, Dear Tribal Leader and Urban Indian Organization Leader, January 15, 2021.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0115202
1.pdf on January 19, 2021.
41 IHS, Dear Tribal Leader and Urban Indian Organization Leader, February 2, 2021.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0202202
1.pdf on February 10, 2021.
42 IHS, Dear Tribal Leader and Urban Indian Organization Leader, March 8, 2021.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_03082021.pdf on
April 5, 2021.
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OEI-06-20-00700 Endnotes | 28
43 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs,
April 14, 2021. Accessed at
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15,
2021.
44 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs,
April 14, 2021. Accessed at
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15,
2021.
45 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs,
April 14, 2021. Accessed at
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15,
2021.
46 IHS, Dear Tribal Leader and Urban Indian Organization Leader, February 2, 2021.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0202202
1.pdf on February 10, 2021.
47 IHS, Dear Tribal Leader and Urban Indian Organization Leader, May 19, 2020.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2020_Letters/DTLL_DUIOLL_0519202
0.pdf on September 4, 2020.
48 IHS, press release, Biden Administration Invests Additional $1.8 Billion in American Rescue Plan Funding to Combat COVID-19
in Indian Country, June 16, 2021. Accessed at https://www.ihs.gov/newsroom/pressreleases/2021-press-releases/biden-
administration-invests-additional-1-8-billion-in-american-rescue-plan-funding-to-combat-covid-19-in-indian-country/ on
June 21, 2021.
49 IHS, Dear Tribal Leader and Urban Indian Organization Leader, March 26, 2021.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2021_Letters/DTLL_DUIOLL_0326202
1.pdf on April 6, 2021.
50 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs,
April 14, 2021. Accessed at
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15,
2021.
51 IHS, Coronavirus (COVID-19), updated August 30, 2021. Accessed at https://www.ihs.gov/coronavirus/ on September 1,
2021.
52 IHS, COVID-19 Response, 100 Day Review. Accessed at
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on
February 10, 2021.
53 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs,
April 14, 2021. Accessed at
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15,
2021.
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OEI-06-20-00700 Endnotes | 29
54 IHS, COVID-19 Response, 100 Day Review. Accessed at
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on
February 10, 2021.
55 IHS, FAQs—Federal Response in Indian Country. Accessed at https://www.ihs.gov/coronavirus/faqs-federal-response-in-
indian-country/ on April 4, 2021.
56 IHS, COVID-19 Response, 100 Day Review. Accessed at
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on
February 10, 2021.
57 IHS, COVID-19 Response, 100 Day Review. Accessed at
https://www.ihs.gov/sites/coronavirus/themes/responsive2017/display_objects/documents/IHS_COVID_100DayReview.pdf on
February 10, 2021.
58 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs,
April 14, 2021. Accessed at
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15,
2021.
59 IHS, Dear Tribal Leader and Urban Indian Organization Leader, November 23, 2020.
Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/2020_Speeches/RADM_Weahkee_Bi-
Weekly_Email_11.23.2020.pdf on April 22, 2021.
60 GAO, Federal Personnel: Public Health Service Commissioned Corps Officers’ Health Care for Native Americans,
GAO/GGD-97-111BR, August 1997. Accessed at https://www.gao.gov/assets/ggd-97-111br.pdf on April 22, 2021.
61 USPHS, Commissioned Corps of the U.S. Public Health Service: About Us. Accessed at https://www.usphs.gov/about-us on
April 2, 2021.
62 USPHS, Fact Sheet: Rapid Deployment Forces.
Accessed at
https://dcp.psc.gov/ccmis/RedDOG/FactSheets/RDF_Fact_Sheet_FINAL.pdf on February 9, 2021.
63 IHS, FAQs—Federal Response in Indian Country. Accessed at https://www.ihs.gov/coronavirus/faqs-federal-response-in-
indian-country/ on April 4, 2021.
64 IHS, National Supply Service Center: About. Accessed at https://www.ihs.gov/nssc/about/ on April 4, 2021.
65 IHS, FAQs—Federal Response in Indian Country. Accessed at https://www.ihs.gov/coronavirus/faqs-federal-response-in-
indian-country/ on April 4, 2021.
66 Testimony of RADM Michael Toedt, then Chief Medical Officer for IHS, before the Senate Committee on Indian Affairs,
April 14, 2021. Accessed at
https://www.indian.senate.gov/sites/default/files/IHS%20COVID%20testimony%20for%20SCIA%204-14-21.pdf on April 15,
2021.
67 IHS, Coronavirus (COVID-19), updated August 30, 2021. Accessed at https://www.ihs.gov/coronavirus/ on September 1,
2021.
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OEI-06-20-00700 Endnotes | 30
68 Richard Hoppe, “Arizona National Guard Partners with Gila River Indian Community For Mass COVID-19 Vaccination Event,”
Luke Air Force Base Thunderbolt, February 24, 2021. Accessed at https://www.aerotechnews.com/lukeafb/2021/02/24/arizona-
national-guard-partners-with-gila-river-indian-community-for-mass-covid-19-vaccination-event/ on April 4, 2021.
69 “CTUIR [Confederated Tribes of the Umatilla Indian Reservation] to hold mass vaccination event with aid of Oregon National
Guard,” East Oregonian, February 22, 2021. Accessed at https://www.eastoregonian.com/coronavirus/ctuir-to-hold-mass-
vaccination-event-with-aid-of-oregon-national-guard/article_3d9feb94-7536-11eb-9531-db0d12fc9ccb.html on April 4, 2021.
70 John Hughel, “Washington Guard partners with Quinault Indian Nation,” U.S. Army, May 27, 2020.
Accessed at
https://www.army.mil/article/235977/washington_guard_partners_with_quinault_indian_nation on April 4, 2021.
71 Emerson Marcus, “Tribes, Nevada Guard combine efforts for COVID-19 testing,” U.S. Army, August 19, 2020. Accessed at
https://www.army.mil/article/238292/tribes_nevada_guard_combine_efforts_for_covid_19_testing on April 4, 2021.
72 IHS, Coronavirus (COVID-19), updated August 30, 2021. Accessed at https://www.ihs.gov/coronavirus/ on September 1,
2021.
73 CDC, COVID Data Tracker, Vaccination Demographics, updated September 1, 2021. Accessed at https://covid.cdc.gov/covid-
data-tracker/index.html#vaccination-demographics-trends on September 1, 2021.
74 Pursuant to 25 U.S.C. § 1680c(d)(2), IHS and Tribal health programs have the authority to vaccinate nonbeneficiaries to
prevent communicable disease. IHS, Coronavirus (COVID-19), section “Frequently Asked Questions (FAQs) regarding the
COVID-19 Vaccine,” subsection “Non-Beneficiaries,” updated August 20, 2021. Accessed at
https://www.ihs.gov/coronavirus/vaccine/ on August 23, 2021.
75 Mary Annette Pember, “Most tribal clinics offer COVID-19 vaccines to non-Natives,” Indian Country Today, March 11, 2021.
Accessed at https://indiancountrytoday.com/news/most-tribal-clinics-offer-covid-19-vaccines-to-non-natives on August 23,
2021.
76 Erin Schumaker, “Native tribes have expanded vaccines to everyone in Oklahoma,” ABC News, March 17, 2021.
Accessed at
https://abcnews.go.com/Health/native-tribes-expanded-vaccines-oklahoma/story?id=76509074 on August 23, 2021.
77 IHS, IHS Contract Action with Fire Creek Services Company, May 22, 2020.
Accessed at
https://www.fpds.gov/ezsearch/fpdsportal?indexName=awardfull&templateName=1.5.1&s=FPDS.GOV&q=75H70420P00027&
x=0&y=0 on September 29, 2020.
78 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2,
2020. Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021.
79 IHS, press release, Critical Care Response Team Will Further Enhance Patient Care Across the Indian Health Service, June 2,
2020. Accessed at
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/IHSPressRelease_CriticalCareRespons
eTeam_06022020.pdf on April 4, 2021.
80 OIG, Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention To Support Quality Care
(OEI-06-14-00011), October 2016.
81 OIG, Indian Health Service Hospitals: More Monitoring Needed To Ensure Quality Care (OEI-06-14-00010), October 2016.
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OEI-06-20-00700 Endnotes | 31
82 OIG, Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening
(OEI-06-17-00270), July 2019.
83 OIG, Organizational Challenges to Improving Quality of Care in Indian Health Service Hospitals (OEI-06-16-00390),
August 2019.
84 OIG, Indian Health Service Has Strengthened Patient Protection Policies but Must Fully Integrate Them Into Practice and
Organizational Culture (OEI-06-19-00330), December 2019.
85 OIG, Indian Health Service Facilities Made Progress Incorporating Patient Protection Policies, but Challenges Remain
(OEI-06-19-00331), December 2020.
86 OIG, Incidence of Adverse Events in Indian Health Service Hospitals (OEI-06-17-00530), December 2020.
87 OIG, Instances of IHS Labor and Delivery Care Not Following National Clinical Guidelines or Best Practices (OEI-06-19-00190),
December 2020.
88 OIG, Hospital Experiences Responding to COVID-19 Pandemic: Results of a National Pulse Survey March 23–27, 2020
(OEI-06-20-00330), April 2020.
89 OIG, Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care Delivery, Results of a National
Pulse Survey February 22-26, 2021 (OEI-09-21-00140), March 2021.
90 OIG, Toolkit: Insights for Health Care Facilities From OIG's Historical Work on Emergency Response (OEI-06-20-00470),
August 2020.
91 OIG, Toolkit: Insights for Communities From OIG's Historical Work on Emergency Response (OEI-06-09-00440), August 2020.
92 Ann M. Price et al., “Using a high-flow respiratory system (Vapotherm) within a high dependency setting,” Nursing in Critical
Care, 13(6), 2008. Accessed at https://pubmed.ncbi.nlm.nih.gov/19128313/ on April 5, 2021.
93 Neal Wiggermann, Jie Zhou, and Dee Kumpar, “Proning Patients With COVID-19: A Review of Equipment and Methods,”
Human Factors, 62(7), 2020. Accessed at https://journals.sagepub.com/doi/10.1177/0018720820950532?url_ver=Z39.88-
2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed& on April 5, 2021.
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