Government Accountability Office releases Udall-requested report evaluating Indian Health Service response management in child patient abuse case
Office of U.S. Senator Tom Udall (D-N.M.)
Yesterday, U.S. Senator Tom Udall (D-N.M.), vice chairman of the Senate Committee on Indian Affairs, responded to the results of an investigation he requested from the Government Accountability Office (GAO) to review management issues at federally-operated Indian Health Service (IHS) facilities that resulted in the cover up of misconduct that endangers patients, other employees, and Tribal communities. U.S. Senators John Hoeven (R-N.D.), Jon Tester (D-Mont.), Lisa Murkowski (R-Alaska), Catherine Cortez Masto (D-Nev.), John Barrasso (R-Wyo.), Tina Smith (D-Minn.), James Lankford (R-Okla.), and Steve Daines (R-Mont.) joined Udall on the request. The senators requested the investigation after the case of former Indian Health Service pediatrician Dr. Stanley Patrick Weber, who abused Native children on multiple reservations he was assigned to by Indian Health Service, came to light.
The Government Accountability Office investigation found that Indian Health Service lacks a standardized oversight policy directed by national headquarters to prevent and evaluate provider misconduct and misconduct allegations, instead delegating primary oversight responsibility for provider misconduct at federally-operated Indian Health Service facilities to the nine Indian Health Service area offices. While each of the nine area offices require new supervisors to attend supervisory training, not all require or provide additional training to identify and prevent provider misconduct and the content of the trainings vary widely between area offices. Additionally, the Government Accountability Office found evidence that patient complaints and reports of provider misconduct were not consistently reviewed and investigated by the governing boards of federally-operated Indian Health Service facilities. The Government Accountability Office issued three recommendations in light of the findings to review and standardize misconduct policies.
“The United States government has fundamental trust and treaty responsibilities to provide medical care to American Indians and Alaska Natives, and every patient receiving care from the Indian Health Service should have full confidence that their care will be safe, professional and high-quality,” Udall said. “Across the country, the vast majority of Indian Health Service medical professionals work hard to provide quality and culturally-competent health care to the Native communities they serve, and are currently demonstrating immense dedication and sacrifice during the COVID-19 pandemic. However, it is unacceptable that Indian Health Service officials failed to address and prevent the abhorrent abuse perpetrated by Dr. Weber on multiple occasions. It is essential that Indian Health Service management takes the steps needed to prevent misconduct from happening in the future, and I am encouraged by Indian Health Service’s commitment to implementing the report’s recommendations. I am calling on Indian Health Service management to open a transparent implementation process in light of the Government Accountability Office report to encourage and restore public trust. And I continue to call for full transparency and for the Department of Health and Human Services to release its internal audit report, with appropriate redactions to protect patient privacy, on Indian Health Service management of this case compiled by Integritas.”
The Government Accountability Office recommends that the Indian Health Service Director:
1. Establish a process to ensure that Indian Health Service area office policies related to misconduct and substandard performance are consistent with the policies of Indian Health Service headquarters.
2. Establish a review process at headquarters to standardize Indian Health Service area office trainings related to misconduct and substandard performance to ensure that staff receive consistent information about how to address misconduct or substandard performance.
3. Establish a standard approach or tool to ensure that the governing boards of federally-operated Indian Health Service facilities consistently document their review of information related to provider misconduct and substandard performance.
The full Government Accountability Office report can be read here.