South Dakota hospital churned through 27 CEOs in 9 years

The Indian Health Service hospital on the Rosebud (S.D.) Sioux reservation made efforts to improve quality of care after its emergency department temporarily closed, but it continued to face several challenges, including untrained staff and leadership turnover, according to HHS' Office of Inspector General.

The IHS closed Rosebud Hospital's emergency department in December 2015 after CMS identified several patient safety issues at the facility. The OIG report identifies several issues that led to the ED closure, including staffing shortages, changing and inconsistent hospital leadership, and lack of oversight by IHS.

The OIG report includes statements from IHS officials about the quality of care and leadership challenges at Rosebud Hospital. Officials said the hospital had 27 CEOs in the 9 years leading up to the ED closure, averaging 3 CEOs per year.

"Many of these CEOs served in an acting capacity and lasted only a few months before they left voluntarily, were fired by IHS, or were removed by a tribal resolution," states the OIG report. "Although many of these CEOs may have initially appeared to be a good fit, several IHS officials indicated that the CEOs often lacked experience and were ill-equipped to fulfill that role."

The emergency department reopened seven months later after IHS provided additional resources to the hospital and entered into a systems improvement agreement with CMS, which required IHS to update certain policies and revise governing board bylaws. Despite the many improvements at Rosebud Hospital prompted by the systems improvement agreement, staff continued to report concerns about the frequent rotation in hospital leadership, according to the OIG.

IHS completed the systems improvement agreement in September 2017. Less than a year later, CMS found new compliance issues in the hospital's ED during a complaint survey. The hospital failed to ensure that the ED call system was working and failed to provide emergency care for two patients who came to the ED with behavioral health needs, according to the OIG.

Rosebud Hospital was set to lose its Medicare contract in August 2018, but CMS extended the termination date to November 2018 after IHS submitted a plan of corrections. CMS revisited the hospital a few weeks before the termination date and determined the deficiencies had been corrected.

To address the problems identified in the case study of Rosebud Hospital and to avoid similar problems at other IHS hospitals, the OIG made the following four recommendations to IHS:

1. Develop and implement a staffing program for recruiting, retaining and training clinical and leadership staff in remote hospitals.

2. Enhance training and orientation for new hospital leaders to ensure that they follow IHS directives and continue improvement efforts.

3. Continue to take steps to ensure early and effective intervention when IHS identifies problems at hospitals.

4. Develop procedures for temporary ED closures and communicate those procedures with receiving hospitals and EMS to ensure that they are adequately prepared to receive diverted patients during such events.

IHS concurred with all four recommendations and said it will use the findings and recommendations in the OIG report to improve its management and operations.

Access the full OIG report here.

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