MINNEAPOLIS (AP) - The Indian Health Service made “significant improvements” at its hospital on the remote Rosebud Sioux Reservation in South Dakota after it abruptly closed its emergency department for several months a few years ago, but it continues to struggle to hire adequate staff and managers for the hospital, according to a report released Monday.

The service closed the 35-bed Rosebud Hospital’s emergency department in December 2015 and the hospital was in danger of losing federal funding after the Centers for Medicare and Medicaid Services determined that patients there were in immediate jeopardy, the report from the Office of Inspector General at the U.S. Department of Health and Human Services noted.

The inspector general conducted the case study to identify lessons learned that the service could apply in similar future situations. It found that although the enhanced federal attention and oversight after the closure provided the impetus to address the hospital’s problems in the short term, the service “did not sustain the improvements in staffing and leadership after this focus diminished.”

Staffing shortages, instability and inexperience in key leadership positions, and inadequate infrastructure for ensuring basic quality care were just some of the factors that led to the closure. Because of the shutdown, the hospital had to divert patients to other small hospitals about an hour away but didn’t give those hospitals or ambulance services time to prepare for the influx of patients, so they were overwhelmed. Tribal officials said the long ambulance rides contributed to several deaths.

The tribe sued the federal government over the closure, saying the government failed to meet its treaty obligations to provide adequate medical care for tribal members. That case is pending.

As an example of the turnover, the report said Rosebud Hospital went through 27 CEOs over a nine-year period, averaging three per year. Many of them served in an acting capacity and lasted only a few months before they left voluntarily, were fired by the Indian Health Service or were removed by the tribe, it said.

The hospital’s emergency department reopened in July 2016 after the service temporarily brought in what the report called “an accomplished team of clinical and management leaders” that extensively overhauled the hospital’s policies, procedures and training. But a follow-up review in July 2018 found deficiencies that had resurfaced under newer leadership, including turnover among long-term staff and an overreliance on contracted providers to temporarily fill the gaps. The report said the solutions implemented by the outside managers “failed to fully take root” due to continued leadership and staff churn.

“To correct underlying problems and better serve its beneficiaries, we recommend that IHS, as a management priority, develop and implement a staffing program for recruiting, retaining, and training clinical and leadership staff in remote hospitals,” the report said. “This is a necessary first step to addressing quality issues long term; however, other actions are also needed, including taking steps to ensure that IHS intervenes early and effectively when problems emerge.”

The IHS said it concurred with all the inspector general’s recommendations and has set target dates for implementing them. The service said it expects to complete a comprehensive workforce plan by next May that will address recruitment, training and placement of staff in remote locations. It also plans to incorporate best practices for training new hospital leaders by next March. And the service said it’s working to improve governance and accountability at its hospitals, and that it expects to complete contingency plans for future closures in December.

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