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U.S. Department of Health and Human Services
IHS Office of Quality

Division of Quality Assurance, Patient Safety, and Clinical Risk Management

Quality Assurance

The Quality Assurance Program supports federal health services to achieve and sustain accreditation through standardizing tools and resources. Accreditation and certification survey activities are monitored in process with regular trend analysis to identify opportunities for improvement. Ongoing multidisciplinary QA activities support overall patient safety and increased communication of accreditation and certification activities agency wide. Federal IHS facilities are also provided training and access to standardized accreditation activities through the Joint Commission Resources (JCR) Portal Exit Disclaimer: You Are Leaving www.ihs.gov .

External Resource Sites

Accreditation Association for Ambulatory Health Care Exit Disclaimer: You Are Leaving www.ihs.gov 

CMS.gov Conditions for Coverage (CfCs) & Conditions of Participation (CoPs) Exit Disclaimer: You Are Leaving www.ihs.gov 

Code of Federal Regulations Title 42 / Chapter IV / Subchapter G / Part 482

Joint Commission Exit Disclaimer: You Are Leaving www.ihs.gov 

Additional Tools and Resources

Credentialing Program

The Credentialing Program supports patient safety and the IHS mission through standardized, compliant and ongoing credentialing and privileging processes and coordinates the usage of and establishes the standardization, optimization and systemization of the IHS credentialing software system. In addition, the Credentialing program provides training, development, and consultative leadership to IHS Medical Staff Professionals to increase their knowledge and practice of credentialing and privileging policies, medical staffing accreditation standards, medical staffing requirements for conditions of participation, following medical staff bylaws, and federal and state laws.

Additional Tools and Resources

Education and Training

Contacts

  • ASM Software User Management for IHS:
    • CAPT (Ret.) Dione Harjo, MPH, CPCS, HQ/Office of Quality, Division of Quality Assurance and Patient Safety, Credentialing Program Manager; Dione.Harjo@ihs.gov
    • CAPT Christel Svingen, PharmD, MHA, CPCS, CPMSM, HQ/Office of Quality, Division of Quality Assurance and Patient Safety, Credentialing Program, Credentialing Specialist; Christel.Svingen@ihs.gov
    • Mr. Derek Smith, HQ/Office of Quality, Division of Quality Assurance and Patient Safety, Enterprise Application Coordinator; Derek.Smith@ihs.gov

Resources, Tools and Standards

Audit Forms

Patient Safety

The Patient Safety Team is working collaboratively with the IHS CMO and Enterprise Risk Management (ERM) to implement an overarching, unified IHS Patient Safety Program. The Total System Safety (TSS) Strategy sets the goals and objectives for patient and workforce safety at all levels of the healthcare system (service unit/ facility, area, and HQ).

The Indian Health Service is committed to utilizing evidence-based practices to guide its programs and services. To that end, our team utilized the IHI Framework for Safe, Reliable and Effective Care Exit Disclaimer: You Are Leaving www.ihs.gov  and the National Action to Advance Patient Safety Exit Disclaimer: You Are Leaving www.ihs.gov  to craft a strategy that meets the unique needs of our agency.

Program implementation is a collaborative process that includes risk identification, stratification, and project prioritization. Our team is excited to collaborate with the Chief Medical Officer, Areas and facilities using the Enterprise Risk Management Assessment and Prioritization tool, during the implementation phase of the TSS Strategy.

Total System Safety is a proactive strategy in which risks are anticipated and system-wide safety processes are established and applied across the entire healthcare continuum in order to constantly improve systems and processes leading to a learning organization that administers highly reliable, quality care. These systems provide a unified approach to both patient and workforce safety in recognition of the importance of workforce safety, and that a safe workforce contributes to a safer patient care environment.

IHS Blog: IHS Re-Commits to Strengthening Patient Safety

Additional resources, including tools, training, SAFE Alerts, Patient Safety Officer (PSO) resources, and RCA materials can be found by visiting the Patient Safety Intranet Page.

Recognition of Patient Safety Excellence across the Indian Health Service

Patient Safety Awareness Week 2023 [PDF - 1.6 MB]
Patient Safety Awareness Week 2024 [PDF - 1.8 MB]

IHS Safety Tracking and Response (I-STAR) Adverse Events System

The IHS Safety Tracking and Response (I-STAR) System provides a web-based application for adverse event reporting for the Agency. This software built upon the RLDatix platform has been customized to allow IHS to have a single portal for reporting patient/staff/visitor, medication and occupational safety events with enhanced data analytics. The I-STAR application and training supports are housed on the intranet I-STAR Webpage. For questions about I-STAR, please reach out via email at IHSI-STAR@ihs.gov.

Infection Control

Infection Prevention and Control: The Infection Prevention and Control (ICP) Program supports federal health services through collaboration with the Centers for Disease Control and Prevention (CDC) and the Partnership to Advance Tribal Health (PATH) to increase surveillance activities and standardize tools, resources, education, training and reporting. Internal and external compliance reviews of infection control standards documented in the Joint Commission Resources (JCR) Portal Exit Disclaimer: You Are Leaving www.ihs.gov , which provides continual monitoring and analysis of current realities in the ICP programs within IHS. This resource provides key stakeholders with a comprehensive summary and gives direction where areas of improvement are needed regarding ICP.

External Resource Sites

Internal Resources

Life Safety and Environment of Care

Life Safety and Environment of Care program (LS/EC) provides agency wide tools and resources to assist with guidance, expertise to plan, coordinate, develop, implement, evaluate and provide oversight to facility LS/EC quality assurance programs related to federal requirements and accreditation standards are in compliance. Collaborative relationships are maintained with Joint Commission Resources (JCR), Centers for Disease Control and Prevention (CDC), Indian Health Service Office of Environmental Health and Engineering (OEHE), and Indian Health Service Health Care Facilities to ensure that Life Safety and Environment of Care accreditation best practices are being shared and utilized agency wide.

The LS/EC program offers data analysis and accreditation strategies related to National Fire Protection Association (NFPA) Health Care Facilities Code (HCFC), The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), Accreditation Association for Ambulatory Healthcare (AAAHC) to ensure national standards are implemented to support the mission of Indian Health Service. Data analysis is aimed at providing key stakeholders information regarding accreditation and regulatory compliance, to ensure strategic planning for evaluation of current preparedness, education, training, and reporting.

Life Safety and Environment of Care Resources

Clinical Risk Management

Clinical Risk Management provides the inherent Federal Residual Function as mandated by statute. Major functions include:

  • Coordinating the federally mandated processing of Medical Malpractice Federal Tort Claims Act (FTCA) filed against IHS, Tribal and Urban Providers
  • Representing the Agency when paid claims are presented for mandatory review to the Department of Human and Health Services (DHHS) Medical Claims Review Panel
  • Representing the Agency as Administrator for the National Practitioner Data Bank and responsible for submitting mandatory payment reports and review of subject matter statements
  • Representing the Agency when filing mandatory reports to State Licensing Boards for the provider for whose benefit settlement was made.