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U.S. Department of Health and Human Services
Indian Health Manual

Chapter 4 Organization and Function

Part 1 - General

Title Section
Purpose 1-4.1
Public Health Service 1-4.2
Division of Indian Health 1-4.3
Indian Health Field Facilities 1-4.4
    Field Facilities 1-4.4A
    Definitions 1-4.4B
      Administrative Facility 1-4.4B(1)
      Training Facility 1-4.4B(2)
      Research Facility 1-4.4B(3)
      Treatment Facility 1-4.4B(4)
      Treatment Location 1-4.4B(5)
    Change in Designations 1-4.4C
    Listing of Major Field Facilities with Appendix 1-4.4D
Organization Relations 1-4.5
    Headquarters, Area Offices, & Service Units 1-4.5A
      Line of Responsibility 1-4.5A(1)
      Organization 1-4.5A(2)
      Functional Relations--Professional Guidance 1-4.5A(3)
    Assignment of Area Responsibility 1-4.5B
      Aberdeen 1-4.5B(1)
      Albuquerque 1-4.5B(2)
      Anchorage 1-4.5B(3)
      Billings 1-4.5B(4)
      Oklahoma 1-4.5B(5)
      Phoenix 1-4.5B(6)
      Portland 1-4.5B(7)
    Extra-Divisional Organization Relationships 1-4.5C
    Other Governmental Organization Relationships 1-4.5D
      General 1-4.5D(1)
      Relationships within the Department 1-4.5D(2)
      Relationships with D/Interior, BIA 1-4.5D(3)
      Relationships with other Federal Agencies 1-4.5D(4)
      Relationships with Local & State Government Agencies 1-4.5D(5)
    Nongovernmental Organization Relationships 1-4.5E
      National, State and Local Professional Organizations 1-4.5E(1)
      National, State and Local Voluntary Health & welfare Agencies 1-4.5E(2)
      Educational Institutions of all Types 1-4.5E(3)
      Tribal Councils and Indian Interest Groups 1-4.5E(4)
Medical Staff Organization 1-4.6
Order of Succession 1-4.7
Appendix Description
1-4-A Statement of Organization and Functions

1-4.1  PURPOSE

This chapter sets forth the organization of the Department, the Public Health Service, Health Services Administration and the Indian Health Service and its field facilities.  The purpose of the chapter is to make available as a part of the Indian Health Manual, organizational and related information issued elsewhere.   This chapter brings together this information to provide a basis for the general orientation of new employees coming to the Service and to keep other employees currently informed as to the organization of the Department, Public Health Service, Health Services Administration and the Indian Health Service.

1-4.2  PUBLIC HEALTH SERVICE - HEALTH SERVICES ADMINISTRATION

The attached charts depict the organization of the Public Health Service as of July 11, 1974 and the Health Services Administration as of March 19, 1974.

Only current org charts are available

1-4.3  INDIAN HEALTH SERVICE

The attached chart depicts the organization of the Headquarters of the Indian Health Service which was approved by the Administrator, Health Services Administration, March 18, 1974.

Only current org charts are available.

1-4.4  INDIAN HEALTH SERVICE LOCATIONS

  1. Service Locations.  The Indian Health Service operating locations are designated, according to their primary functions, as follows:
    1. Administrative Facilities.
      1. Headquarters
      2. Area Offices
      3. Program Offices
      4. Service Unit Offices
      5. Field Offices
    2. Training Facilities.
    3. Research Facilities.
    4. Treatment Facilities.
      1. Public Health Service Indian (or Alaska Native) Hospitals.
      2. Public Health Service Indian (or Alaska Native) Medical Center.
      3. Public Health Service Indian (or Alaska Native} Health Centers.
      4. Public Health Service Indian (or Alaska Native) School Health Centers.
      5. Public Health Service Indian (or Alaska Native) School Infirmary.
      6. Public Health Service Indian (or Alaska Native) Health Stations.
      7. Public Health Service Indian (or Alaska Native) Mobile Units.
    5. Treatment Locations.
  2. Definitions.  Service locations are defined as follows:
    1. Administrative Facility.   A facility having staff necessary to the administration, promotion and support of the Service health program but where Indians and Alaska Natives do not receive clinical treatment services.
      1. Headquarters.   A facility that houses Indian Health Service Headquarters staff.
      2. Area Office.   A facility that houses Area staff.
      3. Program Office.   An office responsible for the administration, coordination, and implementation of the Indian Health program in a designated geographic area.
      4. Service Unit Office.   A facility that houses Service Unit administrative staff and is responsible for the administration, coordination, and implementation of the Indian Health program in a designated geographic portion of the Area.   The Service Unit Director reports directly to the Indian Health Area Director or Program Director.
      5. Field Office.   A facility that houses staff providing non-clinical services such as sanitation services, medical social work, or administrative services (usually within a Service Unit).
    2. Training Facility.   A facility where the primary function is the training of persons for work in the Service programs.
    3. Research Facility.   A facility where the primary function is the conduct of research.
    4. Treatment Facility.   A facility that is owned or leased by or donated to the Public Health Service and contains space which is primarily for Service use to provide direct and/or contract clinical treatment services to Indian consumers.
      1. Public Health Service Indian (or Alaska Native) Hospital.   A permanent facility which contains inpatient beds, organized staff including physician services, and continuous nursing services and provides comprehensive health care including diagnosis and treatment for patients.
      2. Public Health Service Indian (or Alaska Native) Medical Center.  An establishment that provides more comprehensive health service and incorporates more medical specialties than a general hospital and has been designated as a referral center for Service Units in that Area.
      3. Public Health Service Indian (or Alaska native) Health Center.  A facility, physically separated from a hospital, where one or more clinical treatment services, such as physician, dentist or nursing services, are available at least 40 hours a week for outpatient care.
      4. Public Health Service Indian (or Alaska Native) School Health Center.  A facility which is a health center and primarily serves students.
      5. Public Health Service Indian (or Alaska Native) School Infirmary.  A facility that has beds which are primarily for the overnight care of students.
      6. Public Health Service Indian (or Alaska Native) Health Station.  A facility, physically separated from a hospital or health center, where one or more clinical treatment services, such as physician, dentist or nursing services, are available on a regularly scheduled basis but for less than 40 hours a week.
      7. Public Health Service Indian (or Alaska Native) Mobile Unit.  A facility which can be periodically moved from community to community.
    5. Treatment Location.  Geographically described communities where direct and/or contract clinical services are provided but where no fixed Public Health Service health care facility is available; e.g. small Alaska villages, mobile unit sites, etc.
  3. Changes in Designations.  Prior approval must be obtained for all redesignations of facilities whether type or name.   All requests for changes are to be forwarded from Service Units to Areas to Office of Program Statistics, Headquarters.   This request must contain the detailed reason(s) for the change.
  4. Field Facilities.   The appendices to this chapter include a list of the major field facilities of the Service (with the exception of Research Facilities) and the organization and functional charts of the Area Offices.
    1. Major Facilities Listing shows:
      • Area Offices
      • Program Offices
      • Training Facilities
      • Hospitals
      • Medical Centers
      • Health Centers
      • School Health Centers
      • Infirmaries
    2. Area Offices Organization and Functional Charts:
      • Aberdeen, South Dakota
      • Albuquerque, New Mexico
      • Anchorage, Alaska
      • Billings, Montana
      • Oklahoma City, Oklahoma
      • Phoenix, Arizona
      • Portland, Oregon
      • Window Rock, Arizona

1-4.5  ORGANIZATION RELATIONSHIPS

  1. Headquarters - Area - Service Unit Relationships.
    1. Line of Responsibility.  The line of responsibility between headquarters, the area, and the service unit is from the Division Chief to the Indian Health Area Director and from him to the Director of the Service Unit.
    2. Organization.
      1. Chart 1 (Appendix 1-4.5A(1)) describes the organizational relationship at the three levels.
      2. The headquarters organization is shown with five operational offices:
        • Office of Program Services
        • Office of Tribal Affairs
        • Office of Environmental Health
        • Office of Program Planning and Evaluation
        • Office of Administration

        The sixth office, the Office of Special Staff Services, which includes training responsibilities, is a staff office and this is shown on a separate level rather than at the "line" level.

      3. Each Area Office will organize along the lines of the headquarters organization which have counterpart offices at headquarters.  The chart shows four basic groupings for operations:
        • Program Services Activities
        • Environmental Health
        • Tribal Affairs
        • Administrative Services Activities

        Program Planning and Evaluation as well as training activities are shown as staff functions in the office of the Indian Health Area Director.

      4. Program Services Activities include preventive, curative and rehabilitative health services.  Placement of Environmental Health at a lateral position of Program Services does not abridge the requirement for fielding a comprehensive health program, integrating sanitation and all other components.
      5. Since the organization below the basic grouping will vary with the area served, no single pattern is set out.  All area organization structures will be approved at headquarters before implementation.
    3. Functional Relationships - Professional Guidance
      1. Chart 2 (Appendix 1-4.5A(2)) is the functional chart and is illustrative of the application of professional guidance from headquarters to area to service unit.  In this case pharmacy activities are shown as a case in point.   Professional guidance for the program is directed from Chief of Pharmacy Branch, Office of Program Services, at the headquarters level, to the Area Director of Pharmacy Services (with Program Services Activities) and from him to the Service Unit pharmacist.
      2. It should be noted that in purely technical operations (and again with the pharmacy program for illustrative purposes) the headquarters Chief of Pharmacy Branch can be expected to deal on day-to-day matters with the Chief of the area pharmacy program and the latter with the service unit pharmacist.  The decisions on these day-to-day matters, however, must be within the framework of policy set in the first case by the Division Chief and in the latter case by the Indian Health Area Director and the Service Unit Director and supported by an approved plan of operation.
  2. Assignment of Area Responsibility.  In those states where more than one Area Office has an interest (e.g., the Albuquerque, Billings and the Phoenix Area Offices each has responsibilities for certain groups of Indians residing in the State of Utah which is located in the Phoenix Area), the Indian Health Area Director of the Area in which the state is located is responsible for coordinating and representing Indian Health activities within the state with reference to relationships with the state and local officials and the appropriate Regional Medical Director.

    The Indian Health Area Director of the Area is also responsible for keeping the other Indian Health Area Directors whom he represents informed on those matter affecting their respective interests.

    To assure that there will be no confusion as to which Indian Health Area Director will represent the Indian health activities within a state, the following assignments are made:

    1. Aberdeen Indian Health Area Director is responsible for coordinating and representing the Indian health activities within the following states:  Iowa, Michigan, Minnesota, Nebraska, North Dakota, South Dakota, and Wisconsin.
    2. Albuquerque Indian Health Area Director is responsible for coordinating and representing the Indian health activities within the following states:  Colorado and New Mexico.
    3. Anchorage Alaska Native Health Area Director is responsible for coordinating and representing the Alaska Native health activities within the following state:  Alaska.
    4. Billings Indian Health Area Director is responsible for coordinating and representing the Indian health activities within the following states:  Montana and Wyoming.
    5. Oklahoma Indian Health Area Director is responsible for coordinating and representing the Indian health activities within the following states:  Kansas, Mississippi, North Carolina, Oklahoma, South Carolina, and Texas.
    6. Phoenix Indian Health Area Director is responsible for coordinating and representing the Indian health activities within the following states:  Arizona, California, Nevada, and Utah.
    7. Portland Indian Health Area Director is responsible for coordinating and representing the Indian health activities within the following states:  Idaho, Oregon, and Washington.
  3. Extra-Divisional Organizational Relationships

    Relationships between Division of Indian Health Area Offices and Public Health Service Regional Offices and Relationships between Division of Indian Health and Public Health Service Training, Investigative and Research Units.  The need for close working relationships between the Indian Health Area Directors and the Public Health Service Regional Health Directors is recognized by both the Bureau of Medical Services and the Bureau of State Services.   The following statement, signed by the Chief, Bureau of Medical Services and the Assistant Surgeon General for Operations prescribes the procedures to be followed by Area Directors and PHS Regional Officials in carrying out those activities of the Indian Health program which concern relations with the States and with certain activities of other Public Health Service Units.   The text of the statement is as follows:

    OPERATING RELATIONSHIPS OF THE
    DIVISION OF INDIAN HEALTH AREA OFFICES
    AND THE
    PUBLIC HEALTH SERVICE REGIONAL ORGANIZATIONS

    1. Within their respective Areas the Indian Health Area Directors of Indian Health Area Offices are responsible to the Chief of the Service for the conduct of all the Division's operations, and for all relationships with the Indians and groups interested in Indian affairs.
    2. The established channel for Public Health Service relations with the States is through the Health, Education, and Welfare Regional Offices.   The Regional Health Directors are responsible to the Assistant Surgeon General for Operations, and through him to the Surgeon General for coordinating these relations with respect to all programs of the Service.   The Indian Health Area Directors of the Division of Indian Health Area Offices will, therefore, coordinate all their activities involving States relations with the appropriate Regional Health Directors or their designees.
    3. Annually, and more often as may be required, the Indian Health Area Directors, Division of Indian Health Area Offices, shall review their program with the appropriate Regional Health Director for the States in his area.   Such a review is desirable prior to the time the States submit their State plans to the Regional Offices, in order that the Indian health program can be coordinated as far as is practicable with such plans.   In these reviews with the Regional Health Directors, there shall be included a discussion of contractual services to be negotiated with the States and their political subdivisions, in order that there can be understanding on the services to be included and the procedures to be followed in negotiating such contracts.   The Indian Health Area Director, Division of Indian Health Area Office, is responsible for determining the services needed, the negotiations and execution of the contract, evaluation of service, and payment under such contracts.
    4. The Regional Health Director will request States to reflect in their State plans the services they anticipate providing to Indians with State and local funds and with Federal grant-in-aid funds and to include as informational material in their State plans the services which they propose to provide to Indians under contractual arrangements with the Indian health program of the Public Health Service.
    5. The Regional Health Director and Indian Health Area Director, Division of Indian Health Area Office, will at all times keep each other advised of special problems of concern to States and of Indian health problems within the States and, when desirable, plan to make visits together.

    RELATIONSHIPS BETWEEN THE INDIAN HEALTH SERVICE
    AND
    PUBLIC HEALTH SERVICE TRAINING, INVESTIGATIVE, AND RESEARCH UNITS

    1. When the Indian Health Area Director, Division of Indian Health Area Office, requires special assistance from the Communicable Disease Center, National Institutes of Health, Robert A. Taft Sanitary Engineering Center, etc., the request will be made through the Regional Health Director, who will make the necessary arrangements.
    2. Headquarters divisions or field stations of all Bureaus planning visits affecting the Indian health program shall so advise the Indian Health Area Director, Division of Indian Health Area Office, and the Regional Health Director.   Public Health Service programs wishing to conduct or sponsor a training, investigative, or research project at a location for which the Division of Indian Health has program responsibility, shall first obtain concurrence from the Division of Indian Health.

    ______________/Signed/____________________Date:    _____________Date:  August 2, 1963___________
    Assistant Surgeon General
    Chief Bureau of Medical Services

    ______________/Signed/____________________Date:    _____________August 6, 1963___________
    Assistant Surgeon General for Operations

  4. Other Governmental Organization Relationships
    1. General.   A wide range of governmental agencies have an interest in or impact on the conduct of the health program of the American Indian and Alaska Native.   In the conduct of the Division's program working relationships will require a day-to-day contact with some agencies, while the association with other groups will be infrequent.   Though it is not practical to attempt to describe all operational relationships, some of the more important ones are outlined to serve as a guide for others.
    2. Relationships within the Department.   The Division of Indian Health staff will find it necessary from time to time to contact other agencies within the Department.   Some of these agencies which are of particular interest to the Division are listed below with a short statement on functions pertinent to the Indian Health program.
      1. Office of Education.   Administers grants for fellowships to train teachers of mentally retarded children; provides financial assistance for training teachers of the deaf; and assists in the administration of the Juvenile Delinquency and Youth Offenses Control Act of 1961.
      2. Food and Drug Administration.   Provides technical consultation on new and investigational drugs.
      3. Social Security Administration.   Administers old age and survivors insurance programs for which many of the Indian beneficiaries are eligible.
      4. Vocational Rehabilitation Administration.   Administers rehabilitation programs throughout the various state vocational rehabilitation agencies providing services to handicapped who may become employable through rehabilitative services.
      5. Welfare Administration
        1. Office of Aging - Provides stimulation, guidance, and counseling to the states and to local agencies and organizations in this field and serves as liaison with other Federal Agencies on aging matters through the President's Council on Aging.
        2. Office of Juvenile Delinquency and Youth Development - Operates a grant and contract program for the partial support of research studies and demonstration projects aimed at the prevention of juvenile delinquency.
        3. Children's Bureau - Administers grants to State health agencies for extending and improving health services for mothers and children and grants to state crippled children's agencies for crippled children.
        4. Bureau of Family Services - Administers grants to help States provide public assistance under the Social Security Act for old-age assistance, medical assistance for the aged, aid to the blind, aid to families with dependent children, and aid to the permanently and totally disabled.

        At the central office of the Division the formal contacts with other agencies within the Department is through the Surgeon General.   However, an informal working relationship may be maintained between the Division Chief and his key staff and the staffs of the constituent agencies within the Department.   Like the Public Health Service, the other agencies of the Department have representation in the nine Regional Offices of the Department.   The Regional Director represents the Secretary and is responsible for the coordination and general conduct of the constituent agencies.

        The Area Office will in most instances contact these agencies at the regional level and all the formal relationships will be through the Regional Director.   An informal working relationship may be maintained between the key area staff and the key staffs of the constituent agencies within the Regional Office.

        The staff at the service unit level should be working closely with representatives of other agencies in the implementation of any plans, agreements or working arrangements approved at the area level.

    3. Relationships with Department of Interior, Bureau of Indian Affairs - Relationships with the Department of the Interior, Bureau of Indian Affairs and the Division of Indian Health are naturally close since the Bureau of Indian Affairs is responsible for all Indian programs except health.   It is important, therefore, that close working relationships is maintained at all operating levels.

      The organization of the Bureau consists of the Headquarters Office, Area Offices, reservations, off-reservation schools, and various administrative offices such as those of the Branch of Employment Assistance located in various metropolitan communities.

      1. Headquarters Organization

        The Central Office of the Bureau of Indian Affairs consists of the Office of the Commissioner and three program Divisions.

        The Office of the Commissioner consists of (1) the Deputy Commissioner who is responsible for matters involving administration, community services and economic development; (2) the Associate Commissioner who is responsible for matters involving management analysis, policy review, correspondence and reports, and tribal operations; (3) the Assistant Commissioner, Legislation who is responsible for legislative matters; (4) and two Assistants to the Commissioner who are responsible for planning for housing, recreation area development, and economic advice.

        Under the Deputy Commissioner, there are three Assistant Commissioners who are responsible for the Division of Administration, Division of Community Services and the Division of Economic Development respectively.

        The Division of Administration consists of the Branches of Budget and Finance, Personnel, Plant Design and Construction, Plant Management and Property and Supply.

        The Division of Community Services consists of the Branches of Education, Employment Assistance, Law and Order, and Welfare.

        The Division of Economic Development consists of the Branches of Credit and Financing, Forestry, Housing Development, Industrial Development, Land Operations, Real Estate Appraisal and Real Property Management.

        The following are some of the functions of the different branches of the Bureau of Indian Affairs which are pertinent and of particular interest to the activities and programs of the Division of Indian Health.

        Branch of Plant Design and Construction - This branch is responsible for the design and construction of the various facilities of both the Bureau of Indian Affairs and Division of Indian Health.   The branch headquarters is located in Albuquerque and they provide the Division with technical assistance in the design and construction of hospitals and other health facilities.

        Branch of Education - This branch is responsible for the educational program of the Bureau of Indian Affairs.   The Division of Indian Health is particularly interested in this branch's activity as the focal point within the Bureau of Indian Affairs for coordination in construction of school health facilities, immunization programs, health education of school children, and other related activities.

        Branch of Employment Assistance - This branch is responsible for assisting Indian people to obtain employment on or near Indian reservations or in metropolitan communities.   The Division of Indian Health provides individuals seeking employment off the reservation with physical examinations.  The branch also works closely with the branch of Industrial Development by providing financial assistance to Indians employed by industries located in areas on or near the reservation.

        Branch of Law and Order - This branch is responsible for the maintenance of law and order on reservations.   The various hospitals located within a reservation will need to work with the law and order people for the maintenance of order, when necessary, in the hospital and for an effective accident prevention program.

        Branch of Welfare - This branch is responsible for the provision of welfare and social service assistance to eligible beneficiaries usually on the reservation.

        Branch of Housing Development - This branch is responsible for housing programs on Indian reservations.   Close coordination may be necessary if sanitary and water facilities are to be provided through the Division's Sanitation Construction Facilities Program.

        Branch of Industrial Development - This branch is responsible for the location of industries on or near Indian reservations. This activity may result in an increase in the local population with its resultant impact on the local health program.
      2. The Field Organization of the Bureau of Indian Affairs

        An Area Director is in charge of an Area Office.  He reports directly to the Commissioner of Indian Affairs.   Assistant Area Directors are in charge of divisions in the Area office.   The tribal operations officers at the area reports directly to the Area Directors.

      3. Field Relationships with Bureau of Indian Affairs

        At the area level joint planning and coordination of activities is essential to a smooth efficient operation.  Since the staff of both the Bureau of Indian Affairs and the Division of Indian Health work with the same Indian groups, it is desirable and important for them to be familiar with each other's activities.

        At the service unit or reservation level need for cooperation and coordination between the two agencies is even greater.  The medical officer in charge of the Indian Health Service Unit should have frequent and regular meetings with the superintendent of the reservation at which time all problems with Indian groups should be discussed and all plans for program changes or development should be reviewed.  Likewise, the staff members of both organizations should be cognizant of the activities of the other members so that programs may be coordinated.  An interagency planning group with tribal representation frequently aids coordination.

    4. Relationships with other Federal Agencies - There are a number of federal agencies other than those within the Department of Health, Education, and Welfare or the Department of the Interior with which the Division personnel will be developing working relationships.

      The Division should advise the headquarters of any organization when it takes action affecting their activities, e.g. the Food and Drug Administration should be notified when the Division takes action regarding food poisoning where food from commercially prepared or shipped food is suspected.

      The Division has frequent contact with representatives from the following agencies.

      General Accounting Office

      The most frequent contact between the personnel of this agency and the Division is at the field level where the General Accounting Office staff conducts their financial "on-site" audit of the Division operations.

      Civil Service Commission

      The relationship with the Regional Office of the Civil Service Commission is the responsibility of the Area Office.   Frequently, the Commission will audit the personnel activities of the Area Office.   Normally, however, the Regional Office staff assists the Area Office personnel staff in their personnel functions.

      General Services Administration

      This is one of the agencies with which the Area Office staff probably has a great deal of contact.   They are extremely important in the procurement of food, supplies, equipment, etc. needed in the support of program operations.

      Department of Justice

      The Area and Service Unit staffs work with representatives of the Department of Justice from time to time on such matters as fraud or criminal acts involving or on government property, tort claims cases, etc.   While the contacts are infrequent, it would be helpful to be familiar with the legal situation regarding the police protection at hospitals and facilities.   Since the matter of federal property and Indian reservation is involved, the relationships to the Bureau of Indian Affairs and the Department of Justice personnel should be clearly understood.   The Department of Justice advised that it doubted that Public Health Service Indian field personnel, whose duties do not relate to law enforcement, are officers or employees of the "Indian field Service of the United States" within the scope of 18 USC Section 1114 and 111 establishing assaults on such personnel as Federal crimes.

      Veterans Administration

      Where facilities of the Veterans Administration are close, the availability and possible use of this resource in emergency should be explored.  Furthermore, Indian veterans are entitled to the service of the Veterans Administration.

    5. Relationships with Local and State Governmental Agencies - The service units will, in their normal operations, have a close working relationship with state and local governmental units.  In general, the medical officer in charge will function very much as a physician in private practice.   Where feasible, he will be expected to utilize available resources, make referrals to mental health services, crippled children's services, well child services, welfare services, etc.   Laboratory services, epidemic investigations, etc., should also be used if available.   And, of course, there must be compliance with the laws governing the reporting of births, deaths, communicable diseases, reportable diseases, etc.

      Preventive medical activities should be coordinated with the local health department.   Cooperative mass immunization programs, well child conferences, tuberculosis surveys, etc., will usually be quite successful and save time for both agencies.   As a rule, similar cooperative projects can be developed with other local agencies such as the welfare department, the school system, the county hospitals, etc.

  5. Nongovernmental Organization Relationships
    1. National, State and Local Professional Organizations - Some of the more important organizations are: American Medical Association, American Dental Association, American Academy of General Practice, American Public Health Association; National Medical Association, American Nursing Association, National League of Nursing, American Public Welfare Association Council on Social Work Education, National Association of Social Workers, American Pharmaceutical Association, Association of State and Territorial Health Officers, American Hospital Association, National Association of Sanitarians and others.

      Headquarters representatives will be maintaining contacts with the headquarters officials of the various professional groups.  Through these relationships, a promotional program can bring to the professional group a better understanding of our accomplishments, our plans and our needs.   This can also be of some assistance in the recruiting of professional personnel.

      The area office can in like manner work with the state organizations and the service unit personnel can actively participate in the activities of the local professional groups.

    2. National, State and Local voluntary Health and Welfare Agencies - Some of the more prominent agencies are:   American Cancer Society, National Tuberculosis Association, Society for Crippled Children and Adults, National Heart Association, American Red Cross, Salvation Army, National Foundation, etc.

      The appropriate professional groups at the national area and service unit level, can by working with the voluntary agency representatives, develop procedures for a coordinated program which will permit maximum utilization of the services of the non-official organization.

    3. Educational Institutions of all Types, Including State Colleges and Universities - It is desirable to maintain a working relationship with professional and academic schools for the purpose of recruiting staff and developing training facilities for staff improvement.

      The recruitment of Commissioned Officers for the Division will, for the most part, be the responsibility of the Area Offices; however, these recruiting activities will be coordinated by the Central Office and the Office of Personnel.   Each area will be assigned specific professional schools and hospitals to visit for recruiting purposes.   In addition to the more formal recruiting activities, each officer should utilize every opportunity to encourage potential candidates to make application.

      It will also be the responsibility of the area staff to actively recruit for vacancies that can be filled through civil service.   Arrangements for long term training opportunities are circulated to the prospective staff members and applications are made through the usual channels.   Short term training and refresher courses are usually planned by the area office and approved by headquarters.

    4. Tribal Councils and Indian Interest Groups - The accomplishment of the Division's mission depends on an understanding and acceptance of its program by the tribal councils and the Indian people.   For this reason, the service unit staff must develop a close working relationship with the tribal council and other Indian leaders.   Most tribal groups have health committees who are usually glad to assist in the promotion of health programs.   Regular meetings with a planned agenda and active Indian participation will aid in the development of strong support for the health program.   Also, every staff member has many opportunities to do informal teaching and promote better understanding.   The staff at the area level is responsible for providing leadership and guidance to the service unit staff.   They also must meet periodically with the tribal groups and maintain a close relationship with their leaders.

      As a matter of policy, central office will not normally have a direct relationship with tribal representatives, and where possible, this work will be delegated to the area.   However, from time to time most tribal groups will send representatives to Washington and while there they will visit the central office of the Division.   In order that central office staff may be informed and prepared for the visit, the area director should request the service unit and the tribal council to provide him information regarding the date of the proposed Washington meeting and the subject of the discussion so that the Division chief may be properly informed.

1-4.6  MEDICAL STAFF ORGANIZATION

  1. The medical and Dental Staff of each Indian Health Service Hospital will develop Medical and Dental Staff Bylaws, Rules and Regulations which meet the minimum standards of the Joint Commission on Accreditation of Hospitals.

    The Bylaws, Rules and Regulations shall be reviewed annually and revised as required.

  2. Other IHS facilities (infirmaries, health centers and health stations) will develop Medical and Dental Staff Bylaws, Rules and Regulations patterned after the appropriate Joint Commission on Accreditation of Hospitals standards.
  3. The Area/Program Director shall be responsible for approving the Medical and Dental Staff Bylaws, Rules and Regulations for the Service Units in his/her Area or Program, and insuring that the intent of the minimum standards is implemented.
  4. Increasing efforts are being made nationally by optometrists, podiatrists, medical practitioners and allied medical personnel to gain greater recognition by seeking membership on hospital medical staff organizations.

    5. Currently, membership on the hospital medical staff is limited by the Joint commission on Accreditation of Hospitals to qualified physicians and dentists.   Although the JCAH encourages the granting of clinical privileges to health care professionals who provide clinical services to hospital patients, the JCAH standards do not permit the granting of medical staff membership and the privilege of admitting inpatients, voting, and holding office in the hospital medical staff organization to other than physicians and dentists.

    The categories of the medical staff membership consist of the active, associate, courtesy, consulting, and honorary staff, which categories are commonly reserved for qualified members of the medical staff.   In order to accommodate optometrists, podiatrists, medical practitioners and allied medical personnel other than physicians and dentists, hospitals may create separate categories such as "professional staff" or "affiliated staff" or others, in order to grant clinical privileges and to provide a mechanism(s) to allow such individuals to participate in medical staff meetings and deliberations.

  5. POLICY.  It is the policy of the IHS to encourage the medical staff to grant clinical privileges to optometrists, podiatrists, medical practitioners and allied medical personnel who provide clinical services to hospital patients and to encourage the participation of such individuals in medical staff meetings and deliberations.

    The medical staff of each hospital shall delineate in its bylaws, rules and regulations, the qualifications, status, specific clinical duties and responsibilities for each of the categorical professionals and medical practitioners utilized by the hospital.   The training, experience, licensure and demonstrated competence of individuals in such categories shall be sufficient to permit their performance of the following:

    1. Exercising judgment and participating directly in the management of patients within their areas of clinical competence, provided that a physician member of the medical staff shall have the ultimate responsibility for patient care.
    2. Recording reports and progress notes in patient records and writing orders to the extent established for them by the medical staff.
    3. Performing services in conformity with the applicable medical staff bylaws.
    4. Participating in medical staff meetings and deliberations to the extent delineated.

1-4.7  ORDER OF SUCCESSION

During the absence or disability of the Director, Indian Health Service, or in the event of a vacancy in that office, the first official listed below who is available, shall act as Director, except that during a planned period of absence the Director may designate by memorandum a different order of succession.

  1. Deputy Director, Indian Health Service
  2. Director, Division of Program Operations, IHS
  3. Associate Director for Administration, IHS
  4. Director, Division of Resource Coordination, IHS
  5. Chief Medical Officer, IHS
  6. Director, Division of Indian Community Development
  7. Director, Division of Program Formulation, IHS

    During the absence or disability of the Deputy Director, IHS, or in the event of a vacancy in that office, the Associate Director for Administration shall act as Deputy Director.

    Only the principal incumbent in line officer (Division Directors) or staff officer (Officer Directors) positions in the order of succession shall act for the Director in his/her absence.

    Persons officially designated as "acting" in a line or staff position to which authority has been delegated may exercise the authority to the same extent as the incumbent, but the order of succession shall pass by a person designated as "acting" to the next principal line or staff officer incumbent in the order of succession.