07/13/2023

The purpose of this Special General Memorandum (SGM) is to reiterate existing procedures for how the Indian Health Service (IHS) direct service health care facility Governing Boards (GBs) monitor, report, and document oversight of allegations of sexual or physical abuse by a provider at an IHS facility. The IHS is issuing this SGM because this issue requires special attention by IHS employees.

It is the policy of the IHS that all direct service health care facility GBs will provide oversight of all allegations of sexual or physical abuse by a provider by:

1. Ensuring that all allegations of sexual or physical abuse by a provider are reported and investigated consistent with applicable bylaws; and
2. Following all applicable reporting and investigation procedures as defined in policy, regulation, and statute; including Indian Health Manual (IHM) Part 3, Chapter 20, “Protecting Children from Sexual Abuse by Health Care Providers."

The standardized approach to monitoring, reporting, and documenting oversight of allegations of sexual or physical abuse by providers includes the following responsibilities:

1. Area Directors are responsible for:
   1. Ensuring that all GB members receive an orientation on their responsibilities.
   2. Ensuring that the following requirements are included in relevant Area policies or bylaws for governance:
      1. The oversight responsibilities for all GB members.
      2. The parameters or standards for reporting and investigating allegations of sexual or physical abuse of patients by providers are consistent with applicable bylaws.
      3. Documentation on all reviews and discussion of closed sessions of the Executive Committee or relevant committee of the GB related to reports on allegations of sexual or physical abuse of patients by providers, whether at scheduled full GB or ad hoc subcommittee meetings (including documentation if no reports were presented).
      4. Notification by each GB Chair to the IHS designated Headquarters (HQ) contact on the identification of any allegations that give reason to suspect that there has been an incident of abuse within the timeline identified in the Area GB policy/bylaws in accordance with the IHS designed HQ contact reporting requirements.
2. The GBs are responsible for:
   1. Ensuring that the medical staff monitor for sexual or physical abuse of patients by providers through the peer review system and that they report all allegations of such abuse to the Chair of the Medical Executive Committee, Clinical Director, and the Chief Executive Officer (CEO) for initial fact finding activities;
   2. Documenting how and why an oversight decision for granting privileges and evaluating credentials has been made based on GB review of available information for providers with allegations of sexual or physical misconduct;
   3. Ensuring that all appointments (initial and reappointments) which include a history of allegations of sexual or physical misconduct are reviewed and documented through active discussion and deliberation;
   4. Requiring the CEO, Clinical Director (or Service Unit Chief Medical Officer), and supervisors to monitor, address, and report all allegations of sexual or physical abuse of patients by providers according to Service Unit medical staff bylaws, Human Resources, and/or Employee Relations/Labor Relations (ER/LR) requirements; including reporting such allegations to ER/LR, the United States Public Health Service Commissioned Corps liaisons, and contracting for contracted providers, as appropriate; and
   5. Following all requirements outlined in IHM Part 3, Chapter 20, “Protecting Children from Sexual Abuse by Health Care Providers."

Effective Date: This SGM becomes effective on the date signed.

/Roselyn Tso/
Roselyn Tso
Director
Indian Health Service