[Federal Register Volume 89, Number 249 (Monday, December 30, 2024)]
[Notices]
[Pages 106537-106539]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-31273]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
Organization, Functions, and Delegations of Authority; Part G;
Indian Health Service; Headquarters, Office of the Director, Office of
Quality
AGENCY: Indian Health Service, Department of Health and Human Services.
ACTION: Final notice.
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SUMMARY: Part G of the Statement of Organization, Functions, and
Delegations of Authority of the Department of Health and Human Services
(HHS) is hereby amended to reflect a reorganization of the Indian
Health Service (IHS). The purpose of this reorganization proposal is to
update the current approved IHS, Office of the Director (GA),
Congressional and Legislative Affairs Staff (GA1) and the Office of
Quality (GAP) in their entirety and replace with the following:
SUPPLEMENTARY INFORMATION: The IHS is an Operating Division within the
Department of Health and Human Services (HHS) and is under the
leadership and direction of a Director who is directly responsible to
the Secretary of Health and Human Services. The IHS Headquarters is
proposing to reorganize the following major component: Office the
Office of Quality (OQ).
Part G of the Statement of Organization, Functions, and Delegations
of Authority was most recently amended at 89 FR 61126, July 30, 2024.
[[Page 106538]]
Office of the Director, IHS (GA)
Congressional and Legislative Affairs Staff (CLAS) (GA1)
(1) Serves as the principal advisor to the IHS Director on all
legislative and congressional relations matters; (2) advises the IHS
Director and other IHS officials on the need for changes in legislation
and manages the development of IHS legislative initiatives; (3) serves
as the IHS liaison office for congressional and legislative affairs
with Congressional offices, the HHS, the Office of Management and
Budget (OMB), the White House, and other federal agencies; (4) tracks
all major legislative proposals in the Congress that would impact
Indian health; (5) ensures that the IHS Director and appropriate IHS
and HHS officials are briefed on the potential impact of proposed
legislation; (6) develops legislative strategy for key policy and
legislative initiatives; (7) provides technical assistance and advice
relative to the effect that initiatives/implementation would have on
the IHS; (8) provides support and collaborates with the Office of
Finance and Accounting relative to IHS appropriations efforts; (9)
directs the development of IHS briefing materials for congressional
hearings, testimony, and bill reports; (10) analyzes legislation for
necessary action within the IHS; (11) develops appropriate legislative
implementation plans; (12) coordinates with IHS HQ and Area Offices as
appropriate to provide leadership, advocacy, and technical support to
respond to requests from the public, including tribal governments,
tribal organizations, and Indian community organizations regarding IHS
legislative issues.
Office of Quality (GAP)
The Office of Quality (OQ) provides leadership and direction for
quality improvement and patient safety activities and oversees
compliance and risk management throughout the agency. Specifically, the
office (1) advises the Indian Health Service (IHS) Director on assuring
quality health care, maximizing the patient experience, and
systematizing quality improvement activities to improve clinical
outcomes and administrative processes; (2) develops and implements a
strategic quality framework; (3) oversees accreditation readiness
activities and compliance with accreditation requirements at all IHS
Direct Service facilities; (4) conducts performance improvement,
quality assurance, innovative thinking, and risk management trainings;
(5) oversees IHS facilities and staff in intra-agency quality
improvement activities; (6) advises on development and monitoring of
quality assurance and governance metrics for health care delivery
processes and outcomes; (7) develops programs to assess, address, and
improve systems and processes to improve health care quality; (8)
advises on compliance with relevant federal regulations and
accreditation and professional standards; (9) provides guidance for
standardization of health care delivery policies, protocols, and
governance; (10) advises and guides IHS patient-centered care
processes, ensuring engagement of patients as partners in care; (11)
oversees the IHS Enterprise Risk Management (ERM) vision, culture,
strategy, and framework and clinical risk management; (12) oversees and
coordinates the agency's efforts to establish and maintain proper
internal controls; (13) ensures requirements are met under OMB Circular
A-123; (14) develops programs to promote patient safety management and
reporting systems and processes, sentinel event investigations/root
cause analysis; and (15) participates in cross-cutting issues and
processes, including but not limited to, emergency preparedness/
security, quality assurance, recruitment, budget formulation, self-
determination issues, and resolution of audit findings as may be needed
and appropriate.
Division of Quality Assurance and Patient Safety (GAPA)
(1) Develops and implements programs to promote sustained
compliance with relevant federal regulations related to accreditation
and professional standards for health care facilities; (2) manages and
coordinates continuous accreditation compliance programs using
multidisciplinary integration of survey readiness activities; (3)
coordinates health care accreditation resource management; (4) tracks
health care accreditation and certification survey reports; (5)
develops and implements programs to manage credentialing standards and
policy, acquires and maintains centralized credentialing software
system, promotes unification of medical staff professionals (MSP), and
promotes standardized training and support resources for MSP; (6)
develops and implements policies and procedures to promote patient
safety, infection control practices, and environment of care and life
safety practices; (7) establishes policies and guidelines to reduce
adverse events; (8) develops education and training related to the
application of established patient safety and adverse event reporting
systems and metrics; (9) establishes and maintains oversight mechanisms
for incident identification and reporting, adverse events and good
catches, comprehensive systemic analysis/root cause analysis process
and documentation; (10) implements strategies to improve patient and
workforce safety; (11) enhances collaborative communication to
facilitate the sharing of best practices and learning related to
identified risks and mitigation actions across the agency; (12)
identifies IHS and National patient safety trends and investigates
positive and negative patient safety outcomes across the agency; and
(13) provides patient safety consultation regarding industry standards,
best practices, and development of policy, processes, and procedures.
Division of Enterprise Risk Management (GAPB)
(1) Oversees and coordinates the IHS ERM vision, culture, strategy,
and framework; (2) develops goals and objectives for the ERM program,
integrated with broader IHS-wide strategic goals/objectives, and tracks
progress toward achieving them; (3) coordinates the development of risk
policy, including a risk appetite statement, to guide Agency decision-
making and documentation related to risk; (4) advises and collaborates
in the development of the IHS ERM portfolio of enterprise risks and
ensures appropriate and effective management by accountable individual
risk owners; (5) integrates risk assessment activities across the IHS
risk portfolio; (6) advises on ERM and provides expertise, advice, and
assistance to the agency leadership on compliance matters; (7) provides
guidance and training on the risk management process and
prioritization; (8) facilitates the governance policy, process, and
reporting to establish consistency and quality of documentation of
fiduciary responsibilities of governing bodies; (9) oversees tracking
of high-risk administrative, clinical, or personnel incidents to ensure
appropriate local and agency-wide response, timely closure, assessment
of internal controls, and review of case studies to promote a safety
culture based on risk-awareness; (10) collaborates with key HQ Offices
to ensure consistency in cross-cutting agency strategic planning, ERM,
and management of internal controls across IHS; (11) collaborates with
strategic planning process to integrate risk management and strategic
thinking; (12) reviews tort claims files; (13) represents the IHS when
claims are presented for review by the Malpractice Claims
[[Page 106539]]
Review Panel chartered by the HHS, and assists providers with
Malpractice Claims Review Panel interactions; (14) submits payment
reports to the National Practitioner Data Bank; (15) maintains case
files and a malpractice claims database; (16) provides case summaries,
peer review, outcome information, and feedback of risk management
recommendations; (17) disseminates information about the review
process; (18) responds to outside organizations requesting tort claim-
involvement histories on former employees; and (19) responds to Tort
Claims inquiries from governmental agencies, media, Tribal and Urban
Indian organizations, and advocacy groups with the Office of General
Council guidance.
Division of Innovation and Improvement (GAPC)
(1) Provides trainings on innovative thinking and performance
improvement techniques; (2) provides training on empathy and relational
intelligence to better understand colleagues and stakeholders and
maximize teamwork; (3) integrates innovative thinking into quality
improvement and policy formation processes to stimulate rapid idea
generation; (4) oversees training programs to increase quality
improvement capacity and standardize improvement methodology to test
small-scale changes at the local level; (5) reviews use of health
information technology and data to improve performance, quality and
service; (6) monitors patient and staff satisfaction with health care
service delivery; (7) leads change management for practice
transformation to embrace new models of care delivery and to enhance
efficiency of the care delivery process; (8) develops programs to
promote the implementation of patient-centered care models; (9)
coordinates sharing of best practices between Area Quality Managers and
Service Unit Quality Assurance and Performance Improvement officers;
and (10) supports and promotes patient-centered care including Patient
and Family Engagement, and promotes unification of Area Quality
Managers and Service Unit Quality Assurance and Performance Improvement
Officers.
Division of Compliance (GAPD)
(1) Coordinates the IHS's compliance program; (2) administers the
agency's internal control program in accordance with the Federal
Managers' Financial Integrity Act, OMB Circular No. A-123, GAO Green
Book, and other applicable requirements; (3) oversees and coordinates
the agency's efforts to establish and maintain proper internal
controls; (4) oversees and institutionalizes a continuous compliance
review process; (5) manages goals and objectives for the Compliance
program, integrates them with broader IHS-wide strategic goals/
objectives, and tracks progress toward achieving them; (6) evaluates
and monitors systems of internal control across IHS and uses the
assessments of the internal control program as an integral part of ERM
to effectively manage risks across IHS; (7) Serves as the IHS liaison
office to the Government Accountability Office (GAO) and Office of
Inspector General (OIG); (8) coordinates the development, clearance,
and transmittal of IHS responses and follow-up to reports issued by the
OIG, the GAO, and other federal internal and external authorities
reviewing risk management and internal controls; (9) provides
leadership and direction on activities for continuous improvement of
management accountability and administrative systems for effective and
efficient program support services IHS-wide; and (10) oversees and
coordinates the annual development and submission of the agency's
federal Activities Inventory Reform Act report to the HHS.
Section GA-30, Indian Health Service--Delegations of Authority
All delegations of authority and re-delegations of authority made
to IHS officials that were in effect immediately prior to this
reorganization, and that are consistent with this reorganization, shall
continue in effect pending further re-delegation.
Roselyn Tso,
Director, Indian Health Service.
[FR Doc. 2024-31273 Filed 12-27-24; 8:45 am]
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