The view from the inside: Indian Health Service employees

What do people who work (or who have worked) for the Indian Health Service, think about the Indian Health Service?

This is an important question when looking at any organization. Do the health care professionals see themselves as working for a great team? Are they employed by a government agency that’s too stingy with the resources needed to do the job? Is there an internal perception about incompetence or mismanagement? Worse, yet, does the daily grind reduce people’s effectiveness?

First: Context is critical. The Indian Health Service is a large system, employing more than 15,000 people with a budget exceeding $4.3 billion. (As a comparison, Kaiser Permanente, the nation’s largest nonprofit, is more than ten times bigger, employing 181,000 people with a budget of about $34 billion. I should also note the Kaiser Family Foundation is not affiliated with Kaiser Permanente.)

My point about these numbers is that even if 10 percent of the employees are unhappy, that represents a significant number of people. I have been hearing from many people through the year about what doesn’t work in IHS and often why. Some of the complaints involve specific employment issues – problems that, while serious, are not appropriate for a policy review. Others, however, point out specific concerns.

One example is a blunt note posted on Facebook: “I worked at the Aberdeen Area IHS for 2 years. The Property and Supply program for that area is in complete shambles. We definitely needed some HQ support to help create a meaningful accounting system. Every health system is underfunded, but what we do with our meager dollars is just good management to avoid loss, overages and shortages.”

Obviously, this person gave up – and left IHS. But that’s the challenge: How does a government agency tap into criticism in a productive way – so that people remain engaged, the organization learns from that criticism, and the results are real improvements.

Of course learning from criticism is easy with Social Media. It’s an open channel – good and bad. But that same conduit makes it easier for a dialogue. On the Facebook page, “I just spent 6 hours at IHS just for them to give me Tylenol,” this post does just that. “We are working really hard on projects such as “Improving Patient Care” (IPC). I want our patients to talk with our patient advocate about their complaints so we can hold staff accountable. We have monthly meetings scheduled to meet with the community but hardly anyone comes. So this group is helping me to look for these types of problems in our hospital. Keep up the commentary. Thank you.”

IHS Director Yvette Roubideaux uses another method to listen with an internal reform bulletin board launched last summer. “Among the first steps is to look at what our system does well and do more of it,” she wrote. “Also, we must honestly look at what is not working well and take steps to find solutions.”

The top complaint from within: An ineffectual human resource mechanism and “calls to change/overhaul Human Resources – processes to employ people, develop, utilize, and compensate them.” Next on the list were complaints about the financial management and communication practices.

In response, Dr. Roubideaux said in March that the agency is working to “improve/streamline” the hiring process, including a more efficient outreach effort. Similar efforts are underway in financial management and communication.

Another way to look at employee satisfaction at IHS is to compare it with other government agencies. Best Places to Work in the Federal Government reflects a comprehensive survey from 212,000 civil servants in 279 agencies. (It’s produced by the Partnership for Public Service and American University’s Institute for the Study of Public Policy Implementation.) Scores are generated with categories ranging from leadership to matching employee skills with the agency’s mission. The three highest rated places to work: The Nuclear Regulatory Commission, the Government Accountability Office and the National Aeronautics and Space Administration.

Best Places ranks the Indian Health Service at 151st out of 216 agencies surveyed. I compared the IHS with the Bureau of Indian Affairs and the Veterans Administration – where it’s firmly in the middle. The most interesting part of this index was that pay and benefits were seen as better at the BIA – and worse at the VA. The most promising signal in that data is the high correlation between employee skill sets matched with the IHS mission.

The perception of what it’s like to work at the IHS is critical because it’s Indian Country’s largest employer. This is also exactly why data collection is so important. How does IHS employment in terms of pay, skill sets and assessment compare to tribal or other health care agencies? Is there a difference before or after 638 contracts?

The answers could help the agency – and the larger Indian health system – improve the way people are hired, trained and managed.