The small IHS facility in Winnebago, which is only a little over a decade old, has a glistening lobby with decorative native art and wide, tidy hallways leading from the emergency room to the inpatient area. A spacious spiritual room offers comfort to grieving families.

Yet this same hospital also had an untrained staff person who sent a patient home from the ER last year even though tests showed the patient’s kidneys were shutting down, according to the CMS report from 2015. The patient died.

Rendering of the IHS Winnebago/Omaha hospital by Fan Fei. Photography was not allowed inside the hospital.

Seneca Smith, a short man with broad shoulders who serves in the U.S. Public Health Service Commissioned Corps, is the hospital’s acting CEO. Smith wasn’t around when the hospital lost its federal funding. He has been at the helm for less than a year, giving him the difficult task of changing the culture at a facility that has endured frequent management turnover. The Winnebago hospital has had eight permanent or acting CEOs over the last five years.

“I’ll take whatever time is needed to make sure the patient safety is where it needs to be,” Smith said.

Other IHS facilities have had serious patient safety violations. The Pine Ridge and Rosebud hospitals in South Dakota nearly lost their funding this year for substandard conditions. The Sioux San Hospital, also in South Dakota, had its emergency room shut down in September. IHS hammered out agreements with the Pine Ridge and Rosebud hospitals in May to avoid rescinding certification that would shut down its ability to bill Medicare and Medicaid.

Smith said Winnebago’s quality and safety record has improved in the past year. But the hospital’s quality data on Medicare’s Hospital Compare website are scant and often rank below average for measures that have enough data.

Smith’s reassurances fall flat with people who have heard similar statements many times in the past.

“IHS is trying to fix the problem with the same old tools that crippled the situation. It’s just a merry-go-round of ineffective, inefficient and unprofessional people that continue, especially in the Great Plains area.” — Ken Mallory, Winnebago tribe member

One of the hospital’s more recent controversial moves, which infuriated members of the Winnebago and Omaha tribes, was inking a new contract with temporary staffing firm AB Staffing Solutions. This past year, IHS signed a five-year, $60 million deal that allows AB Staffing to supervise the emergency department and other operations at the Winnebago, Rosebud and Pine Ridge facilities. The first year of the contract is worth $15 million.

Both Nebraska tribes condemned the decision. They claimed AB Staffing’s employees provide inferior care and don’t have proper credentials and training. Kitcheyan and others on the Winnebago Tribal Council say they were not involved in the decision and that it would cost the agency more money in the long run because of the high expenses associated with temporary staffing.

AB Staffing CEO Evan Burks defends his company. “The provision of medical care is a very emotional issue,” he said. “If the results aren’t what they expect, then there’s going to be some disappointment, some second-guessing.”

IHS has since amended the AB Staffing contract to include additional qualifications for contract providers. “There’s always going to be patient complaints no matter what facility you’re in,” acting Winnebago CEO Smith said. “Patient complaints are not specifically unique to the Omaha Winnebago service unit.”

But the controversy stoked further distrust of IHS and built more support for getting the hospital out of the system. “I left (IHS) because I could not … I couldn’t be a part of a machine that it had become,” said Wehnona Stabler, a member of the Omaha tribe who is the CEO of the Carl T. Curtis Health Education Center, a nearby clinic that provides primary care and nursing. Stabler, a longtime IHS leader, ran the hospital in the 1990s and is a longtime critic of AB Staffing.

Stabler and other former IHS directors believe there are qualified people in the agency who are trying to make reforms. They don’t want to impugn everyone in a system that largely employs Native Americans.

Yet the constant management turnover suggests the paucity of qualified personnel in the facilities extends to top management. The IHS has placed 13 people at the Winnebago facility on administrative leave for an average of three weeks between January 2005 and September 2010.

Across 14 Great Plains facilities during the same period of time, 169 people were on administrative leave. Many were repeat offenders, according to a congressional report.

“I didn’t feel like (quality care) was supported by those above me,” said Anna Whiting Sorrell, the former IHS director of the Billings, Mont., area office who is now director of tribal health operations for the Confederated Salish and Kootenai tribes in Montana. She quit less than two years into her expected five-year tenure.

Sens. Barrasso and Thune say the legislation introduced last May would address some of the grievances. The IHS Accountability Act would make it easier to remove top officials for misconduct instead of shuffling them off to new area offices or putting them on paid administrative leave. IHS whistle-blowers would also receive greater protections.

Although the bill doesn’t directly call for increased funding, it would give the government flexibility to revamp its depressed salary system and provide housing vouchers to attract more doctors and nurses instead of relying on traveling clinical teams who rotate from facility to facility.

Despite the policy tweaks, tribal members here still view IHS as an opaque bureaucracy that often leaves everyone in the dark. “We’ve tried to work with them. We try our best,” Bass said. “But … they lie to us. They don’t communicate with us in a timely manner. Information we do get is vague.”

IHS turned down requests to interview top leaders, including Principal Deputy Director Mary Smith, who&’s been in charge of the agency since March, or those at the Great Plains area office. Dr. Yvette Roubideaux, former IHS director, declined to comment. Modern Healthcare also was asked to leave the Winnebago hospital after interviewing people inside.

“IHS takes personnel matters seriously and is committed to creating a culture of quality, leadership and accountability,” an IHS statement reads. “That commitment includes holding our people accountable for quality healthcare.”