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1. Indian Health Service has strengthened patient protection policies but must fully integrate them into practice and organizational culture

2. Instances of IHS labor and delivery care not following national clinical guidelines or best practices

3. Few patients received high amounts of opioids from IHS-run pharmacies

4. Indian Health Service facilities made progress incorporating patient protection policies, but challenges remain

6. Indian Health Service use of critical care response teams has helped to meet facility needs during the COVID-19 pandemic