Deficiencies in Sterile Processing Services and Decreased Surgical Volume at the VA Connecticut Healthcare System, Newington and West Haven, Connecticut

Report Information

Issue Date
Closure Date
Report Number
19-00075-14
VISN
State
Connecticut
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
11
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted an inspection in response to a request from Senator Richard Blumenthal to review issues related to Surgical and Sterile Processing Services (SPS) within the VA Connecticut Healthcare System (system). The request came after an unannounced survey of the system by The Joint Commission (TJC) in February 2018 and a subsequent site review by VHA’s National Program Office for Sterile Processing (NPOSP) in May 2018. Both reviews found deficiencies in the system’s SPS. System leaders began an immediate reduction in SPS reprocessing of instruments and limited Surgical Services procedures to focus efforts on correcting the SPS deficiencies. This inspection focused on the implementation of TJC and NPOSP recommendations; SPS standard operating procedures (SOPs), training, competence, and staffing; surgical cancellations and outsourcing to the community; patient safety and undue burden; and surgical and post-operative infection rates. The OIG team identified additional concerns related to leaders’ decision-making and actions, how the current infrastructure (specifically aging buildings) impacted remediation, and the residency program. The OIG made two recommendations to the Veterans Integrated Service Network Director related to oversight of timely completion of the OIG’s recommendations and hiring actions. The OIG made nine recommendations to the System Director related to inclusion of operating room, surgery, and SPS clinical leaders in remediation efforts; an action plan to establish communication, foster collaboration, and restore trust in system leaders; oversight for the timely completion of pending projects impacting Surgical Services; the development, review, and revision of SOPs and a sustainable SOP maintenance process; SPS staff training and competencies; SPS staffing plan maintenance; readiness evaluation of supplies and equipment prior to anesthetizing a patient; evaluation of the impact and identified needs of the residency programs; and collaboration between the System and Veterans Integrated Service Network 1 Director.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The Veterans Integrated Service Network 1 Director provides oversight for the timely implementation of Office of Inspector General recommendations directed to the VA Connecticut Healthcare System Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The Veterans Integrated Service Network 1 Director ensures the timely completion of hiring actions at the VA Connecticut Healthcare System until staffing deficiencies in Sterile Processing Services and Facility Management Services are fully resolved.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures clinical leaders with working knowledge of and/or expertise in operating room, surgery, and Sterile Processing Services are included in the decision-making and resolution of Sterile Processing Service remediation efforts.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The VA Connecticut Healthcare System Director ensures the development and implementation of a clear action plan to establish communication, foster collaboration, and restore system staff trust in system leaders, and, as necessary, consult with Veterans Health Administration’s National Center for Organizational Development.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The VA Connecticut Healthcare System Director provides oversight for the timely completion of the projects impacting Sterile Processing Services and Surgical Services that remain pending.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The VA Connecticut Healthcare System Director ensures that the development, review, and revision of standard operating procedures is completed, and that a sustainable process is in place to maintain standard operating procedures.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures that all Sterile Processing Services staff complete and maintain Sterile Processing Services training and competencies.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures that Sterile Processing Services leaders maintain a staffing plan that includes an accurate number of authorized positions that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The VA Connecticut Healthcare System Director ensures that surgery and anesthesia staff evaluate the readiness of all supplies and equipment for use before anesthetizing a patient.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2020
The VA Connecticut Healthcare System Director evaluates and reports the impact on and identified needs of the VA Connecticut Healthcare System residency program.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2021
The VA Connecticut Healthcare System Director works collaboratively with Veterans Integrated Service Network 1 Director to ensure the timely implementation of future Sterile Processing Services planned projects.