Improvements in Sterile Processing Service and Leadership Oversight at the Edward Hines, Jr. VA Hospital in Hines, Illinois

The Office of Inspector General (OIG) initiated an inspection to assess allegations of deficient practices within the Sterile Processing Service (SPS) at the Edward Hines, Jr. VA Hospital (facility) in Hines, Illinois, as well as the alleged failure of SPS leaders to provide adequate oversight, quality control, education, and training to SPS staff. The OIG did not substantiate that dirty instruments were sent to the operating room, that endoscopes were not being cleaned properly, that loaner trays were not reprocessed appropriately, or that SPS standard operating procedures were chaotic and incomplete. The OIG found no reported deficiencies in reprocessing of reusable medical equipment for operating room use during the period of the inspection. The OIG also assessed the status of facility action plans from April 2021, which addressed prior SPS deficiencies, and found that the facility had implemented and sustained process improvement actions. The OIG did not substantiate that SPS leaders failed to provide adequate oversight, quality control, education, and training to SPS staff or that SPS leaders and education and training staff lacked appropriate knowledge to provide staff training. SPS leaders and education and training staff implemented relevant training plans and assessed staff competencies in accordance with VHA policy. SPS leaders conducted oversight of staff competencies per VHA policy. Although the OIG noted instability within SPS leadership positions, facility leaders worked with Veterans Integrated Service Network (VISN) subject matter experts to ensure continuity of leadership when vacancies existed. The OIG learned of challenges related to workplace culture within SPS, which may have factored into unsubstantiated negative perceptions of service leadership. The OIG determined that both the VISN and facility leaders maintained adequate oversight, identifying and taking actions in response to concerns, and providing support for quality improvement efforts within SPS at the facility.