Sterile Processing Service Deficiencies and Leaders’ Response at the Carl Vinson VA Medical Center in Dublin, Georgia

Report Information

Issue Date
Report Number
22-01315-90
VISN
7
State
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Supplies and Equipment
Major Management Challenges
Leadership and Governance
Recommendations
9
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) substantiated allegations from January 2022 that employees did not properly reprocess reusable medical equipment (RME) within the facility’s Sterile Processing Service (SPS). Facility leaders halted all endoscope usage, as well as stopped surgeries and procedures requiring RME, until an investigation was completed.

The OIG identified multiple issues that contributed to SPS deficiencies, including unaddressed, previously-identified issues within SPS, such as the failure to implement CensiTrac Instrument Tracking System, SPS standard operating procedures (SOPs) being out of date and not accessible to staff, competency training being inadequate and ineffective, failure to control traffic in the sterile area that potentially impacted the integrity of RME, and the negative impact of interim and acting leaders within SPS.

In April 2022, the facility had potentially harmful, abnormal critical water test results, which led to another halting of all RME reprocessing. The OIG found that leaders delayed addressing consistently abnormal testing results within SPS.

The OIG made two recommendations to the VISN Director related to reviewing the facility’s SPS water management program and ensuring the VISN SPS Management Board reviews critical water testing results.

The OIG made seven recommendations to the Facility Director related to ensuring that the SPS chief conducts comprehensive staff competency assessments for reprocessing RME; the CensiTrac Instrument Tracking System is fully implemented and staff are trained in its use; SPS maintains a safe and clean environment in all areas where RME processing is performed; a plan is developed for remediation of the location of the training room adjacent to SPS’s clean storage area; all clinic areas have or share a designated soiled utility storage room; SOPs for all RME are developed and disseminated; and the facility Water Working Group submits critical water test results to the VISN. 

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Carl Vinson VA Medical Center Director ensures that the Sterile Processing Services chief conducts comprehensive staff competency assessments for the reprocessing of reusable medical equipment, and monitors for compliance.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Carl Vinson VA Medical Center Director ensures that the CensiTrac Instrument Tracking System is fully implemented, and that training is provided to the CensiTrac coordinator and Sterile Processing Services staff, and monitors for compliance.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Carl Vinson VA Medical Center Director evaluates and ensures that Sterile Processing Services maintains a safe and clean environment in all areas where decontamination, sterilization, or clean and sterile storage of reusable medical equipment are performed, and monitors for compliance.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Carl Vinson VA Medical Center Director develops an action plan for remediation of the location and use of the training room adjacent to Sterile Processing Services’ clean and sterile storage area, and monitors for compliance.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Carl Vinson VA Medical Center Director ensures that clinic areas, including radiology, have or share a designated soiled utility room as required by Veterans Health Administration policy, and monitors for compliance.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Carl Vinson VA Medical Center Director ensures that Sterile Processing Service standard operating procedures for reusable medical equipment are developed, updated consistent with manufacturer’s instructions for use, disseminated, and available at the point of use, and monitors for compliance.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director reviews the facility’s Sterile Processing Service water management program and takes action as necessary to ensure compliance with Veterans Health Administration guidance, and monitors for compliance.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Carl Vinson VA Medical Center Director ensures that the facility Water Working Group submits critical water system test results to the Veterans Integrated Service Network Sterile Processing Services Management Board, as required, and monitors for compliance.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures all critical water system test results are reviewed by the Veterans Integrated Service Network Sterile Processing Services Management Board, corrective action is taken when appropriate, and all corrective actions are reported to the National Program Office for Sterile Processing, and monitors for compliance.