Comprehensive Healthcare Inspection Summary Report: Evaluation of High-Risk Processes in Veterans Health Administration Facilities, Fiscal Year 2020

Report Information

Issue Date
Closure Date
Report Number
21-01509-264
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Report Topic
Supplies and Equipment
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ reusable medical equipment (RME) programs. This evaluation focused on facility Sterile Processing Services (SPS) processes for reusable medical equipment related to administration, quality assurance, and staff training. This report describes RME-related findings from healthcare inspections performed at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG reviewers examined relevant documents and training records, observed reprocessing and storage areas, and interviewed key managers and staff. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews. The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses in various key RME-related processes and issued seven recommendations related to: • Standard operating procedures aligning with manufacturers’ guidelines • Annual risk analysis reporting to the VISN SPS Management Board • SPS chiefs developing, implementing, and enforcing a daily cleaning schedule for all SPS areas • Equipment storage • Completion of Level 1 training within 90 days of hire, competency assessments for RME, and monthly continuing education for SPS staff

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: 9/19/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility staff use standard operating procedures that align with manufacturers’ guidelines when reprocessing colonoscopes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures Sterile Processing Services chiefs report annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that Sterile Processing Services chiefs develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures Sterile Processing Services staff properly store high-level disinfected endoscopes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/27/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that Sterile Processing Services staff complete competency assessments for reprocessing reusable medical equipment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that Sterile Processing Services staff receive monthly continuing education.