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

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