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Healthcare Inspection – Operating Room Reusable Medical Equipment and Sterile Processing Service Concerns, VA New York Harbor Healthcare System, New York, New York

Report Information

Issue Date
Report Number
14-04274-418
VISN
State
New York
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to complaints about operating room (OR) reusable medical equipment (RME) and Sterile Processing Service (SPS) at the Manhattan Campus of the VA New York Harbor Healthcare System (facility), New York, NY. Following our first site visit, the Veterans Health Administration (VHA) completed external reviews of select components of the OR/SPS program. The facility made some progress in addressing the recommendations. On a second visit in October 2015, OIG found continued unresolved concerns in aspects of the program. We substantiated that some OR RME trays were missing instruments and/or were not properly processed with filters or indicators. We found that SPS medical support technicians failed to place external tags on rigid containers or use standardized methods on count sheets. We determined there was no significant harm to 14 patients who had SPS-related cancellations or delays of surgeries or other SPS-related concerns during a 5-month period. We substantiated that some OR RME containers and packages were heavy and stored above head level, which placed nurses at risk for injury. We did not find documentation of training for proper handling of sterile packages for OR staff or a formal process in place to track and trend issues with packages. We confirmed that SPS staff were not consistently available in the SPS-OR sterile storage rooms. We did not substantiate that OR nurses had to leave patients to get supplies and instruments, creating a dangerous patient care situation. We found that SPS staffing levels appeared inadequate and may not support newly expanded hours. We found the facility did not have an effective SPS quality control program and that OR and SPS staff members did not collaborate or communicate well, which created a contentious culture and interfered with resolving problems. We made eight recommendations to the System 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)
We recommended that the System Director charter a team to evaluate the facility's entire process involving reusable medical equipment in accordance with applicable guidelines, integrate reviews' recommendations, and develop an overarching reusable medical equipment management plan.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable national and local policies and guidelines for the reprocessing of reusable medical equipment and the preparation of trays and instrument lists.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable guidelines to record daily temperature and humidity levels in Sterile Processing Service areas and act upon and document actions when temperature and humidity levels are out of range.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that an ergonomic assessment be made of the physical access and weight of items stored in the operating room Sterile Processing Service storage area and ensure staff safety and compliance with applicable Occupational Safety and Health Administration standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure training of operating room staff in proper handling of sterile packages and establish a formal process to track and trend issues with packages.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure adequate staffing to manage the operational requirements of Sterile Processing Service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that the operating room and Sterile Processing Service staff implement a reusable medical equipment quality control program consistent with Veteran Health Administration guidelines.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director implement measures to improve collaboration and communication within and between operating room and Sterile Processing Service staff.