Critical Deficiencies at the Washington DC VAMC

Report Information

Issue Date
Report Number
17-02644-130
VISN
State
District of Columbia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
40
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This report is the result of an Office of Inspector General (OIG) inspection of the VA Medical Center in Washington, D.C., (DC VAMC) that began in March 2017 after receiving a confidential complaint. The OIG released an interim report on April 12, 2017, identifying risks to patients and VA assets. This final report provided findings in four areas: (1) risk of harm to patients, (2) hospital service deficiencies affecting patient care, (3) lack of financial controls, and 4) failures in leadership. The OIG found that critical deficiencies at the DC VAMC were pervasive and persistent—often spanning many years—but were not successfully remediated by leaders at multiple levels within VA. These deficiencies impacted core medical center functions that healthcare providers need to effectively provide quality care. The report details the DC VAMC’s failures in ensuring supplies and equipment reached patient care areas when needed, processing and sterilizing instruments, managing and securing assets, maintaining cleanliness, providing timely prosthetic devices, properly reporting and analyzing patient safety events, and receiving the staffing and leadership needed for sustainable change. The OIG did not find evidence of adverse clinical outcomes, a condition that is largely attributable to front-line care providers who were committed to providing the best possible care by borrowing supplies, improvising, or personally ensuring patients received what they needed. The OIG made 40 recommendations and VA concurred with each one. VA also provided detailed action plans on how the recommendations are going to be implemented and identified the progress they have already made. This report is meant to not only improve conditions at the DC VAMC, but also to serve as a roadmap for other VA medical facilities and to improve integrated reviews and oversight by Veterans Integrated Service Networks and VA central offices.

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)
The Medical Center Director ensures that necessary supplies, instruments, and equipment are available in patient care areas at the Medical Center when and where they are needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director requires operating room staff to conduct the final validation that all supplies, instruments, and equipment needed to perform the planned procedure and to address potential complications are in the operating room and available for use.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director makes certain that the OR staff have accurate lists of surgical instruments needed for particular procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health specifies criteria under which individual medical centers will conduct wild card Aggregated Reviews for high-frequency patient safety events.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures that routine audits of incident reporting system entries are completed to ascertain that all patient safety events are in the National Center for Patient Safety database as required by VHA policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director requires Medical Center oversight committees to follow up and initiate action as necessary on quality assurance matters related to supplies, instruments, or equipment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director confirms the full utilization of a VHA authorized inventory system that contains accurate and reliable information regarding the availability of supplies throughout the Medical Center.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director makes certain that the environmental integrity of clean/sterile storerooms complies with VHA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures there are clearly defined and effective procedures for replacing missing or broken instruments, and that staff responsible for this function have been educated on the process.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director confirms that clearly defined and effective procedures address the disposition of discolored instruments during reprocessing and that staff responsible for this function have been educated on the process.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures that the Sterile Processing Service (SPS) implements a quality assurance program to verify the cleanliness, functionality, and completeness of instrument sets prior to their reaching clinical areas.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director makes certain that SPS and OR personnel comply with policies and procedures for the proper reprocessing of loaner instruments and trays.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director verifies that SPS managers maintain an accurate Master List for reusable medical equipment and file copies of manufacturer’s instructions as required by VHA policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures that the SPS maintains updated and readily accessible standard operating procedures for all instruments and equipment within SPS and its satellite areas in accordance with VHA policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director verifies that all SPS employees have appropriate, updated competencies and a demonstrated proficiency to perform their assigned duties.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director secures adequate space and funding for the Medical Center satellite reprocessing areas, which includes separate decontamination, processing, and packaging areas in accordance with VHA SPS policies.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director makes certain that the Medical Center Director resolves open and pending prosthetic consults and implements a plan to address future prosthetic consults in accordance with VHA policy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures the revision of Medical Center Fiscal Service practices to eliminate unnecessary cessations of prosthetic device purchasing, including at fiscal year-end.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director, together with Medical Center leaders, develops a staffing plan to fill vacancies that includes accurate numbers of authorized positions by service that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director ensures the timely completion of hiring actions at the Medical Center until staffing deficiencies in Logistics Service and Sterile Processing Services are fully resolved.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director transitions purchase cards held by clinical staff and used for expendable medical supplies to Logistics Service staff, while ensuring that medical supplies can be obtained in a timely manner.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures that medical supply items are added to the prime vendor formulary in order to meet prime vendor purchasing goals.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director makes certain that the Purchase Card Coordinator and approving officials monitor the issuance and future use of government purchase cards in accordance with VA Financial Policy.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director maintains segregation of duties between personnel who order and purchase expendable and nonexpendable items and those who receive the items.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director ensures that the Medical Center updates and maintains the Equipment Inventory List (EIL) as required by VA policy and makes certain that the Medical Center Director and Chief Logistics Officer are held accountable for the timely and accurate reporting of the Medical Center EIL.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures that equipment is accurately and timely entered into the Automated Engineering Management System/Medical Equipment Reporting System.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director ensures that unrequired equipment is turned in for disposition consistent with VHA policies and procedures
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director properly secures all areas used to store medical equipment and supplies.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director designates an official records manager, alternate records manager, and official records liaisons, as well as implements a records management program in accordance with the National Archives and Records Administration requirements.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director verifies that actions have been taken to notify patients when their information may have been improperly accessed, as appropriate.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Medical Center Director verifies that accurate and complete financial documentation to support medical supply and equipment purchases is readily available in accordance with GAO Standards for Internal Control in the Federal Government.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director audits a representative sample of FY 2017 Medical Center supply, instrument, and equipment purchases and ensures adequate internal controls for future purchases are in place.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Deputy Under Secretary for Health for Operations and Management ensures that the VHA Procurement and Logistics Office conducts regular audits of the logistics services within VHA medical centers to assess compliance with VA and VHA policies pertaining to procurement and logistics, and makes certain that timely and effective remediation occurs in response to all noncompliant conditions identified as a result of those audits.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director evaluates the accuracy of representations made by Medical Center staff in connection with the completion of action plans arising out of the National Program Office of Sterile Processing October 2016 site visit and determines whether administrative actions should be taken as a result of those representations.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director institutes procedures designed to ensure the accuracy of future representations made by Washington DC VA Medical Center staff in connection with action plans submitted to oversight bodies such as VHA program offices.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health clearly defines program offices’ responsibility for reporting high-priority recommendations to responsible individuals within VHACO, and requires independent verification that the relevant medical center and/or VISN have implemented the recommendations.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health develops a means of aggregating and analyzing available data on Logistics, Sterile Processing, Prosthetics, and Human Resources services (or other services as the Under Secretary for Health deems appropriate) so that major operational deficiencies at a medical center or VISN that affect multiple services or functions may be detected and corrected.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health takes appropriate administrative action to address the conditions identified in this report.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VISN 5 Director oversees implementation of recommendations directed to the Medical Center Director.
No. 40
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health verifies the successful implementation of all recommendations contained within this report.