Alleged Concerns in Sterile Processing Services at the New Mexico VA Health Care System, Albuquerque, New Mexico

Report Information

Issue Date
Report Number
17-04593-10
VISN
State
New Mexico
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The OIG conducted a healthcare inspection in response to allegations regarding Sterile Processing Services (SPS) at the New Mexico VA Health Care System. The OIG team did not substantiate tampering with equipment was occurring or that sterile sets were incorrectly stored or damaged. Thirty-eight of 356 sterile sets inspected were missing instruments; those sets were not consistently labeled as to which instruments were missing. Not all patient safety events were reported as required. Additionally, some surgical procedures were delayed or canceled due to unavailable sterile instruments and equipment. The OIG team determined that, while no patient experienced an adverse clinical outcome related to delays or cancellations, three patients were exposed to increased risks for adverse clinical outcomes. The contract for SPS technicians responsible for reusable medical equipment (RME) reprocessing lapsed in spring 2017. An increase in the number of surgical delays and cancellations occurred for the two months after the contract ended, but the OIG could not establish the surgical delays were related to SPS staffing. Deficiencies in the documentation of SPS staff training and competency records as well as in the maintenance of a comprehensive list of RME and standard operating procedures for some items were identified. The OIG determined the VISN did not provide effective oversight and the facility did not effectively implement proposed action plans, as evidenced by recurring findings reported in multiple inspections. The OIG made 12 recommendations related to missing instruments, verification of items in sterile sets, accurate patient safety event reporting, SPS training, maintenance of an accurate RME list, standard operating procedures, competencies, a review of the SPS contract, implementation of actions from previous reviews and this review, evaluation of the SPS risk assessment, and independent verification by VISN staff, if necessary, to implementation of action plans related to SPS recommendations.

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 New Mexico VA Health Care System Director ensures that Sterile Processing Services staff adhere to the missing instrument procedures for sterile sets as required by Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director ensures that Sterile Processing Services staff adhere to the requirements for verification of items in sterile sets as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director evaluates patient safety reporting systems to ensure that all events are captured in WebSPOT as required by Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director ensures that all Sterile Processing Services staff, including contract staff, complete training as required by Veterans Health Administration Directive 1116 (2).
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director verifies that Sterile Processing Services managers maintain an accurate list for reusable medical equipment and copies of manufacturers’ instructions as required by Veterans Health Administration policy and the April 2017 Deputy Under Secretary for Health for Operations and Management memorandum.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director ensures that Sterile Processing Services maintain updated and readily accessible standard operating procedures for all instruments and equipment within Sterile Processing Services in accordance with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director ensures that competency assessments for all Sterile Processing Services staff, including contract staff, are conducted and documented as required by Veterans Health Administration Directive 1116 (2).
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The New Mexico VA Health Care System Director reviews the contract related to Sterile Processing Services technicians to determine if requirements for training and certification are consistent with Veterans Health Administration Directive 1116 (2) and takes action as necessary.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network 22 Director ensures that the New Mexico VA Health Care System Director implements action items from previous external Sterile Processing Services inspection reviews.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network 22 Director oversees implementation of this report’s recommendations that are directed to the New Mexico VA Health Care System Director.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network 22 Director reviews the New Mexico VA Health Care System’s Sterile Processing Services risk assessment to determine if identified high-risk items and areas are in alignment with guidance from the Deputy Under Secretary for Health for Operations and Management and takes action as necessary.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network 22 implements a process that identifies instances when independent verification by Veterans Integrated Service Network staff is necessary to ensure that the Facility implements action plans related to Sterile Processing Services recommendations.