Report Summary

Title: Deficient Staffing and Competencies in Sterile Processing Services at the VA Black Hills Healthcare System, Fort Meade Campus, South Dakota
Report Number: 19-07096-108 Download
Issue Date: 3/23/2020
City/State: Fort Meade, SD
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that the Associate Director for Patient Care Services endangered patient safety by placing an unqualified leader as the Acting Chief of Sterile Processing Services (SPS) at the facility.

The OIG did not substantiate that the detailed Acting Chief endangered patient safety. Facility leaders based incumbent selection on leadership experience and the individual’s workload, which the detailed Acting Chief had. The OIG reviewed issue briefs submitted during the time of the detail and found no patients were harmed.

Facility leaders failed to comply with a 2009 memorandum requiring complexity Level 1 and 2 facilities to have an SPS assistant chief position.

Facility leaders failed to ensure a reliable process was in place for identifying changes in manufacturer’s instructions. Moreover, from 2011 to 2017, SPS staff reassembled the arthroscopes and cystoscopes prior to sterilization contrary to the manufacturer’s instructions. However, once the issue was identified, the facility, Veterans Integrated Service Network, and Veterans Health Administration leaders took appropriate action to address the problem, evaluated associated risk, consulted with the required experts, and decided based on their risk analysis that patient exposure risk was minimal and no further actions were needed.

A possible reason for the facility’s failure to identify the change to the manufacturer’s instructions was a series of acting and permanent chiefs of SPS. This lack of stable SPS leadership also contributed to the failure to review and update SPS staff competencies.

The OIG made three recommendations relating to staffing, compliance with manufacturer’s instructions, and competencies.