VA has established roles and responsibilities  within its system for purchasing, tracking, and reprocessing of these items  and policies that VAMCs are required to follow when purchasing and  tracking these items at their facilities. These inadequacies create potential risks to the safety of  veterans who receive care at VAMCs. However, we did not identify any  inadequacies in the purchasing requirements we selected for review that  may create potential risks to veterans’ safety. VAMCs Are Not Required to Track Certain Expendable Medical Supplies and RME

VA does not require VAMCs to enter information about certain expendable  medical supplies and RME into their inventory management systems, and  therefore, VAMC inventories have incomplete information on these items. Incomplete inventories of these items at VAMCs can pose  potential risks to veterans’ safety. In the  event of a manufacturer recall or patient safety alert related to an  expendable medical supply item or RME, VAMCs may be unable to use  their inventory management systems to systematically determine whether  the affected item is in their facilities and should therefore be removed so  that it is not used when providing care to veterans. Selected VA Reprocessing Requirements Are Inadequate

The VA reprocessing requirements we selected for review are inadequate  to help ensure veterans’ safety in two respects: (1) they do not specify the  types of RME for which VAMCs must develop device-specific training, and  (2) VA has provided VAMCs with conflicting guidance on how to develop  this training. While VA requires VAMCs to develop device-specific training on  reprocessing RME, VA headquarters officials provided VAMCs with  conflicting guidance on how they should develop this training. VA’s lack of specificity and conflicting guidance regarding its requirement  to develop device-specific training for reprocessing RME may have  contributed to delays in developing this training at several of the VAMCs  we visited. VA’s Oversight of VAMCs’ Compliance with Selected Purchasing and Reprocessing Requirements Has Weaknesses

VA’s oversight of VAMCs’ compliance with selected purchasing and  reprocessing requirements has weaknesses, which result in VA not being  able to systematically identify and address noncompliance. We did not  identify any weaknesses in VA’s oversight of the tracking requirements we  selected for review. VA  headquarters officials told us that VA intends to improve oversight over  the selected purchasing requirements, but has not yet developed a plan for  doing so. VA Has Limited Oversight of VAMCs’ Compliance with Selected Purchasing Requirements

We found that, in general, VA does not oversee VAMCs’ compliance with  the purchasing requirements we selected for review. Despite Changes Intended to Improve Its Oversight of VAMCs’ Compliance with Selected Reprocessing Requirements, VA’s Oversight Has Weaknesses

Beginning in fiscal year 2011, VA headquarters directed VISNs to make  three changes intended to improve its oversight of VAMCs’ compliance  with the selected reprocessing requirements at VAMCs. Similarly, because VA  headquarters does not analyze information from VAMCs’ corrective action  plans to address noncompliance with VA reprocessing requirements, it is  unable to confirm, for example, whether VAMCs have addressed  noncompliance with its operational reprocessing requirement to separate  clean and dirty RME. VA headquarters officials told us that VA plans to address the weaknesses  we identified in its oversight of VAMCs’ compliance with reprocessing  requirements. Specifically, VA headquarters officials told us that they  intend to develop a systematic approach to analyze the information on  VAMCs’ noncompliance and corrective action plans to identify areas of  noncompliance across all VAMCs, including those that occur frequently,  pose high risks to veterans’ safety, or have not been addressed in a timely  manner. Appendix I: Scope and Methodology

To examine Department of Veterans Affairs (VA) purchasing, tracking, and  reprocessing requirements, we reviewed relevant VA policies and from  these policies we judgmentally selected two purchasing requirements, two  tracking requirements, and two reprocessing requirements that we  determined were relevant to veterans’ safety issues that were identified at  certain VA medical centers (VAMC) in 2008 and 2009. At these six VAMCs, we examined the adequacy of the selected  purchasing, tracking, and reprocessing requirements to help ensure the  safety of veterans who received care.
Why GAO Did This Study

Department of Veterans Affairs (VA) clinicians use expendable medical supplies--disposable items that are generally used one time--and reusable medical equipment (RME), which is designed to be reused for multiple patients. VA has policies that VA medical centers (VAMC) must follow when purchasing such supplies and equipment, tracking these items at VAMCs, and reprocessing--that is, cleaning, disinfecting, and sterilizing--RME. GAO was asked to evaluate (1) purchasing, tracking, and reprocessing requirements in VA policies and (2) VA's oversight of VAMCs' compliance with these requirements. GAO reviewed VA policies and selected two purchasing requirements, two tracking requirements, and two reprocessing requirements. At the six VAMCs GAO visited, GAO interviewed officials and reviewed documents to examine the adequacy of the selected requirements to help ensure veterans' safety. GAO also interviewed officials from VA headquarters and from six Veterans Integrated Service Networks (VISN), which oversee VAMCs, and obtained and reviewed documents regarding VA's oversight.

What GAO Found

GAO found that the VA tracking and reprocessing requirements selected for review are inadequate to help ensure the safety of veterans who receive care at VAMCs. GAO did not identify inadequacies in selected VA purchasing requirements that may create potential risks to veterans' safety. GAO found the following: (1) Tracking requirements. Because VA does not require VAMCs to enter information about certain expendable medical supplies and RME in their facilities into VA's inventory management systems, VAMCs may have incomplete inventories of these items. This, in turn, creates potential risks to veterans' safety. For example, in the event of a manufacturer recall involving these items, VAMCs may be unable to readily determine whether the items are in their facilities and should be removed and not used when providing care to veterans. (2) Reprocessing requirements. Although VA requires VAMCs to develop device-specific training for staff on how to correctly reprocess RME, VA has not specified the types of RME for which this training is required. VA has also provided conflicting guidance to VAMCs on how to develop this training. This lack of clarity may have contributed to delays in developing the required training. Without appropriate training on reprocessing, VAMC staff may not be reprocessing RME correctly, which poses potential risks to the safety of veterans. VA headquarters officials told GAO that VA has plans to develop training for certain RME, but VA lacks a timeline for developing this training. GAO also found weaknesses in VA's oversight of VAMCs' compliance with the selected purchasing and reprocessing requirements. These weaknesses render VA unable to systematically identify and address noncompliance with the requirements, which poses potential risks to the safety of veterans. GAO did not identify weaknesses in VA's oversight of VAMCs' compliance with the selected tracking requirements. GAO found the following: (1) Oversight over purchasing requirements. In general, VA does not oversee VAMCs' compliance with the selected purchasing requirements. While VA intends to improve oversight over these requirements, it has not yet developed a plan for doing so. (2) Oversight over reprocessing requirements. Although VA headquarters receives information from the VISNs on any noncompliance they identify as well as VAMCs' corrective action plans to address this noncompliance, VA headquarters does not analyze this information to inform its oversight. According to VA headquarters officials, VA intends to develop a plan for analyzing this information to systematically identify areas of noncompliance that occur frequently, pose high risks to veterans' safety, or have not been addressed across all VAMCs.

What GAO Recommends

GAO is making several recommendations for VA to address the inadequacies identified in selected tracking and reprocessing requirements and the weaknesses in its oversight over selected purchasing and reprocessing requirements. VA concurred with these recommendations.