	Selected VA Reprocessing Requirements Are Inadequate to Help Ensure Veterans’ Safety

We found that the VA reprocessing requirements we selected for review  are inadequate to help ensure veterans’ safety. 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 headquarters officials told us that they are aware of the lack of  specificity and conflicting guidance provided to VAMCs regarding the  development of training for reprocessing RME and were also aware of  inefficiencies resulting from each VAMC developing its own training for  reprocessing types of RME that are used in multiple VAMCs. The officials also  told us that VA headquarters is planning to develop device-specific training  available to all VAMCs for certain critical and semi-critical RME for which  RME manufacturers have not developed this training, such as dental  instruments. Despite Changes Intended to Improve VA’s Oversight of VAMCs’ Compliance with Selected Reprocessing Requirements, Weaknesses Continue to Exist

We found that VA recently made changes to its oversight of VAMCs’  compliance with selected reprocessing requirements; however, this  oversight continues to have weaknesses. Prior  to fiscal year 2011, VISNs were generally not required to report this  information to VA headquarters. However, VA headquarters does not analyze  information to identify the extent of noncompliance across all VAMCs,  including noncompliance that occurs frequently or poses high risks to  veterans’ safety. 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. In conclusion, weaknesses exist in VA’s policies for reprocessing RME that  create potential safety risks to veterans. Moreover, weaknesses in oversight of VAMCs’ compliance with the  selected reprocessing requirements do not allow VA to identify and  address areas of noncompliance across VAMCs, including those that occur  frequently, pose high risks to veterans’ safety, or have not been addressed  by VAMCs. We recommend that  the Secretary of Veterans Affairs direct the Under Secretary for Health to  take the following actions:    Develop and implement an approach for providing standardized training  for reprocessing all critical and semi-critical RME to VAMCs. Use the information on noncompliance identified by the VISNs and  information on VAMCs’ corrective action plans to identify areas of  noncompliance across all 153 VAMCs, including those that occur  frequently, pose high risks to veterans’ safety, or have not been addressed,  and take action to improve compliance in those areas. In responding to a draft of the report from which this testimony is based,  VA concurred with these recommendations. This is a work of the U.S. government and is not subject to copyright protection in the  United States.
Why GAO Did This Study

This testimony discusses patient safety incidents at Department of Veterans Affairs (VA) medical centers and potential strategies to address the underlying causes of those incidents. VA operates one of the largest integrated health care delivery systems in the United States, providing care to over 5.5 million veterans annually. Organized into 21 Veterans Integrated Service Networks (VISN), VA's health care system includes 153 VA medical centers (VAMC) nationwide that offer a variety of outpatient, residential, and inpatient services. In providing health care services to veterans, clinicians at VAMCs use reusable medical equipment (RME), which is designed to be reused for multiple patients and includes such equipment as endoscopes and some surgical and dental instruments. Because RME is used when providing care to multiple veterans, this equipment must be reprocessed--that is, cleaned and disinfected or sterilized--between uses. VA has established requirements for VAMCs to follow when reprocessing RME, which are designed, in part, to help ensure the safety of the veterans who receive care at VAMCs. This testimony, based on our May 2011 report, which is being released today, examines issues related to veterans' safety, including (1) selected reprocessing requirements established in VA policies, based on their relevance to patient safety incidents and (2) VA's oversight of VAMCs' compliance with these selected requirements.

What GAO Found

In summary, we found that the VA reprocessing requirements we selected for review are inadequate to help ensure the safety of veterans who receive care at VAMCs. Although VA requires VAMCs to develop devicespecific training for staff on how to correctly reprocess RME, it has not specified the types of RME for which this training is required. Furthermore, VA has provided conflicting guidance to VAMCs on how to develop device-specific training on reprocessing RME. 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 veterans' safety. VA headquarters officials told us that VA has plans to develop training for certain RME, but VA lacks a timeline for developing this training. We also found that despite changes to improve VA's oversight of VAMCs' compliance with selected reprocessing requirements, weaknesses still exist. These weaknesses render VA unable to systematically identify and address noncompliance with the requirements, which poses potential risks to the safety of veterans. 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

To address the inadequacies we identified in selected VA reprocessing requirements, GAO recommends that VA develop and implement an approach for providing standardized training for reprocessing all critical and semi-critical RME to VAMCs and hold VAMCs accountable for implementing this training. To address the weaknesses in VA's oversight of VAMCs' compliance with selected requirements, GAO recommends that VA use information on noncompliance identified by the VISNs and information on VAMCs' corrective action plans to identify areas of noncompliance across all 153 VAMCs and take action to improve compliance in those areas.