	Background

In providing health care services to veterans, clinicians at VAMCs use  RME, such as endoscopes and surgical instruments, which must be  reprocessed between uses. In addition, VHA policy requires that VHA and  VISNs oversee VAMCs’ reprocessing of RME and that VAMCs report  incidents involving improperly reprocessed RME. 2.) VHA’s Oversight Does Not Provide Reasonable Assurance that VAMCs Are Following RME Policies

		VHA Does Not Have Complete Information on Adherence to RME Policies from Inspections of VAMCs

VHA has not ensured that it has complete information from the annual  inspections VISNs conduct—a key oversight tool providing the most  current VA-wide information on adherence to RME policies—and  therefore does not have reasonable assurance that VAMCs are following  RME policies intended to ensure veterans are receiving safe care. VISNs provided us with evidence showing that they conducted 27 of 39  inspections that were missing from VHA’s data. As a result, VHA  did not have assurance that all of the inspections had been conducted. When asked why VHA hadn’t been aware that it didn’t have all VISN SPS  inspection reports, a VHA official said that the office has largely relied on  the VISNs to ensure complete inspection result reporting because it  hasn’t had the resources to dedicate to monitoring inspections. VHA’s lack of complete information from  inspection results is inconsistent with standards for internal control in the  federal government regarding monitoring and information that state  management should establish and operate monitoring activities and use  quality information to achieve the entity’s objectives. VAMCs Report Facing Challenges Related to RME Policies and Workforce Needs, but VHA Has Not Sufficiently Addressed These Challenges

According to interviews with officials from all of the VISNs and selected  VAMCs, the top five challenges VAMCs face in operating their SPS  programs are related to meeting certain RME policies and challenges  addressing SPS workforce needs. We also found some  instances of non-adherence on this issue in the group of VISN  inspection reports we reviewed. Regarding the challenges VAMCs face in meeting SPS workforce needs,  almost all of the 18 VISN officials and officials from the three selected  VAMCs reported experiencing challenges related to lengthy hiring  timeframes, need for consistent overtime, and limited pay and  professional growth. According to officials, these challenges result in SPS  programs having difficulty maintaining sufficient staffing levels. As a result, it  does not know whether or to what extent the workforce challenges VISNs  and VAMCs report adversely affect VAMCs’ ability to effectively operate  their SPS programs and ensure safe care for veterans. Without examining SPS workforce needs,  and taking action based on this assessment, as appropriate, VHA lacks  reasonable assurance that its approach to SPS staffing helps ensure  veterans’ access to care and safety. Until it conducts such a  study, VHA will not know whether or to what extent reported SPS  workforce challenges adversely affect the ability of VAMCs to effectively  operate their SPS programs and ensure access to safe care for veterans. Recommendations for Executive Action

We are making the following three recommendations to VHA:
The Under Secretary of Health should ensure all RME inspections are  being conducted and reported as required and that the inspection  results VHA has are complete. Appendix I: Top VHA Reusable Medical Equipment Issues among Select Veterans Affairs Medical Centers, Fiscal Year 2017

Our review of the 27 fiscal year 2017 inspections of VAMCs conducted by  Veterans Integrated Service Networks (VISN) for which VHA did not have  inspection reports identified a number of common reusable medical  equipment (RME) issues among the select VAMCs.
Why GAO Did This Study

VHA operates one of the largest health care delivery systems in the nation, serving over 9 million enrolled veterans. In providing health care services to veterans, VAMCs use RME which must be reprocessed—that is, cleaned, disinfected, or sterilized—between uses. Improper reprocessing of RME can negatively affect patient care. To help ensure the safety of veterans, VHA policy establishes requirements VAMCs must follow when reprocessing RME and requires a number of related oversight efforts.
GAO was asked to review VHA's reprocessing of RME. This report examines (1) VHA's oversight of VAMCs' adherence to RME policies and (2) challenges VAMCs face in operating their Sterile Processing Services programs, and any efforts by VHA to address these challenges. GAO reviewed relevant VHA documents including RME policies and VISN inspection results for fiscal year 2017. GAO interviewed officials from VHA, all 18 VISNs, and four VAMCs, selected based on geographic variation, VAMC complexity, and data on operating room delays. GAO examined VHA's oversight in the context of federal internal control standards on communication, monitoring, and information.

What GAO Found

GAO found that the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) does not have reasonable assurance that VA Medical Centers (VAMC) are following policies related to reprocessing reusable medical equipment (RME). Reprocessing involves cleaning, sterilizing, and storing surgical instruments and other RME, such as endoscopes. VHA has not ensured that all VAMCs' RME inspections have been conducted because it has incomplete information from the annual inspections by Veterans Integrated Service Networks (VISN), which oversee VAMCs. For fiscal year 2017, VHA did not have 39 of the 144 VISN reports from the VISNs' inspections of their VAMCs' Sterile Processing Services departments. VISNs were able to provide GAO with evidence that they had conducted 27 of the 39 missing inspections; top areas of non-adherence in these inspections were related to quality and training, among other things. Although VHA has ultimate oversight responsibility, a VHA official told GAO that VHA had not been aware it lacked complete inspection results because it has largely relied on the VISNs to ensure complete inspection result reporting. Without analyzing and sharing complete information from inspections, VHA does not have assurance that its VAMCs are following RME policies designed to ensure that veterans receive safe care.
GAO also found that VAMCs face challenges operating their Sterile Processing Services programs—notably, addressing workforce needs. Almost all of the officials from all 18 VISNs and selected VAMCs GAO interviewed reported Sterile Processing Services workforce challenges, such as lengthy hiring timeframes and limited pay and professional growth potential. According to officials, these challenges result in programs having difficulty maintaining sufficient staffing. VHA officials told GAO that the office is considering studying Sterile Processing Services staffing at VAMCs, although VHA does not have definitive plans to do so. VHA's Sterile Processing Services workforce challenges pose a potential risk to VAMCs' ability to ensure access to sterilized medical equipment, and VHA's failure to address this risk is inconsistent with standards for internal control in the federal government. Until VHA examines these workforce needs, VHA won't know whether or to what extent the reported challenges adversely affect VAMCs' ability to effectively operate their Sterile Processing Services programs and ensure access to safe care for veterans.

What GAO Recommends

GAO is making three recommendations to VHA, including that it ensure all RME inspections are being conducted and complete results reported, and that it examine Sterile Processing Services workforce needs and make adjustments, as appropriate. VA concurred with these recommendations.