VA Health Care:

Weaknesses in Policies and Oversight Governing Medical Supplies and Equipment Pose Risks to Veterans' Safety

GAO-11-391: Published: May 3, 2011. Publicly Released: May 3, 2011.

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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.

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. 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.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To help ensure veterans' safety through VA's purchasing, tracking, and reprocessing requirements, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require VAMCs to enter information about all expendable medical supplies and RME into an appropriate inventory management system.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA concurred with the recommendation and issued a memorandum to the VISN directors in October 2011 requiring them to take several actions to address our recommendation. First, the memorandum requires VISN directors to capture procurement data on all clinical items within the Integrated Funds Distribution Control Point Activity and Procurement (IFCAP) Item Master File (IMF). The memorandum also requires VISN directors to restrict the use of purchase cards for clinical items to logistics staff to ensure procured items are approved for use and items are captured in the IMF; validate VAMC compliance with all applicable directives and policies relating to the management of expendable and nonexpendable supplies and equipment throughout the supply chain; and implement a process to validate that required VISN and facility logistics reviews are performed, action plans are generated and completed, and aggregate data is captured for analysis. As a result of this memorandum, VA has required VAMCs to enter information about all expendable medical supplies and RME into an appropriate inventory management system.

    Recommendation: To help ensure veterans' safety through VA's purchasing, tracking, and reprocessing requirements, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop and implement an approach for providing standardized training for reprocessing all critical and semi-critical RME to VAMCs. Additionally, hold VAMCs accountable for implementing device-specific training for all of these RME.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: VA concurred with our recommendation and, in November 2012, stated that over 1,200 employees had been certified by the International Association of Healthcare Central Service Materiel Management, a professional organization dedicated to the education and certification of Sterile Processing Department employees. In addition, VA stated that it was in the process of developing an updated handbook on reusable medical equipment reprocessing.

    Recommendation: To help ensure veterans' safety through VA's purchasing, tracking, and reprocessing requirements, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop and implement an approach to oversee compliance at all VAMCs with the selected purchasing requirements.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: VA concurred with our recommendation and, in fiscal year 2012, began requiring VISNs and VAMCs to conduct oversight of VAMCs' compliance with purchasing and tracking requirements. To conduct this oversight, VA headquarters provided VISNs and VAMCs with a standardized assessment tool and required VAMCs to document corrective actions taken in response to identified non-compliance on an action plan.

    Recommendation: To help ensure veterans' safety through VA's purchasing, tracking, and reprocessing requirements, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: VA concurred with our recommendation and, in November 2012, noted that VA headquarters tracks completion of action plans that are the result of specific incidents through an electronic tool. VA also noted that VISNs track action plans related to deficiencies identified at VAMCs and that VA is in the process of developing a dashboard for tracking the extent to which required oversight activities have been completed and identified deficiencies have been addressed.

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