GAO Says VHA Inadequately Overseeing Reusable Device Sterility

According to a report from the Government Accountability Office (GAO), the Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) is not adequately overseeing the reprocessing of endoscopes and other reusable medical equipment.

“GAO found that the Department of Veterans Affairs’ Veterans Health Administration does not have reasonable assurance that VA Medical Centers are following policies related to reprocessing reusable medical equipment (RME),” the report read. “Reprocessing involves cleaning, sterilizing, and storing surgical instruments and other RME, such as endoscopes.”

Although the VHA has put a RME reprocessing system in place to ensure equipment is clean and ready for use when needed, the VHA has struggled with RME reprocessing in the past. Notable in 2009, two medical centers warned 10,000 veterans that they may have been exposed to hepatitis B, hepatitis C, and HIV because they were treated with poorly-processed endoscopes. Further, two years after this revelation, the GAO found that the VHA failed to ensure its medical centers were up to date with reprocessing.

In the new report, the GAO identified sources of the VHA’s reprocessing problems. According to the report, annual inspections by the Veterans Integrated Service Networks are supposed to give the VHA a look at practices at VA medical centers. However, the GAO found that the VHA was missing inspection reports for 27% of the center’s sterile processing units, and there was no evidence that 8% of the inspections were performed. According to the reports that are available, there is room for improvement with these medical centers. Further, the GAO found issues related to quality and training—the most common causes of nonadherence. The GAO is also concerned that sterile processing units struggle to hire and retain qualified staff.

“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.”

The VA has agreed with the recommendations and will set up an oversight process for site inspections and reporting, according to the report. The VA will analyze the report findings in a written brief that will be available by July 2019.

—Julie Gould